Ijcp april 2018 by IJCP

ISSN 0971-0876 RNI 50798/1990 University Grants Commission 20737/15554

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A Multispecialty Journal Volume 28, Number 11

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April 2018, Pages 1001â&#x20AC;&#x201C;1100

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yy American Family Physician yy Community Medicine yy Dermatology yy ENT yy Internal Medicine yy Neurology yy Obstetrics and Gynecology yy Surgery yy Imaging and Investigations

an i c i ys ians

yy Medicolegal

Phly Physic y l mi ami

yy Conference Proceedings

Fademy of F n ica Aca

yy Around the Globe

er merican m A eA

yy Spiritual Update

ingurnal of th t a or d Jo

yy Lighter Reading

rp-reviewe o c In eer AP

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IJCP Group of Publications

A Multispecialty Journal Volume 28, Number 11, April 2018

Dr Sanjiv Chopra Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

Dr KK Aggarwal Padma Shri Awardee Group Editor-in-Chief Dr Veena Aggarwal Group Executive Editor

IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani, Dr Thankam Verma, Dr Kamala Selvaraj Cardiology Dr Praveen Chandra Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses, Dr Sidhartha Das, Dr A Ramachandran, Dr Samith A Shetty, Dr Vijay Viswanathan, Dr V Mohan, Dr V Seshiah, Dr Vijayakumar ENT Dr Jasveer Singh, Dr Chanchal Pal Dentistry Dr KMK Masthan, Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar, Dr Rajiv Khosla, Dr JS Rajkumar Dermatology Dr Hasmukh J Shroff, Dr Pasricha, Dr Koushik Lahiri, Dr Jayakar Thomas Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan, Dr Vineet Suri, Dr AV Srinivasan Oncology Dr V Shanta Orthopedics Dr J Maheshwari

From the desk of THE group editor-in-chief

1005 Supreme Court Allows ‘Living Will’

American Family Physician

1007 Medications for Alcohol Use Disorder

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.

Bradford T. Winslow, Mary Onysko, Melanie Hebert

1015 Practice Guidelines 1017 Photo Quiz Community medicine

1020 A Study of Maternal Mortality

Sunanda R Kulkarni

DERMATOLOGY

1024 A Rare Association of Psoriasis Vulgaris with Bullous Pemphigoid

Sukumar D, Namitha Chathra, Srinath MK

ENT

1027 All Opaque Sinuses are not Sinusitis

Ponnathpur Lakshmi, Shruti Manjunath

1031 Thyroglossal Cyst in a Young Adult: A Case Report

Ponnathpur Lakshmi, Shruti Manjunath

INTERNAL MEDICINE

1034 Association of Fructose Enriched Foods with Metabolic Syndrome and Cardiovascular Diseases

Anita Sharma, Kanupriya Vashishth, Yash Paul Sharma, Gaurav Gupta, Devendra Kumar Singh

NEUROLOGY

1042 Kartagener’s Syndrome with Seizures: A Rare Case Report

Anand Gopal Bhatnagar Editorial Anchor Advisory Bodies Heart Care Foundation of India

KK Aggarwal

Chandramohan Sharma, Banshi Lal Kumawat, Deepika Sagar

OBSTETRICS AND GYNECOLOGY

1045 A Rare Case of Huge Central Cervical Fibroid with Characteristic “Lantern on Top of St. Paul’s Cathedral” Appearance

Tamal Kumar Mandal, Pratima Garain, Debjani Deb, Shyam Sundar Halder, Preeti Dewangan

1052 Acoustic Neuroma and Hydrocephalus in Pregnancy: A Case Report

Avinash Patil, Poornima R, M Narayana Swamy, Gomathy

1056 To Evaluate the Etiological Determinants of Rhesus Isoimmunization and to Study Its Perinatal Outcome

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

Neetu Singh, Kiran Pandey, Preeti Dubey, Yashwant Rao

1060 Lower Segment Large Fibroid in a Unicornuate Uterus with 34 Weeks Pregnancy

Printed at New Edge Communications Pvt. Ltd., New Delhi E-mail: edgecommunication@gmail.com

Urvashi Singh, Shivangi Panchpal

SURGERY

1062 Cotton Bezoar Causing Intestinal Obstruction

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.

Jagannath Kulkarni, Sanjiv Kumar Goyal, Girish Singla

IMAGING AND INVESTIGATIONS

1066 Low Molecular Weight Dextran: An Alternative to Radiographic Contrast Agent for OCT Imaging

Editorial Policies

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.

Rajesh Vijayvergiya

1067 Mirage Pneumonia

Bhavana Venkata Nagabhushana Rao, Bvs Raman

MEDICOLEGAL

1069 In the Supreme Court of India Civil Appellate Jurisdiction CONFERENCE PROCEEDINGS

1075 69th Annual Conference of Cardiological Society of India (CSI 2017) AROUND THE GLOBE

1082 News and Views Spiritual Update

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.

1092 Spiritual Prescription: Yoga Nidra

KK Aggarwal

Lighter reading

1094 Lighter Side of Medicine

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From the desk of THE group editor-in-chief

Dr KK Aggarwal

Padma Shri Awardee President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group

Supreme Court Allows ‘Living Will’

n a landmark judgment delivered on March 9, the Supreme Court of India has allowed an individual to draft a living will specifying that they not be put on life support if they slip into an incurable coma. The order was passed by a five judge Constitutional bench comprising Chief Justice of India (CJI) Dipak Misra and Justices AK Sikri, AM Khanwilkar, DY Chandrachud and Ashok Bhushan, which said “Human beings have the right to die with dignity.” Though the judges gave four separate opinions, all of them were unanimous that a 'Living Will' should be allowed, because an individual should not be allowed to continue suffering in a vegetative state when they don't wish to continue living, and know fully well that they will not revive. The Apex Court has set forth strict guidelines on how to execute the mandate of the living will. Four terminologies need to be understood in context of this judgment: Advanced directive, living will, health care proxy and DNR. Advance directive: This is a legal document made when the person is alive and still in possession of decisional capacity about how treatment decisions should be made on her or his behalf if they are no longer able to make decisions for themselves or lose the capacity to make such decisions. Advanced directives are acted upon only when the patient has lost the ability to make decisions for himself. They can be revoked orally or in writing by the patient at any time (so long as he or she has maintained decisional capacity).

Advanced directive is a Durable Power of Attorney for Health Care (DPAHC or Health Care Proxy) and living will. Living will: A living will is a document that summarizes a person’s preferences for future medical care including specific interventions such as cardiopulmonary resuscitation (CPR), ventilatory support or enteral feeding. It is a document in which patients give clear instructions about treatment to be administered or state their wishes for end-of-life medical care, when they are no longer able to communicate their decisions. A living will takes effect when the person is terminally ill without chance of recovery, and outlines the desire to withhold heroic measures. Health care proxy: A health care proxy is a person identified by the patient who will take decision with regard to treatment on his/her behalf in case he/she is incapacitated. Simply put, it can be likened to giving “power of attorney” but for medical decisions. DNR or Do not resuscitate: This document applies specifically to cardiopulmonary arrest and not to the current health status, even when the patient becomes progressively more ill. It indicates whether the patient wishes for all efforts to be made to revive him by CPR and to be put on lifesaving ventilator. The American Heart Association recommends that all patients in cardiac arrest should be resuscitated unless they have a valid DNR order, or in cases where resuscitation is physiologically futile (signs of irreversible death).

IJCP Sutra 157: A nationwide cohort study showed that alcoholic cirrhosis is a significant risk factor for type 2 diabetes mellitus in contrast to cirrhosis without alcohol.

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Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018

A series of workshops and guidelines have discussed end of life choices. It was also discussed at ‘End of Life Care’ CMAAO meeting in Tokyo, Japan in September 2017. Active euthanasia was given a big ‘no’ at this meeting, while with regard to withdrawal of ventilation, two options were suggested: either do not put the patient on ventilator or remove the ventilator. In its Position Statement on End-of-Life Care and Advance Care Planning, the American Medical Association (AMA) advocates that advance care planning become part of routine clinical practice so that patients’ wishes and preferences for health care, particularly endof-life care, are known and met. AMA further says, “The planning process respects the patient’s right to take an active role in their health care, in an environment of shared decision-making between the patient and doctor. It may involve family members, religious advisors, friends and other people the patient feels should be involved.” However, “an advance directive never takes precedence over the contemporaneous wishes of a patient who has decision-making capacity.” Advance care planning is also considered a routine part of a person's health care in Australia, which allows competent patients the right to make their own decisions involving the withholding and/or withdrawal of life-sustaining treatment. However, the complete judgment needs to be read to fully understand its implications in practice.

In its judgment in Aruna Shanbaug case, the Supreme Court had permitted passive euthanasia for a patient in permanent vegetative state, provided it had the approval of the High Court. “Hence, even if a decision is taken by the near relatives or doctors or next friend to withdraw life support, such a decision requires approval from the High Court concerned as laid down in Airedale's case (supra). In our opinion, this is even more necessary in our country as we cannot rule out the possibility of mischief being done by relatives or others for inheriting the property of the patient.” “132. In our opinion, in the case of an incompetent person who is unable to take a decision whether to withdraw life support or not, it is the Court alone, as parens patriae, which ultimately must take this decision, though, no doubt, the views of the near relatives, next friend and doctors must be given due weight.” The judgment of the Supreme Court does not answer the question as to who will take the decision to withdraw or remove the ventilator if there is no living will. The current practice (though not legal) is that all legal heirs sign a document for DNR or withdrawal. Read the Complete Judgment: http://supremecourtof india.nic.in/supremecourt/2005/9123/9123_2005_ Judgement_09-Mar-2018.pdf

■■■■

Chat with Dr KK

Control HbA1c

1006

IJCP Sutra 158: According to the ADA, screening and treatment of modifiable risk factors for cardiovascular disease is advised for people with prediabetes.

American Family Physician

Medications for Alcohol Use Disorder BRADFORD T. WINSLOW, Mary onysko, MELANIE HEBERT

Abstract The U.S. Preventive Services Task Force recommends that clinicians screen adults for alcohol misuse and provide persons engaged in risky or hazardous drinking behaviors with brief behavioral counseling to reduce alcohol misuse. However, only a minority of American adults with high-risk alcohol use receive treatment. Three medications are approved by the U.S. Food and Drug Administration to treat alcohol use disorder: acamprosate, disulfiram, and naltrexone. Acamprosate and naltrexone reduce alcohol consumption and increase abstinence rates, although the effects appear to be modest. Disulfiram has been used for years, but evidence supporting its effectiveness is inconsistent. Other medications may be beneficial to reduce heavy alcohol use. The anticonvulsants topiramate and gabapentin may reduce alcohol ingestion, although long-term studies are lacking. Antidepressants do not decrease alcohol use in patients without mood disorders, but sertraline and fluoxetine may help depressed patients decrease alcohol ingestion. Ondansetron may reduce alcohol use, particularly in selected subpopulations. Further study is needed for genetically targeted or as-needed medications to reduce alcohol use.

Keywords: Alcohol misuse, hazardous drinking behaviors, alcohol use disorder, behavioral counseling, medications

xcessive alcohol use is the third leading cause of preventable death in the United States.1 The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., integrates the previous categories of alcohol abuse and alcohol dependence into the diagnosis of alcohol use disorder (AUD); Table 1 shows the complete criteria.2 The National Institutes of Health estimates that AUD affected 9% of adult men and 5% of adult women in the United States in 2013, and many more adults and adolescents engaged in high-risk alcohol use.3

Guidelines The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for alcohol misuse and providing persons engaged in risky or hazardous drinking behaviors with brief behavioral counseling to reduce alcohol misuse.4 Table 2 lists

USPSTF-recommended screening methods that have been validated in primary care settings.4,5 Although the CAGE questionnaire is familiar to clinicians, its accuracy varies in ambulatory settings, and it is not recommended by the USPSTF. Individuals who engage in high-risk drinking should be counseled to decrease their alcohol use, and patients diagnosed with AUD should be offered treatment, such as brief behavioral interventions, support programs such as Alcoholics Anonymous, individual and group therapy, and medications. A study of more Table 2. Validated Screening Methods for Alcohol Use Disorder Recommended by the U.S. Preventive Services Task Force AUDIT (10-item questionnaire) http://www.talkingalcohol.com/files/pdfs/WHO_audit.pdf Abbreviated AUDIT-C (three-item questionnaire) http://www.integration.samhsa.gov/images/res/tool_auditc.pdf Single-question screening*

BRADFORD T. WINSLOW, MD, is program director of the Swedish Family Medicine Residency Program in Littleton, Colo. He is also an associate professor of family medicine at the University of Colorado School of Medicine in Aurora. MARY ONYSKO, PharmD, BCPS, is an associate professor of pharmacy practice at the University of Wyoming School of Pharmacy in Laramie, and a faculty member at the Swedish Family Medicine Residency Program. MELANIE HEBERT, MD, is a physician with Kaiser Permanente in Highlands Ranch, Colo. At the time this article was written, she was a third-year resident at the Swedish Family Medicine Residency Program. Source: Adapted from Am Fam Physician. 2016;93(6):457-465.

“How many times in the past year have you had five (for men) or four (for women and all adults older than 65 years) or more drinks per day?” Note: All of these screening tests are self-reported. AUDIT = Alcohol Use Disorders Identification Test; AUDIT-C = Alcohol Use Disorders Identification Test–Consumption. *An answer of one or more is considered a positive screen. Information from references 4 and 5.

IJCP Sutra 159: The GERODIAB study indicates that cardiovascular complications are associated with poor survival in elderly patients with type 2 diabetes, particularly heart failure.

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Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018

than 43,000 American adults found that only 24% of those with AUD received treatment.6 Possible reasons for low treatment rates include the social stigma of AUD, a lack of understanding of AUD as a treatable condition, and a lack of clinician familiarity with pharmacotherapy and other treatment options for the disorder. Patients with AUD are at risk of alcohol withdrawal and may require medical management for withdrawal before initiating treatment.7 A Substance Abuse and Mental Health Services Administration/National Institute on Alcohol Abuse and Alcoholism Consensus Panel recommends pharmacotherapy along with behavioral interventions for AUD.8 However, less than 10% of patients with AUD are treated with medications.9 It is difficult to assess the benefit of medications because most studies assess outcomes such as alcoholic drinks per day and drinking days over a period of time, rather than abstinence and complications of alcohol abuse (e.g., mortality, cirrhosis, alcoholrelated arrests, job loss). Most studies of medications for AUD also include counseling, so it is difficult to assess medication effects without counseling. The Department of Veterans Affairs recommends the consideration of naltrexone and/or acamprosate for AUD treatment, along with counseling.10 The United Kingdom’s National Institute for Health and Care Excellence recommends the consideration of acamprosate or naltrexone to treat AUD, with disulfiram as a second-line medication.11 The Substance Abuse and Mental Health Services Administration/National Institute on Alcohol Abuse and Alcoholism Consensus Panel provides a guide for the use of acamprosate, disulfiram, and naltrexone.8 No medications are approved for the treatment of AUD in adolescents younger than 18 years; therefore, these patients should be referred for subspecialist treatment. None of the medications used to treat AUD have been proven completely safe during pregnancy or lactation, so they should be used cautiously in women of childbearing age. Medications for the Treatment of AUD An Agency for Healthcare Research and Quality (AHRQ) review that included 135 studies of pharmacologic treatment of AUD in outpatient settings found moderate evidence to support the use of naltrexone and acamprosate, and insufficient evidence to support the use of disulfiram. The review also concluded that the evidence was lacking for most other medications,

1008

including those for off-label use and those undergoing trials. However, there is some evidence for topiramate and valproic acid.12 Table 3 summarizes the medications used to treat AUD.13

Approved by the U.S. Food and Drug Administration Acamprosate This drug appears to be most effective at maintaining abstinence in patients who are not currently drinking alcohol.14 Acamprosate seems to interact with glutamate at the N-methyl-d-aspartate receptor, although its exact mechanism is unclear.15 It is safe in patients with impaired hepatic function but should be avoided in patients with severe renal dysfunction. A systematic review of 27 studies including 7,519 patients using acamprosate showed a number needed to treat (NNT) of 12 to prevent a return to any drinking.9 A Cochrane review of 24 trials including 6,915 patients concluded that acamprosate reduced drinking compared with placebo (NNT = 9).16 One randomized trial found no difference between acamprosate and placebo, although outcomes improved significantly in both groups. This may be because enrolled patients were highly motivated to decrease alcohol use, increasing the likelihood of success with any treatment.17 Disulfiram There are limited trials to support the effectiveness of disulfiram. It does not reduce the craving for alcohol, but it causes unpleasant symptoms when alcohol is ingested because it inhibits aldehyde dehydrogenase and alcohol metabolism. Compliance is a major limitation, and disulfiram is more effective when taken under supervision. One trial randomized 243 patients to naltrexone, acamprosate, or disulfiram with supervision over 12 weeks and determined that patients taking disulfiram had fewer heavy drinking days, lower weekly consumption, and a longer period of abstinence compared with the other drugs.18 However, a 2014 metaanalysis of 22 randomized trials found that in open-label studies, disulfiram was more effective than naltrexone, acamprosate, and no disulfiram, but blinded studies did not demonstrate benefit for disulfiram.19 In a systematic review of two studies including 492 patients, disulfiram did not reduce drinking rates.9 As noted earlier, the AHRQ review found insufficient evidence to support disulfiram’s effectiveness.12 Naltrexone Naltrexone, an opioid antagonist, reduces alcohol consumption in patients with AUD, and is more

IJCP Sutra 160: A standardized slow enteral feeding (SSEF) protocol significantly reduces the incidence of necrotizing enterocolitis (NEC) and combined NEC/ death in infants with birth weight <750 g.

American Family Physician successful in those who are abstinent before starting the medication.8 The opioid receptor system mediates the pleasurable effects of alcohol. Alcohol ingestion stimulates endogenous opioid release and increases dopamine transmission. Naltrexone blocks these effects, reducing euphoria and cravings.20 Naltrexone is available in oral and injectable long-acting formulations. A Cochrane review that included 50 randomized trials and 7,793 patients found that oral naltrexone decreased heavy drinking (NNT = 10) and slightly decreased daily drinking (NNT = 25). The number of heavy drinking days and the amount of alcohol consumed also decreased. Injectable naltrexone did not decrease heavy drinking, but the sample size was small.21 A subsequent systematic review of 53 randomized trials including 9,140 patients found that oral naltrexone increased abstinence rates (NNT = 20) and decreased heavy drinking (NNT = 12). There was no difference between naltrexone and acamprosate. Injectable naltrexone did not demonstrate benefit.9 A randomized trial of 627 veterans with AUD who received injectable naltrexone or placebo found that 380 mg of naltrexone given intramuscularly decreased heavy drinking days over six months but did not increase abstinence rates.22 Another meta-analysis found no difference in heavy drinking between acamprosate and naltrexone; however, it favored acamprosate for abstinence and naltrexone for cravings.14 Studies of combination therapy with acamprosate and naltrexone have produced mixed results. The COMBINE study did not show that combined therapy was more effective than either agent alone.23 Another study showed that relapse rates were lower with combined therapy compared with placebo or acamprosate alone, but not compared with naltrexone alone.24 It is unclear if and when combination therapy should be used, although it may be reasonable to consider it if monotherapy fails. Opioid antagonists may also be helpful when used as needed during high-risk situations, such as social events or weekends.25 Naltrexone is well tolerated and is not habit-forming. Because it is metabolized by the liver, hepatotoxicity is possible, although uncommon. Patients with AUD may have liver dysfunction; therefore, caution is warranted. Naltrexone can precipitate severe opioid withdrawal in patients who are opioid-dependent, so these agents should not be used together, and opioids should not be used for at least seven days before

starting naltrexone.8 Pain management is challenging for patients taking naltrexone; these patients should carry a medical alert card.

Off-Label Medications Anticonvulsants There are several anticonvulsants that may help patients with AUD decrease alcohol consumption, but data are limited. A Cochrane review of 25 trials including 2,641 patients showed that those taking an anticonvulsant (i.e., topiramate, gabapentin, valproate, levetiracetam, oxcarbazepine, zonisamide, carbamazepine, pregabalin, or tiagabine) consumed 1.5 fewer drinks per day than those taking placebo. There was no difference in abstinence rates compared with naltrexone, but anticonvulsants were associated with fewer heavy drinking days and a longer time to relapse; many of the studies were of low quality.26 Topiramate appears to decrease alcohol consumption. The AHRQ review concluded that there is moderate evidence that topiramate decreases number of drinking days, heavy drinking days, and drinks per day based on two randomized trials.12,27,28 An openlabel study compared topiramate plus psychotherapy with psychotherapy alone in hospitalized patients after alcohol withdrawal treatment. The topiramate group had lower rates of depression and anxiety and a lower relapse rate after four months.29 However, a randomized trial of 106 patients did not show a difference in alcohol consumption between topiramate therapy and placebo.30 Another randomized trial found that topiramate increased abstinence rates in patients with a specific genetic polymorphism.31 Such targeted medication use for specific populations warrants further study. Three randomized trials suggest a possible benefit from gabapentin. A study of 150 patients found higher abstinence rates in those taking gabapentin compared with placebo (NNT = 8), as well as lower rates of heavy drinking, improved mood, fewer cravings, and improved sleep.32 A study of 60 males with an average alcohol consumption of 17 drinks per day in the previous 90 days who underwent alcohol withdrawal treatment and were treated with gabapentin or placebo found that those in the gabapentin group had fewer heavy drinking days and drank less during the 30-day trial.33 A small study of 21 patients had similar results and also found that gabapentin was more effective at improving sleep over the first six weeks of therapy. Dosages of gabapentin used in the study varied

IJCP Sutra 161: Preterm infants born after 32 weeks gestational age have an increased risk of iron deficiency compared with those born at term, thus supporting the need of iron supplementation.

1009

1010

Gabapentin

Could begin with 300 mg per day on the first day, then 300 mg twice per day on the second day and 300 mg three times per day on the third day; may increase

Studies have used 300 mg twice per day or once-daily dosages up to 1,800 mg at bedtime

Variable

Dizziness, somnolence, fatigue, peripheral edema, hostility, diarrhea, asthenia, infection, dry mouth, nystagmus, constipation, nausea, vomiting, ataxia, fever, amblyopia

FDA warning§

Begin with 20 mg per day; Ejaculatory dysfunction, nausea, may increase to 60 to 80 headache, insomnia, nervousness, mg per day somnolence, anxiety, diarrhea, anorexia, dry mouth, tremor, asthenia, sweating, dyspepsia, influenza-like illness, serotonin syndrome

None

Use of an MAOI such as mesoridazine, thioridazine, or linezolid

Fluoxetine

impotence, headache, acneiform eruptions, allergic dermatitis, metallic or garlic-like aftertaste

Begin with 250 mg once per Disulfiram-alcohol interaction: flushing, Alcohol, metronidazole, or day; if not effective, increase palpitations, nausea, vomiting, to 500 mg once per day headache paraldehyde use; psychosis; Optic neuritis, peripheral neuritis, cardiovascular polyneuritis, peripheral neuropathy, disease hepatitis, drowsiness, fatigability,

Yes

Comments

Cost†

IJCP Sutra 162: Intake of a mixed glucose/protein beverage acutely decreases testosterone levels in overweight and obese peripubertal boys.

Opioids may increase levels of gabapentin

Decreased bioavailability with aluminum hydroxide/magnesium hydroxide

Decreases levels of hydrocodone in a dose-dependent manner

Use lower dose if patient has renal impairment (creatinine clearance < 60 mL per minute per 1.73 m2 [1.00 mL per second per m2])

Pregnancy category C, safety unknown in breastfeeding

$11 ($200)

Recommended only in patients with $4 ($330) comorbid depression

Pregnancy category C, safety unknown in breastfeeding

Patient should carry an identification card describing the disulfiram-alcohol interaction; liver function should be monitored for hepatotoxicity

Initiate only after patient has abstained $50 ($190) from alcohol for at least 12 hours

Severe renal Pregnancy category C, safety $55 ($145) impairment (creatinine unknown in breastfeeding clearance < 30 mL per minute per 1.73 m2)

Contraindications*

Disulfiram

50 mL per minute per 1.73 m2 [0.50 to 0.83 mL per second per m2]): initially, one tablet three times per day

Adverse effects

Two 333-mg enteric-coated Diarrhea, insomnia, anxiety, depression, tablets three times per day asthenia, anorexia, pain, flatulence, Moderate renal impairment nausea, dizziness, pruritus, dry mouth, (creatinine clearance of 30 to paresthesia, sweating

FDA approved Dosage for alcohol use disorder

Acamprosate‡ Yes

Medication

Table 3. Medications for the Treatment of Alcohol Use Disorder

Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018

IJCP Sutra 163: Excess weight in 2- to 9-year-old children is significantly associated with cardiovascular disease risk factors.

Ondansetron

Sertraline

Topiramate

Hyperchloremic, nonanion gap, metabolic acidosis; acute myopia associated with secondary angleclosure glaucoma has been reported Anorexia, anxiety, diarrhea, fatigue, fever, infection, weight loss, cognitive problems, paresthesia, somnolence, taste perversion, mood problems, nausea, nervousness, confusion

Renal impairment (creatinine clearance < 60 mL per minute per 1.73 m2 [1.17 mL per second per m2]): one-half of usual dosage

FDA warning§

Ejaculatory dysfunction, dry mouth, sweating, somnolence, fatigue, tremor, anorexia, dizziness, headache, diarrhea, dyspepsia, nausea, constipation, agitation, insomnia, serotonin syndrome

Malaise, fatigue, headache, dizziness, anxiety, serotonin syndrome; QT interval prolongation and torsades de pointes have been reported

Nausea, vomiting, headache, dizziness, nervousness,fatigue, low energy, insomnia, anxiety, difficulty sleeping, abdominal pain or cramps, joint or muscle pain

Begin with 25-mg dose; increase to a total of 300 mg given twice per day in divided doses

Begin with 50 mg per day; may increase to 200 mg per day

4 mcg per kg twice per day (higher dosages may be used); available in 4-mg, 8-mg, 16-mg, and 24-mg oral doses

Injectable: 380 mg once every four weeks

Oral: 50 to 100 mg per day (alternative dosing: 50 mg every weekday with a 100-mg dose on Saturday, 100 mg every other day, or 150 mg every third day)

None

Use of an MAOI such as mesoridazine, thioridazine, or linezolid

Apomorphine use

Opioid use, acute opioid withdrawal, acute hepatitis, liver failure

Pregnancy category D, safety unknown in breastfeeding

Serum bicarbonate and blood ammonia levels should be monitored

Pregnancy category C, safe in breastfeeding

May be helpful in patients with comorbid depression when prescribed in conjunction with naltrexone

Pregnancy category B, safety unknown in breastfeeding

Should be avoided in patients with congenital long QT syndrome

Patients with electrolyte abnormalities should be monitored with electrocardiography

Pregnancy category C, safety unknown in breastfeeding

Liver function tests should be performed to monitor for hepatotoxicity

Pregnancy category C, limited data that it is safe in breastfeeding

Information from reference 13.

FDA = U.S. Food and Drug Administration; MAOI = monoamine oxidase inhibitor. *Other than hypersensitivity to the drug, which is a possible contraindication for all medications listed. †Estimated retail price of one month’s supply based on information obtained from http://www.goodrx.com (accessed December 3, 2015). Generic price listed first, brand price listed in parentheses. ‡Good evidence to support use in patients with alcohol use disorder. §Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder and other psychiatric disorders.

Yes

Naltrexone (oral, injectable)‡

to maximum dosage of 1,800 mg per day

$10 ($140)

$10 ($210)

$20 ($670)

Injectable: not available ($1,300)

Oral: $45 ($106)

American Family Physician

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from 300 mg twice per day to 1,800 mg at bedtime.34 Longer studies are needed to evaluate gabapentin for AUD. Pregabalin is classified as a controlled substance, and there are limited data regarding its use in AUD. A randomized trial comparing pregabalin and naltrexone in 71 patients found no difference in drinking outcomes or cravings, but the pregabalin group had less anxiety, hostility, and psychotic symptomatology.35 Antidepressants Antidepressants are not effective in decreasing alcohol use in persons without coexisting mental health disorders.36 Antidepressants can be helpful in some instances, however, because patients with AUD often have coexisting mental health disorders. A trial randomized 170 patients with alcohol dependence and depression to 14 weeks of cognitive behavior therapy plus sertraline (200 mg per day), naltrexone (100 mg per day), both medications, or double placebo. Those taking a combination of sertraline and naltrexone had higher abstinence rates and a longer delay before relapse to heavy drinking compared with those taking placebo or either agent alone. Neither agent alone was superior to placebo.37 A study of patients with AUD and major depression found that 20 to 40 mg per day of fluoxetine reduced drinking, drinking days, and heavy drinking days over 12 weeks.38 There is inconclusive evidence regarding the effectiveness of treating AUD with the atypical antipsychotics olanzapine and quetiapine. Ondansetron Ondansetron may decrease alcohol consumption in patients with AUD. In three studies, ondansetron (4 mcg per kg twice per day) combined with cognitive behavior therapy decreased alcohol consumption and cravings and increased abstinence in young adults with early AUD.39-41 In another trial, a higher dosage of ondansetron (16 mcg per kg twice per day) combined with cognitive behavior therapy decreased depression, anxiety, and hostility.42 This effect may be due to the serotonin-3 antagonist properties of ondansetron. In another randomized trial, men taking ondansetron (8 mg twice per day) had fewer heavy drinking days compared with those taking placebo, although they did not have increased abstinence rates.43 The combination of ondansetron (4 mcg per kg twice per day) and naltrexone (25 mg twice per day) may be effective in treating early AUD.43 The dosages commonly studied (4 to 16 mcg per kg twice per day) are much lower

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than the current available formulations of 4-mg and 8-mg tablets. Other

There is inconclusive evidence to support baclofen and various supplements for AUD. Gamma hydroxybutyrate is used in some countries to treat AUD; however, because of its central nervous system effects and its potential use as a date rape drug, it is not recommended.44 Note: For compete article visit: www.aafp.org/afp.

REFERENCES 1. Centers for Disease Control and Prevention. Alcohol use and your health. http://www.cdc.gov/alcohol/fact-sheets/ alcohol-use.htm. Accessed January 11, 2015. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013:490-491. 3. National Institute on Alcohol Abuse and Alcoholism. National Institutes of Health. Alcohol facts and statistics. March 2015. http://www.niaaa.nih.gov/alcohol-health/ overview-alcohol-consumption/alcoholfacts-andstatistics. Accessed December 2, 2015. 4. U.S. Preventive Services Task Force. Alcohol misuse: screening and behavioral counseling interventions in primary care. May 2013. http://www.uspreventive services taskforce.org/Page/Topic/recommendationsummary/ alcohol-misuse-screening-and-behavioralcounselinginterventions-in-primary-care. Accessed February 9, 2015. 5. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test [published correction appears in J Gen Intern Med. 2010;25(4):375]. J Gen Intern Med. 2009; 24(7):783-788. 6. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007; 64(7):830-842. 7. Muncie HL Jr, Yasinian Y, Oge’ L. Outpatient management of alcohol withdrawal syndrome. Am Fam Physician. 2013;88(9):589-595. 8. Substance Abuse and Mental Health Services Administration, National Institute on Alcohol Abuse and Alcoholism. Medication for the treatment of alcohol use disorder: a brief guide. 2015. http://store.samhsa.gov/ shin/content/SMA15-4907/SMA15-4907.pdf. Accessed December 4, 2015. 9. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889-1900.

IJCP Sutra 164: Secondhand smoke exposure during childhood and adolescence adversely affects vascular health.

American Family Physician 10. VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist Executives. Alcohol use disorder pharmacotherapy. Naltrexone, acamprosate, and disulfiram. Recommendations for Use. December 2013. http://www.pbm.va.gov/PBM/clinicalguidance/clinical recommendations/Alcohol_Use_Disorder_Pharmacoth erapy_Acamprosate_Naltrexone_Disulfiram_Recommen dations_for_Use.docx. Accessed February 21, 2015. 11. National Institute for Health and Care Excellence. Alcoholuse disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. April 2015. https://www.nice.org.uk/guidance/cg115. Accessed December 4, 2015. 12. Agency for Healthcare Research and Quality. Pharmacotherapy for adults with alcohol-use disorders in outpatient settings. Executive summary. http:// effectivehealthcare.ahrq.gov/ehc/products/477/1907/ alcohol-misuse-drug-therapy-executive-140513.pdf. Accessed February 21, 2015. 13. Epocrates. http://epocrates.com/. Accessed January 19, 2016. 14. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275-293. 15. Yahn SL, Watterson LR, Olive MF. Safety and efficacy of acamprosate for the treatment of alcohol dependence. Subst Abuse. 2013;6:1-12. 16. Rösner S, Hackl-Herrwerth A, Leucht S, Lehert P, Vecchi S, Soyka M. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010;(9):CD004332. 17. Berger L, Fisher M, Brondino M, et al. Efficacy of acamprosate for alcohol dependence in a family medicine setting in the United States: a randomized, doubleblind, placebo-controlled study. Alcohol Clin Exp Res. 2013;37(4):668-674. 18. Laaksonen E, Koski-Jännes A, Salaspuro M, Ahtinen H, Alho H. A randomized, multicentre, open-label, comparative trial of disulfiram, naltrexone and acamprosate in the treatment of alcohol dependence. Alcohol Alcohol. 2008;43(1):53-61. 19. Skinner MD, Lahmek P, Pham H, Aubin HJ. Disulfiram efficacy in the treatment of alcohol dependence: a metaanalysis. PLoS One. 2014;9(2):e87366. 20. Niciu MJ, Arias AJ. Targeted opioid receptor antagonists in the treatment of alcohol use disorders. CNS Drugs. 2013;27(10):777-787. 21. Rösner S, Hackl-Herrwerth A, Leucht S, Vecchi S, Srisurapanont M, Soyka M. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010;(12):CD001867. 22. Garbutt JC, Kranzler HR, O’Malley SS, et al.; Vivitrex Study Group. Efficacy and tolerability of longacting injectable naltrexone for alcohol dependence: a randomized controlled trial [published corrections appear in JAMA.

2005;293(16):1978, and JAMA. 2005;293(23):2864]. JAMA. 2005;293(13):1617-1625. 23. Anton RF, O’Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17):2003-2017. 24. Kiefer F, Jahn H, Tarnaske combining naltrexone and prevention of alcoholism: controlled study. Arch 60(1):92-99.

T, et al. Comparing and acamprosate in relapse a double-blind, placeboGen Psychiatry. 2003;

25. van den Brink W, Aubin HJ, Bladström A, Torup L, Gual A, Mann K. Efficacy of as-needed nalmefene in alcoholdependent patients with at least a high drinking risk level: results from a subgroup analysis of two randomized controlled 6-month studies [published correction appears in Alcohol Alcohol. 2013;48(6):746]. Alcohol Alcohol. 2013;48(5):570-578. 26. Pani PP, Trogu E, Pacini M, Maremmani I. Anticonvulsants for alcohol dependence. Cochrane Database Syst Rev. 2014;(2):CD008544. 27. Johnson BA, Rosenthal N, Capece JA, et al.; Topiramate for Alcoholism Advisory Board; Topiramate for Alcoholism Study Group. Topiramate for treating alcohol dependence: a randomized controlled trial. JAMA. 2007; 298(14):1641-1651. 28. Johnson BA, Ait-Daoud N, Bowden CL, et al. Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. Lancet. 2003;361(9370): 1677-1685. 29. Paparrigopoulos T, Tzavellas E, Karaiskos D, Kourlaba G, Liappas I. Treatment of alcohol dependence with lowdose topiramate: an open-label controlled study. BMC Psychiatry. 2011;11:41. 30. Likhitsathian S, Uttawichai K, Booncharoen H, Wittayanookulluk A, Angkurawaranon C, Srisurapanont M. Topiramate treatment for alcoholic outpatients recently receiving residential treatment programs: a 12-week, randomized, placebo-controlled trial. Drug Alcohol Depend. 2013;133(2):440-446. 31. Kranzler HR, Covault J, Feinn R, et al. Topiramate treatment for heavy drinkers: moderation by a GRIK1 polymorphism [published correction appears in Am J Psychiatry. 2014;171(5):585]. Am J Psychiatry. 2014;171(4):445-452. 32. Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med. 2014;174(1):70-77. 33. Furieri FA, Nakamura-Palacios EM. Gabapentin reduces alcohol consumption and craving: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2007;68(11):1691-1700. 34. Leung JG, Hall-Flavin D, Nelson S, Schmidt KA, Schak KM. The role of gabapentin in the management of

IJCP Sutra 165: Acute exercise can possibly create an anti-inflammatory environment in children and adolescents with chronic kidney disease stages III-V.

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Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018 alcohol withdrawal and dependence. Ann Pharmacother. 2015;49(8):897-906. 35. Martinotti G, Di Nicola M, Tedeschi D, et al. Pregabalin versus naltrexone in alcohol dependence: a randomised, double-blind, comparison trial. J Psychopharmacol. 2010;24(9):1367-1374. 36. Torrens M, Fonseca F, Mateu G, Farré M. Efficacy of antidepressants in substance use disorders with and without comorbid depression. A systematic review and meta-analysis. Drug Alcohol Depend. 2005;78(1):1-22. 37. Pettinati HM, Oslin DW, Kampman KM, et al. A doubleblind, placebo-controlled trial combining sertraline and naltrexone for treating co-occurring depression and alcohol dependence. Am J Psychiatry. 2010; 167(6):668-675. 38. Cornelius JR, Salloum IM, Ehler JG, et al. Fluoxetine in depressed alcoholics. A double-blind, placebo-controlled trial. Arch Gen Psychiatry. 1997;54(8):700-705. 39. Johnson BA, Roache JD, Javors MA, et al. Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: a randomized controlled trial. JAMA. 2000;284(8):963-971.

40. Johnson BA, Roache JD, Ait-Daoud N, Zanca NA, Velazquez M. Ondansetron reduces the craving of biologically predisposed alcoholics. Psychopharmacology (Berl). 2002;160(4):408-413. 41. Kranzler HR, Pierucci-Lagha A, Feinn R, HernandezAvila C. Effects of ondansetron in early- versus late-onset alcoholics: a prospective, open-label study. Alcohol Clin Exp Res. 2003;27(7):1150-1155. 42. Johnson BA, Ait-Daoud N, Ma JZ, Wang Y. Ondansetron reduces mood disturbance among biologically predisposed, alcohol-dependent individuals. Alcohol Clin Exp Res. 2003;27(11):1773-1779. 43. Corrêa Filho JM, Baltieri DA. A pilot study of fulldose ondansetron to treat heavy-drinking men withdrawing from alcohol in Brazil. Addict Behav. 2013;38(4): 2044-2051. 44. Leone MA, Vigna-Taglianti F, Avanzi G, Brambilla R, Faggiano F. Gamma-hydroxybutyrate (GHB) for treatment of alcohol withdrawal and prevention of relapses. Cochrane Database Syst Rev. 2010;(2):CD006266. 45. Williams SH. Medications for treating alcohol dependence. Am Fam Physician. 2005;72(9):1775-1780.

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IJCP Sutra 166: Recombinant human erythropoietin treatment has beneficial effect on the neurodevelopment outcomes without severe adverse side effect in preterm infants.

American Family Physician

Practice Guidelines AHA/ATS Release Guidelines on the Diagnosis and Treatment of Pediatric Pulmonary Hypertension Pulmonary hypertension in children is distinct from adult hypertension. It is linked to issues of lung growth and development, and is often related to impaired functional and structural adaptation of pulmonary circulation during transition from fetal to postnatal life. Pulmonary hypertension in children is defined as a resting mean pulmonary artery pressure of more than 25 mm Hg beyond the first few months of life. These guidelines from the American Heart Association (AHA) and the American Thoracic Society (ATS) address evaluation and treatment of pediatric pulmonary hypertension, including diagnosis, pharmacotherapy, and outpatient treatment recommendations.

Cardiac Catheterization Cardiac catheterization should be performed before starting therapy for pulmonary hypertension unless a patient is critically ill with an immediate need to start treatment. There are six general goals for catheterization in children with pulmonary hypertension: confirm diagnosis and severity of disease; assess response of the pulmonary bed to pulmonary vasodilators before starting therapy (acute vasoreactivity testing [AVT]); evaluate response to or need for changes in therapy; exclude other diagnoses; assess operability as part of the assessment of patients with systemic to pulmonary artery shunts; and assist in determining heart or heartlung transplantation suitability. It is recommended that repeat catheterization be performed at clinical worsening, three to 12 months after a significant change in therapy, or every one to two years during follow-up.

Diagnosis

Other Diagnostic Tools

A comprehensive history and physical examination, combined with diagnostic testing and formal assessment of cardiac function, should be done at the time of initial pulmonary hypertension diagnosis. Critical diagnostic testing includes chest radiography, electrocardiography, echocardiography, chest computed tomography (CT) with or without contrast media, six-minute walk test, laboratory studies including brain natriuretic peptide levels, and cardiac catheterization. Targeted evaluation with pulmonary function testing, magnetic resonance imaging, lung perfusion scanning, cardiopulmonary exercise testing, and a sleep study may be appropriate in some patients. Follow-up visits should be performed every three to six months, with more frequent visits for patients with advanced disease or after initiation of or change in therapy.

CT may produce useful information on disease pathogenesis when evaluating for pulmonary hypertension. CT angiography is the preferred method for detecting pulmonary embolism. Smaller children are able to tolerate chest CT angiography better than ventilation/perfusion scanning, which requires the child to be motionless for several minutes after inhaling a radioisotope and being injected with radioisotopetagged albumin.

Echocardiography Echocardiography is noninvasive and useful in identifying potential causes of pulmonary hypertension, right ventricular function, and assessing related comorbidities. It is the preferred tool for screening and should typically be performed every four to six months to monitor disease progression, or if there is a change in therapy.

Source: Adapted from Am Fam Physician. 2016;93(7):605-614.

Magnetic resonance imaging is the best option for the evaluation of the right ventricle. It is most commonly usedÂ in children with pulmonary hypertension to evaluate right ventricle size, mass, and function in the initial evaluation and during follow-up. Echocardiography is still preferred for frequent assessments. Physiologic assessments such as the six-minute walk test and cardiopulmonary exercise testing are used for evaluation and follow-up, but have not been standardized in children.

Pharmacotherapy Vasodilator responsiveness should be assessed by cardiac catheterization, and anatomic obstruction resulting from pulmonary venous disease or leftsided heart disease should be excluded before targeted therapy is started. Vasodilators are commonly used to decrease pulmonary artery hypertension, improve

IJCP Sutra 167: Vitamin D3 supplementation during pregnancy and infancy reduces primary care visits for acute respiratory infection during early childhood.

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cardiac output, and possibly reverse pulmonary vascular changes in the lung. New evidence suggests that cellular growth, inflammation, and fibroproliferative changes play an important role in pulmonary artery hypertension that may not be adequately addressed by current therapies. Conventional Therapy Conventional therapies used for heart failure are also used to treat right ventricular failure. Digitalis may be beneficial in patients with overt right-sided cardiac dysfunction and clinical heart failure. Diuretic therapy should be used carefully because patients with pulmonary artery hypertension are often preload dependent to maintain an optimal cardiac output. Although long-term studies in children are lacking, anticoagulation with warfarin may be considered in patients with low cardiac output, longterm indwelling catheters, hypercoagulable states, idiopathic pulmonary artery hypertension, or heritable pulmonary artery hypertension. Anticoagulation should not be used in young children with pulmonary artery hypertension who may be prone to hemorrhagic complications. Other Therapies Adding specific targeted therapy for pulmonary hypertension to achieve specified therapeutic goals is recommended. Transitioning from parenteral to oral or inhaled therapy can be done in asymptomatic children with stable near-normal pulmonary hemodynamics, as long as close monitoring is done in a specialized treatment center. Oxygen therapy can be useful for patients with a saturation of less than 92%, especially in the scenario of underlying respiratory disease. Calcium channel blockers (CCBs) are indicated for patients who are reactive with AVT and older than one year. CCB therapy is contraindicated in children who have not undergone AVT, are nonresponders, or have right ventricular failure, regardless of acute response. Long-term CCB therapies recommended for use in acute responders include nifedipine, diltiazem, and amlodipine. These agents may lower heart rate, and diltiazem is used more commonly in young children with higher heart rates.

Prostacyclin analogues can be used to increase pulmonary vasodilatation. Intravenous or subcutaneous analogues (i.e., epoprostenol, treprostinil, or their analogues) should be started immediately in patients with severe pulmonary artery hypertension. Phosphodiesterase-5 inhibitors (i.e., sildenafil or tadalafil) and endothelin receptor antagonists (i.e., bosentan and ambrisentan) can be used for oral therapy in children with lower-risk pulmonary hypertension.

Outpatient Care Establishing experienced, knowledgeable, and multidisciplinary pediatric pulmonary hypertension programs, as well as teams of pediatric subspecialists, can improve the care of children with pulmonary hypertension. A critical aspect of these programs is successful coordination of inpatient and outpatient care. There is risk of syncope or sudden death with exertion in patients with pulmonary hypertension. It is recommended that a thorough evaluation be performed before the patient engages in athletic activities. Patients with severe pulmonary hypertension should be advised not to participate in competitive sports. In general, these patients should avoid strenuous exertion and should engage in light to moderate aerobic activity, stay well hydrated, and be allowed to selflimit as required. Because of risks to the mother and fetus during pregnancy, age-appropriate counseling on contraception should be provided to female adolescents with pulmonary hypertension. During travel on airplanes, oxygen may be necessary. Respiratory viral and bacterial infections are common in childhood and adversely affect outcomes in children with pulmonary hypertension, so it is important that they are treated promptly. For prevention, they should receive the influenza, pneumococcal, and respiratory syncytial virus vaccinations. An experienced pulmonary hypertension team involved during routine surgical and dental procedures can reduce complications related to anesthesia in children. Frequent outpatient visits at three- to six-month intervals and closer follow-up for monitoring changes in disease course can improve communication with families and caregivers. Children and their siblings and caregivers should be assessed for psychosocial stress, with referral as needed.

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IJCP Sutra 168: Management of allergic rhinitis might be associated with improvement of attention in children.

American Family Physician

Photo Quiz A Fungating Lesion on the Tongue A 31-year-old man presented with a lesion on his tongue that he first noticed six months earlier as small red dots. His dentist thought it was caused by irritation from his dental bridge. It was painless, but he had some bleeding after brushing his teeth and tongue. He had not received any medical care for the lesion. His medical history was significant for hypertension treated with hydrochlorothiazide, and a recent clavicle fracture after a motorcycle accident. He never smoked, but he used one can per week of chewing tobacco for one year. He quit five years before presentation. He drank less than three alcoholic beverages per week. A review of systems was negative. He was not using any new toothpastes or mouthwashes. On physical examination, he was well appearing and afebrile, but overweight. His tongue had a large lateral fungating, whitish, exophytic lesion with anterior fissuring of the entire left side of the tongue (Figure 1). There was no tenderness or ulceration. He had a slight speech impediment secondary to mouth fullness but no difficulty swallowing. There were no palpable cervical lymph nodes.

Question Based on the patientâ&#x20AC;&#x2122;s history and physical examination findings, which one of the following is the most likely diagnosis? A. Mucosal candidiasis. B. Oral leukoplakia. C. Oral pyogenic granuloma. D. Squamous cell carcinoma.

Discussion The answer is D: squamous cell carcinoma, which required urgent biopsy and surgical excision. The characteristic features of oral squamous cell carcinoma include lateral location, fungating appearance, whitish color, and central ulceration. The history of tobacco use

Source: Adapted from Am Fam Physician. 2016;93(7):599-600.

IJCP Sutra 169: Childhood obesity is a strong risk factor for high blood pressure.

Figure 1.

lasting for one year also makes cancer more likely. The history suggests that the lesion began as erythroplakia, which was thought to be related to his dental work. He never received follow-up because of an overseas deployment. After the biopsy confirmed squamous cell carcinoma, he underwent subtotal left glossectomy, bilateral radical neck dissection, tracheotomy, and radical forearm free flap reconstruction. The patient was treated with adjuvant chemotherapy. Oral squamous cell carcinomas are often preceded by potentially malignant disorders. Patients may have erythroplakia, an ulcer with fissuring or exophytic margins, a speckled (red/white) leukoplakia, a lump with abnormal blood vessels, an indurated lump or ulcer, or a nonhealing socket after tooth extraction.1-3 Diagnosis may be delayed for up to six months. Early detection and treatment are the key to significantly decreased morbidity and mortality. Approximately 90% of oral cancers are squamous. Squamous cell carcinoma is common in men, with an average age of onset of 50 years. The etiology is multifactorial and related to lifestyle, including use of tobacco, betel nut, and alcohol.4-6 This patient had never received the human papillomavirus (HPV) vaccine, and HPV infection has a potential role in the transformation of cells into precancerous and cancerous oral lesions.7

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Summary Table Condition

Rash characteristics

Mucosal candidiasis

Multiple white patches resembling milk curds; can be wiped off, revealing a raw erythematous base; irritation and pain are common

Oral leukoplakia

Bright white, sharply defined patch or plaque that cannot be rubbed off

Oral pyogenic granuloma

Nodular and erythematous in appearance, often develops on the buccal gingiva between teeth, typically bleeds spontaneously without irritation

Squamous cell carcinoma

Early-stage white or red speckled patch or plaque typically laterally located, progresses to fungating or ulcerating lesion with fissuring; painless

Mucosal candidiasis, or thrush, is less common in adults. It typically occurs with immune suppression, such as in those with human immunodeficiency virus infection or AIDS, those who have had an organ transplant, and those taking immunosuppressants or antimicrobials. Mucosal candidiasis presents as multiple white patches resembling milk curds. The patches can be wiped off, revealing a raw erythematous base. Irritation and pain are common. Oral leukoplakia is a bright white, sharply defined patch or plaque that cannot be wiped off. It is a diagnosis of exclusion pending appropriate histologic workup. Oral leukoplakia is thought to be a premalignant condition and does not typically cause symptoms. Oral pyogenic granulomas have a rapid growth pattern (over one to two weeks) and are nodular and

erythematous in appearance. They can undergo fibrous maturation, appearing more whitish, or transform completely to fibromas. They often occur on the buccal gingiva between the teeth and typically bleed spontaneously without irritation. REFERENCES 1. Scully C, Kirby J. Statement on mouth cancer diagnosis and prevention. Br Dent J. 2014;216(1):37-38. 2. Scully C. Challenges in predicting which oral mucosal potentially malignant disease will progress to neoplasia. Oral Dis. 2014;20(1):1-5. 3. Walsh T, Liu JL, Brocklehurst P, et al. Clinical assessment to screen for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev. 2013;11: CD010173. 4. Su CC, Yang HF, Huang SJ, Lian IeB. Distinctive features of oral cancer in Changhua County: high incidence, buccal mucosa preponderance, and a close relation to betel quid chewing habit. J Formos Med Assoc. 2007;106(3): 225-233. 5. Rodu B, Jansson C. Smokeless tobacco and oral cancer: a review of the risks and determinants. Crit Rev Oral Biol Med. 2004;15(5):252-263. 6. Warnakulasuriya S. Smokeless tobacco and oral cancer. Oral Dis. 2004;10(1):1-4. 7. Reddout N, Christensen T, Bunnell A, et al. High risk HPV types 18 and 16 are potent modulators of oral squamous cell carcinoma phenotypes in vitro. Infect Agents Cancer. 2007;2:21.

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Preventing Heart Attacks Formula of 9 Nine preventable risk factors are responsible for 90% of heart attacks. They are (in order of importance) as follows: ÂÂ

Increased LDL/HDL ratios (elevated LDL ‘bad’ and low HDL ‘good’ cholesterol levels)

ÂÂ

Smoking

ÂÂ

Diabetes

ÂÂ

Hypertension

ÂÂ

Abdominal obesity

ÂÂ

Psychosocial (stress or depression)

ÂÂ

Failure to eat fruits and vegetables daily

ÂÂ

Failure to exercise

ÂÂ

Failure to drink any alcohol.

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IJCP Sutra 170: Enteral supplementation of probiotics prevents severe necrotizing enterocolitis and all cause mortality in preterm infants.

2018

Community medicine

A Study of Maternal Mortality SUNANDA R KULKARNI

Abstract Objective(s): To study and analyze the maternal deaths occurring due to various causes. Method(s): A retrospective study of maternal deaths occurring due to various causes and to find out the factors responsible for deaths. Results: There were a total number of 31,298 deliveries and 46 deaths. Out of 46 deaths, 34 (73.89% of all deaths) were due to direct causes and 10Â (21.73% of deaths) were due to indirect causes and 2 (4.34% of all deaths) were due to unrelated causes. The most common direct causes for death were hemorrhage (26.08% of all deaths), pregnancy-induced hypertension and eclampsia (23.9% of all deaths). On the other hand, the most common indirect causes for death were anemia (13.04% of all deaths) and jaundice (6.52% of all deaths). Conclusion(s): Hemorrhage was the most common cause of death and the most vulnerable time for death was within the first 24 hours after delivery.

Keywords: Maternal death, hemorrhage, pregnancy-induced hypertension

aternal morality is an index of obstetric care in the community. Healthcare extends from antenatal to postnatal period. The major causes of death are hemorrhage, pregnancy-induced hypertension (PIH) and anemia. Hence, a study was conducted to find out the causes of death and the factors responsible for it. The study also examined implementable interventions, if any, to reduce the maternal mortality.

Material and Methods

Table 1 shows that the maximum number of patients delivered via the vaginal route. Nine patients (19.56% of all deaths) required surgery. One case of triplets and another case of twins underwent lower segment cesarean section (LSCS). Table 2 depicts the time interval from admission to death. As seen in the table, most deaths occurred within 24 hours of admission (63.05%). Table 1. Outcome of Pregnancy Number of cases

Percentage (%)

LSCS

15.22

Laparotomy

2.17

Subtotal hysterectomy

2.17

Vaginal delivery

54.35

Results

Undelivered

26.08

In 7-year retrospective study, there were a total of 31,298 live births and 46 deaths resulting in a maternal mortality rate (MMR) of 1.46/1,000. Of the 46 deaths, 36Â cases were unbooked (78.26% of all deaths).

Total

100.00

A retrospective study of maternal mortality due to various causes from 1st January, 2002 to 31st December, 2006 was carried out. Cases of maternal deaths were analyzed and factors responsible for death were scrutinized in detail.

Outcome

Table 2. Admission to Death Interval Time

Professor Dept. of Obstetrics and Gynecology Bowring and Lady Curzon Hospital, Bengaluru, Karnataka Address for correspondence Dr Sunanda R Kulkarni 575, 21st Main, 4th T Block, Jayanagar, Bengaluru, Karnataka - 560 041 E-mail: sunanda28@yahoo.com

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IJCP Sutra 171: Keep your blood sugar in good control.

Number of cases

Percentage (%)

<24 hours

63.05

25-72

21.74

73 hours to 7 days

4.34

>7 days

10.87

Total

100.00

Community medicine Table 3. Causes of Death Direct causes

Number of causes

Indirect causes

Number of causes

Unrelated causes

Number of causes

PIH & Eclampsia

23.91

Jaundice

6.52

Myocardial infarction

2.17

Hemorrhage

26.08

Anemia

13.04

Pneumonia

2.17

Atonic PPH

2.17

Heart disease

Accidental Placenta previa

Others

Retained placenta

Sepsis

Septic abortion

Puerperal sepsis

Other causes

Amniotic fluid embolism

Pulmonary embolism

Total

21.73

4.34

10.86

13.04

73.89

Table 4. MMR/1,000 Live Births Over the Years Year

Number of maternal deaths

Total number of live births

MMR/1,000

2000

4,516

2.43

2001

4,666

2002

4,815

1.03

2003

4,815

0.83

2004

4,669

1.07

2005

3,750

1.33

2006

4,267

0.43

Total

31,498

Table 3 shows that the majority of patients died due to direct causes, in particular, due to hemorrhage. InÂ indirect causes, anemia and jaundice were the main culprits. There were two cases of unrelated causes. Table 4 shows that there is a gradual decline in the death rate at Bowring and Lady Curzon Hospital, Bengaluru over the years except in 2001. Discussion The mother is the pivot of the family and maternal health is an index of reproductive healthcare in the

country. Maternal death has serious implications not only to the family but to the society and nation as well. Table 1 shows that the majority of women delivered vaginally.1,2 The cases were referred even after LSCS for sepsis. One particular case needed re-laparotomy for burst abdomen and this particular patient had jaundice. Table 2 shows that the maximum number of deaths occurred within 24 hours3,4 and the shortest interval was 20 minutes and the longest was 18 days. The late deaths we observed in our study were mostly caused by sepsis. As seen in Table 3, the maximum number

IJCP Sutra 172: Eat a healthy diet rich in fruits, vegetables and whole wheat grains.

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of patients died due to direct causes and in particular due to atonic hemorrhage.1,2 All these patients had started their pregnancy with anemia and even a slight bleeding pushes them to shock. Out of 5 cases of sepsis, 2 underwent surgery for perforation, during medical termination of pregnancy (MTP). Of these two, one underwent laparatomy for drainage of pus and the other underwent subtotal hysterectomy. The other 3 patients had intrauterine device (IUD) and sepsis. These patients were referred from other hospitals. The possible reasons behind sepsis in these patients could be due to late referral, anemia and malnutrition. Amniotic fluid embolism was seen in 5 cases. Out of 5 cases, 3 died after delivery. One had still birth. All of them had died from 20 minutes to 2 hours 35 minutes. Amongst indirect causes, anemia killed 13.04% of cases. All these patients had hemoglobin <6 g. One patient had mitral stenosis, tricuspid regurgitation and congestive cardiac failure. Conclusion The present study shows that the hemorrhage is the most common cause of death, which is accentuated by

co-existing anemia. Detection of the disease at an early or pre-pregnant stage is essential. The most vulnerable time of death is within the first 24 hours after delivery. Though the specialist service is available at places, if the infrastructure is not there, cases should be referred early. Postmortem examination in all cases will help in understanding the cause of death, than clinical diagnosis. There is a strong need for intensive care unit (ICU) for critically ill mothers in all hospitals. References 1. Sharma N. Maternal mortality: a retrospective study of 10 years. J Obstet Gynecol India. 2001;51(1):60-2. 2. Patel DA, Gangopadhyay S, Vaishnav SB, Shrinivastava RG, Rajgopalan R. Maternal mortality at Karamsad - the only Rural Medical College in Gujarat (January 1994 to December 1997). J Obstet Gynecol India. 2001;51(1):63-6. 3. Joophy R, Thomas A, Ahaskar A. Ectopic pregnancy: 5 years experience. J Obstet Gynecol India. 2002;52(5):55-8. 4. Bhattacharjee S. A study on maternal mortality in Silchar Medical College & Hospital. J Obstet Gynecol India. 2001;51(1):67-70.

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IJCP Sutra 173: Limit your alcohol intake.

2018

DERMATOLOGY

A Rare Association of Psoriasis Vulgaris with Bullous Pemphigoid SUKUMAR D*, NAMITHA CHATHRA†, SRINATH MK†

Abstract The concomitant occurrence of psoriasis vulgaris and bullous pemphigoid in a patient is a rarity. We describe a 45-year-old male with 8-year history of plaque-type psoriasis who presented with disseminated tense bullae and psoriatic erythroderma. Skin biopsies showed the typical histologic traits of bullous pemphigoid and direct immunofluorescence showed deposition of IgG and C3 in a linear pattern along the basement membrane zone confirming the diagnosis. The bullous eruption and erythroderma were successfully treated with intramuscular and oral methotrexate.

Keywords: Psoriasis vulgaris, bullous pemphigoid, psoriatic erythroderma, direct immunofluorescence, methotrexate

soriasis vulgaris and bullous pemphigoid represent two clinically well-characterized, chronic and inflammatory skin diseases. Seldom do they occur concomitantly in a patient and the pathogenic implications of this phenomenon are unknown. Here we report the appearance of disseminated tense bullae in a 45-year-old male with psoriatic erythroderma and its successful treatment with methotrexate. Case Report A 45-year-old male, who is a known case of psoriasis for 8 years, presented with extensive plaques involving most of the body surface area along with fluid filled lesions of 10 days duration over both the hands and thighs. The lesion had first appeared over the right thigh and then progressed to involve the left thigh and left arm. Prior to the appearance of lesion, he had applied homeopathic medication to bring psoriasis under control.

posteromedial aspect of upper one-third of both legs and medial aspect of left arm (Fig. 1). He also had extensive erythematous, scaly, discoid plaques coalescing over the scalp, face, abdomen, back, bilateral arms and lower limbs covering more than 90% of body surface area. Islands of normal skin were seen over chest, scapular area, groin and lower one-third of both lower limbs along with sparing of both ears and infralabial area (Fig. 2).

Investigations Routine blood investigations were within normal limits except for raised erythrocyte sedimentation rate (ESR) of 35 mm at the end of 1st hour and neutrophilic leukocytosis seen in peripheral smear. Tzanck smear

Examination The patient had multiple tense bullae along with a few erosions over anteromedial aspect of both thighs,

*Professor and Head †Assistant Professor Dept. of Dermatology Father Muller Medical College and Hospital, Kankanady, Mangalore, Karnataka Address for correspondence Dr Sukumar D Dept. of Dermatology Father Muller Medical College and Hospital, Kankanady, Mangalore - 575 002, Karnataka

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Figure 1. Multiple tense bullae over the anteromedial aspect of right thigh.

IJCP Sutra 174: Exercise regularly. Do at least 30 minutes of physical activity daily.

DERMATOLOGY

Figure 3. Histopathologic section of the psoriatic plaque. Figure 2. Multiple erythematous coalescing plaques.

from a fresh bullae revealed inflammatory cells. HeÂ was subjected to skin biopsies from 3 sites; first one from a psoriatic plaque on the right thigh, second, an intact bulla on the left thigh and the third one from normal skin over left thigh which was sent for direct immunofluorescence. Histopathologic findings of the first specimen confirmed psoriasis (Fig. 3), that of the second specimen was suggestive of bullous pemphigoid as it showed a blister at the subepidermal region containing few neutrophils, eosinophils, lymphocytes and fibrin along with mild inflammatory infiltrate in the dermis (Fig. 4). Direct immunofluorescence demonstrated deposits of immunoglobulin G (IgG) and C3 in a linear pattern along the basement membrane zone confirming the diagnosis of bullous pemphigoid.

Treatment In view of erythrodermic psoriasis and normal hematologic, hepatic and renal profiles, he was administered intramuscular injection methotrexate 7.5 mg. Within 4 days, he showed considerable improvement in both the bullous and psoriatic lesions without exhibiting any signs of intolerance. The following week, he was administered second dose of intramuscular injection methotrexate 7.5 mg. As there was a subsidence in his lesions, he was discharged with oral methotrexate 7.5 mg, once a week in three divided doses at 12-hourly interval along with folic acid supplement. His hematologic, hepatic and renal profiles were within normal limits on review after 2 weeks and after 4 weeks and we noticed near total resolution of his lesions.

IJCP Sutra 175: If you smoke, then QUIT.

Figure 4. Histopathological section of the intact bulla showingÂ subepidermal blister with infiltrates of neutrophils and eosinophils.

Discussion Psoriasis is a chronic inflammatory skin disease, with a strong genetic basis, characterized by complex alterations in epidermal growth and differentiation and multiple biochemical, immunologic and vascular abnormalities. Clinically, psoriasis manifests in several ways but most commonly, the disease presents as chronic plaque psoriasis, characterized by symmetrical, erythematous, well-defined, scaly papules and plaques. The lesions are stable and remain unchanged for a long period but may become confluent and extensive resulting in psoriatic erythroderma, which is one of the indications of methotrexate therapy. There are several associations of psoriasis including arthritis, immunobullous disorders, vitiligo, metabolic syndrome and synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. Although incidence of

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immunobullous disorders with psoriasis is not frequent, more than 50 cases have been reported in literature, with co-existing psoriasis and bullous pemphigoid. Bullous pemphigoid is an acquired nonscarring autoimmune blistering disease of the elderly age group characterized histologically by subepidermal bullae and immunopathologically by deposition of antibodies and complement along the epidermal basement membrane zone. The pathogenic relationship between psoriasis and bullous pemphigoid is unclear but it has been postulated that the autoimmune process responsible for bullous pemphigoid lesions may be induced by ultraviolet light therapy, topical corticosteroids and/or the inflammatory processes that occur in psoriasis. Methotrexate is a folic acid analog which inhibits folate dependent enzyme aminoimidazolecarboxamide ribonucleotide formyltransferase (AICART), thus inhibiting hyperproliferation of epidermal cells but more importantly it inhibits the proliferation of lymphoid cells. It also has activity as a immunosuppressive agent, probably because of inhibition of DNA synthesis in immunologically competent cells. The drug can suppress primary and secondary antibody responses. Hence, it may have a beneficial role in curbing psoriasis as well as vesiculobullous eruptions. Learning Points ÂÂ

In the rare event of encountering vesiculobullous lesions in psoriasis, bullous pemphigoid should

be considered as the foremost differential diagnosis. ÂÂ

Methotrexate, well known for its use in psoriasis, is also therapeutic in bullous pemphigoid.

Suggested Reading 1. Grattan CE. Evidence of an association between bullous pemphigoid and psoriasis. Br J Dermatol. 1985; 113(3):281-3. 2. Wilczek A, Sticherling M. Concomitant psoriasis and bullous pemphigoid: coincidence or pathogenic relationship? Int J Dermatol. 2006;45(11):1353-7. 3. Yasuda H, Tomita Y, Shibaki A, Hashimoto T. Two cases of subepidermal blistering disease with anti-p200 or 180-kD bullous pemphigoid antigen associated with psoriasis. Dermatology. 2004;209(2):149-55. 4. Dogra S, Yadav S. Psoriasis in India: prevalence and pattern. Indian J Dermatol Venereol Leprol. 2010;76(6):595-601. 5. Paul MA, Jorizzo JL, Fleischer AB Jr, White WL. Low-dose methotrexate treatment in elderly patients with bullous pemphigoid. J Am Acad Dermatol. 1994;31(4):620-5. 6. Bara C, Maillard H, Briand N, Celerier P. Methotrexate for bullous pemphigoid: preliminary study. Arch Dermatol. 2003;139(11):1506-7. 7. Jaiswal AK, Verma R. Chancroid. In: Valia RG, Valia AR (Eds.). IADVL Textbook of Dermatology. 3rd Edition, Mumbai: Bhalani Publishing House; 2008. pp. 1873-83.

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IJCP Sutra 176: Our greatest weakness lies in giving up. The most certain way to succeed is always to try just one more time. —Thomas A. Edison

ENT

All Opaque Sinuses are not Sinusitis PONNATHPUR LAKSHMI*, SHRUTI MANJUNATH†

Abstract Opacity of maxillary antrum is encountered frequently in radiological reports, and often gets treated as inflammation of the maxillary sinus. However, there is a wide variety of differential diagnosis along with anatomical and technical factors, which can give rise to opacity of maxillary antrum. It is a dangerous trend to think mostly in terms of chronic infection and subject the patient to unnecessary antibiotics and undue procedures like antral lavage. An opaque maxillary antrum should be treated as a sign and not as a definite diagnosis and a detailed evaluation should be done to identify the cause. Here we present a case of dentigerous cyst that presented as an opacified maxillary sinus on X-ray.

Keywords: Dentigerous cyst, opaque sinus, odontogenic cyst, chronic maxillary sinusitis

nilateral maxillary sinus opacity can be caused by many diseases, the most common being chronic rhinosinusitis (52.6%), fungus ball (29.3%), antrochoanal polyp (2.6%), benign tumor (10.4%) and malignancy (5.1%).1 However, possibility of other causes like mucocele, dentigerous cyst and ameloblastoma should be kept in mind.2 Dentigerous cyst is a type of odontogenic cyst that forms between the enamel epithelium and the enamel of the crown of the unerupted or impacted tooth.3-5 Around 20-24% of all the jaw cysts can be attributed to dentigerous cysts.6 It’s peak incidence is during the 2nd and 3rd decade of life and is more common in males (2:1). It is commonly observed in the mandibular third molar region (75%) followed by maxillary third molar (2nd most common), maxillary canine and mandibular second premolar.

Radiological examination is the choice of investigation to diagnose a dentigerous cyst. However, a histopathological confirmation leads to a final diagnosis.7 Surgical excision of the entire cyst along with the tooth is the treatment of choice and is done through a Caldwell-Luc approach. Few cases of marsupialization have also been reported.7 Case Report A 24-year-old overweight female with a chubby face presented to our clinic with pain and puffiness of the right cheek since 3 months (Fig. 1) and also had yellowish discharge from the right nasal cavity. She had undergone right-sided antral lavage for similar complaints in another hospital 1 month back as the

Dentigerous cysts are painless and most commonly are discovered during a routine radiographic examination. Sometimes, they may be large and result in a palpable mass. Additionally, as they grow, they displace adjacent teeth.7 Cysts extending in the maxillary sinus can mimic a sinus infection. Rarely, these cysts may present as recurrent head and neck infections.

*Senior Consultant Sagar Hospital and Skin Cosmetic & ENT Care Center (SCENT), Bengaluru, Karnataka †Junior Consultant Skin Cosmetic & ENT Care Center (SCENT) and Deepak Hospital, Bengaluru, Karnataka Address for correspondence Dr Ponnathpur Lakshmi 742, “Bhagyashree”, 18th Main, 37th F Cross, 4th T Block, Jayanagar, Bengaluru - 560 041, Karnataka E-mail: ponnathpurlakshmi@gmail.com/shruti2888@yahoo.co.in

Figure 1. Preoperative image showing fullness of the right cheek.

IJCP Sutra 177: Just know, when you truly want success, you’ll never give up on it. No matter how bad the situation may get.

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X-ray for the paranasal sinuses showed complete opacification of the right maxillary sinus (Fig. 2). When she presented to us with persistence of the symptoms, we observed that there was prominence of the right cheek and the right 3rd maxillary molar was missing. A CT scan of the paranasal sinuses was performed. This revealed a unilocular well-defined large cystic lesion confined to the right maxillary sinus with expansion and thinning of its walls. An unerupted tooth embedded in the cyst wall was noted, suggestive of a dentigerous cyst (Fig. 3).

After obtaining all the relevant blood investigations and surgical fitness, the patient was taken up for surgery. Complete obliteration of the upper gingivolabial sulcus and egg shell crackling of the anterolateral wall of the right maxilla was noted. Complete excision of the cyst along with the tooth was done through a sublabial approach (Caldwell-Luc operation) (Figs. 4 and 5). The right maxillary sinus cavity was irrigated with

Figure 4. Visualization of the dentigerous cyst seen through the Caldwell-Luc approach.

Figure 2. X-ray image showing opacity of the right maxillary sinus.

Figure 3. CT image showing the dentigerous cyst in the right maxillary sinus.

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Figure 5. The maxillary sinus cavity after complete excision of the cyst.

IJCP Sutra 178: Challenges are what make life interesting and overcoming them is what makes life meaningful. —Joshua J. Marine

ENT The inflammatory type of dentigerous cyst is from the overlying nonvital necrotic deciduous tooth. The periapical inflammation spreads to involve the follicle of the unerupted permanent tooth and an inflammatory exudate ensues to form a dentigerous cyst.6 Differential diagnoses of a dentigerous cyst are a large periapical cyst, odontogenic keratocyst, central giantcell granuloma and unicystic ameloblastoma.6 As it can present as an opacified maxillary sinus when the sinus is involved, differentials of sinus inflammation, fungal ball, AC polyp, benign and malignant tumors of the sinus are also considered.1 The cyst may be an incidental radiological finding as it is painless. Sometimes, it may present as a palpable mass when large and very rarely presents with infection.7

Figure 6. The dentigerous cyst.

betadine solution and the sublabial wound was closed in layers. A check endoscopy was done. As the accessory ostium on the right side was wide and patent, an intranasal antrostomy was not performed. The cyst measured about 5 × 6 cm and also contained a molar tooth (Fig. 6). Postoperative period was uneventful and the patient was discharged the following day. Histopathological examination confirmed the diagnosis of dentigerous cyst. Discussion Odontogenic cysts are lesions derived from epithelial elements that have been part of the tooth-forming apparatus. They arise as a result of proliferation and cystic degeneration of odontogenic epithelial rests. Dentigerous cysts are among the most common odontogenic cysts.8 Two types of dentigerous cysts have been reported in the literature: Developmental and inflammatory types. Pathogenesis: The developmental type of dentigerous cyst is formed around the crown of an unerupted tooth by accumulation of fluid either between the reduced enamel epithelium and the enamel or in between the layers of the enamel organ. The pressure exerted by an erupting tooth on an impacted follicle obstructs, the venous outflow and induces rapid transudation of serum across the capillary wall forming a cyst. The other theory is that the origin of the dentigerous cyst is due to the breakdown of proliferating cells of the follicle after impeded eruption.

IJCP Sutra 179: Check your feet every day for cuts, scratches, blisters, etc.

The ideal investigations to diagnose a dentigerous cyst are orthopantomogram and CT scan although a histopathological confirmation is necessary to rule out the other differentials.7 The treatment of choice is complete surgical excision of the cyst along with the tooth. When the cyst is involving the maxillary sinus, a Caldwell-Luc approach is done. Marsupialization or decompression of the cyst is reserved for very large or infected cysts.9 Conclusion In our routine practice, we often come across an opaque sinus when an initial X-ray of the paranasal sinuses is performed. Even though inflammation of the sinuses is the most common cause of an opaque sinus, other causes should always be considered. We had one such experience where a previously misdiagnosed sinusitis turned out to be a dentigerous cyst. Hence while evaluating an opaque sinus, knowledge of the various etiologies and a stepwise approach when reviewing images can be helpful in both narrowing the differential and formulating a correct diagnosis.

Acknowledgment We would like to thank Dr Adithya Murthy (Oral Maxillofacial Surgeon) and Dr Chaitra (Anesthetist) for their help with this case.

References 1. Chen HJ, Chen HS, Chang YL, Huang YC. Complete unilateral maxillary sinus opacity in computed tomography. J Formos Med Assoc. 2010;109(10): 709-15. 2. Broderick DF. The opacified paranasal sinus: Approach and differential. Appl Radiol. 2015; August p. 9-17.

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Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018 3. Kalaskar RR, Tiku A, Damle SG. Dentigerous cysts of anterior maxilla in a young child: a case report. J Indian Soc Pedod Prev Dent. 2007;25(4):187-90. 4. Tilakraj TN, Kiran NK, Mukunda KS, Rao S. Non syndromic unilateral dentigerous cyst in a 4-year-old child: A rare case report. Contemp Clin Dent. 2011;2(4):398-401. 5. Demirkol M, Ege B, Yanik S, Aras MH, Ay S. Clinicopathological study of jaw cysts in Southeast region of Turkey. Eur J Dent. 2014;8(1):107-11. 6. Kirtaniya BC, Sachdev V, Singla A, Sharma AK. Marsupialization: a conservative approach for treating

dentigerous cyst in children in the mixed dentition. J Indian Soc Pedod Prev Dent. 2010;28(3):203-8. 7. Gaillard F. Dentigerous cyst. Available at: https:// radiopaedia.org/cases/dentigerous-cyst 8. Imran A, Jayanthi P, Tanveer S, Gobu SC. Classification of odontogenic cysts and tumors - Antecedents. J Oral Maxillofac Pathol. 2016;20(2):269-71. 9. Carrera M, Dantas DB, Marchionni AM, de Oliveira MG, Setúbal Andrade MG. Conservative treatment of the dentigerous cyst: report of two cases. Braz J Oral Sci. 12(1):52-6.

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Make sure During Medical Practice

Situation:

A patient on triple combination antihypertensive therapy who consistently had office blood pressure (BP) measurement >135/85 mmHg was given a diagnosis of white-coat hypertension.

Why did you give a diagnosis of white-coat hypertension? This is refractory hypertension.

Lesson:

Make sure to remember that white-coat effect is largely absent in patients with refractory hypertension. White-coat effect is not a common cause of apparent lack of BP control in patients failing maximal antihypertensive treatment. Hypertension. 2017;70(3):645-51.

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IJCP Sutra 180: Maintain good oral hygiene.

ENT

Thyroglossal Cyst in a Young Adult: A Case Report PONNATHPUR LAKSHMI*, SHRUTI MANJUNATH†

Abstract Thyroglossal duct cysts occur due to incomplete involution of thyroglossal duct and are the most common midline congenital neck swelling. A 20-year-old college girl presenting with a swelling in the right submandibular region, which moved with tongue protrusion underwent the relevant investigations to confirm the diagnosis of a thyroglossal cyst. A Sistrunk operation was performed where the tract and part of the hyoid bone were removed. Thyroglossal cyst should always be part of the differential diagnosis in an adult presenting with a neck mass.

Keywords: Thyroglossal cyst, congenital neck mass, midline neck mass, Sistrunk operation

he thyroid gland arises as an invagination of endoderm in the floor of the pharynx and develops caudally descending into the neck. The most common cystic lesion in the neck, a thyroglossal cyst, develops when there is failure of the tract to involute. The epithelial remnants may expand into a cyst.1 Thyroglossal duct cyst typically occurs before 20 years of age and a small percentage of patients are over 20 at the time of diagnosis.2 Forty percent of the cases are usually seen in children up to 10 years, 33% are seen in adults around 20 years of age and 25% are seen in preschool children. Occurrence in the elderly is rare and only 28% occur over 50 years and 10% over 60 years.3,4 They present most commonly as a painless neck mass, that moves with tongue protrusion with the most common site being inferior to the hyoid bone.1 Neck ultrasound is the most common preoperative diagnostic procedure along with thyroid profile.5

degeneration, recurrent infection and rarely intermittent upper airway obstruction.1,7,10-12 Case Report A 20-year-old college girl presented with a rightsided neck swelling in the submandibular area since 1 year. It was insidious in onset and gradually increased to the present size of a small lemon. The swelling was associated with difficulty in swallowing and the large lump in the neck was unacceptable cosmetically to her. On examination, there was a soft, smooth surfaced swelling to the right of the midline in the submandibular area, measuring about 2.5 × 2.5 cm (Fig. 1). The swelling moved with protrusion of the tongue. There were no signs of inflammation. Rest of ENT examination, including indirect laryngoscopy, was normal.

Radionuclide scanning is justified in cases of lingual thyroid and where a normally located thyroid gland cannot be detected.6 Sistrunk’s operation is the treatment of choice. Indications for surgery include cosmesis, malignant

*Senior Consultant Sagar Hospital and Skin Cosmetic & ENT Care Center (SCENT), Bengaluru, Karnataka †Junior Consultant Skin Cosmetic & ENT Care Center (SCENT) and Deepak Hospital, Bengaluru, Karnataka Address for correspondence Dr Shruti Manjunath 550, 10th A Main Road, 36th Cross, 5th Block, Jayanagar, Bengaluru - 560 041, Karnataka E-mail: shruti2888@yahoo.co.in

IJCP Sutra 181: Get an annual dilated eye exam.

Figure 1. Preoperative image showing the midline neck swelling.

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Figure 2. Sistrunk operation - The thyroglossal tract along with a part of the hyoid bone is being excised.

Figure 4. Image shows Sistrunk operation in progress where part of the hyoid bone is being excised along with the thyroglossal tract.

the patient in supine position and neck extended, a 3-4 cm transverse curvilinear incision was put on the cyst along the skin crease. Cyst was in the immediate subplatysmal plane. Careful and sharp dissection was done avoiding rupture as far as possible (Fig. 2). Strap muscles were dissected off the hyoid bone by diathermy and the middle portion of hyoid bone excised. The tract was identified under the surface of hyoid bone and dissected up to the tongue base, following which the duct was transfixed, ligated and divided (Figs. 3 and 4). The wound was closed in layers after obtaining hemostasis. Postoperative period was uneventful. Figure 3. The thyroglossal tract along with a segment of the hyoid bone.

A clinical diagnosis of thyroglossal cyst was made and the following investigations were done.

Investigations ÂÂ

Complete blood count, coagulation profile and thyroid function tests were normal.

ÂÂ

Ultrasound scan of neck - showed features consistent with a thyroglossal cyst.

ÂÂ

Fine needle aspiration cytology (FNAC) of the neck swelling confirmed our diagnosis.

ÂÂ

Radioisotope scanning was not done as thyroid gland was seen in the neck in its normal position.

Treatment With the patient’s informed consent a Sistrunk operation was planned. Under general anesthesia, with

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Discussion Thyroglossal cysts are ectodermal remnants along the line of descent of the thyroid gland in the neck anywhere from foramen cecum at base of tongue to pyramidal lobe of thyroid gland. Thyroid gland develops from the thyroid diverticulum arising from the caudal part of tuberculum impar. As the tongue develops from tuberculum impar, the thyroid diverticulum descends into the neck, maintaining connection with foramen cecum, behind the hyoid bone. Hyoid bone develops from 2nd branchial arch, behind which descends the thyroglossal tract. As a result of simultaneous development, thyroid gland develops and descends into the pretracheal position in the neck. Error in thyroid descent or thyroglossal duct persistence can lead to formation of lingual thyroid or ectopic thyroid tissue, or pyramidal lobe of thyroid gland or thyroglossal cyst.

IJCP Sutra 182: Maintain good control of your blood pressure, blood cholesterol and body weight.

ENT Ectopic thyroid tissue within thyroglossal duct remnant is reported in 20-45% of cases. Ectopic thyroid tissue may be the only functioning thyroid tissue in the neck. Radioisotope scanning is required to confirm normally functioning thyroid gland in neck.

References

Thyroglossal cysts commonly present as a midline cystic swelling in the neck that moves with deglutition. An infected neck mass is the common presentation of thyroglossal duct cysts in adults.8 Differential diagnosis includes dermoid cyst; branchial cyst; pyramidal lobe hyperplasia; teratoma; hamartoma; lipoma; sebaceous cyst; cavernous hemangioma; lymph nodes, etc.9 Since, the differential diagnosis among adults is broader, likelihood of misdiagnosis is greater.

2. Mondin V, Ferlito A, Muzzi E, Silver CE, Fagan JJ, Devaney KO, et al. Thyroglossal duct cyst: personal experience and literature review. Auris Nasus Larynx. 2008;35(1):11-25.

An ultrasound scan of the neck, FNAC of the lump, thyroid function test and other tests like a radioactive iodine scan, complete blood count is ideal for diagnosis. Sistrunk’s operation was described in 1920 by Prof. Sistrunk and is the treatment of choice in this case. It includes complete excision of the cyst up to the base tongue, including central part of hyoid bone. Antibiotics are given if secondary infection is present. Conclusion Although uncommon in adults, thyroglossal duct cysts should be a part of the surgeon’s differential diagnosis when presented with a neck mass. Sistrunk’s operation is a safe and time-tested operation for complete excision of thyroglossal cyst. However, thorough knowledge of regional anatomy and careful dissection and removal of body of hyoid bone are important for complete removal and to prevent messy recurrences.

1. Gluson M, Browing GG, Burton MJ, Clarke R, Hibbat J, Jones NS, et al. Surgical anatomy of the neck. In: ScottBrown’s Otorhinolaryngology, Head and Neck Surgery. 7th Edition, Great Britain: Edward Arnold (Publishers) Ltd.; 2008. pp. 1739-53.

3. Baisakhiya N. Giant thyroglossal cyst in an elderly patient. Indian J Otolaryngol Head Neck Surg. 2011;63(Suppl 1):27-8. 4. Katz AD, Hachigian M. Thyroglossal duct cysts. A thirty year experience with emphasis on occurrence in older patients. Am J Surg. 1988;155(6):741-4. 5. Yaman H, Durmaz A, Arslan HH, Ozcan A, Karahatay S, Gerek M. Thyroglossal duct cysts: evaluation and treatment of 49 cases. B-ENT. 2011;7(4):267-71. 6. Kessler A, Eviatar E, Lapinsky J, Horne T, Shlamkovitch N, Segal S. Thyroglossal duct cyst: is thyroid scanning necessary in the preoperative evaluation? Isr Med Assoc J. 2001;3(6):409-10. 7. Brousseau VJ, Solares CA, Xu M, Krakovitz P, Koltai PJ. Thyroglossal duct cysts: presentation and management in children versus adults. Int J Pediatr Otorhinolaryngol. 2003;67(12):1285-90. 8. Snow JB, Ballenger JJ. Ballenger’s Otolaryngology: Head and Neck Surgery. 17th Edition, Ontario: BC Decker Inc.; 2009. 9. Watkinson JJ, Gaz MN, Wilson JA. Tracheostomy. In: Watkinson JC, Gaze MN, Wilson JS (Eds.). Stell and Maran’s Head and Neck Surgery. 4th Edition, Oxford, UK: Butterworth Heinemann; 2000. pp. 67-84. 10. Lin ST, Tseng FY, Hsu CJ, Yeh TH, Chen YS. Thyroglossal duct cyst: a comparison between children and adults. Am J Otolaryngol. 2008;29(2):83-7.

Acknowledgment

11. Iwata T, Nakata S, Tsuge H, Koide F, Sugiura M, Otake H, et al. Anatomy-based surgery to remove thyroglossal duct cyst: two anomalous cases. J Laryngol Otol. 2010;124(4):443-6.

We would like to thank Dr MS Sridhar (General Surgeon) and Dr PM Chandrashekar (Anesthetist) for their help with this case.

12. Bennett KG, Organ CH Jr, Williams GR. Is the treatment for thyroglossal duct cysts too extensive? Am J Surg. 1986;152(6):602-5.

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Rule of 5 of Hypertension ÂÂ

A 5 mmHg reduction in diastolic ‘lower’ BP can reduce heart disease risk by 25% (Magnus and Beaglehole, 2001)

ÂÂ

An 1 mmHg reduction in diastolic ‘lower’ BP can reduce heart disease risk by 5%.

ÂÂ

Brisk walking (aerobic) 5 days a week can reduce BP by 5 mmHg.

IJCP Sutra 183: Take all medications as prescribed by your doctor.

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INTERNAL MEDICINE

Association of Fructose Enriched Foods with Metabolic Syndrome and Cardiovascular Diseases ANITA SHARMA*, KANUPRIYA VASHISHTH†, YASH PAUL SHARMA‡, GAURAV GUPTA#, DEVENDRA KUMAR SINGH¶

Abstract Cardiovascular diseases (CVDs) are the major causes of mortality and morbidity worldwide as well as in the Indian subcontinent, causing more than 25% of deaths. It has been predicted that these diseases will increase rapidly in India, making it a host to more than half the cases of heart disease in the world within the next 15 years. The World Health Organization (WHO) reports that in the year 2005 CVDs caused 17.5 million (30%) of the 58 million deaths that occurred worldwide. In the recent times, the association of metabolic syndrome (MS) is strongly linked with CVDs. MS is defined as a constellation of metabolic disorders in an individual. The main components of MS are dyslipidemia (higher triglyceride, low-density lipoproteins [LDL] and low high-density lipoproteins [HDL]), elevated blood pressure (BP), dysregulated glucose homeostasis, abdominal obesity and insulin resistance. Being one of the most widespread diseases in the world, almost half of the population of specific age groups in developed countries is affected by it. Studies have shown that the independent risk factors associated with MS increase the likelihood of CVDs. It has been postulated that excess intake of fructose promotes cell dysfunction, inflammation, intraabdominal (visceral) adiposity, atherogenic dyslipidemia, weight gain, insulin resistance, hypertension thereby aggravating the chances for developing MS, type 2 diabetes and coronary heart disease.

Keywords: Cardiovascular diseases, metabolic syndrome, dyslipidemia, abdominal obesity, fructose, insulin resistance

s the engines of health transition gather pace, the epidemic of cardiovascular diseases (CVDs) is accelerating globally, advancing across regions and social classes. CVDs, one of the non-communicable diseases have become the major public health problem in developed and developing countries. Globally CVD deaths represent about 30% of all deaths.1 The Global Burden of Disease Study projects that in the year 2020, an estimated 6.4 million deaths will occur due to CVD in the age group of 30-69 years, in the developing countries.2 As per WHO reports, it is predicted that

*Consultant Anesthesiologist Grecian Hospital, Mohali, Punjab †Research Scholar ‡Professor Dept. of Cardiology Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab #Head of Department ¶Senior Resident (Anesthesiologist) Dept. of Anesthesiology and Critical Care Medicine Grecian Hospital, Mohali, Punjab Address for correspondence Dr Gaurav Gupta Head of Department Dept. of Anesthesiology and Critical Care Medicine Grecian Super Speciality Hospital, SAS Nagar, Mohali - 160 062, Punjab E-mail: drgauravgupta433@gmail.com

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IJCP Sutra 184: Control your stress.

almost 23.6 million people will die from CVDs, mainly from heart disease and stroke by 2030,3 both becoming the single leading cause of death. Different studies are throwing light on the diseases associated with increased CVD risk such as metabolic syndrome (MS) as with lifestyle changes new and more complex disease conditions have emerged. The new millennium is witnessing the emergence of a modern epidemic, i.e., MS, with frightful consequences to the health of humans worldwide and its associated comorbid conditions. Studies have shown that MS patients possess a significantly greater risk for the development of CVD in general and coronary artery disease (CAD) in particular, studies have even reported a positive correlation between MS and carotid atherosclerosis.4-9 The etiology of CVD in patients with MS may involve: coronary atherosclerotic disease, arterial hypertension, left ventricular (LV) hypertrophy, diastolic dysfunction, endothelial dysfunction, coronary microvascular disease and autonomic dysfunction.10-14 The pathogenesis of CVD in the MS is multifactorial as it can be caused by one or more factors associated with this condition such as the systemic abnormalities, insulin resistance, diabetes and/or inflammation. It is seen that each component of MS independently affects

INTERNAL MEDICINE cardiac structure and function, but their combination under this syndrome seems to carry additional risk.15,16 MS is a complex disease bearing a high socioeconomic cost and being considered as a major epidemic worldwide. Although many definitions and classifications of MS are available two definitions in the widespread are used globally; one proposed by the World Health Organization (WHO) and other by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) (Table 1).17-19 Broadly MS is defined as concurrence of overweight, abdominal fat distribution, dyslipidemia, disturbed glucose and insulin metabolism and hypertension (Fig. 1), historically the concept of MS dates back to 1988 when Raven20 for the first time had put forward the concept of syndrome X, which was later named as MetS. However in 1999, WHO introduced the term ‘metabolic syndrome’ to include the cluster of factors as a clinical entity.17,20,21 Recent studies have also added other abnormalities such chronic pro-inflammatory, hyperuricemia, prothrombogenic states, nonalcoholic fatty liver disease (NAFLD) and sleep apnea to the entity of this syndrome making its definition even more complex.22 Along with being a risk factor for

CVDs, MS even predisposes an individual to a greater risk for developing type 2 diabetes.23-25 Changes in human behavior, high energy fast food environment, sedentary lifestyle, have recently been attributed to be associated with progression towards MS.24,26 In the present world, there has been an augmented understanding of MS and its associated diseases followed by a subsequent increase in clinical attention directed towards its prevention, due to its strong association with premature morbidity and mortality.27 Numerous studies have reached to the consensus now that insulin resistance and obesity are main determining factors involved in the common pathologic mechanism of the MS and its associated comorbid conditions. Evidences have suggested that the progression towards MS begins early in life and with persistence from childhood to adolescent/adult life results in type 2 diabetes, CVDs and other associated diseases. The symptoms of MS develop over a predisposed background thought to be established at a young age and are not necessarily manifestations of age, recent trends in modern diets, habits, lifestyle changes likely influencing health and behavior in increasingly younger populations makes up for a dangerous predisposition.

Table 1. Consensus Definitions from Different Associations on Metabolic Syndrome National Cholesterol Education Program-Adult Treatment Panel III, 2001

American Heart Association/ International Diabetes National Heart, Lung and Blood Federation, 2006 Institute Scientific Statement, 2005

Harmonizing the Metabolic Syndrome, 2009

Three or more of the following:

Measure (any 3 of 5 constitute diagnosis of metabolic syndrome)

Central obesity as defined by ethnic/racial, specific WC and two of the following:

Three or more of the following:

WC >102 cm for men, >88 cm for women

WC >102 cm in men, >88 cm in women

Triglycerides ≥150 mg/dL

Central obesity as defined by ethnic/racial, Specific WC

Triglycerides ≥150 mg/dL

Triglycerides ≥150 mg/dL or on drug treatment for elevated triglycerides

HDL-chol <40 mg/dL for men; <50 mg/dL for women

Triglycerides ≥150 mg/dL or on drug treatment for elevated triglycerides

HDL-chol <40 mg/dL in men; <50 mg/dL in women

HDL-chol <40 mg/dL in men; <50 mg/dL in women or on drug treatment for reduced HDL-chol

BP ≥130/85 mmHg

HDL-chol <40 mg/dL in men; <50 mg/dL in women or on drug treatment for reduced HDL-chol

BP ≥130/85 mmHg

BP ≥130/85 mmHg or on antihypertensive drug treatment in a patient with a history of hypertension

FPG ≥100 mg/dL

BP ≥130/85 mmHg or antihypertensive drug treatment

FPG ≥110 mg/dL

FPG ≥100 mg/dL or on drug treatment for elevated glucose

WHR = Waist-to-hip ratio; WC = Waist circumference; BP = Blood pressure; FPG = Fasting plasma glucose; Chol = Cholesterol.

IJCP Sutra 185: Get plenty of sleep.

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Dyslipidemia and hypercholesterolemia

Behavioral changes

Fetal programming

Stress CRH/AVP

NAFLD

↑Appetite

Type 2 diabetes

Renin-angiotensin- 11b-HSD aldosterone system dysregulation dysregulation

PCOD Hypertension and CVD

Sympathetic system activation

HPA axis (↑cortisol)

Visceral obesity

Obstructive sleep apnea

Metabolic syndrome

↑Inflammatory cytokines ↑Adipose tissue

Dyslipidemia

Micro-RNAs

Oxidative stress

DMT2

Sleep apnea

HTN

Figure 1. Metabolic syndrome and its associated disorders.

Pathophysiology of Metabolic Syndrome and CVD Progression Understanding the pathophysiology responsible for MS will prove to be a beneficial aid for best treatment options. While the exact mechanisms responsible for increased CVD risk has not been elucidated, studies have thrown light on insulin’s action and the role of obesity and its associated pathological mechanisms (Fig. 2). The excess adiposity associated with MS plays an important role towards the progression of MS associated CVD. Obesity especially abdominovisceral, is associated with certain pathogenic factors that contribute to normal glucose homeostasis: high plasma levels of free-fatty acids (FFAs), increased hepatic glycogenesis and peripheral insulin resistance. It is seen that in obesity, cytokines mediated release of inflammatory molecules such as tumor necrosis factor (TNF)-α, interleukin (IL)-6, plasminogen activator inhibitor (PAI), C-reactive protein and resist in occurs from adipose tissues and immune cells due to the initiation of a chronic inflammatory state via cytokines. The link between obesity and inflammation stems from the fact that pro-inflammatory cytokines are over expressed in obesity, this inflammatory process acts as a homeostatic mechanism to prevent the accumulation of excess fat. It is established that the starting signal for inflammation in obesity is overfeeding and the pathway origins in all metabolic cells e.g., in adipocyte, hepatocyte or myocyte. Clinical and non-clinical studies have shown that consumption of nutrients may acutely evoke inflammatory responses, furthermore metabolic cells such as adipocytes respond to this insult by beginning inflammatory response. It is seen that lipid storage

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CVD

Figure 2. Metabolic syndrome and CVD progression.22

and weight increase requires an anabolic process while inflammation stimulates catabolism including lipolysis, as a result due to chronic lipolysis FFAs are liberated continuously and are further transferred via portal vein to liver. Studies have shown that increased plasma FFAs along with inflammatory cytokines trigger a response that results in decreased insulin sensitivity in tissues that depend on insulin which is caused by inhibition of receptor signaling, this situation is also referred to as insulin resistance (IR) further leading to increased insulin synthesis and secretion by β pancreatic cells and resulting in compensatory hyperinsulinemia, following it FFAs are oxidized simultaneously in the liver, triggering neoglucogenesis and thus increasing glycemia. Concomitantly, there is an increase in the synthesis of very low-density lipoproteins (VLDLs) that further generate small, dense atherogenic LDLs. Studies have shown an extensive role of TNF-α in the systemic inflammatory response triggered by obesity, it is seen that within adipose tissue macrophages account for maximum TNF-α production and it has also been seen that TNF-α expression levels are higher in obese patients, a link between increased levels of circulating TNF-α levels and IR has been established. The pathway of IR via TNF-α occurs through serine phosphorylation (inactivation) of both the insulin receptor and insulin receptor substrate-1 (IRS-1), as a result a diminished activation of PI-3 kinase occurs which is a main governing molecule of insulin’s metabolic effects. One of the mechanisms by which TNF-α is thought to trigger IR is via activation of

IJCP Sutra 186: Pain which is heart based is generally felt in the chest or sometimes in the left arm and shoulder.

INTERNAL MEDICINE nuclear factor-κB (NFκB) signaling, which further results in activation of inflammatory cascade. Another mechanism by which TNF-α is thought to contribute to IR is through the elevated levels of circulating FFAs caused by induction of lipolysis and stimulation of hepatic lipolysis; however, this mechanism has only preliminary supporting evidence and extensive studies are needed to completely validate the findings. Studies have depicted that insulin’s action also play a crucial role towards CVD progression in MS patients, Deedwania in his study; noted that insulin’s action can lead to hypertension via stimulation of vascular smooth muscle cell hypertrophy; in addition, insulin could also cause hypertriglyceridemia and high-density lipoprotein (HDL) cholesterol through increased catecholamines, it is also reported that insulin can lead to secretion of prothrombogenic PAI-1. Studies have shown that hyperinsulinemia may even lead to increased sensitivity to angiotensin II, which further could result in increases in cell growth, PAI-1, intracellular adhesion molecule-1, etc. Defects in insulin sensitivity may interfere with insulin-stimulated vasodilation. IR is also associated with endothelial dysfunction, which is characterized by impaired endothelium-dependent vasodilation, reduced arterial compliance and accelerated process of atherosclerosis. Along with obesity and IR, studies have even thrown light on the role of matrix metalloproteinase (MMPs) in MS and associated CVDs. Progression towards MS associated CVD begins via alterations of the arterial vasculature, which begins with endothelial dysfunction and lead to micro- and macrovascular complications. It is seen that remodeling of the endothelial basal membrane that promotes erosion and thrombosis occurs due to multifactorial pathogenesis that includes leukocyte activation, increased oxidative stress and also an altered MMP. Being endopeptidases, the primary role of MMPs is to degrade matrix proteins, such as collagen, gelatins, fibronectin and lamin, and can be secreted by several cells within vascular wall. The activity of MMPs is regulated by tissue inhibitors of MMP (TIMPs) and also by other molecules, such as plasmin. The role of MMPs in plaque instability causing serious vascular complications has been reported in several studies. It has been demonstrated that an impaired MMP or TIMP expression is associated with higher risk of allcause mortality. In the recent years, MMPs have garnered considerable interest due of their association with many disease conditions. It is seen that different components of the MS provide an impetus for MMP synthesis and even

their activity; these include hypertension, dyslipidemia, hyperglycemia, pro-inflammatory and pro-oxidant markers, on the other hand, anti-inflammatory cytokines like adiponectin are inversely associated with MMPs. Extensive studies have come up to the conclusion that among the several MMPs collagenases (MMP-1 and MMP-8) and gelatinases (MMP-2 and MMP-9) are strongly associated with MS progression and its associated diseases, even few studies targeting MMPs in patients coronary diseases and diabetes and have shown fruitful results. In the near future, targeting MMPs and their activators can prove beneficial in treating and understanding the MS complexity and its associated diseases. Nutritional Factors Influencing Metabolic Syndrome In the recent times, a trend towards the shift in the energy balance accompanied by sedentary lifestyle and increased caloric intake is gathering considerable importance, and is being attributed to technological advances and improved economic status in Western countries and even developing countries. Studies have shown that the Westernization of diets, along with high calorie foods is certainly becoming an important contributor to MS epidemic, and the increased incidence of the MS now even threatens developing countries. In the past, physicians and scientists have made an association between dietary energy from fat and body fat, following which a large market is being popularized and promoted for low fat diets, interestingly however, the decline in dietary fat consumption has not corresponded to a decrease in obesity in fact, an opposite trend has emerged. It is seen that diets high in saturated fats induce weight gain, IR and hyperlipidemia in humans and animals. Despite putting effortless emphasis on fat reductions no significant benefits relative to the obesity epidemic have emerged, increasing evidence now suggests that the rise in consumption of carbohydrates, particularly refined sugars high in fructose, appears to be at least one very important contributing factor. Recent epidemiological and biochemical studies clearly suggest that high-fructose intake may play an important role in progression towards MS. At present, the market is flooded with large quantities of popular, convenient, prepackaged foods, soft drinks and juice beverages containing sucrose or high-fructose corn syrup. Fructose, which is found naturally in many fruits, is now consumed by humans in large quantities in the commonly available popular foods. Studies have shown that an approximate 25% increase in per capita

IJCP Sutra 187: Any pain, which is of less than 30 seconds duration is unlikely to be heart pain.

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fructose consumption over the past 30 years clearly co-exists, which increase in the prevalence of obesity and MS; high-fructose diets have been shown to induce IR, weight gain, hyperlipidemia and hypertension in several animal models including rats, hamsters and dogs. In human studies, fructose consumption is seen to be associated with the development of hepatic and adipose tissue IR and dyslipidemia due to its ability to induce hepatic de novo lipogenesis (Fig. 3). Different biomechanical studies have suggested that sugar consumption causes adverse effects because of rapid hepatic metabolism of fructose which is catalyzed by fructokinase C, which further results in increased uric acid levels and even generates substrate for de novo lipogenesis. Studies have shown glucose transporter 5 (GLUT5) present at the brush border and basolateral membranes of the jejunum aids in the absorption of fructose from the intestine into the portal blood; as a result massive fructose uptake by the liver occurs via this route. It is noted that the hepatic metabolisms of both glucose and fructose are different; fructose is phosphorylated by fructokinase, forming fructose-1-phosphate, which can then be converted to several three-carbon molecules, including glyceraldehyde, dihydroxyacetone phosphate and glyceral-dehyde-3-phosphate. It is seen that some of these three-carbon molecules via the process of gluconeogenesis could be converted to glucose, or could also be used to generate other products such as triglycerides (TGs), which further can be packaged into VLDL by the liver. As VLDLs travel through the bloodstream, TGs can be hydrolyzed by lipoprotein lipase to form nonesterified fatty acids (NEFAs) and monoacylglycerol, which are further taken up by adipose tissue and resynthesize to TGs, therefore excessive fructose consumption can lead to high levels of FFAs and obesity. It is already stated that the role of the adipose tissue is to take up FFAs and store it in the form of TGs, however in obesity it is seen that this storage capacity reaches to its maximum resulting in an impaired ability of adipose tissue to acquire dietary fatty acids, as a result increased levels of fatty acids occurs in circulation. Studies have shown that signaling abnormalities in adipocytes can also trigger lipolysis of TG stores resulting in efflux of fatty acids into the bloodstream thereby augmenting the problem. Few studies have thrown light that high levels of NEFAs in the bloodstream have a positive correlation between obesity, IR, type 2 diabetes and metabolic dyslipidemia, these NEFAs are eventually taken up ectopically by nonadipose tissues such as the

1038

High-fructose diet and syrup

Obesity and hyperglycemia

Inflammation

Liver disease (NAFLD)

NFκB activation and TNF-α up-regulation

Kidney damage

Insulin resistance

CVD

Figure 3. High-fructose consumption and its associated effects.

liver and skeletal muscle, where they may be stored as TG or diacylglycerol and interfere with metabolic pathways such as the response to insulin, contributing to IR and MS. Numerous studies have shown that the build-up of lipids in the liver and other tissues in obesity contributes to an increased mitochondrial oxidation of fatty acids, further generating peroxidation products that stimulates IκB kinase (IKK)β and, therefore, NFκB activation. Various studies have even found a correlation between fatty acid or lipid treatment and NFκB activation. Under basal conditions NFκB is found in the cytosol bound to its inhibitor, IkB, but upon activation of IKKβ, which phosphorylates IkB and marks it for degradation, NFκB is allowed to enter the nucleus, where it induces transcription of specific genes. The proteins encoded by these genes include proinflammatory cytokines such as PAI-1, TNF-α, IL-6 and IL-1β; however, the mechanisms responsible for IKKβ and NFκB activation in obesity are unclear. TNF-α being a mediator of inflammation and immune response is a versatile cytokine that alters tissue remodeling, epithelial cell barrier permeability, activation of macrophages and recruitment of inflammatory filtrates different downstream signaling cascades activated by TNF-α have been elucidated. TNF-α, by binding to various receptors such as TNFR1 results in the activation of various transcription factors e.g., NFкB as well as intrinsic and extrinsic apoptotic cascades mediated by caspase-8 and cytochrome C. Recent studies have shown the involvement of TNF-α in mitochondrial membrane destabilization, resulting in formation of pathological pores causing mitochondrial permeability transition thereby activating the intrinsic pathway of apoptosis mediated by cytochrome C in many diseases. Numerous nonclinical studies have delineated the effect of fructose and its associated activated pathological pathways on the progression towards MS associated CVDs in rodents. In a recent study, Shiu et al delineated the apoptotic and antisurvival effects on rats hearts when administered high fructose diet (HFD).

IJCP Sutra 188: Pain of a heart attack is diffuse in nature and cannot be pinpointed.

INTERNAL MEDICINE It was seen that rats on HFD besides having elevated levels of all MS markers of had abnormal myocardial architecture, enlarged interstitial space and increased cardiac apoptotic cells. The role of intrinsic and extrinsic apoptotic markers such as Fas-dependent apoptotic proteins (TNF-α, TNFR1, Fas ligand, Fas receptor, FADD, activated caspase-8 and activated caspase-3), mitochondria dependent apoptotic proteins (Bax, Bak, Bax/Bcl-2, Bak/Bcl-xL, cytosolic cytochrome C, activated caspase-9 and activated caspase-3) was delineated in the study. Rats on HFD had up-regulated levels of the above stated markers. Further cardiac insulin-like growth factor 1 (IGF1-related survival proteins (IGF-1, IGF-1R, p-PI3K and p-Akt) and Bcl-2 family associated pro-survival proteins (Bcl-2 and Bcl-xL) were downregulated in rats on HFD. Parks et al and Katan et al, showed in their short-term studies that diets rich in carbohydrates, particularly sugars (sucrose, fructose) resulted in increase in serum triacylglycerol concentrations and decreased HDL concentration, therefore indicating a risk towards developing CVD. Few studies have also thrown light on the involvement of various oxidative stress markers (nicotinamide adenine dinucleotide phosphate or NADPH) and pro-inflammatory cytokines (IL-1, IL-6) and hypothesize a possible role of NFκB and TNF-α in the progression of MS thereby leading to CVDs. Numerous studies have found that dietary composition of carbohydrate can result in development of left ventricular hypertrophy and cardiac pathology. It is believed that with increased concentrations of fructose diets the trend towards CVD risk will markedly rise in near future. Conclusion With rising financial implications and with a concomitant impact on human health, MS in the recent past has gathered considerable concern; its presence is an important risk factor for the development of CVDs and type 2 diabetes. At present, the key principles involved in the management of patients with MS are early identification of patients, effective treatment regular follow-up, pharmacological therapy and lifestyle modifications. In the current scenario, the mechanisms that contribute to MS associated diseases remain unclear, extensive research is underway that might help in understanding the pathological pathways and novel treatment options. The most important contributory factors which have emerged as the important links in MS are sedentary lifestyle, altered dietary requirements and obesity.19,22

The consumption of fructose has increased, largely because of an increased consumption of soft drinks and many juice beverages containing sucrose or high-fructose corn syrup. Dietary high-fructose intake has been suggested to be an important factor contributing to the development of symptoms of MS. Recent evidences suggests that fructose feeding in rats develops the features of the MS model in many of the same pathophysiological deficits as noted in MS in humans, such as IR, dyslipidemia, hyperinsulinemia, hypertricylglycerolemia, impaired glucose tolerance, increased uric acid levels, hypertension, myocardial functional abnormalities and heart failure. If not alarmed and the different economies do not make necessary interventions to the growing MS epidemic, individuals from all age groups will be severely affected limiting their full overall development and progression. References 1. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing epidemic of coronary heart disease in low- and middle-income countries. Curr Probl Cardiol. 2010;35(2):72-115. 2. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet. 1997;349(9063):1436-42. 3. World Health Organization ((WHO). Cardiovascular disease. Fact sheet N°317. Geneva. September 2009. Available at: http://wwwwhoint/mediacentre/factsheets/ fs317/en/indexhtml 4. Hutcheson R, Rocic P. The metabolic syndrome, oxidative stress, environment, and cardiovascular disease: the great exploration. Exp Diab Res. 2012;2012: 271028. 5. Iglseder B, Cip P, Malaimare L, Ladurner G, Paulweber B. The metabolic syndrome is a stronger risk factor for early carotid atherosclerosis in women than in men. Stroke. 2005;36(6):1212-7. 6. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics - 2011 update: a report from the American Heart Association. Circulation. 2011;123(4):e18-e209. 7. Kim JY, Mun HS, Lee BK, Yoon SB, Choi EY, Min PK, et al. Impact of metabolic syndrome and its individual components on the presence and severity of angiographic coronary artery disease. Yonsei Med J. 2010;51(5):676-82. 8. Schernthaner G. Cardiovascular mortality and morbidity in type-2 diabetes mellitus. Diabetes Res Clin Pract. 1996;31 Suppl:S3-13. 9. Lakka HM, Laaksonen DE, Lakka TA, Niskanen LK, Kumpusalo E, Tuomilehto J, et al. The metabolic syndrome

IJCP Sutra 189: Silent angina is a condition where inadequate blood supply to the heart does not cause any symptoms, even pain.

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Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018 and total and cardiovascular disease mortality in middleaged men. JAMA. 2002;288(21):2709-16.

provisional report of a WHO consultation. Diabet Med. 1998;15(7):539-53.

10. Ilkun O, Boudina S. Cardiac dysfunction and oxidative stress in the metabolic syndrome: an update on antioxidant therapies. Curr Pharm Des. 2013;19(27):4806-17.

18. 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.

11. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al; American Heart Association; National Heart, Lung, and Blood Institute. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112(17):2735-52. 12. Grundy SM. Metabolic syndrome: a multiplex cardiovascular risk factor. J Clin Endocrinol Metab. 2007;92(2):399-404. 13. Bugger H, Abel ED. Molecular mechanisms for myocardial mitochondrial dysfunction in the metabolic syndrome. Clin Sci (Lond). 2008;114(3):195-210. 14. Nicolson GL. Metabolic syndrome and mitochondrial function: molecular replacement and antioxidant supplements to prevent membrane peroxidation and restore mitochondrial function. J Cell Biochem. 2007;100(6):1352-69. 15. Klein BE, Klein R, Lee KE. Components of the metabolic syndrome and risk of cardiovascular disease and diabetes in Beaver Dam. Diabetes Care. 2002;25(10):1790-4.

19. Tuomilehto J. Cardiovascular risk: prevention and treatment of the metabolic syndrome. Diabetes Res Clin Pract. 2005;68 Suppl 2:S28-35. 20. Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes. 1988;37(12):1595-607. 21. Consultation W. Definition, diagnosis and classification of diabetes mellitus and its complications: Part; 1999. 22. Kassi E, Pervanidou P, Kaltsas G, Chrousos G. Metabolic syndrome: definitions and controversies. BMC Med. 2011;9:48. 23. Huang PL. A comprehensive definition for metabolic syndrome. Dis Model Mech. 2009;2(5-6):231-7. 24. Oda E. Metabolic syndrome: its history, mechanisms, and limitations. Acta Diabetol. 2012;49(2):89-95. 25. Moller DE, Kaufman KD. Metabolic syndrome: a clinical and molecular perspective. Annu Rev Med. 2005;56:45-62.

16. Kaur J. A comprehensive review on metabolic syndrome. Cardiol Res Pract. 2014;2014:943162.

26. Tappy L, Lê KA, Tran C, Paquot N. Fructose and metabolic diseases: new findings, new questions. Nutrition. 2010;26(11-12):1044-9.

17. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus

27. Basciano H, Federico L, Adeli K. Fructose, insulin resistance, and metabolic dyslipidemia. Nutr Metab (Lond). 2005;2(1):5.

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IJCP Sutra 190: Don’t be afraid to stand for what you believe in, even if that means standing alone.

2018

NEUROLOGY

Kartagener’s Syndrome with Seizures: A Rare Case Report CHANDRAMOHAN SHARMA*, BANSHI LAL KUMAWAT*, DEEPIKA SAGAR†

Abstract Primary ciliary dyskinesia (PCD) is a genetic disorder with an autosomal recessive mode of inheritance. It is caused by a defect in the structure of cilia, due to which ciliary movement and consequently, its function, are impaired. Sinusitis, nasal polyposis and otitis media with effusion are commonly seen among patients. Seizures are rare in such patients. We are presenting a rare case report of a patient with Kartagener’s syndrome who presented with seizure.

Keywords: Kartagener's syndrome, seizure, sinus thrombosis

artagener’s syndrome (KS) is a subset of a larger group of ciliary motility disorders called primary ciliary dyskinesias (PCDs). It is a genetic condition with an autosomal recessive inheritance,1,2 comprising a triad of situs inversus, bronchiectasis and sinusitis.1,2 Although Siewert first described this condition in 1904, it was Kartagener who recognized the etiological correlation between the elements of the triad and reported four cases in 1933.2 The estimated prevalence of PCD is about 1 in 30,000,3 though it may range from 1 in 12,500 to 1 in 50,000.1 In KS, the ultrastructural genetic defect leads to impaired ciliary motility which causes recurrent chest, ear/nose/ throat (ENT) and sinus infections and infertility. A high index of suspicion is needed to make an early diagnosis, so that timely treatment options may be offered for infertility in these young patients, wherever feasible. Seizures are very rare in such patients. We present a case of a 38-year-old female patient of KS with seizures. Case Report A 38-year-old nonsmoker female presented to us with chief complaints of throbbing type of diffuse headache

*Senior Professor †Senior Resident Dept. of Neurology SMS Medical College, Jaipur, Rajasthan Address for correspondence Dr Deepika Sagar 847, 1st Floor, Adarsh Nagar, Jaipur, Rajasthan - 302 004 E-mail: deepikakgmu@gmail.com

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since 5 days and 3 episodes of generalized tonic-clonic seizures since 2 days. There was no history of fever, nausea, vomiting or any symptoms suggestive of other focal neurological deficit. There was history of recurrent chest infections since her childhood and progressively increasing breathlessness for last 30 years. She had been married for last 20 years but had no children. She received anti-tubercular treatment for chronic cough for 8 months, 10-year back with no relief. Her family history revealed no paternal consanguinity. On examination, patient was conscious but drowsy. Her pulse rate was 122/min and regular, respiratory rate was 27/min, blood pressure was 110/74 mmHg, SpO2 81% on room air. Bilateral pedal edema and Grade III clubbing was present. On auscultation, diffuse rhonchi and crackles were heard. Rest of systemic examinations was within normal limits. Routine investigations were normal except high total leukocyte count (17,000/mm3) with neutrophilic predominance. Electrocardiogram (ECG) was suggestive of dextrocardia. Electroencephalography (EEG) of the patient was normal. Chest X-ray film posteroanterior view showed bronchiectatic changes with dextrocardia (Fig. 1). CT abdomen was suggestive of situs inversus (Fig. 2). CECT thorax revealed bronchiectasis and situs inversus (Fig. 3). CT brain showed left middle cerebral artery territory hemorrhagic infarct (Fig. 4). CT venography brain of the patient was suggestive of left transverse sinus and superior sagittal sinus thrombosis (Fig. 5). Patient was managed with antibiotics, antiepileptics, low-molecular-weight heparin and other supportive treatment. Patient was doing well on follow-up.

IJCP Sutra 191: Your time is limited, so don’t waste it living someone else’s life. —Steve Jobs

NEUROLOGY

Figure 1. Chest X-ray film PA view showing dextrocardia.

Figure 2. CT abdomen showing situs inversus.

Figure 4. CT brain showing hemorrhagic infarct in left middle cerebral artery territory.

Figure 5. CT venogram brain showing left transverse and superior sagittal sinus thrombosis.

Discussion

Figure 3. CECT thorax showing bronchicetatic changes in upper and lower lobe of left lung.

PCD is a rare genetic disorder with an autosomal recessive mode of inheritance.4 It is caused by a defect in the dynein arm structure of cilia, due to which ciliary movement and consequently its function, are impaired. Ciliary movements are responsible for the rotation and orientation of internal organs in the 10th to 15th days of gestation. In PCD, the underlying ciliary dysfunction causes incomplete rotation or malrotation of one or many internal organs, most commonly the heart.5 Isolated malrotation of the heart (situs solitus) is associated with severe anomalies of the vessels connecting the heart and is thus relatively rare as such cases have a very low survival. More commonly, a right-sided heart (dextrocardia) exists along with malrotation of the other internal organs,

IJCP Sutra 192: You can never cross the ocean until you have the courage to lose sight of the shore. â&#x20AC;&#x201D;Christopher Columbus

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namely: lungs, liver, spleen, kidneys and intestines (situs inversus). About 50% of PCD patients develop situs inversus and KS, which has been classically described as a triad of dextrocardia, sinusitis and bronchiectasis, and male infertility; the incidence of KS is estimated to be around 1:15,000 with variable penetrance, and phenotypic differences have been observed because the underlying genetic mutation has a pleiotropic effect. Radiology, in the form of a chest X-ray, quickly corroborates the clinical suspicion of dextrocardia, but may also reveal dextrocardia and situs inversus as an incidental finding on routine preoperative work-up. CT thorax may further delineate malrotation, and bronchiectasis if any, and other changes found in PCD. In the event of the CT scan being inconclusive, a Gallium-67 scan can establish the bronchiectatic changes.6 Seizures are not reported in any case in the literature as a manifestation of KS previously. In our case, patient developed venous sinus thrombosis as a result

of chronic infection due to bronchiectasis, which may be the cause for seizures. References 1. Barthwal MS. Kartagener’s syndrome in a fertile male - An uncommon variant. Lung India. 2006;23(3):123-5. 2. Dixit R, Dixit K, Jindal S, Shah KV. An unusual presentation of immotile-cilia syndrome with azoospermia: Case report and literature review. Lung India. 2009;26(4):142-5. 3. Seaton D. Bronchiectasis. In: Seaton A, Seaton D, Leitch AG (Eds.). Crofton and Douglas’s Respiratory Diseases. 5th Edition, Oxford: Blackwell Science; 2004. pp. 794-828. 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. Afzelius BA. A human syndrome caused by immotile cilia. Science. 1976;193(4250):317-9. 6. Becker MD, Berkmen YM, Fawwaz R, Van Heertum R. Ga-67 scintigraphy showing the triad of bronchiectasis, paranasal sinusitis, and situs inversus in a patient with Kartagener's syndrome. Clin Nucl Med. 2000; 25(12):1050-1.

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Chat with Dr KK Jiska Koi Nahi Uska IMA

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IJCP Sutra 193: Happiness is not something readymade. It comes from your own actions. —Dalai Lama

OBSTETRICS AND GYNECOLOGY

A Rare Case of Huge Central Cervical Fibroid with Characteristic “Lantern on Top of St. Paul’s Cathedral” Appearance TAMAL KUMAR MANDAL*, PRATIMA GARAIN†, DEBJANI DEB‡, SHYAM SUNDAR HALDER#, PREETI DEWANGAN#

Abstract Cervical myomas arise from the smooth muscle cells of the cervix accounting for 2% of all uterine leiomyomas. They may disturb the pelvic anatomy and the ureter producing different type of pressure symptoms. Management of symptomatic huge cervical fibroid is myomectomy or hysterectomy and needs an expert hand. Here we report a case of huge central cervical fibroid of size 30 × 20 × 15 cm and weighing 5.5 kg with typical “Lantern on top of St. Paul’s cathedral” appearance on naked eye examination.

Keywords: Leiomyoma, cervical fibroid, myomectomy, hysterectomy

ibroids are not only the commonest benign tumor of the uterus but are the commonest benign solid tumor in females.1 They are responsible for about one-third of the hospital admission in the gynecological department.2 Their incidence among women is generally cited as 20-25%, but has been shown to be as high as 70-80% in studies using histologic or sonographic examination.3 Most of the leiomyomas are situated in the body of the uterus, but in 1-2% of the cases, they are confined to cervix.4 Histologically fibroids are composed of smooth muscle and fibrous connective tissue, so named as uterine leiomyoma, myoma or fibromyoma. The paucity of smooth muscles in the cervical stroma makes leiomyomas in the cervix uncommon. Presence of isolated fibromyoma in cervix with intact uterus is infrequent. Cervical fibroids with excessive growth are uncommon. A central cervical fibroid is usually either interstitial or subserous in origin and arises from supravaginal portion of the cervix, so that it expands the

*RMO cum Clinical Tutor †Associate Professor ‡Assistant Professor #Post Graduate Trainee Dept. of Obstetrics and Gynecology Bankura Sammilani Medical College and Hospital, Bankura, West Bengal Address for correspondence Dr Tamal Kumar Mandal C/o: Bhim Bhabani Mandal North Pratapbagan, Sarani No. 5, Bankura - 722 101, West Bengal E-mail: tamal.cool2011@gmail.com

cervix equally in all directions. On laparotomy, it can be recognized at once, as it fills pelvis, with uterus on top of tumor like “Lantern on top of St. Paul’s cathedral” and poses practical problems during surgery.5 This characteristic appearance doesn’t occur when there are 2 or more fibroids in the body of the uterus. Rarely, a submucous fibroid arising from the fundus of the uterus may burrow downwards to lie in the position of the cervix and simulates to form a pseudocervical fibroid. Cervical fibroid can change the shape of the cervix or may lengthen it. If cervical fibroid grows rapidly, it may push the uterus upwards or obstruct the cervical canal. Without proper anatomical knowledge, large cervical fibroids are difficult to handle and need an expert hand to operate these cases.6 We report a case of huge central cervical fibroid because of its rarity and being prone for complications during its removal. Case Report A 28-year-old woman; para 2, living issue 2, tubectomized, reported at Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, with mass in the lower abdomen, noticed since 3 months, associated with dyspepsia. There was no history of menstrual irregularities, loss of appetite, weight loss and pressure symptoms. Her bladder and bowel habits were normal. She had previous two spontaneous vaginal births with her last child birth was 8 years back. The examination was carried on with the prior consent from the patient. General examination revealed no

IJCP Sutra 194: The weak can never forgive. Forgiveness is the attribute of the strong. —Mahatma Gandhi

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abnormality except moderate pallor. On abdominal examination, a huge mass like full-term pregnant uterus with restricted mobility was palpated. The mass was nontender, firm to hard in consistency with well-defined margins except the lower pole, which was not palpable suggesting the mass to be of pelvic origin. There was no ascites clinically. A small firm mass with size and shape like normal uterus was palpated through anterior abdominal wall in subumbilical region with restricted mobility continuous with abdominopelvic mass. On speculum examination, cervix was pushed high up and visualized with great difficulty. On per vaginal examination, a huge firm to hard mass was made out, cervix was felt with great difficulty, anterior lip of cervix was felt as a rim and uterus could not be felt separately. Fullness was noted in all vaginal fornices. On preoperative investigations her hemoglobin was 5.9 g/dL. Peripheral blood film showed normocytic normochromic anemia. Three units whole blood were transfused preoperatively. The corrected hemoglobin level was 10.1 g/dL. Renal and liver function tests were normal. Her CA-125 was 17.3 U/mL.

Figure 1. MDCT scan of whole abdomen showing a huge well-defined heterogeneous enhancing SOL at pelvis predominantly on left side extending to the upper abdomen.

USG showed a huge heterogeneous space-occupying lesion (SOL) arising from pelvis almost filling the entire abdomen, size was too large to be determined, organ of origin could not be determined. Bilateral ovaries could not be visualized. Gross hydronephrotic changes were seen in left kidney, which right kidney was normal. Multiple detector computed tomography (MDCT) scan of whole abdomen (oral and IV contrast) showed a huge well-defined heterogeneous enhancing SOL measuring 23.74 × 12.58 cm at pelvis predominantly on left side extending to the upper abdomen displacing the uterus right anterolaterally and urinary bladder to the right side. Left ureter was compressed by the pelvic mass leading to proximal dilatation (Fig. 1).

Figure 2. Normal uterus and ovaries sitting on top of the central cervical fibroid “Lantern on top of St. Paul’s cathedral”.

Fine needle aspiration cytology (FNAC) from abdominopelvic SOL showed occasional small clusters of degenerated epithelial cells in a hemorrhagic background. No definite opinion was possible. Exploratory laparotomy and proceed was planned. Laparotomy revealed a large central cervical fibroid of 30 × 20 × 15 cm, while the uterus was normal in size and shape placed above the mass with both-sided normal ovaries with typical appearance of “Lantern on top of St. Paul’s cathedral” (Fig. 2 and 6). The mass was filling the whole pelvis extending up to the xiphisternum displacing the uterus right anterolaterally and urinary bladder to the right side. After clamping and dividing the round ligaments and the ovarian vessels (Fig. 3),

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Figure 3. Clamping and dividing the round ligaments and the ovarian vessels.

IJCP Sutra 195: Most heart attacks occur during the early hours of the morning. Hence any chest pain during this period should never be ignored.

OBSTETRICS AND GYNECOLOGY separation of the anterior peritoneum and bladder was done. The peritoneum, together with the bladder, was pushed downwards with a swab as far as possible off the face of the expanded supravaginal cervix. First intracapsular myomectomy was done (Fig. 4). After cutting the false capsule the impacted cervical fibroid was mobilized upwards and removed in toto and sent for histopathological examination. Total abdominal hysterectomy with right-sided salpingo-oophorectomy with left-sided salpingectomy was performed and specimen was sent for histopathological examination (Fig. 5). Left-sided ovary was retained. Left-sided

Figure 6. Gross appearance of cervical leiomyoma after resection.

internal iliac artery ligation done to secure hemostasis of the fibroid base. Bilaterally ureters were traced till bladder and found intact. Abdomen was closed in layers after placing intra-abdominal drain and taking count of the instruments and the mops. The mass with uterus weighed 5.5 kg. Cut section revealed a firm mass with whorled appearance and pseudocapsule.

Figure 4. Intracapsular enucleation of cervical fibroid.

Postoperative period was uneventful. Two units of whole blood and 2 units fresh frozen plasma (FFP) were transfused. Abdominal drain was removed after 48Â hours. Patient was discharged in satisfactory condition after stitch removal. Histopathological examination showed leiomyoma with hyaline degeneration. No evidence of malignancy was seen. Discussion

Figure 5. Total abdominal hysterectomy and right-sided salpingo-oophorectomy specimen showing huge central cervical fibroid with normal uterus on top.

Fibroid is the commonest benign solid tumor of uterus arising from the neoplastic single smooth muscle cell of myometrium. Cervical fibroids can arise from supravaginal or vaginal portion of cervix. Supravaginal cervical fibroids may be interstitial or subperitoneal and rarely polypoidal. Depending upon the position they may be anterior, posterior, lateral and central. Interstitial growths may displace the cervix or expand it so much that the external os is difficult to recognize. They may disturb the pelvic anatomy and the ureter. Vaginal cervical fibroid is usually pedunculated and rarely sessile.4 Anterior fibroid bulges forward and undermines the bladder while posterior fibroid flattens the pouch of Douglas backwards, compressing rectum against sacrum. Lateral cervical fibroid, starting on the side of the cervix burrows out into the broad

IJCP Sutra 196: A heart attack when the blood supply to the heart is cut-off completely, the result is a heart attack.

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ligament and expands it. Their relation to the ureter is important. Wherever the ureter and uterine artery may be in relation to the fibroid, they will always be extracapsular, lateral and posterior.5 The knowledge of this fact can turn potentially dangerous procedure into a relatively safe operation. The symptoms of cervical fibroid depend upon the type of cervical fibroid. Anterior cervical fibroid produces symptoms like frequency or even retention of urine. Retention is more due to pressure than the elongation of the urethra. Rectal symptoms are more common with posterior cervical fibroid in the form of constipation. Lateral cervical fibroid causes vascular obstruction which may lead to hemorrhoids and edema of legs (rare) and symptoms due to obstructive uropathy. Pelvic pain and foul smelling vaginal discharge can be associated with the above mentioned symptoms. A cervical fibroid can lead to abdominal mass, menstrual abnormalities, dyspareunia and sometimes post-coital bleeding, incarcerated procidentia, sensation of something coming down and in case of pregnancy, it can cause obstructed labor. For symptomatic women, consideration of medical therapy, noninvasive procedures or surgery depends on an accurate assessment of the size, number and position of fibroids. Magnetic resonance imaging (MRI) allows evaluation of the number, size and position of submucous, intramural and subserosal fibroids and can evaluate their proximity to the bladder, rectum and endometrial cavity. Sonography is the most readily available and least costly imaging technique to differentiate fibroids from other pelvic pathology.7,8 A central cervical fibroid forms a special case as it is not usually suitable for treatment by standard hysterectomy techniques,5 hence prone for complications like hemorrhage and urological injuries. Altered anatomical relations of the surrounding structures is important. The problems encountered during hysterectomy for cervical fibroids are: 1) the uterine vessels-distortion of normal anatomy- this is because the uterine vessels are so elevated as to run parallel to the ovarian vessels forming a vascular leash close to the ureters; 2) the bladder is pulled up; 3) ureter distortion- the tumor may be impacted in the pelvis displacing the ureters and over hangs the vaginal vault so much that this cannot be reached until the myoma is dislocated upwards or removed by myomectomy. Therefore, more chances of injury to the ureters, bladder and uterine vessels.9 The principal to be followed is enucleation followed by hysterectomy to minimize injury to ureter or one can

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also give preoperative gonadotropin-releasing hormone (GnRH) analogs 3 months prior to facilitate surgery by reducing the size and vascularity of fibroids, improving the hemoglobin status.8-11 The disadvantage of GnRH analog is that they can destroy the fine plane of cleavage between the capsule of the tumor and the surrounding structures, thus eliminating one of the very few “godsends” that are available when attempting to deal with fibroids surgically.5 Intracapsular enucleation of fibroid is the best approach to prevent injury to bladder and ureters.12 For enucleation, the capsular incision may be transverse or vertical one. The advantage of the transverse incision is that it can be placed above the bladder reflection and so reducing the risk of bladder damage. The disadvantage is that it cuts through blood vessels, which results in severe hemorrhage. The vertical incision can be placed over avascular area, usually midline and extended into the body of uterus if necessary to expose the upper limits of tumor.10 When the tumor is completely impacted in the pelvis so that there is no place for the hand to separate the tumor from its capsule, myomectomy screw is employed. Sometimes, experience with a large fibroid is traumatic, although traction on the screw undoubtedly will reduce the hemorrhage. The principle of wedge resection can be used or hemi-hysterectomy till the capsule of the myoma.5,10,13 In vaginal part fibroids, if the tumor is sessile, myomectomy and if pedunculated, polypectomy is done. As regards to injuries to the pelvic ureter, it is rare to partially resect the ureter; more commonly, it is completely resected. The management is to anastomose the ends of the ureter, having first made the ends spatulate. The ends will be sutured using 4.0 vicryl over a ureteric stent. The commonest stent used is the “pigtail” Silastic stent. The upper end of the stent is inserted into the renal pelvis and the lower end into the bladder. Extraperitoneal drainage is needed. The operative area should be drained to monitor for leakage of urine during the first few days.3,4 Conclusion In case of large cervical fibroids, the anatomy will be altered and there are chances of injuring the uterine vessels, the bladder and the ureters as they will be in close proximity to the fibroid. In our case in spite of the fibroid being huge, vascular and deeply impacted in the pelvis, the whole tumor was removed in toto successfully without any significant hemorrhage. The patient was

IJCP Sutra 197: Heart clots can be dissolved with medicines, if the victim reaches the hospital within 3 hours.

OBSTETRICS AND GYNECOLOGY discharged without any residual complications. Thus, we conclude when myomectomy is planned it is always preferred to work within the capsule as it prevents ureteric injuries. A sound anatomical knowledge and proper surgical techniques are essential to prevent complication while operating such cases. Intraoperative delineation of ureters and preoperative ureteric stenting are essential precautions, but could not be done in above case due to anatomical distortion. New diagnostic modalities like USG (transvaginal sonography), CT scan, IVU (intravenous urogram) can improve the accuracy of preoperative diagnosis but final diagnosis can only be made at the time of laparotomy. References 1. Dutta DC. Benign lesions of the uterus. In: Konar H (Ed.). Textbook of Gynaecology Including Contraception. 5th Edition, Kolkata: New Central Book Agency (P) Ltd; 2009. p. 262. 2. Garg R. Two uncommon presentation of cervical fibroids. People’s J Sci Res. 2012;5(2):36-8. 3. Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril. 1981;36(4):433-45. 4. Kumar P, Malhotra N. Tumours of the corpus uteri. In: Kumar P (Ed.). Jeffcoat’s Principles of Gynaecology. 7th Editon, New Dehi: Jaypee Brothers Medical Publishers (P) Ltd; 2008. pp. 487-516. 5. Monaghan JM, Lopes AB, Naik R. Total hysterectomy for cervical and broad ligament fibroids. In: Huxley R, Taylor S, Chandler K (Eds.). Bonney’s Gynaecological

Surgery. 10th Edition, Maiden, USA: Blackwell Publishing Company; 2004. pp. 74-86. 6. Kshirsagar SN, Laddad MM. Unusual presentation of cervical fibroid: two case reports. Int J Gynae Plast Surg. 2011;3(1):38-9. 7. Dueholm M, Lundorf E, Olesen F. Imaging techniques for evaluation of the uterine cavity and endometrium in premenopausal patients before minimally invasive surgery. Obstet Gynecol Surv. 2002;57(6):388-403. 8. Jayashree V, Mahjabeen B, Thariq IA. A case of huge cervical fibroid with characteristic “Lantern on St. Paul’s cathedral” appearance. Indian J Basic Appl Med Res. 2015;4(3):455-8. 9. Samal SK, Rathod S, Rajsekaran A, Rani R. An unusual presentation of central cervical fibroid: a case report. Int J Res Med Sci. 2014;2(3):1226-8. 10. Singh S, Chaudhary P. Central cervical fibroid mimicking as chronic uterine inversion: a case report. Int J Reprod Contracept Obstet Gynecol. 2013;2(4):687-8. 11. Lethaby A, Vollenhoven B, Sowter M. Efficacy of pre-operative gonadotrophin hormone releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy: a systematic review. BJOG. 2002;109(10):1097-108. 12. Kavitha B, Jyothi R, Rama Devi A, Madhuri K, Sachin Avinash K, SGK Murthy. A rare case of central cervical fibroid with characteristic “Lantern on top of St. Paul” appearance. Int J Res Dev Health. 2014;2(1):45-7. 13. Basnet N, Banerjee B, Badani U, Tiwari A, Raina A, Pokharel H, et al. An unusual presentation of huge cervical fibroid. Kathmandu Univ Med J (KUMJ). 2005; 3(2):173-4.

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Cardiac Arrest Formula of 10: Within 10 minutes of cardiac arrest for the next at least 10 minutes compress the center of the chest (as hard as one can) with a speed of at least 10 × 10 = 100/minute and do not stop chest compressions for more than 10 seconds (for using a defibrillator to give an electric shock). Eighty percent people can be saved with this. Formula of 2: While doing chest compression CPR, give 2 thumps in the center of the chest every 2 minutes or defibrillate every 2 minutes and change guards every 2 minutes.

Prehypertension Rule of 3: A person with prehypertension, systolic ‘upper’ BP between 120-140 mmHg and diastolic ‘lower’ BP between 80-90 mmHg, is more than three times likely to have a heart attack and 1.7 times more likely to have heart disease than a person whose BP is lower than 120/80 mmHg. Rule of 45: If prehypertension is aggressively treated, 45% of all heart attacks can be prevented.

IJCP Sutra 198: Over 50% of the cardiac deaths occur within 1 hour of the start of symptoms.

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Every citizen of India should have the right to accessible, affordable, quality and safe heart care irrespective of his/her economical background

Sameer Malik Heart Care Foundation Fund An Initiative of Heart Care Foundation of India

E-219, Greater Kailash, Part I, New Delhi - 110048 E-mail: heartcarefoundationfund@gmail.com Helpline Number: +91 - 9958771177

“No one should die of heart disease just because he/she cannot afford it” About Sameer Malik Heart Care Foundation Fund

Who is Eligible?

“Sameer Malik Heart Care Foundation Fund” it is an initiative of the Heart Care Foundation of India created with an objective to cater to the heart care needs of people.

Objectives Assist heart patients belonging to economically weaker sections of the society in getting affordable and quality treatment. Raise awareness about the fundamental right of individuals to medical treatment irrespective of their religion or economical background. Sensitize the central and state government about the need for a National Cardiovascular Disease Control Program. Encourage and involve key stakeholders such as other NGOs, private institutions and individual to help reduce the number of deaths due to heart disease in the country. To promote heart care research in India.

All heart patients who need pacemakers, valve replacement, bypass surgery, surgery for congenital heart diseases, etc. are eligible to apply for assistance from the Fund. The Application form can be downloaded from the website of the Fund. http://heartcarefoundationfund.heartcarefoundation. org and submitted in the HCFI Fund office.

Important Notes The patient must be a citizen of India with valid Voter ID Card/ Aadhaar Card/Driving License. The patient must be needy and underprivileged, to be assessed by Fund Committee. The HCFI Fund reserves the right to accept/reject any application for financial assistance without assigning any reasons thereof. The review of applications may take 4-6 weeks. All applications are judged on merit by a Medical Advisory Board who meet every Tuesday and decide on the acceptance/rejection of applications. The HCFI Fund is not responsible for failure of treatment/death of patient during or after the treatment has been rendered to the patient at designated hospitals.

To promote and train hands-only CPR.

Activities of the Fund Financial Assistance

The HCFI Fund reserves the right to advise/direct the beneficiary to the designated hospital for the treatment.

Financial assistance is given to eligible non emergent heart patients. Apart from its own resources, the fund raises money through donations, aid from individuals, organizations, professional bodies, associations and other philanthropic organizations, etc.

The financial assistance granted will be given directly to the treating hospital/medical center.

After the sanction of grant, the fund members facilitate the patient in getting his/her heart intervention done at state of art heart hospitals in Delhi NCR like Medanta – The Medicity, National Heart Institute, All India Institute of Medical Sciences (AIIMS), RML Hospital, GB Pant Hospital, Jaipur Golden Hospital, etc. The money is transferred directly to the concerned hospital where surgery is to be done.

Drug Subsidy

The HCFI Fund has the right to print/publish/webcast/web post details of the patient including photos, and other details. (Under taking needs to be given to the HCFI Fund to publish the medical details so that more people can be benefitted). The HCFI Fund does not provide assistance for any emergent heart interventions.

Check List of Documents to be Submitted with Application Form Passport size photo of the patient and the family A copy of medical records Identity proof with proof of residence Income proof (preferably given by SDM)

The HCFI Fund has tied up with Helpline Pharmacy in Delhi to facilitate

BPL Card (If Card holder)

patients with medicines at highly discounted rates (up to 50%) post surgery.

Details of financial assistance taken/applied from other sources (Prime Minister’s Relief Fund, National Illness Assistance Fund Ministry of Health Govt of India, Rotary Relief Fund, Delhi Arogya Kosh, Delhi Arogya Nidhi), etc., if anyone.

The HCFI Fund has also tied up for providing up to 50% discount on imaging (CT, MR, CT angiography, etc.)

Free Diagnostic Facility

Free Education and Employment Facility

The Fund has installed the latest State-of-the-Art 3 D Color Doppler EPIQ 7C Philips at E – 219, Greater Kailash, Part 1, New Delhi.

HCFI has tied up with a leading educational institution and an export house in Delhi NCR to adopt and to provide free education and employment opportunities to needy heart patients post surgery. Girls and women will be preferred.

This machine is used to screen children and adult patients for any heart disease.

Laboratory Subsidy HCFI has also tied up with leading laboratories in Delhi to give up to 50% discounts on all pathological lab tests.

About Heart Care Foundation of India

Help Us to Save Lives The Foundation seeks support, donations and contributions from individuals, organizations and establishments both private and governmental in its endeavor to reduce the number of deaths due to heart disease in the country. All donations made towards the Heart Care Foundation Fund are exempted from tax under Section 80 G of the IT Act (1961) within India. The Fund is also eligible for overseas donations under FCRA Registration (Reg. No 231650979). The objectives and activities of the trust are charitable within the meaning of 2 (15) of the IT Act 1961.

Heart Care Foundation of India was founded in 1986 as a National Charitable Trust with the basic objective of creating awareness about all aspects of health for people from all walks of life incorporating all pathies using low-cost infotainment modules under one roof. HCFI is the only NGO in the country on whose community-based health awareness events, the Government of India has released two commemorative national stamps (Rs 1 in 1991 on Run For The Heart and Rs 6.50 in 1993 on Heart Care Festival- First Perfect Health Mela). In February 2012, Government of Rajasthan also released one Cancellation stamp for organizing the first mega health camp at Ajmer.

Objectives Preventive Health Care Education Perfect Health Mela Providing Financial Support for Heart Care Interventions Reversal of Sudden Cardiac Death Through CPR-10 Training Workshops Research in Heart Care

Donate Now... Heart Care Foundation Blood Donation Camps The Heart Care Foundation organizes regular blood donation camps. The blood collected is used for patients undergoing heart surgeries in various institutions across Delhi.

Committee Members

Chief Patron

President

Raghu Kataria

Dr KK Aggarwal

Entrepreneur

Padma Shri, Dr BC Roy National & DST National Science Communication Awardee

Governing Council Members Sumi Malik Vivek Kumar Karna Chopra Dr Veena Aggarwal Veena Jaju Naina Aggarwal Nilesh Aggarwal H M Bangur

Advisors Mukul Rohtagi Ashok Chakradhar

Executive Council Members Deep Malik Geeta Anand Dr Uday Kakroo Harish Malik Aarti Upadhyay Raj Kumar Daga Shalin Kataria Anisha Kataria Vishnu Sureka

This Fund is dedicated to the memory of Sameer Malik who was an unfortunate victim of sudden cardiac death at a young age.

Rishab Soni

HCFI has associated with Shree Cement Ltd. for newspaper and outdoor publicity campaign HCFI also provides Free ambulance services for adopted heart patients HCFI has also tied up with Manav Ashray to provide free/highly subsidized accommodation to heart patients & their families visiting Delhi for treatment.

http://heartcarefoundationfund.heartcarefoundation.org

OBSTETRICS AND GYNECOLOGY

Acoustic Neuroma and Hydrocephalus in Pregnancy: A Case Report AVINASH PATIL*, POORNIMA R†, M NARAYANA SWAMY‡, GOMATHY#

Abstract The diagnosis of acoustic neuroma during pregnancy is often delayed because symptoms like nausea, vomiting, headache and tinnitus, which are nonspecific, are often attributed to pregnancy itself. Even though vestibular schwannomas rarely present during pregnancy, symptoms may appear or worsen particularly in this period.

Keywords: Acoustic neuroma, cesarean section, pregnancy

he diagnosis and management of acoustic neuroma in a pregnant woman presents a real challenge to the obstetrician, neurosurgeon and anesthesiologist who must work as a close team.1 Since nausea, vomiting, headaches and vertigo are common complaints both during pregnancy and in the presence of brain tumors, the later ones though rare, may be underdiagnosed or even missed in the pregnant woman, until real neurological signs appear. Though case reports of acoustic neuroma in pregnant patients are few, the signs and symptoms of these tumors can dramatically worsen during the last 3 or 4 months of pregnancy. Advances in techniques of general anesthesia permit urgent operations on pregnant women with minimal risks to the fetus and mother.2 Case Report A 26-year-old primigravida with 8½ months of amenorrhea and well-appreciated fetal movements got

*Assistant Professor Dept. of Obstetrics and Gynecology PES IMSR, Kuppam, Andhra Pradesh †Senior Resident Dept. of Ophthalmology ‡Professor and Head #Assistant Professor Dept. of Obstetrics and Gynecology Sri Devaraj Urs Academy of Higher Education and Research Center Tamaka, Kolar, Karnataka Address for correspondence Dr Avinash Patil Assistant Professor Dept. of Obstetrics and Gynecology PES IMSR, Beggilipalle Palamaner Road, Kuppam - 517 425, Chittoor, Andhra Pradesh E-mail: avinashjkd9@gmail.com

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admitted to our hospital with complaints of headache and vomiting since 15 days, tingling sensation on right cheek since 7 days, blurring of vision since 3 days. Headache which was localized to right side of face, more in the morning was associated with vomiting, which was projectile in nature. Headache usually subsided after vomiting. Tingling sensation on the right cheek since 7 days, aggravated in the morning, and on exposure to cool breeze, relieved on exposure to sun light. Blurring of vision was more on the right side, not associated with pain, diplopia of right eye, no floaters and no aggravating or relieving factors. She was married for 1 year, nonconsanguineous marriage, her last menstrual period (LMP) was on 1/1/09 and expected delivery date (EDD) - 8/10/09 with gestational age of 34 weeks + 2 days. On examination, patient was moderately built and nourished, conscious, co-operative and well-oriented. Her pulse rate was 82 beats/min and blood pressure (BP) was 130/80 mmHg. On neurological examination, she was conscious, oriented, cranial nerves intact, except for tingling sensation on right side of face in trigeminal nerve distribution. Gross motor function and muscle strength were normal, superficial and deep tendon reflexes were normal and her cerebellar functions were intact. Abdominal examination revealed symphysiofundal height of 34 cm. Uterus 34 weeks size, fetal heart rate (FHR) 134/min, regular. On ophthalmic examination, she could perceive only hand movements close to face and vision in left eye was 6/36. Both the pupils were 3 mm, round, regular, reactive

IJCP Sutra 199: First onset of breathlessness after the 40 of age is likely to be cardiac in origin, unless proved otherwise.

OBSTETRICS AND GYNECOLOGY to light. Fundoscopic examination was suggestive of left optic disc drusen (Fig. 1). Complete hemogram, urine examination and renal and liver function test results were normal. USG examination was suggestive of single live intrauterine pregnancy of 30 ± 3 weeks of gestation in cephalic presentation. Placenta: Body anterior Grade 1, amniotic fluid index (AFI) - 9 cm. Estimated fetal weight (EFW) - 1.5 kg. Right eye

Diagnosis

Left eye

Figure 1. Left optic disc drusen.

Magnetic resonance imaging (MRI) showed a large, well-defined, extra-axial infratentorial mass lesion seen in right CP angle (Fig. 2). Mass was measuring about 4.4 × 3.5 × 4 cm. Medially, there was extension across midline. There was slight extension into the internal auditory canal. Prominent CP angle cistern mass from cerebellum-cerebrospinal fluid (CSF) cleft. Fourth ventricle was squashed and displaced to left. Midbrain and pons were deviated to left. Right lobe of cerebellum was compressed and draped over the postero-inferior aspect of the mass. Lateral and third ventricles were moderately dilated (Fig. 3).

Treatment In agreement with the neurosurgeons, the patient underwent emergency cesarean delivery under general anesthesia with controlled ventillation. Preoperatively, she received injection ranitidine 50 mg, injection metoclopromide 10 mg, injection phenytoin sodium 200 mg, injection 3% normal saline (NS) 100 mL. A single live preterm baby was extracted. The baby cried immediately after birth with Apgar score of 7 and 9 at one and fifth minute, respectively and 20 IU of oxytocin was added to RL. Patient was hemodynamically stable during perioperative period, with occasional raise in BP managed with injection esmolol. Recovery was uneventful. One week after surgery, patient was referred to National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore (India) where she underwent ventriculoperitoneal (VP) shunting. Following the procedure, patient was shifted back home with the advice for definitive surgery at later date. After 2 months of VP shunt operation, the patient had similar complaints and rapid diminishing of vision and progressive hearing loss, right (Rt) side V and VIII nerve palsy and bilateral cerebellar signs were positive (Rt >> Lt). She could perceive only light close to face. She underwent right retromastoid suboccipital craniotomy and total excision of acoustic neuroma. There was a

Figure 2. Extra-axial infratentorial mass lesion.

Figure 3. Moderately dilated lateral ventricles.

cystic component posteriorly so facial nerve could not be preserved. Immediate postoperative period, patient had Rt LMN (lower motor neuron) facial palsy and lateral rectus palsy in the Rt eye, so she underwent Rt tarsorrhaphy. Histopathology report was suggestive of vestibular schwannoma.

IJCP Sutra 200: Problems associated with how of blood in the heart may be accompanied with in the kidney and brain vessels as well.

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Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018

Discussion Acoustic neuromas constitute 6% of all intracranial tumors. The diagnosis of acoustic neuroma during pregnancy is often delayed because symptoms like nausea, vomiting, headache and tinnitus, which are nonspecific, are often attributed to pregnancy itself. Headache and high BP in advanced pregnancy may be mistaken for pre-eclampsia. Small acoustic neuromas are usually accompanied by hearing abnormalities or tinnitus. Large tumors are accompanied by headache and vomiting due to obstructive or communicating hydrocephalus, cerebellar signs such as ataxia and there is involvement of cranial nerves, including the trigeminal, facial, glossopharyngeal and vagus nerves (trigeminal nerve was involved in the present case). When an acoustic neuroma with no neurological signs and with normal intracranial pressure (ICP) is diagnosed during pregnancy, vaginal delivery may be planned with a low maternal risk. In the case of an advanced pregnancy and a large symptomatic neuroma, raised ICP and hydrocephalus, the best maternal and fetal outcomes are offered by emergency cesarean delivery after drainage of CSF, followed by definitive neurosurgery. Even though the incidence of vestibular schwannomas is not higher in pregnancy than in non-pregnant age-matched patients, it may become symptomatic in pregnancy. Failure to

diagnose a large lesion compressing the brainstem may cause sudden deterioration, and an attempted delivery in the presence of untreated high ICP can be disastrous. If performing cesarean section (either for obstetric indications or due to fears regarding ICP), general anesthesia offers greater control of ICP intraoperatively, than does regional anesthesia. Attention should be paid to raised ICP and risk of aspiration for the mother, placental blood flow and risk of immediate neonatal respiratory depression for the fetus.3 Comment Only multidisciplinary and co-operative teamwork of obstetrician, neurosurgeon, anesthesiologist and pediatrician can lead to a possible excellent prognosis in difficult cases of acoustic neuromas, diagnosed in late stage of pregnancy. References 1. Beni-Adani L, Pomeranz S, Flores I, Shoshan Y, Ginosar Y, Ben-Shachar I. Huge acoustic neurinomas presenting in the late stage of pregnancy. Treatment options and review of literature. Acta Obstet Gynecol Scand. 2001;80(2): 179-84. 2. Allen J, Eldridge R, Koerber T. Acoustic neuroma in the last months of pregnancy. Am J Obstet Gynecol. 1974;119(4):516-20. 3. Sharma JB, Pundir P, Sharma A. Acoustic neuroma in pregnancy: emergency cesarean section and definitive neurosurgery. Int J Gynaecol Obstet. 2003;80(3):321-3.

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IJCP Sutra 201: One of the most important keys to success is having the discipline to do what you know you should do, even when you don’t feel like doing it.

2018

OBSTETRICS AND GYNECOLOGY

To Evaluate the Etiological Determinants of Rhesus Isoimmunization and to Study Its Perinatal Outcome NEETU SINGH*, KIRAN PANDEY†, PREETI DUBEY‡, YASHWANT RAO#

Abstract Aims and objectives: To evaluate the etiological determinants of Rhesus (Rh)-immunization and to study the prevalence of perinatal mortality and morbidity in Rh-immunization. Material and methods: This retrospective study was carried out in the Dept. of Obstetrics and Gynecology, UISEMH, Kanpur from November 2007 to November 2010. All cases were thoroughly studied specially their history, examination, investigation, mode of delivery, passive immunization and their perinatal outcome. Results: We found an increased rate of isoimmunization with increasing parity. Most of our patients were gravida 4 (44%). In our study, we found that 84% of isoimmunized patients had a history of previous delivery in which there must have been a large fetomaternal hemorrhage (FMH). It was found that 80% did not receive ante-D while 20% received. Rh-immunization in 20% of those who received ante-D could be explained due to inadequate dosage. The major cause of perinatal morbidity was hyperbilirubinemia followed by anemia. Conclusion: Rh-immunization is a persistent problem in developing countries. As Rhimmunizing stimulus occurs late in pregnancy and most often at delivery, a successful program for Rh immunoprophylaxis with Rh-Ig, prevents not only fetal death but also sensitizing prospects. Early reference of affected patients with early assessment and judicial interventions as well as intensive neonatal care is essential in ensuring satisfactory results.

Keywords: Rhesus (Rh)-immunization, isoimmunization, perinatal outcome, Rh-Ig, Rh immunoprophylaxis, intensive neonatal care

bout 5-10% of Indian population is Rhesus (Rh)negative. The Rh gene is located on short-arm of chromosome-1. In utero, the Rh-antigen is well-developed by Day 38. Rh-immunization is a major problem in developing countries like India. Rh-stimulus occurs late in the course of pregnancy mostly at the time of delivery. It should be kept in mind that 1-2% of Rh-negative mothers become sensitized to the Rh-antigen during pregnancy by what is known as “silent bleeds”. There are many causes of Rh-immunization such as fetomaternal hemorrhage (FMH) during delivery, medical termination of pregnancy (MTP), abruption,

*Assistant Professor †Professor and Head ‡Professor Dept. of Obstetrics and Gynecology #Assistant Professor Dept. of Pediatrics GSVM Medical College, Kanpur, Uttar Pradesh Address for correspondence Dr Neetu Singh Assistant Professor Dept. of Obstetrics and Gynecology GSVM Medical College Campus, Kanpur, Uttar Pradesh E-mail: drneetusingh73@gmail.com

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placenta previa (PP), bleeding in first trimester, external cephalic version, etc. So, in present day practice, utilization of antibody-mediated immune-suppression in order to assure a more effective disappearance of Rh-disease, is needed and will require a timely antepartum and postpartum prophylaxis to reduce perinatal morbidity and mortality. The relationship between hemolytic disease of newborn (HDN) and Rh-sensitization is wellestablished by Levine et al in 1941. An approach to prevention and eradication of this disease has been developed by techniques of preventing immunization in mothers. The development of real time ultrasound and Doppler not only helped us to understand fetal anatomy but also physiological states and dynamics of blood flow in fetal circulation. Intrauterine transfusion have become routine to treat fetal anemia. Several recent improvements like phototherapy, fibro-optic delivery system and IV-IG have revolutionized the management of hemolytic disease of newborn. Anti-D prophylaxis has been a remarkable step to prevent Rh-immunization. Despite such progress in prevention, Rh-immunization is still widespread. Cases of Rh-immunization are still occurring at an increased rate in India and this urgently calls for re-evaluation of the cases of anti-D prophylaxis.

IJCP Sutra 202: Welcome those big, sticky, complicated problems. In them are your most powerful opportunities. —Ralph Mar

OBSTETRICS AND GYNECOLOGY Table 1. Demographic Profile of Rh-immunized Pregnancies Age in years

No. of cases/ (Percentage) (n = 96)

Parity

No. of cases/ (Percentage) (n = 96)

Incidence of babies affected (n = 86)

1 (1%)

<34 weeks

24 (28%)

21-25

21 (22%)

13 (14%)

34-37 weeks

20 (24%)

26-30

61 (64%)

15 (16%)

37-40 weeks

37 (42%)

31-35

10 (10%)

43 (44%)

>40 weeks

36-40

2 (2%)

18 (19%)

>40

1 (1%)

6 (6%)

<20

Aims and Objectives To evaluate the etiological determinates of Rhimmunization and to study the prevalence of perinatal mortality and morbidity in Rh-immunization.

05 (06%) Excluding IUD

Table 2. To Evaluate the Etiological Determinants of FMH Leading to Rh-immunization Sensitizing events

No. of cases (n = 96)

Percentage (%)

Bleeding in first trimester

Material and Methods

MTP

This retrospective study was carried out on 96 patients in the Dept. of Obstetrics and Gynecology, UISEMH, GSVM Medical College, Kanpur from November 2007 to November 2010. All cases were thoroughly studied specially their history, examination, investigation, mode of delivery, passive immunization and their perinatal outcome.

Abortion

Ectopic

Nil

H. mole

Nil

Abruption

PP with bleeding

ECV

Delivery

Observations During 3 years study period, 7920 deliveries occurred in UISEMH. Out of 7,920 deliveries, 560 patients were Rh-negative; giving an incidence of 7%. Out of 560 Rh-negative women, 96 were isoimmunized patients according to their Coombâ&#x20AC;&#x2122;s titer status. In these 96 cases; 69 women (72%) were unbooked, while 27 women (28%) were booked. Table 1 shows that maximum women were in the age group 26-30 years (64%). We found an increased rate of isoimmunization with increasing parity. Most of our patients were gravida 4 (44%). It also shows the correlation of outcome of the babies with their respective gestational age. Our study showed that 90% of the preterm babies required treatment while only 27% of term babies required treatment reflecting that preterm babies are more susceptible. Table 2 shows the etiological determinants. In our study, we found that 84% of isoimmunized patients had a history of previous delivery in which there must have been a large FMH; 10% had a history of antepartum hemorrhage (APH) (abruption - 6%; PP - 4%).

Table 3. Association of Mode of Delivery of Previous Pregnancy with FMH Mode of delivery

Incidence (n = 81)

Percentage (%)

Normal

Forceps

Ventouse

LSCS

Breech

IUD

Table 3 shows that out of those; 58% were complicated deliveries and 22% had a history of cesarean; 20% of patients who had a normal delivery also had FMH. Table 4 shows relation of isoimmunization with history of anti-D received, it was found that 80% did not receive ante-D, while 20% received. Rh-immunization in 20% of those who received ante-D could be explained due to inadequate dosage. Table 5 shows the clinical outcome; 45% had hyperbilirubinemia, 28% were anemic while

IJCP Sutra 203: Obstacles are those frightful things you see when you take your eyes off your goal. â&#x20AC;&#x201D;Henry Ford

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Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018

Table 4. History of Anti-D Received Received

20%

Not received

80%

Table 5. Clinical Outcome of Rh-positive Babies Clinical outcome

No. of cases

Percentage (%)

Hyperbilirubinemia

Anemia

Kernicterus

Hypoglycemia

Hydrops-fetalis

IUD

Table 6. Perinatal Outcome in Rh-sensitized Pregnancies Perinatal outcome

No. of cases

Percentage (%)

NICU admission Expired

IUD

Recovered

No treatment required

kernicterus, hypoglycemia, hydrops and intrauterine device (IUD) were found in 8%, 7%, 2% and 10% cases, respectively. The major causes of perinatal morbidity were hyperbilirubinemia followed by anemia. Table 6 shows perinatal outcome 40% required no treatment while 50% required treatment out of which 12% expired. Recovery was noted in 38% of cases. Discussion One would expect the incidence of Rh-immunization to be low but this does not appear to be the case due to lack of ante-D prophylaxis and inadequate dosage of anti-D given after delivery. Therefore, the exact incidence is probably unknown due to failure to diagnose or under reporting as stated by Mandeep et al. The prevalence of Rh-immunization in our study was 15% out of those who were Rh-negative. According to Lau et al (1995) external cephalic version (ECV) caused FMH in 2-6% cases, though in our study only 1% had a history of ECV. Reddy et al (1999), reported incidence of FMH in first, second and third trimester as 6.7%, 13.9% and 29%, which was similar in our study which reported the incidence of 4.5%, 9.5% in first and second trimester. In our study, majority (84%) of the patients who were isoimmunized had a previous history of delivery.

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Bowman et al (1988) evaluated and found that FMH occurred at delivery in 90% and antenatally in 10%; in concordance to his study 84% of patients had history of delivery, while 16% cases were associated with antenatal FMH in our study. In one case, primigravida was noted to be isoimmunized. After a proper evaluation, she had no history of any FMH or any blood transfusion. This may be explained by silent FMH occurring throughout pregnancy. Frigolette et al (1983) showed in his study that 1-2% of cases may have FMH known as “silent bleeds”. The majority of the cases were having no history anti-D after delivery (80%), it was found that 60% patients with previous history of complicated vaginal delivery and cesarean section had large amount of FMH leading to isoimmunization. This was supported by Mehta et al (1979) who showed that complicated or instrumental deliveries increase the risk of FMH to around 80%. Rh-immunization causes significant perinatal mortality and morbidity; this was shown by Diamond et al (1932) and Levine et al (1941). The clinical outcome varied, out of which the most common morbidity was hyperbilirubinemia followed by anemia. Our study reported a perinatal mortality of 22% (including IUD) and perinatal morbidity of 38%. Higher perinatal mortality in our study may be due to 72% of unbooked cases, which did not receive any antenatal care and were referred to our tertiary care center with antepartum and intrapartum complications. Our results for perinatal morbidity shows that 40% required no treatment, 38% recovered after treatment, while 22% expired despite treatment due to severe disease. Our outcomes were comparable to Alvin et al (1995) who during their study noted that 51% required no treatment, 31% required treatment after term delivery. Ashma Madan et al (2004) also showed that 25% have severe disease, 20% have no apparent disease. Conclusion Rh-immunization is a persistent problem in developing countries. As Rh-immunizing stimulus occurs late in pregnancy and most often at delivery, a successful program for Rh immunoprophylaxis with RhIgG, prevents not only fetal death but also sensitizing prospects. Early reference of affected patients from periphery to higher center, with early assessment and judicial interventions as well as intensive neonatal care are essential in ensuring satisfactory results.

IJCP Sutra 204: The will to win, the desire to succeed, the urge to reach your full potential... these are the keys that will unlock the door to personal excellence. —Confucius

OBSTETRICS AND GYNECOLOGY Future challenges such as spreading awareness of the need of antenatal prophylaxis, routine postpartum prophylaxis is to be emphasized. Advanced method for increasing safety of anti-D preparations, use of monoclonal Rh-D antibodies and newer future test for FMH will need future researches. Suggested reading 1. Alvin: Avery’s Textbook of Neonatology, Isoimmune HD. Alvin Zipursky, John M, Bowman; 1995. pp. 44-66. 2. Neonatal Hyperbilirubinemia (Chapter 79). Asthma Avery’s Textbook of Neonatology. 8th Edition, 2004. p. 1231. 3. Bowman JM. The prevention of Rh immunization. Transfus Med Rev. 1988;2(3):129-50. 4. Diamond LK, Blackfan KD, Baty JM. Erythroblastosis fetalis and its association with universal oedema of fetus; icterus gravis neonatorum as anaemia of the newborn. J Pediatr. 1932;1(3):269-76.

5. Frigolette FD Jr (Ed.). Antepartum administration of Rh immune globulin: a guide to office procedure. Raritan, NJ: Ortho-Diagnostic Systems, Inc.; 1983. 6. Lau TK, Stock A, Rogers M. Fetomaternal haemorrhage after external cephalic version at term. Aust N Z J Obstet Gynaecol. 1995;35(2):173-4. 7. Levine P, Burnham L, Katzin EM, Vogel P. The role of iso-immunization in the pathogenesis of erythroblastosis fetalis. Am J Obset Gynecol. 1941;42:925-37. 8. Mandeep et al. FOGSI FOCUS. 2006;11. 9. Mehta DM, Gupte SC, Bhatia HM. Transplacental haemorrhage and maternal iso-immunization. J Postgrad Med. 1979;25(2):75-80. 10. Reddy U, Wilter. Isoimmunization. In: Lambrous N, Morse. A Wallach EE (Eds.). John Hopkins Manual of Obstetrics and Gynaecology. Baltimore: Lippincott Williams & Wilkins; 1999. p. 199.

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IJCP Sutra 205: Pinch test: Pinch the skin at the side fold of abdomen, if it can come in the two fingers pinch grip one is obese.

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OBSTETRICS AND GYNECOLOGY

Lower Segment Large Fibroid in a Unicornuate Uterus with 34 Weeks Pregnancy URVASHI SINGH*, SHIVANGI PANCHPAL†

Abstract Uterine fibroids are slow growing, benign tumors that arises from smooth muscle cell of the uterus. They are found in 25% of women in the reproductive age group. The reported prevalence of fibroids in pregnancy varies from 0.09% to 3.9%. Also, unicornuate uterus is associated with poor reproductive performance. The chance of the pregnancy reaching term is just 20-30% and the live birth rate is around 40% in a unicornuate uterus. We report the case of a 24-year-old infertility treated primigravida with 34 weeks pregnancy with cephalic presentation and regular fetal heart beats who presented complaint of leaking per vaginum for 12 hours. Diagnostic laparoscopy had revealed a unicornuate uterus with a rudimentary horn on left side and her ultrasonography showed a fibroid measuring 5.1 × 3.9 × 5.2 cm involving body of uterus and part of cervix. She was immediately taken up for cesarean section. Though myomectomy at the time of cesarean delivery is associated with significant morbidity (hemorrhage) it should be pursued with caution and only in select patients. Intrapartum myomectomy was decided and injection vasopressin 20 U diluted in 20 mL normal saline was given over the fibroid to maintain hemostasis. Whole of fibroid was enucleated and a preterm female baby weighing 2.25 kg was extracted out with Apgar score 7/10 at 1 minute and 8/10 at 5 minutes. Hemostasis was maintained and abdomen was closed in layers.

Keywords: Uterine fibroids, unicornuate uterus, pregnancy, cesarean section, intrapartum myomectomy, hemostasis

Case Report A 24-year-old infertility treated primigravida with 34 weeks pregnancy was seen on 2nd June, 2011 with complaint of leaking per vaginum for 12 hours. She had been married for 8 years. She was referred from Military Hospital. On examination, there was a single fetus of 34 weeks with cephalic presentation with regular fetal heart beat. Per speculum examination showed leaking and the liquor was clear. Per vaginal examination showed cervical dilatation of 2 cm with cord below presenting part. Cord pulsations were felt. Her routine investigations showed hemoglobin - 9.6 g/dL, blood group Rh-O+ve, hepatitis B surface antigen (HBsAg) -negative, Venereal

*Lecturer †3rd Year Resident Dept. of Obstetrics and Gynecology Motilal Nehru Medical College, Allahabad, Uttar Pradesh Address for correspondence Dr Urvashi Singh Lecturer Motilal Nehru Medical College, Allahabad - 211 001, Uttar Pradesh E-mail: oshidr@indiatimes.com

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Disease Research Laboratory (VDRL) - negative, urine routine and microscopic - NAD. She had undergone diagnostic laparoscopy, which revealed a unicornuate uterus with a rudimentary horn on left side. Her ultrasonography had showed a fibroid measuring 5.1 × 3.9 × 5.2 cm involving body of uterus and part of cervix. Hysteroscopic myomectomy was done and the fibroid was resected. Her third trimester scan showed a uterine fibroid measuring 7.5 × 7.6 × 9.6 cm involving lower segment. She was immediately taken up for cesarean section. One unit of cross-matched blood was arranged. On opening the abdomen, there was a large fibroid occupying whole of the lower segment and part of upper segment anteriorly. There was no place to go through the upper segment. So, intrapartum myomectomy was decided. Injection vasopressin 20 U diluted in 20 mL normal saline was given over the fibroid to maintain hemostasis. A transverse incision was given over the myoma on the lower segment and whole of fibroid was enucleated. Removal of fibroid opened the lower segment. A loop of cord was first seen. A preterm female baby weighing 2.25 kg was extracted out with Apgar score 7/10 at 1 minute and 8/10 at 5 minutes. The uterus was unicornuate with a rudimentary horn

IJCP Sutra 206: Waist-to-hip ratio (WHR) is the ratio of the circumference of the waist to that of the hips. It measures the proportion by which fat is distributed around the torso.

OBSTETRICS AND GYNECOLOGY on the left side. Bilateral ovaries were normal. Lower segment contracted slowly with 40 U syntocinon drip. Injection methylergometrine and injection prostodin were given. Hemostasis was maintained and abdomen was closed in layers. Average blood loss during surgery was about 750 mL. Duration of surgery was about 1 hour 10 minutes. She received 1 unit of blood transfusion and antibiotic coverage. Baby was admitted in neonatal intensive care unit (NICU) for 7 days. Patient was discharged on 10th postoperative day with a hemoglobin of 9.0 g/dL. Discussion Figure 1. Fibroid being removed.

Figure 2. Unicornuate uterus with absent left side tube.

Fibroids are found in 25% of women in the reproductive age group. Accurate incidence is difficult to ascertain as majority of fibroids are asymptomatic. However, the reported prevalence in pregnancy varies from 0.09% to 3.9%.1 Fibroids, particularly submucous may cause infertility or repeated pregnancy loss. The risk of myomectomy in terms of excessive hemorrhage is significantly greater in the third trimester. In a series of 9 patients who underwent cesarean myomectomy, 3 of them had profuse bleeding and required a hysterectomy.2 However, some studies have shown that there is no significant difference in blood loss, the need for blood transfusion and postoperative morbidity between women undergoing cesarean section and cesarean myomectomy.3,4 Also, unicornuate uterus is associated with poor reproductive performance. Chances of pregnancy reaching term is just 20-30% and the live birth rate is around 40% in a unicornuate uterus.5 References 1. Ouyang DW, Economy KE, Norwitz ER. Obstetric complications of fibroids. Obstet Gynecol Clin North Am. 2006;33(1):153-69. 2. Exacoustòs C, Rosati P. Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obstet Gynecol. 1993;82(1):97-101. 3. Kwawukume EY. Caesarean myomectomy. Afr J Reprod Health. 2002;6(3):38-43. 4. Brown D, Fletcher HM, Myrie MO, Reid M. Caesarean myomectomy - a safe procedure. A retrospective case controlled study. J Obstet Gynaecol. 1999;19(2):139-41.

Figure 3. Rudimentary horn on left side.

5. Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simón C, Pellicer A. Reproductive impact of congenital Müllerian anomalies. Hum Reprod. 1997;12(10):2277-81. ■■■■

IJCP Sutra 207: Women basal metabolic rate (BMR) formula: BMR = 655 + (9.6 × weight in kilos) + (1.8 × height in cm) - (4.7 × age in years).

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SURGERY

Cotton Bezoar Causing Intestinal Obstruction JAGANNATH KULKARNI*, SANJIV KUMAR GOYAL*, GIRISH SINGLA*

Abstract Background: The unusual urge to eat cotton fibers is usually seen in people whose mental health is affected. Presentation could be in the form of trichophagy (eating hair), followed by trichobezoar or phytobezoar (eating vegetable fibers), which is a rare entity. Rapunzel syndrome is a term for trichobezoar where the parent bezoar is in the stomach and a tail of the fibers or hair extends into the jejunum. Presentation as gastric outlet obstruction due to a cotton bezoar in the stomach and intestine is rare, hence we report it here. Case report: A 60-year-old gentleman with no known comorbidities presented to the emergency room with history of pain abdomen, vomiting and loss of weight. Ultrasound followed by CT abdomen and pelvis revealed features of gastric outlet obstruction due to foreign body. On emergency exploratory laparotomy after initial resuscitation, he was found to have a large gastric cotton bezoar possibly extending into the proximal jejunum. The bezoar was extracted via gastrostomy and on-table enteroscopy confirmed complete evacuation of the bezoar. On postoperative Day 5, patient was discharged on soft diet. Conclusion: Gastrointestinal bezoars are a rare entity, and when cotton is the nature of bezoar with possible gastric outlet obstruction Rapunzel syndrome, it qualifies for inclusion into the literature.

Keywords: Cotton bezoar, Rapunzel syndrome, gastric outlet obstruction

tomach bezoars if detected in time may be treated by endoscopic retrieval but if presentation is in the form of intestinal obstruction with or without perforation management is by a formal exploratory laparotomy followed up by treatment for the underlying psychiatric disorder.1,2 Bezoars are rare and are often reported in patients with some psychiatric ailment.3,4 They usually present with signs and symptoms due to a mass in the stomach, which may rarely extend into the jejunum as a tail (Rapunzel syndrome).1,5,6 Such instances where in an elderly male patient presents to the Emergency Room (ER) with signs of gastric outlet obstruction due to cotton bezoar and successful management surgically is rare in literature. Case Report A 60-year-old gentleman with no known comorbidities was brought to the ER with history of pain abdomen recurrent episodes of vomiting for 4 days. On examination, he appeared dehydrated, his heart

*Consultant Gen/Lap Surgeon Grecian Super Speciality Hospital, Mohali, Punjab Address for correspondence Dr Girish Singla Consultant Gen/Lap Surgeon Grecian Super Speciality Hospital, Sector 69, SAS Nagar, Mohali -160 062, Punjab E-mail: drgirishsingla@gmail.com

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rate (HR) - 98 bpm, blood pressure (BP) - 130/80 mmHg, conscious and oriented. Per abdominal examination revealed vague palpable mass and signs of gastric outlet obstruction. Per-rectal examination had empty rectum and no growth was palpated. Other systems examination was normal. He was resuscitated in ER with IV fluids, antispasmodics, antiemetics and was started on broadspectrum IV antibiotics. Blood samples were sent for all the preoperative values. Baseline ECG, X-ray chest was done. Ryle’s tube aspiration was started and a Foley’s catheter was placed. Ultrasound followed by CT abdomen showed features of gastric outlet obstruction possibly due to a foreign body. The patient underwent emergency exploratory laparotomy. Gastric palpation suggested foreign body and on gastrotomy (Fig. 1) a large and a long band/ball of cotton fibers was seen. After complete extraction of the bezoar, it was found to measure 2.4 feet in length and was made up of varying girths and colors of cotton fibers (Fig. 2). On table enteroscopy via the gastrotomy confirmed complete extraction of the bezoar. Gastrotomy and abdomen were closed with drain. He improved over a period of 3 days after the surgery and was taking liquids on post-op Day 3. He was started on soft diet on post-op Day 5 and discharged on post-op Day 6 in stable condition.

IJCP Sutra 208: Men basal metabolic rate (BMR) formula: BMR = 66 + (13.7 × weight in kilos) + (5 × height in cm) - (6.8 × age in years).

SURGERY and even plague. A genuine bezoar was recognized by its failure to smoke when a red-hot needle was plunged into it.3,5,6 Causes of bezoar include the presence of indigestible material in the lumen, gastric dysmotility (including previous surgery like vagotomy and partial gastrectomy, etc.) and certain other substances that encourage stickiness and concretion formation. The clinical presentation may be a palpable, firm, nontender epigastric mass, which is either discovered, on routine physical examination in an asymptomatic patient. Bezoars have been reported between the ages of 1 and 56 years, most presenting between the ages of 15-20 years and 90% are in females. Approximately 10% show psychiatric abnormalities or mental retardation.1

Figure 1. Gastrotomy and extraction of bezoar.

Figure 2. Cotton bezoar measuring 2.4 feet.

Discussion and Conclusion Around 400 cases of trichobezoar and a larger number of phytobezoars have been reported in the literature but many go unreported.1,4 They occur mainly in the young women who chew and swallow their hair (trichobezoar) or phytobezoar (vegetable fibers) or diospyrobezoar (persimmon fibers) or pharmacobezoar (tablets/semiliquid masses of drugs).3,6,7 With time, these are retained by mucus and become enmeshed, creating a mass in the shape of the stomach where they are usually found. They may attain large sizes owing to the chronicity of the problem and delayed reporting by the patients. The term bezoar comes from the Arabic “badzehr” or from the Persian “panzer” both meaning counter poison or antidote.4,5 Hindus used bezoars in the 12th century BC for rejuvenating the old, neutralizing snake venom and other poisons, treating vertigo, epilepsy, melancholia

Rarely, the bezoars may extend into the small intestine as a tail (Rapunzel syndrome after “Rapunzel” the fair, long haired maiden in the Grimm brother’s fairy tail who lowered her tresses to allow Prince charming to climb up to her prison tower to rescue her) or may get broken lodging in the intestine to cause intestinal obstruction, ulceration, bleeding and perforation. Small intestinal bezoars have also been reported after truncal vagotomy and with compression of the duodenum by the superior mesenteric artery.8 Bezoars mostly originate in the stomach and are probably related to high fat diet causing nonspecific symptoms like epigastric pain, dyspepsia and postprandial fullness; the stomach is not able to push the hair/cotton or other substance out of the lumen because the friction surface is insufficient for propulsion by peristalsis.3,5,6 They may also present with gastrointestinal bleeding (6%) and intestinal obstruction or perforation (10%).3,5,6 Diagnosis at an early stage is important since conservative treatment (fragmentation and endoscopic extraction, enzymatic destruction) is possible for gastric bezoars. If available, endoscopic examination of the stomach is the preferred method of exploring the stomach for the concomitant bezoar while managing a case of intestinal bezoar. Exploration may reveal concomitant gastric bezoar, which may be retrieved endoscopically or by gastrotomy.7 Escamilla et al reported 23 cases of concomitant gastric bezoars (extracted by gastrotomies) out of 87 cases of intestinal bezoars.7 If detected in the intestine, they may be milked down to the enterotomy site for retrieval through one opening or they may require multiple enterotomies. Treatment is removal of the mass by a single enterotomy or resection of the bowel if not viable.2,7 Duncan

IJCP Sutra 209: Diet and lifestyle: All patients who are overweight (BMI 27 kg/ m2) or obese (BMI 30 kg/m2), should receive counseling on diet, lifestyle and goals for weight loss.

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Indian Journal of Clinical Practice, Vol. 28, No. 11, April 2018

et al recommended bezoar extraction by multiple enterotomies in the Rapunzel syndrome.9 DeBakey and Ochsner reported an operative mortality of 10.4%.10 It is mandatory to do a thorough exploration of the rest of the small intestine and the stomach to look for retained bezoars.11 References 1. Senapati MK, Subramanian S. Rapunzel syndrome. Trop Doct. 1997;27(1):53-4. 2. Santiago Sánchez CA, Garau Díaz P, Lugo Vicente HL. Trichobezoar in a 11-year old girl: a case report. Bol Asoc Med P R. 1996;88(1-3):8-11.

5. Allred-Crouch AL, Young EA. Bezoars - when the ‘knot in the stomach’ is real. Postgrad Med. 1985;78(5):261-5. 6. Goldstein SS, Lewis JH, Rothstein R. Intestinal obstruction due to bezoars. Am J Gastroenterol. 1984;79(4):313-8. 7. Escamilla C, Robles-Campos R, Parrilla-Paricio P, LujanMompean J, Liron-Ruiz R, Torralba-Martinez JA. Intestinal obstruction and bezoars. J Am Coll Surg. 1994;179(3):285-8. 8. Doski JJ, Priebe CJ Jr, Smith T, Chumas JC. Duodenal trichobezoar caused by compression of the superior mesenteric artery. J Pediatr Surg. 1995;30(11):1598-9. 9. Duncan ND, Aitken R, Venugopal S, West W, Carpenter R. The Rapunzel syndrome. Report of a case and review of the literature. West Indian Med J. 1994;43(2):63-5.

3. Andrus CH, Ponsky JL. Bezoars: classification, pathophysiology, and treatment. Am J Gastroenterol. 1988;83(5):476-8.

10. DeBakey M, Ochsner W. Bezoars and concretions: A comprehensive review of the literature with an analysis of 303 collected cases and a presentation of 8 additional cases. Surgery. 1939;5:132-60.

4. Sharma RD, Kotwal S, Chintamani, Bhatnagar D. Trichobezoar obstructing the terminal ileum. Trop Doct. 2002;32(2):99-100.

11. Chintamani, Durkhure R, Singh JP, Singhal V. Cotton Bezoar - a rare cause of intestinal obstruction: case report. BMC Surg. 2003;3:5.

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IJCP Sutra 210: The LDL cholesterol goal for people with diabetes is below 70 mg%.

2018

IMAGING AND INVESTIGATIONS

Low Molecular Weight Dextran: An Alternative to Radiographic Contrast Agent for OCT Imaging RAJESH VIJAYVERGIYA

ptical coherence tomography (OCT) requires a radiographic contrast agent to replace the blood during intravascular imaging. Increased use of contrast volume during OCT imaging may further worsen the renal functions in patients who are at high risk for contrast-induced nephropathy (CIN). Low molecular weight dextran-40 can be an alternative to contrast agent during OCT imaging. Dextran-40 is a sterile, nonpyrogenic preparation of low molecular weight dextran (40,000 molecular weightÂ 10 gm%) in 5% dextrose or 0.9% sodium chloride injection. We compared the image quality of iohexol 350 mg I/ mL radiographic contrast agent (GE Healthcare, Princeton,Â NJ) with dextran in 5 patients of percutaneous coronary intervention (PCI). During frequency domain OCT imaging with 2.7 French C7 Dragonfly TM imaging catheter (St Jude, Minneapolis, MN), contrast and dextran was given in succession to acquire intravascular imaging. The image quality of normal coronary segment, plaque morphology like calcified, lipid rich plaque, fibrous plaque (Fig. 1) and thrombus, thrombus protrusion through stent struts, post-stenting struts apposition, side branch visualization and plaque protrusion (Fig. 2) was comparable and of good quality in both the arms. There was no complication of intracoronary dextran injection in any of the patients. We are now routinely using dextran as an alternative to contrast agent for OCT imaging in high risk patients for CIN. A small amount of dextran used during OCT imaging does not have any deleterious hemodynamic, hematological or nephrotoxic effects. Anaphylactic

Normal

Lipid rich plaque

Fibrous plaque

Contrast

Dextran

Figure 1. Image quality of normal coronary segment, plaque morphology like calcified, lipid rich plaque, fibrous plaque with both contrast and dextran were of good quality.

Thrombus

Thrombus protrusion

Side branch ostium

Plaque protrusion

Contrast

Dextran

Figure 2. Image quality of thrombus, thrombus protrusion through stent struts, post-stenting struts apposition, side branch visualization and plaque protrusion with both contrast and dextran was comparable and of good quality.

reaction can be a serious side effect as it is a synthetic colloid produced from a bacterium. Dextran can be used as an alternative to contrast agent in certain high risk patients of CIN.

Professor Dept. of Cardiology PGIMER, Chandigarh

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Calcified plaque

IJCP Sutra 211: The blood pressure goal for people with diabetes is below 130/80 mmHg.

IMAGING AND INVESTIGATIONS

Mirage Pneumonia BHAVANA VENKATA NAGABHUSHANA RAO*, BVS RAMAN†

23-year-old female engineering graduate came with complaints of fever, cold, postnasal discharge, cough and breathlessness of 1 week duration. She was an asthmatic on salbutamol inhalation whenever necessary. On examination, she had bilateral rhonchi but no crepitations. Leukocytosis and elevated erythrocyte sedimentation rate (ESR) were found on blood examination. Skiagram of paranasal sinuses showed bilateral maxillary sinusitis (Fig. 1) and skiagram of chest demonstrated left lower zone haziness (Fig. 2). It was suspected that she had left lower lobe pneumonia, hence planned for emergency admission and intravenous antibiotics. As there were no crepitations on auscultation, lateral view chest X-ray was taken to localize the pneumonia (Fig. 3). It was found that a lobular soft tissue in the breast that was casting shadow in the left lower zone. Now a closer look at the PA view revealed lobulated, nonsegmental shadow without any air bronchogram suggestive of an artefact. Then on further inquiry, it was learned that the patient underwent breast augmentation surgery for hypoplastic left breast. She improved with cefditoren and levofloxacin given for 10 days.

Figure 1. X-ray paranasal sinus demonstrating bilateral maxillary sinusitis.

It is rare for doctors from developing countries to come across with a young patient with breast augmentation surgery. It may lead to over or misdiagnosis more so when surgery was unilateral. Implants also interfere with mammography and cardiac imaging leading to diagnostic difficulty. Silicone breast implants were first introduced in breast reconstruction surgery in 1964. Since then, implants further evolved over time. Either they can be filled with silicone gel or saline. Breast implants can be Figure 2. Chest PA view sowing left lower zone opacity suggestive of pneumonia. *Dept. of Medicine †Dept. of Surgery Queen’s NRI Hospital, Seethammadhara, Visakhapatnam, Andhra Pradesh Address for correspondence Dr Bhavana Venkata Nagabhushana Rao Dept. of Medicine Queen’s NRI Hospital, Seethammadhara, Visakhapatnam - 530 013, Andhra Pradesh E-mail: bhavanavnrao@gmail.com

IJCP Sutra 212: LDL = Total cholesterol minus (HDL plus VLDL).

utilized for the reconstruction or cosmetic purposes. Implants may have single or double lumen. They are of diverse shapes and surfaces. There is concern about long-term deleterious effects of the implants. But there is no strong evidence of such ill effects except for surgical or implant related local effects. A systematic

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connective tissue disorders in breast implant usage. However, rare association of low-grade anaplastic large cell lymphoma was reported by the US Food and Drug Administration (FDA). Breastfeeding is not affected by implants and no evidence of an increment in the silicone excretion in breast milk.2 They neither increase the risk of breast malignancy nor interfere with cancer detection by mammography.3 Ruptured breast implant may interfere with mammography. Magnetic resonance imaging (MRI) is the best modality in such clinical situations and is also superior in delineating the infections and their sequelae. Breast implants may pose a problem due to abnormal shadows they create in chest X-ray taken for visa or immigration purposes. References 1. Brinton LA. The relationship of silicone breast implants and cancer at other sites. Plast Reconstr Surg. 2007;120 (7 Suppl 1):94S-102S. Figure 3. Lateral view of chest delineating soft tissue density in the breast and no parenchymal lesion.

review found no evidence of increased incidence of malignancy in other organs.1 The American Association of Rheumatology opined that there is no increase in

2. Semple JL. Breast-feeding and silicone implants. Plast Reconstr Surg. 2007;120(7 Suppl 1):123S-128S. 3. Jakubietz MG, Janis JE, Jakubietz RG, Rohrich RJ. Breast augmentation: cancer concerns and mammography A literature review. Plast Reconstr Surg. 2004;113(7):117e-22e.

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Rule of 6 for Hypertension Reducing dietary sodium intake to less than 6 g sodium chloride can alone reduce BP by 6 mmHg (2-8 mmHg).

Rule of 9 for Hypertension Eating 9 servings of fruits and vegetables (low fat dairy products with reduced saturated and total fats) can reduce BP by 9 mmHg.

Rule of 10 for Hypertension ÂÂ

In patients with stage 1 hypertension (upper BP 140-159 and lower BP 90-99 mmHg) and additional cardiovascular risk factors, achieving a sustained 10 mmHg reduction in upper BP over 10 years will prevent 1 death for every 10 patients treated.

ÂÂ

For every 10 kg weight reduction, a reduction of BP by 10 mmHg (5-20 mmHg) can be achieved.

Formula of 20 for Hypertension Appearance of high BP before the age of 20 means investigations.

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IJCP Sutra 213: Non-HDL = Total cholesterol minus HDL cholesterol.

Medicolegal IN THE SUPREME COURT OF INDIA CIVIL APPELLATE JURISDICTION I.A Nos. 13-15 of 2017 IN SPECIAL LEAVE PETITION (C) Nos. 16657-16659 OF 2016 Union of India ..... Petitioner Versus Indian Radiological and Imaging Association and ORS. ETC. ETC. ..... Respondents ORDER

1. We have heard learned counsel for the contesting parties and considered the written submissions tendered, for the purpose of evaluating the grant of interim relief. 2. In Voluntary Health Association of Punjab v Union of India,1 this Court by a judgment dated 8 November 2016 issued comprehensive directions for the purpose of effective implementation of the provisions of the Pre-conception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994.2 The directions issued by this Court are extracted below: â&#x20AC;&#x153;33. Keeping in view the deliberations made from time to time and regard being had to the purpose of the Act and the far reaching impact of the problem, we think it appropriate to issue the following directions in addition to the directions issued in the earlier order:

(a) All the States and the Union Territories in India shall maintain a centralized database of civil registration records from all registration units so that information can be made available from the website regarding the number of boys and girls being born. (b) The information that shall be displayed on the website shall contain the birth information for each District, Municipality, Corporation or Gram Panchayat so that a visual comparison of boys and girls born can be immediately seen. (c) The statutory authorities if not constituted as envisaged under the Act shall be constituted forthwith and the competent authorities shall take steps for the reconstitution of the statutory

IJCP Sutra 214: VLDL = Triglycerides divided by 5 or Triglyceride/5.

bodies so that they can become immediately functional after expiry of the term. That apart, they shall meet regularly so that the provisions of the Act can be implemented in reality and the effectiveness of the legislation is felt and realized in the society.

(d) The provisions contained in Sections 22 and 23 shall be strictly adhered to. Section 23(2) shall be duly complied with and it shall be reported by the authorities so that the State Medical Council takes necessary action after the intimation is given under the said provision. The Appropriate Authorities who have been appointed under Section 17(1) and 17(2) shall be imparted periodical training to carry out the functions as required under various provisions of the Act.

(e) If there has been violation of any of the provisions of the Act or the Rules, proper action has to be taken by the authorities under the Act so that the legally inapposite acts are immediately curbed.

(f) The Courts which deal with the complaints under the Act shall be fast tracked and the concerned High Courts shall issue appropriate directions in that regard.

(g) The judicial officers who are to deal with these cases under the Act shall be periodically imparted training in the Judicial Academies or Training Institutes, as the case may be, so that they can be sensitive and develop the requisite sensitivity as projected in the objects and reasons of the Act and its various provisions and in view of the need of the society.

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(h) The Director of Prosecution or, if the said post is not there, the Legal Remembrancer or the Law Secretary shall take stock of things with regard to the lodging of prosecution so that the purpose of the Act is subserved. (I) The Courts that deal with the complaints under the Act shall deal with the matters in promptitude and submit the quarterly report to the High Courts through the concerned Sessions and District Judge.

(j) The learned Chief Justices of each of the High Courts in the country are requested to constitute a Committee of three Judges that can periodically oversee the progress of the cases.

(k) The awareness campaigns with regard to the provisions of the Act as well as the social awareness shall be undertaken as per the direction No. 9.8 in the order dated March 4, 2013 passed in Voluntary Health Association of Punjab (supra).

(l) The State Legal Services Authorities of the States shall give emphasis on this campaign during the spread of legal aid and involve the para-legal volunteers.

(m) The Union of India and the States shall see to it that appropriate directions are issued to the authorities of All India Radio and Doordarshan functioning in various States to give wide publicity pertaining to the saving of the girl child and the grave dangers the society shall face because of female feticide.

(n) All the appropriate authorities including the States and Districts notified under the Act shall submit quarterly progress report to the Government of India through the State Government and maintain Form H for keeping the information of all registrations readily available as per sub-rule 6 of Rule 18A of the Rules.

(o) The States and Union Territories shall implement the Pre-conception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) (Six Months Training) Rules, 2014 forthwith considering that the training provided therein is imperative for realising the objects and purpose of this Act.

(p) As the Union of India and some States framed incentive schemes for the girl child, the States

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that have not framed such schemes, may introduce such schemes.”(Emphasis Supplied) 3. The PCPNDT Act was enacted by Parliament, as its Preamble indicates, to prohibit sex-selection, and to regulate pre-natal diagnostic techniques so as to prevent their misuse for sex determination. The Preamble reads thus: “An Act to provide for the regulation of the use of pre-natal diagnostic techniques for the purpose of detecting genetic or metabolic disorders or chromosomal abnormalities or certain congenital malformations or sex linked disorders and for the prevention of the misuse of such techniques for the purpose of pre-natal sex determination leading to female feticide; and, for matters connected there with or incidental thereto.” 4. The intent of Parliament in enacting the law is clarified in the Statement of Objects and Reasons which accompanied the introduction of the Bill. Insofar as it is material to the present controversy, the Statement of Objects and Reasons reads thus: “Introduction: In the recent past Pre-natal Diagnostic Centers sprang up in the urban areas of the country using pre-natal diagnostic techniques for determination of sex of the fetus. Such centers became very popular and their growth was tremendous as the female child is not welcomed with open arms in most of the Indian families. The result was that such centers became centers of female feticide. Such abuse of the technique is against the female sex and affects the dignity and status of women. Various Organization working for the welfare and uplift of the women raised their heads against such an abuse.”

Statement of Objects and Reasons

It is proposed to prohibit pre-natal diagnostic techniques for determination of sex of the fetus leading to female feticide. Such abuse of techniques is determination against the female sex and affects the dignity and status of women. A legislation is required to regulate the use of such techniques and to provide deterrent punishment to stop such inhuman Act. The Bill, inter alia provides for: (i) prohibition of the misuse of pre-natal diagnostic techniques for determination of sex of fetus, leading to female feticide;

IJCP Sutra 215: Total cholesterol/HDL ratio =Total cholesterol/HDL cholesterol.

Medicolegal (ii) prohibition of advertisement of pre-natal diagnostic techniques for detection or determination of sex;

(iii) permission and regulation of the use of prenatal diagnostic techniques for the purpose of detection of specific genetic abnormalities or disorders; (iv) permitting the use of such techniques only under certain conditions by the registered institutions; and

(v) punishment for violation of the provisions of the proposed legislation.

2. The Bill seeks to achieve the above objectives.”

5. The comprehensive directions issued by this Court in its decision in Voluntary Health Association of Punjab (Supra) must be read as integral to the enforcement of a law which has been enacted by Parliament to curb a grave social evil and to render the statutory provisions truly effective to curb the mischief which was sought to be addressed by enacting the law. More specifically, in its judgment dated 8 November 2016, this Court has required the States and the Union Territories to implement the Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) (Six Months Training) Rules, 2014 forthwith. The decision explains that the provision for training required under the above subordinate legislation, is imperative to realise the objects and purposes of the Act. 6. The impact of the directions which have been issued by this Court is negated by a judgment rendered by a Division Bench of the Delhi High Court on 17 February 2016 in a batch of cases including Indian Radiological and Imaging Association (IRIA) v Union of India,3 Indian Medical Association v Union of India4 and Sonological Society of India v Union of India.5 Before the Delhi High Court, there was a challenge to the provisions of Rule 3(3)(1)(b) of the PCPNDT Rules, 1996 and Rule 6 of the Six Months Training Rules as amended by a notification dated 9 January 2014. Rule 3.3(1)(b), which was in challenge reads as follows: “3.3(1) Any person having adequate space and being or employing…. (a)… (b)…a Sonologist, Imaging Specialist, Radiologist or Registered Medical Practitioner

having Post Graduate degree or diploma or six months training duly imparted in the manner prescribed in the “the Pre-conception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) (Six Months Training) Rules, 2014.” Rule 6 of the Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) (Six Months Training) Rules, 2014 is in the following terms:

“6. Eligibility for training.-

(1) Any registered medical practitioner shall be eligible for undertaking the said six months training.

(2) The existing registered medical practitioners, who are conducting ultrasound procedures in a Genetic Clinic or Ultrasound Clinic or Imaging Center on the basis of one year experience or six months training are exempted from undertaking the said training provided they are able to qualify the competency based assessment specified in Schedule II and in case of failure to clear the said competency based exam, they shall be required to undertake the complete six months training, as provided under these rules, for the purpose of renewal of registrations.”

Rule 6(2) provides for an exemption to existing registered medical practitioners conducting ultrasound procedures in a genetic or ultrasound clinic or imaging center subject to qualifying in the competency based assessment. 7. The Delhi High Court has inter alia held that it was unable to find any provision in the PCPNDT Act empowering any of the bodies constituted under the law or even the Central Government to prescribe qualifications for practicing medicine with the aid of an ultrasound imaging equipment or to prescribe the nature and content of the curriculum or duration of the qualification. While disposing of the batch of writ petitions, the Delhi High Court has issued the following directions:

(i) “that Section 2(p) of the PNDT Act defining a Sonologist or Imaging Specialist, is bad to the extent it includes persons possessing a postgraduate qualification in ultrasonography or imaging techniques – because there is no such qualification recognized by MCI and the PNDT Act does not empower the statutory bodies constituted thereunder or the

IJCP Sutra 216: ABC of heart disease prevention: A: Keep A1c <6.5%.; B: Keep blood pressure <120/80 mmHg.; C: Keep LDL cholesterol <100 mg%.

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Central Government to devise and coin new qualification;

(ii) We hold that all places including vehicles where ultrasound machine or imaging machine or scanner or other equipment capable of determining sex of the fetus or has the potential of detection of sex during pregnancy or selection of sex before conception, require registration under the Act; (iii) However, if the person seeking registration (a) makes a declaration in the form to be prescribed by the Central Supervisory Board to the effect that the said machine or equipment is not intended for conducting pre-natal diagnostic procedures; (b) gives an undertaking to not use or allow the use of the same for pre-natal diagnostic procedures; and, (c) has a “silent observer” or any other equipment installed on the ultrasound machines, as may be prescribed by the Central Supervisory Board, capable of storing images of each sonography tests done therewith, such person would be exempt from complying with the provisions of the Act and the Rules with respect to Genetic Clinics, Genetic Laboratory or Genetic Counseling Centers; (iv) If however for any technical reasons, the Central Supervisory Board is of the view that such “silent observer” cannot be installed or would not serve the purpose, then the Central Supervisory Board would prescribe other conditions which such registrant would require to fulfil, to remain exempt as aforesaid; (v) However, such registrants would otherwise remain bound by the prohibitory and penal provisions of the Act and would further remain liable to give inspection of the “silent observer” or other such equipment and their places, from time to time and in such manner as may be prescribed by the Central Supervisory Board; and (vi) Rule 3(3)(1)(b) of the PNDT Rules (as it stands after the amendment with effect from 9th January, 2014) is ultra vires the PNDT Act to the extent it requires a person desirous of setting up a Genetic Clinic/Ultrasound Clinic/ Imaging Center to undergo six months training imparted in the manner prescribed in the Six Months Training Rules.”

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8. Prima facie, the High Court has erred in its finding that there is an absence of statutory power. Subsection 1 of Section 32 of the PCPNDT Act confers rule making power upon Central Government for “carrying out the provisions of the Act”. Illustratively, Sub Section 2 of Section 32 stipulates that the rules may provide for:

“(i) the minimum qualifications for persons employed at a registered Genetic Counseling Center, Genetic Laboratory or Genetic Clinic under Clause (1) of Section 3.”

The above provision refers to minimum qualifications required of persons employed at registered genetic counseling centers, genetic laboratories or genetic clinics under Section 3(2). Hence, it would be necessary to understand the import of Section 3 which reads thus: “3. Regulation of Genetic Counseling Centers, Genetic Laboratories and Genetic Clinics.

On and from the commencement of this Act,--

(1) no Genetic Counseling Center, Genetic Laboratory or Genetic Clinic unless registered under this Act, shall conduct or associate with, or help in, conducting activities relating to pre-natal diagnostic techniques; (2) no Genetic Counseling Center, Genetic Laboratory or Genetic Clinic shall employ or cause to be employed any person who does not possess the prescribed qualifications; (3) no medical geneticist, gynecologist, pediatrician, registered medical practitioner or any other person shall conduct or cause to be conducted or aid in conducting by himself or through any other person, any pre-natal diagnostic techniques at a place other than a place registered under this Act.” The expression ‘genetic counseling center’ has been defined in Section 2(c) as follows: “(c) “Genetic Counseling Center” means an institute, hospital, nursing home or any place, by whatever name called, which provides for genetic counseling to patients.” The expression ‘genetic laboratory’ is defined in Section 2(e) as follows: (e) “Genetic Laboratory” means a laboratory and includes a place where facilities are provided for conducting analysis or tests of samples received from Genetic Clinic for pre-natal diagnostic test.”

IJCP Sutra 217: Basic management of MI: BOOMAR - Bed rest; Oxygen; Opiate; Monitor; Anticoagulate; Reduce clot size.

Medicolegal The expression ‘genetic clinic’ is defined in Section 2(d) as follows:

(iii) hemoglobinopathies;

“(d) “Genetic Clinic” means a clinic, institute, hospital, nursing home or any place, by whatever name called, which is used for conducting prenatal diagnostic procedures.”

(iv) sex-linked genetic diseases;

(v) congenital anomalies;

(vi) any other abnormalities or diseases as may be specified by the Central Supervisory Board;

Under Section 2(d), ‘genetic clinic’ is defined with reference to the place which is used for conducting pre-natal diagnostic procedures. ‘Genetic laboratory’ in Section 2(e) includes a place where facilities are provided for conducting analysis or tests of samples received from a genetic clinic for a pre-natal diagnostic test. The expression ‘pre-natal diagnostic procedures’ is defined in Section 2(i) as follows: “(i) “pre-natal diagnostic procedures” means all gynecological or obstetrical or medical procedures such as ultrasonography fetoscopy, taking or removing samples of amniotic fluid, chorionic villi, blood or any tissue of a pregnant woman for being sent to a Genetic Laboratory or Genetic Clinic for conducting pre-natal diagnostic test.” Both Sections 2(i) and Section 2(k) contain a specific reference to ultrasonography. The expression ‘sonologist or imaging specialist’ is defined in Section 2(p) as follows: “(p) sonologist or imaging specialist” means a person who possesses any one of the medical qualifications recognized under the Indian Medical Council Act, 1956 (105 of 1956) or who possesses a post-graduate qualification in ultrasonography or imaging techniques or radiology.” Section 4 provides thus: “4. Regulation of pre-natal diagnostic techniques.On and from the commencement of this Act,- (1) no place including a registered Genetic Counseling Center or Genetic Laboratory or Genetic Clinic shall be used or caused to be used by any person for conducting pre-natal diagnostic techniques except for the purposes specified in Clause (2) and after satisfying any of the conditions specified in Clause (3); (2) no pre-natal diagnostic techniques shall be conducted except for the purposes of detection of any of the following abnormalities, namely:-

(i) chromosomal abnormalities;

(ii) genetic metabolic diseases;

[(3) no pre-natal diagnostic techniques shall be used or conducted unless the person qualified to do so is satisfied that any of the following conditions are fulfilled, namely:--

(i) age of the pregnant woman is above thirty-five years;

(ii) the pregnant woman has undergone two or more spontaneous abortions or fetal loss;

(iii) the pregnant woman had been exposed to potentially teratogenic agents such as drugs, radiation, infection or chemicals;

(iv) the pregnant woman or her spouse has a family history of mental retardation or physical deformities such as, spasticity or any other genetic disease;

(v) any other condition as may be specified by the Central Supervisory Board;

Provided that the person conducting ultrasonography on a pregnant woman shall keep complete record thereof in the clinic in such manner, as may be prescribed, and any deficiency or inaccuracy found therein shall amount to contravention of the provisions of Section 5 or Section 6 unless contrary is proved by the person conducting such ultrasonography;

(4) no person including a relative or husband of the pregnant woman shall seek or encourage the conduct of any pre-natal diagnostic techniques on her except for the purpose specified in Clause (2).

(5) no person including a relative or husband of a woman shall seek or encourage the conduct of any sex-selection technique on her/him or both.]”

Section 4(2) specifies exceptional situations in which a pre-natal diagnostic test may be conducted to detect certain specified abnormalities. Section 4(3) provides that no pre-natal diagnostic test shall be used or conducted unless the person qualified to do so, is satisfied for reasons to be recorded in writing that

IJCP Sutra 218: Thrombolytic agents: USA – Urokinase, Streptokinase, Alteplase (tPA).

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specific conditions (which have been laid down) are fulfilled. Section 5(2) contains a prohibition on the disclosure to a pregnant woman or to a relative of the sex of the fetus. Section 6 contains a prohibition on the determination of sex and on sex selection.

Rules 2014 were made by the Central Government in exercise of the power conferred by Parliament. Prima facie, the rules are neither ultra vires the parent legislation nor do they suffer from manifest arbitrariness.

9. Prima facie, these provisions indicate that Parliament has conferred upon the Central Government rule making authority to specify minimum qualification for persons to be employed at genetic counseling centers, laboratories and clinics. Specification of qualifications, in our view, should be read in a purposive sense which will fulfil the object of the law. Even on a plain and natural construction of the words used by Parliament, specification of qualifications must necessarily comprehend the power to prescribe training. The rationale for this is that the training would sensitize the person concerned to the salutary object and purpose of the legislation which has been enacted by Parliament to deal with a serious social evil and be conscious of the misuse of sex-selection tests. Pre-natal diagnostic procedures are susceptible to grave misuse.

11. For the reasons that we have indicated, we are of the view that the judgment of the Delhi High Court needs to be stayed during the pendency of these proceedings. The judgment of the High Court squarely impinges upon the directions issued by this Court in Voluntary Health Association of Punjab. We direct in consequence that the judgment of this Court in Voluntary Health Association of Punjab shall be strictly enforced by all states and union territories untrammelled by any order of any High Court or any other court.

10. Parliament which has the unquestioned authority and legislative competence to frame the law considered it necessary to empower the Central government to frame rules to govern the qualifications of persons employed in genetic counseling centers, laboratories and clinics. The wisdom of the legislature in adopting the policy cannot be substituted by the court in the exercise of the power of judicial review. Prima facie the judgment of the Delhi High Court has trenched upon an area of legislative policy. Judicial review cannot extend to reappreciating the efficacy of a legislative policy adopted in a law which has been enacted by the competent legislature. Both the Indian Medical Council Act, 1956 and the PCPNDT Act are enacted by Parliament. Parliament has the legislative competence to do so. The Training

[DIPAK MISRA]

12. Pending final disposal, there shall be a stay of the operation of the judgment and order of the Delhi High Court dated 17 February 2016. The interlocutory applications are disposed of accordingly. .............................................CJI

.................................................J [A M KHANWILKAR] ...…............................................J [Dr D Y CHANDRACHUD] New Delhi; March 14, 2018. References 1. 2. 3. 4. 5.

Writ Petition (c) No. 349 of 2006. PCPNDT Act. Writ Petition (C) No. 6968 of 2011. Writ Petition (C) No. 2721 of 2014. Writ Petition (C) No. 3184 of 2014.

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Rule of 50 for Hypertension ÂÂ

Treating high BP can reduce chances of paralysis and heart failure by 50%.

ÂÂ

Eliminating prehypertension from society can prevent 50% of all heart attacks.

ÂÂ

Appearance of high BP after the age of 50 means investigations.

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IJCP Sutra 219: MI: MONA - M: Morphine, O: Oxygen, N: Nitrates (hold of RV infarct), A: Aspirin.

Conference Proceedings

69th Annual Conference of Cardiological Society of India (CSI 2017) Latest 2017 Hypertension Guidelines

ÂÂ

Expanding indications for TAVR: Intermediate to low risk patients, bicuspid aortic valve, degenerating surgical bioprosthetic valves and AR.

ÂÂ

In elderly patients >75 years of age, TAVI is superior to medical therapy in extreme risk patients, noninferior or superior to surgery in high risk patients and noninferior or even superior to surgery when transfemoral access is possible in intermediate risk patients (2017 ESC/EACTS guidelines for the management of valvular heart disease).

ÂÂ

In patients with severe aortic stenosis at intermediate surgical risk, TAVR was a noninferior alternative to surgery (N Engl J Med. 2017;376(14):1321-31).

Dr C Venkata S Ram, Australia ÂÂ

The new definition of HT given by AHA/ACC is BP >130/80 mmHg.

ÂÂ

Anyone with BP >130/80 mmHg is now considered as having HT.

ÂÂ

There is lot of evidence to suggest that any BP >130/80 mmHg can be detrimental to health.

ÂÂ

So, the gold standard for HT diagnosis is not 140/90 but 130/80 mmHg. This applies to all age groups and comorbidities.

ÂÂ

People with BP >130/80 mmHg should be counseled for lifestyle changes and then, drug treatment. So, the new cut-off between normal and high BP is 130/80 and not 140/90 mmHg.

ÂÂ

b blockers are now rated as “secondary” drugs for HT, not primary.

NSTEMI ACS Management Prof Dr Saumitra Ray, Kolkata ÂÂ

All NSTEMI ACS are not the same.

ÂÂ

Early risk stratification should guide initial management.

ÂÂ

First-line drugs for HT are diuretics, CCBs, ACEIs and ARBs.

ÂÂ

Among the diuretics, the preferred choice is chlorthalidone, not HCTZ or indapamide.

In high or moderate risk patients, early invasive management is useful.

ÂÂ

Low risk patients should be treated conservatively with close watch.

ÂÂ

DAPT for at least 1 year is the dictum unless very high bleeding risk.

ÂÂ

High dose statin is useful.

ÂÂ

Total revascularization should be the aim, as opposed to STEMI.

ÂÂ

The new guidelines will change the way medicine will be practiced from now on. The BP should be 130/80 mmHg or lower (New Recommendation).

5 main points to be emphasized in the new guideline ÂÂ

A strong emphasis on BP measurement.

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A new BP classification system.

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A new approach to decision making for treatment that incorporates the underlying CV risk.

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Lower targets for BP during HT management.

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Strategies to improve BP control during treatment with an emphasis on lifestyle approaches.

ACEI remains the “Gold Standard” Dr PK Deb, Kolkata ÂÂ

ARB was introduced in 1990 for treatment of HT and subsequently used for HFrEF.

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As compared to ACEI, ARBs were not found to be superior in reducing all-cause mortality or HF hospitalizations in symptomatic HF (JACC. 2002;39(3):463).

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In 2004, controversy surfaced with the reports that ARBs may increase MI and patients need to be told about this (ARB-MI Paradox). A flow of

Changing Indications of TAVR Dr Ashok Seth, New Delhi “My daily dilemma is not, which patient should have TAVR but who should have a surgical AVR and why?” —Thomas Modine

IJCP Sutra 220: Coronary artery bypass graft: Indications - DUST:- Depressed ventricular function, unstable angina, stenosis of the left main stem, triple vessel disease.

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controversial editorials continued to question the safety of ARBs.

clinical literature. It is recommendary in nature and carries no statutory status. ÂÂ

The CSI position statement recommends nonpharmacological therapy including lifestyle modifications, exercise rehabilitation and vaccination.

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The natriuretic peptides represent the gold standard biomarkers in HF. BNP or NT-proBNP “guided therapy” is not routinely recommended in India.

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Pharmacological management of chronic HFrEF recommends ACEI/ARB/ARNI, BB, MRA in all patients; diuretics in symptomatic patients and use of hydralazine, ivabradine and digoxin as complementary.

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Statins are not recommended to be initiated, unless the patient is already on statin. Carnitine/CoQ/ intermittent inotropes/CCB-verapamil/diltiazem are not to be used. All patients with prior or current symptoms of HFrEF regardless of aetiology should be started on ACEI, unless contraindicated.

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Replacement of ACEI with ARNI should be considered in patients who remain symptomatic despite optimal therapy with an ACEI, b-blocker and MRA. In patients who are tolerating ACEI (or ARB) well, replacement by ARNI may be considered on an individual basis.

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Use of b blockers (bisoprolol, metoprolol succinate extended release or carvedilol) is recommended for all patients with current/prior symptoms of HFrEF in absence of contraindications.

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Patients with prior or current symptoms of chronic HFrEF who are intolerant to ACEI (due to cough) are candidates for ARBs.

CSI Position Statement on Management of HF in India 2017

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b blockers and ACEIs can be initiated together as soon as the diagnosis of HFrEF is made.

Dr Santanu Guha, Kolkata

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Diuretics should be used in HFrEF patients who have evidence of fluid retention and are usually combined with an ACEI (or ARB), b-blocker and MRAs.

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Ivabradine can be considered for symptomatic HF patients who are in sinus rhythm and have resting HR >70 bpm despite maximally tolerated doses of BB, ACEI (ARB) and MRA. Optimal use of device therapy in our country will require better risk stratification methods or lowering of initial device cost.

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Surgery for HF comprises of mitral valve reconstruction, external support, myocyte restoration and replacement, ventricle restoration,

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Patients intolerant to ACEI due to hyperkalemia, worsening of renal function or hypotension may have a similar response to ARB also.

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The PARADIGM study in 2014 introduced angiotensin-neprilysin inhibition, following a fast track mechanism: 2014-study published, 2015: FDA approval, 2016: Guidelines updated to include ARNI.

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Questions were raised on the PARADIGM study about the rationale of combining an ARB with a neprilysin inhibitor and not with an ACEI; why was neprilysin inhibitor not used alone; the study design; why was a lower dose of enalapril used in the study; did the impact on efficacy of LCZ696 depend on the patient’s baseline characteristics; effect on renal impairment and the efficacy of LCZ696 on changes in BP and types of HF. The cost-effectiveness and the sponsorship bias also came under scrutiny.

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As per ESC 2016 recommendations, ACEI, MRAs and β blockers continue to be standard of care in HF management. Sacubitril/valsartan is recommended as a replacement and not as first-line therapy.

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The 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for HF recommend substituting ACEI/ARB with ARNI. Addition of ACEI with LCZ696 would have been a scientific compulsion, but addition of valsartan with LCZ696 is a sponsor’s compulsion. It can be easily concluded that ACEI is the corner stone of HF therapy and is still the Gold Standard.

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HF presents about a decade earlier in India, most of the burden is <65 years.

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The commonest etiology is CAD followed by idiopathic dilated cardiomyopathy. RHD still contributes 10% of the disease burden.

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There is a need for a statement on HF as it is emerging as an important public health problem in India.

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The purpose of CSI position statement on HF is to provide a single document for the whole country which provides the latest available data from India and also serves as a reference regarding the latest

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IJCP Sutra 221: Antihypertensive drugs - A: Ace inhibitors, B: Beta blockers, C: Calcium channel blockers, D: Diuretics.

Conference Proceedings revascularization, mechanical support and heart transplantation. ÂÂ

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CRT can be considered for patient with LVEF <35% and are undergoing placement of a new or replacement pacemaker implantation. It should not be considered in patients whose comorbidities limit expected survival to <1 year; HF with non-LBBB pattern with QRS <150 ms. Preventing or delaying onset of HF is a feasible task and should be a priority for our country because of cost-effectiveness. It can be achieved either by targeting those at high risk or promoting healthy lifestyle for entire population.

What’s Trending in the Management of HF in 2017? Dr Ramachandra Barik, Hyderabad ÂÂ

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The burden of heart failure (HF) in India appears to be high. A conservative estimation of the prevalence of HF in India due to CHD, HT, obesity, diabetes and rheumatic heart disease ranges from 1.3 to 4.6 million, with an annual incidence of 491,600 to 1.8 million.1 There is a need to include new therapies which complement established pharmacological and device-based therapies in the treatment of patients with HF. The ACC, the AHA and the Heart Failure Society of America have updated treatment guidelines to incorporate two new pharmacological therapies for HFrEF: Sacubitril-valsartan and ivabradine.2 The guidelines recommend that in patients with chronic symptomatic HFrEF NYHA Class II or III who tolerate an ACEI or ARB, replacement by ARNI (valsartan/sacubitril) will further reduce morbidity and mortality.2

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ARNI has shown to reduce the composite endpoint of CV death or HF hospitalization in an RCT comparing the first approved ARNI (valsartan/ sacubitril) with enalapril in symptomatic patients with HFrEF tolerating an adequate dose of either ACEI or ARB.2

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Focused update on clinical guidelines recommend that ivabradine can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA Class II-III) stable chronic HFrEF (LVEF ≤35%) who are receiving GDEH, including a β-blocker at maximum tolerated dose and who are in sinus rhythm with a heart rate ≥70 bpm at rest.2

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Ivabradine is a new therapeutic agent that selectively inhibits the It current in the sinoatrial node, providing heart rate reduction.2

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The QUALIFY international registry has also shown that good adherence to pharmacologic treatment guidelines for ACEIs, ARBs, BBs, MRAs and ivabradine, with prescription of at least 50% of recommended dosages was associated with better clinical outcomes during the 5-month follow-up.

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Continuing global educational initiatives are imperative to emphasize and ensure the implementation of guidelines to optimize drug therapy and prescribing evidence-based doses in clinical practice.

References: 1Huffman MD, et al. Natl Med J India. 2010;23(5):283-8. 2Yancy et al. Circulation. 2016;134:e282-e293. 3Komadja M, et al. Eur J Heart Failure. 2017;19(11):1414-23.

ARNI as First-line Therapy in the Management of Heart Failure Dr Bhagirath Raghuraman, Bengaluru ÂÂ

Augmentation of the natriuretic peptide systems is a novel approach in the management of HF and a new paradigm in neurohormonal modulation for HFrEF.

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LCZ696 (Sacubitril+Valsartan) is a first in class ARNI, which simultaneously inhibits neprilysin and blocks AT1 receptor.

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Sacubitril, a prodrug inhibits neprilysin → ↑ natriuretic peptide, while valsartan causes direct antagonism of AT II receptors → vasoconstriction, smooth muscle cell proliferation and decreased renal BF.

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ARNI should be prescribed in adult patients with systolic HF, patients with NYHA Class II-IV, LVEF <40% on b-blocker and MRA, eGFR >30 ml/min/1.73 m2, SBP >100 mmHg, serum potassium ≤5.2 mmol/L. ARNI should be initiated 36 hours after stopping ACEI, at a dose of 50 mg b.i.d. and doubling the dose every 2-4 weeks till 100 mg b.i.d. is reached. β blockers, MRAs, ivabradine and digoxin can be continued with ARNI, with devices as appropriate. While on ARNI, the patients should be monitored for renal function and serum K. Do not uptitrate if BP >100. BNP is not useful for monitoring as ARNI increases its level.

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ARNI is contraindicated in patients with hypersensitivity to any component, history of angioedema related to previous ACEI or ARB therapy,

IJCP Sutra 222: Don't read success stories....you will only get a message; read failure stories...you will get some ideas to get success. —Dr APJ Abdul Kalam

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along with ACEIs or concomitantly with aliskiren in patients with diabetes. In PARADIGM-HF, LCZ696 was found to be superior to enalapril in patients with HFrEF. LCZ696 also reduced hospitalization risk for HF by 21% (p < 0.001) and decreased symptoms and limitations of HF (p = 0.001).

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Post-surgical probability of a cardiac event is low even if DSE is positive. If DSE shows high risk features indicative of multivessel/LMCA/proximal LAD disease or large areas of myocardium in jeopardy, consider invasive coronary evaluation and even urgent preop coronary revascularization.

The 2016 ACC/AHA/HFSA focused update recommend ARNI along with a BB and MRA as therapy of patients with HFrEF. The guidelines also recommend that ARNI should replace ACEIs when stable patients with mild-to-moderate HF on these therapies have adequate BP and are tolerating these therapies well.

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In general, there is no role for routine prophylactic coronary angiography (CAG) or revascularization in stable CAD awaiting noncardiac surgery. In subjects at risk of, or with proven IHD, aspirin nonadherence/withdrawal triples the risk of MACE.

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DVT prophylaxis following the hip surgery 28-35 days of added anticoagulants - NOACs have an edge over heparin/VKA.

HCM: Epidemiology, Genetic s and Risk Stratification

PTCA or CABG in Diabetes Mellitus

Dr Ajay Bahl, Chandigarh ÂÂ

Hypertrophic cardiomyopathy (HCM) is a common inherited cardiac disorder caused by mutations in cardiac sarcomeric genes.

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Mutations are most commonly found in genes encoding myosin heavy chain (MYH7) and myosinbinding protein C (MyBPC3).

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HCM is the commonest cause of sudden death in young individuals. Sudden death may be the first presentation of HCM.

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Screening of first-degree relatives of the patient should be advised.

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Family screening may be either clinical, ECG and echocardiography based or by genotyping in case a mutation is identified in the proband.

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Risk stratification for sudden death is important since patients at high risk of sudden death may be offered ICD implantation.

Management Issues in Patients Requiring Antiplatelets and Anticoagulation Dr Suresh K, Trivandrum A 74-year-old diabetic gentleman with fracture hip and positive dobutamine stress echo ÂÂ

Hip fracture obviously needs urgent or semiurgent hip surgery.

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Proper preoperative cardiac risk assessment using conventional risk scoring systems helps in planning appropriate management strategy.

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Dobutamine stress echo (DSE) indicates presence of CAD.

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Prof Sundeep Mishra, New Delhi ÂÂ

Several pathophysiological factors confer high risk after revascularization.

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Trials reveal higher MACE after revascularization with PCI compared with CABG in patients with triple vessel disease.

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Most of this higher MACE is associated with increased requirement of repeat procedure with PCI.

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However, this risk may not hold true for single vessel disease or with latest generation of stents.

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The risks of death and target vessel MI with PCI are particularly high in insulin-dependent patients with diabetes.

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Even risk of stent thrombosis is higher in these patients.

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In patients with high surgical risk, PCI still remains an option.

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Newer antiplatelets are better than clopidogrel in patients with diabetes.

How can we in India Adopt these Latest Guidelines Dr Gurpreet S Wander, Ludhiana ÂÂ

The term ‘prehypertension’ used in JNC 7 was not adopted by anyone else and also in Indian guidelines.

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JNC 8 (2014) threshold and targets higher for age >60 was widely criticized.

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Issue of AOBP is important since devices are expensive. The definition and classification of HT does not need to be changed.

IJCP Sutra 223: Do not spoil what you have by desiring what you have not; remember that what you now have was once among the things you only hoped for. —Epicurus

Conference Proceedings ÂÂ

Longevity in India is less than in US and same targets cannot be applied for the frail old individuals.

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Physicians should be oriented towards reducing risk in high risk individuals.

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Two latest guidelines have reacted less strongly to the SPRINT trial than the ACC/AHA. We possibly need to follow this approach.

after angiography, administer either ticagrelor 180 mg or prasugrel 60 mg. For ischemia-guided (conservative) strategy: Ticagrelor 180 mg loading dose is recommended. ÂÂ

Most patients do not require IV glycoprotein IIb/IIIa inhibitor. Indications for IV glycoprotein IIb/IIIa inhibitor include patients with evidence of ongoing ischemia despite therapy with aspirin + P2Y12 inhibitor for whom invasive approach is planned; and patients who have high-risk features during angiography such as large thrombus burden or intraprocedural thrombotic complication, particularly if they have not received prasugrel or ticagrelor.

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For those patients with a history of GI bleeding, drugs that reduce the risk of recurrent bleeding (e.g., PPIs) should be given.

Digoxin in Heart Failure: “Kabhi Haan, Kabhi Naa” Dr Nagaraj Desai, Mysuru ÂÂ

Use of digoxin, in some contemporary clinical practices, is rapidly dwindling.

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There are no major studies to reassess the readmission rates, a major issue in current HF practice.

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It may be used in selected individuals only as addon therapy albeit with well-known caveats like its narrow therapeutic window.

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A typical example may be a patient of systolic HF in AF with faster heart rate who is not responding adequately despite routine guideline directed therapies including RAAS modulators and b blockers.

Antiplatelets and Anticoagulants in NSTEMIToo Much Confusion: Which Ones should I Choose? Dr Smit Shrivastava, Kanpur ÂÂ

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Aspirin is for all patients. Loading dose is 162-325 mg of uncoated aspirin; the first tablet should be chewed or crushed to establish a high blood level quickly, should be given as soon as possible to any patient with NSTEMI, irrespective of treatment strategy. There is no evidence that higher doses are more effective and they may lead to greater gastric irritation. Aspirin (75-100 mg o.d.) should be continued indefinitely for secondary prevention. P2Y12 inhibitors for all patients. All NSTEACS patients should be treated with a P2Y receptor blocker and aspirin. Timing of administration depends on the choice between invasive or ischemiaguided management strategies. For invasive strategy: Ticagrelor 180 mg loading dose is recommended. For patients in whom there is a concern about a need for urgent CABG surgery, the P2Y receptor blocker may be given after diagnostic coronary angiography. If the P2Y receptor blocker is given

Peripartum Cardiomyopathy: Changing Definition and Newer Therapies Dr Asha Moorthy, Chennai ÂÂ

Definition of PCPM: Loose definition - Identify more Cases (ESC).

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How common is it? One in 1,500 live pregnancies.

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What are the complications of PPCM? HF, death, arrhythmias, thromboembolism.

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How do we diagnose? ECG, NPs and Echo/CMR or both.

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When to treat PPCM in a lactating mother? Both before and after delivery.

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Natural history of PPCM: High risk of recurrence.

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How to diagnose recurrence of PPCM in a subsequent pregnancy? NPs and Echo.

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What is the role of device therapy in PPCM? Limited role and not before 6 months.

Which NOAC for which Patient with Nonvalvular AF? Dr Srinivasa Rao Maddury, Hyderabad ÂÂ

In clinical trials, non-vitamin K antagonist oral anticoagulants (NOACs) have demonstrated favorable efficacy and safety profiles vs. vitamin K anatagonist (VKAs). They are all noninferior to VKA with regards to ischemic stroke and systemic embolization, but superior with regard to preventing systemic bleeding, especially intracranial bleed. They have the advantage of once- or twicedaily dosing and also do not require monitoring of

IJCP Sutra 224: Success is not measured by what you accomplish but by the opposition you have encountered, and the courage with which you have maintained the struggle against overwhelming odds. —Orison Swett Marden

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dosing unlike VKA. But, they differ slightly from each other in their pharmacological properties. ÂÂ

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Rivaroxaban and edoxaban are given oncedaily; apixaban and dabigatran given twicedaily. Rivaroxaban needs to be given with food to facilitate gut absorption. Renal clearance for dabigatran is 80%, adaxoban 50%, rivaroxaban 33% and apixaban 25%. Dose reductions for NOACs is needed in renal dysfunction. Dabigatran is not recommended with CrCl <30, apixaban <15 mL. Although rivaroxaban and edoxaban are not recommended below CrCl of 15 mL, caution should be exercised if CrCl <30 mL. Patients with AF have other comorbidities: HT (70-80%), HF (40%), coronary disease (30%), diabetes (25%); hence they are already taking many pills. If they want to reduce their pill burden, rivaroxaban and edoxaban taken once-daily would be the preferred choices. Dabigatran is a prodrug, highly acidic in nature and tends to get activated in GI wall. It produces more GI irritation and may enhance GI bleed in those patients with tendency to GI bleed. So, it may be given with food to minimize the gastric irritation. Dabigatran may not be right choice in these subset of patients. Although there is no head-to-head trial comparing different NOACs with each other, from the individual clinical trials with each of the NOAC, dabigatran 150 mg b.i.d. was far superior in preventing ischemic stroke. In RE-LY trial, dabigatran has shown a 34% risk reduction (rivaroxaban and edoxaban 22%, apixaban 22% in ROCKET, ARISTOTEL and ENGAGE AF trials, respectively). Hence, dabigatran may be preferred choice in those who have highest risk ischemic stroke. GI absorption of NOACs is influenced by P-glycoprotein(P-gp) in GI tract. Concomitant administration of known P-gp inhibitors e.g., quinidine, verapamil, ketoconazole, cyclosporine, dronedarone, amiodarone and certain macrolide antibiotics influences the plasma levels of NOACS; hence, dose reduction is needed. In the presence of reduced renal function with a NOAC like dabigatran, which has 80% excretion through renal route, a concomitant administration of above drugs is likely to increase plasma levels of dabigatran. Hence, in these situations apixaban which has least renal clearance may be a better choice.

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Ongoing Dilemmas in RHD Dr Vikas Singh, Patna ÂÂ

Rheumatic heart diseases (RHDs), in spite of having seen a big decline even to the extent of near eradication in some developed countries, is still a major health challenge in our country.

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Involvement of the heart mostly in the form of endocarditis and pericarditis is recognized. Myocardial involvement is missed many times, and requires a careful view in suspected cases.

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Modified Jones Criteria have been the backbone of diagnosis of acute rheumatic fever for decades. But, the availability and advantages of echocardiography cannot be undermined, and it is now a very important tool in the diagnosis and management decisions.

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Leaky valves in adolescents is a cause of concern both for the patient and the treating physicians.

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Reassurance and discussing the natural history with the patient is an important part.

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It is equally important to have a clear idea about the medical management and when to intervene. Most of these conditions can be managed in a fairly nice way at present.

Accurate Measurement of BP is the Key to Control HT Dr BA Muruganathan, Tamil Nadu ÂÂ

Accurate measurement of BP, as per protocol, is a must for correct diagnosis.

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Periodic measurement, documentation and followup are necessary.

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BP apparatus used for measuring BP should be validated.

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Recent guidelines recommend HBPM as a routine component of BP measurement in most patients with suspected or known HT. HBPM is well-coordinated with organ damage as is the ambulatory BP.

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While ABPM is the current gold standard in the correct diagnosis of HT and/or borderline HT, HBPM should now be considered as an alternative and not complementary, to ABPM for decision making in HT management.

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Doctors must check the BP and whenever required standing BP must be taken and the timing of BP measurement in concordance with medicine to be taken.

IJCP Sutra 225: Six essential qualities that are the key to success: Sincerity, personal integrity, humility, courtesy, wisdom and charity. —William Menninger

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AROUND THE GLOBE

News and Views IMA Rejects Suggestions on NMC Bill, Calls Strike from April 2 Rejecting the recommendations of the Parliamentary Standing Committee on the National Medical Commission (NMC) Bill, the Indian Medical Association (IMA), the largest body of private doctors in India, on Sunday called for an indefinite strike from April 2. More than 25,000 doctors from across India on Sunday (1st April) held a ‘Mahapanchayat’ at the Indira Gandhi Stadium in Delhi and opposed the parliament panel’s recommendations and the bill. The NMC Bill proposes to allow practitioners of alternative medicines - such as homoeopathy and ayurveda - to practice modern medicine once they complete a ‘bridge course’. It also proposes that the National Licentiate Examination (NLE) be made compulsory for any MBBS doctor, including a foreign graduate, to make them eligible to practice medicine in India. The parliamentary panel has recommended that the ‘bridge course’ should not be made a mandatory provision. It has also suggested to integrate the NLE with the final year MBBS exam. The doctors say the panel’s suggestions are “deceptive”. IMA National President Ravi Wankhedkar said all medical students and doctors will go on an indefinite strike on April 2. He said there was no need for the government to make any law if they want to boost only AYUSH, homeopathy, pharmacists and dentist. “The PSC report is deceptive to such an extent that it will open up the floodgates to allow back-door entry to cross-pathy, thereby promoting quackery legally. Even after the cosmetic amendments, the core issues still remain where it is,” Wankhedkar said. Declaring hospitals “safe zones” was one of the issues discussed at the Mahapanchayat. Vinay Aggarwal, coordinator of the Mahapanchayat, emphasized on the issue of violence against doctors and insisted that the “problems faced by doctors are enough, now it’s time to payback”. People should understand the meaning of medical negligence and that a doctor never intends to perform a wrong surgery, the IMA said. It demanded no criminal prosecution for “minor clinical errors”.

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RN Tandon, Honorary Secretary General of the IMA, said: “The NMC is a pro-private management bill paving the way for widespread corruption… All arguments of the government are hollow and its intention is malafide and harmful.” Wankhedkar said the provisions to open new medical colleges are ambiguous and the provisions to begin PG courses are unregulated. “Recommendation to increase the regulation of fee in private medical colleges from 40% to 50% does not make a material difference. However, lack of clarity on implementation may jeopardise the decision itself,” he added.

Parliamentary Panel Recommends Fixing of Minimum Compulsory Period of Working within Country for Doctors A parliamentary panel has recommended that a minimum compulsory period of working within the country be fixed for doctors, asserting that a large number of medics studying in government medical colleges on taxpayers money leave the country at the first given opportunity. The department-related Parliamentary Standing Committee on Health and Family Welfare has also asked the health ministry to explore the possibility of restructuring and revamping the Dental Council of India, the Nursing Council of India and other such councils for their effective regulation as envisaged by National Medical Commission Bill, 2017 Observing that there had been a loss of credibility of the Medical Council of India (MCI), the Committee has recommended that all the members of the proposed National Medical Commission mandatorily declare their professional and commercial involvements. The recommendations were made by the panel in its report on the National Medical Commission Bill 2017, tabled in Parliament last week. The Committee is also given to understand that a large number of doctors who study in government medical colleges at the cost of the taxpayers money leave the country at the first given opportunity. The committee recommends that in all such cases a minimum compulsory period of working within

IJCP Sutra 226: It's up to an individual to decide how he uses his emotions. Which way will you decide? Life is like an unsolved puzzle. No one can define what life is because it is a very complex thing.

AROUND THE GLOBE the country be prescribed before such doctors can be allowed to serve outside the country, the committee chaired by Prof Ram Gopal Yadav said. It also recommended for consideration a compulsory 1 year rural posting for all doctors graduating out of medical schools subject to the condition that the requisite infrastructure facilities in terms of supporting staff, decent remuneration, necessary medical equipment and appropriate security are made available so that their training can be appropriately utilized for dealing with shortage of doctors in rural and remote areas. The Committee observed that medical healthcare system encompasses health professionals working in the area of para medical disciplines like physiotherapy, optometry and other allied fields where there is no standardization of curriculum or regulation of the quality of education and practice. It said that the current bill presents a policy window for the government to overhaul the regulatory oversight of other streams of health professions as well. The Committee is of the view that the department should explore the possibility of restructuring and revamping the Dental Council of India, the Nursing Council of India and other such councils so that there is effective regulation of their education and practice similar to the reform process as envisaged by National Medical Commission Bill, 2017, the panel said. The Committee, accordingly, recommends for formulation of regulatory, licensing or accreditation norms for all paramedical and allied health care professions like physiotherapy, optometry, etc. so as to regulate such professionals and their scope of practice in various clinical settings, it added.

The Protocol: Patient consumes 500-1,000 mL oral fluids in the clinic or the ER and continue rehydrating at home, along with pain relief, antipyretics and antiemetics as needed. Patient can chose from water, dilute juice, an artificially flavored oral electrolyte solution or dilute sports drinks (latter two if clinicians suspect electrolyte imbalance). After receiving a straw, a 30-mL medicine cup and 1,000 mL of the liquid chosen, the patient is instructed to drink 30 mL every 3-5 minutes. Consume half within 50-80 minutes, and all of it between 1 hour 40 minutes and 2 hours 40 minutes. A 20-minute delay in drinking is recommended for patients who vomit. Patient can be discharged once he or she passes urine. Give antiemetics or pain control as needed, and switch out drinks if the patient does not like the first one. Clinical judgment is used when choosing oral hydration in patients with co-existing conditions such as renal disease, diabetes or heart failure.

Medtalks with Dr KK Aggarwal ÂÂ

IMA Mahapanchayat Held at Indira Gandhi Stadium. IMA announced indefinite strike if the NMC is passed by the government.

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The National Consumer Commission has issued notice to Fernandez Hospital and the Aarohi Blood Bank in Hyderabad in a complaint seeking Rs. 6 crores in damages for a botched platelet transfusion resulting in an infant becoming infected with human immunodeficiency virus (HIV).

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Scientists from the University of Lincoln, UK, have now successfully created a simplified, synthesized form of teixobactin which has been used to treat a bacterial infection in mice, demonstrating the first proof that such simplified versions of its real form could be used to treat real bacterial infection as the basis of a new drug.

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The government proposal to increase the retirement age of doctors from 62 to 65 was met with serious opposition by the Senior Resident Doctors’ Association. Senior resident doctors alleged that the state government has not been advertising posts of assistant professors in medical colleges. And now they are shutting the young doctors away from government jobs by increasing the retirement age of senior doctors.

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The Karnataka government has defended before the Supreme Court its criteria for Karnataka origin or minimum 10-year study requirement for candidates

Outpatient ORS Protocol No IV in Mild Dehydration in Adults Oral hydration is a low-cost, evidence-based solution hospitals can implement to treat adults with mild rehydration. The suggested protocol is for people with mild dehydration from diarrhea, vomiting, morning sickness but not for people who have major electrolyte imbalances, such as kidney disease. Also oral rehydration should not replace IV fluids in patients with moderate or severe dehydration or in those unable to take liquids orally but is ideal for patients with pharyngitis, gastroenteritis and upper respiratory tract infections.

IJCP Sutra 227: In Life, in every moment, something new happens; something that you never expected, something that you were waiting from a long while to happen and something you were expecting to happen.

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outside the state to get admission to Post Graduate seats in medical and dental colleges. ÂÂ

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Giving its nod to the much-awaited demand of the medicine Post Graduate students, the State Legislative Assembly on Saturday did away with the compulsory rural practice clause for the purpose of registering as the medical practitioners. Moving the Bill in the Assembly, Health Minister Dr C Laxma Reddy said similar conditions imposed for MBBS degree holders were also lifted as the 1-year compulsory rural service failed to achieve its objective. Supreme Court has admitted a writ petition against Fortis Hospital Gurugram, in Adya’ Dengue Death case and issued notice to Central Government, Haryana Govt., FMRI, MCI, NPPA and Dr Vikas Verma. Seven resident doctors of the DY Patil Hospital were beaten up, allegedly by a mob that was upset about the death of a local youth. The mob damaged hospital property. Resident doctors of the Pimpri hospital held protests. Lifestyle changes and treatment with metformin both reduces the incidence of diabetes in persons at high risk. Lifestyle intervention is more effective than metformin (Diabetes Prevention Program Research Group).

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The Word Health Organization (WHO) estimated 6,00,000 cases of rifampicin-resistant tuberculosis in 2016—of which 4,90,000 were multidrug resistant, with less than 50% survival.

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According to WHO, a pregnant lady must pay visits to a doctor for at least 4 times during the pregnancy period.

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Medical expulsive therapy, which is routinely used to hasten the passage of ureteral or kidney stones in patients experiencing acute ureteric colic, has no effect on spontaneous stone passage (MIMIC study). Most stones smaller than 10 mm, and particularly those smaller than 5 mm, will pass naturally, without needing to intervene surgically. On average, it takes about a month to pass a kidney Stone, depending on its size.

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Neither a blockers nor calcium-channel blockers showed any benefit in the large SUSPEND trial (Health Technol Assess. 2015;19:vii-viii, 1-171).

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But a blockers were shown to be beneficial in a large systematic review and meta-analysis (BMJ. 2016;355:i6112).

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A woman who was verbally and physically abused after giving birth on the floor of a Hospital won a landmark $24,789 in damages. She delivered her baby on the floor as all beds were occupied. Nurses slapped and insulted her for dirtying the hospital floor.

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One of the most avant-garde obesity policy experiments is happening in Chile, where health officials are trying to revolutionize nutrition labeling. Instead of cramming percentages and numbers onto the back of food packages, the Chilean government now requires symbol-based warning labels on the front of food products that contain high levels of salt, sugar, calories and saturated fat.

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Canada, where 20% of adults have obesity, has taken notice. It’s now on the cusp of becoming the first high-income country to adopt a similar warning system. Meanwhile, Mexico, which has called overweight, obesity and diabetes public health emergencies, is also considering following Chile’s lead.

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There are more than 40,838 doctors of Indian origin in America today. The actual number could be higher.

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As reported by The Times of India, between April 2013 and March 2016, 4,701 doctors who graduated from India chose to go abroad.

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The European Commission has approved Alofisel for the treatment of complex perianal fistulas in adult patients with nonactive-to-mild luminal Crohn's disease who have shown inadequate response to at least one conventional or biologic therapy.

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Alofisel (darvadstrocel; Takeda, TiGenix) is the first allogeneic stem cell therapy to receive central marketing authorization in Europe.

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Free Press Journal: The insecticide control department of the BMC will start fumigation program at all 2605 under-construction sites of Mumbai to control mosquito menace. BMC will appoint volunteers.

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Dr Jasjeet Kaur, Deputy Director, Government of Haryana: Haryana has conducted highest 338 decoy operations through their informer scheme that has nabbed 77 people involved in the illegal practice of sex selection. One hundred twenty-nine informers have been incentivized. Sex ratio at birth has improved from 817 in 2014 to 9l4 in 2017. Eighteen districts out of total 2l districts have crossed the 900 girls/1,000 boys mark.

IJCP Sutra 228: Prayer is not a "spare wheel" that you pull out when in trouble, but it is a "steering wheel" that directs the right path throughout.

AROUND THE GLOBE ÂÂ

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Shri Raghuveer Singh, State Nodal Officer - PNDT Rajasthan: Total 101 decoy operations have been conducted. State of Rajasthan has been innovative in forming a dedicated police Bureau at the state level. To make the punishments more stringent for the violators state has also used related provisions of the Code of Criminal Procedure (CrPC) to complement the provisions of the PV-PNDT Act.

F = Factor depending on the age of the subject as per Annexure 2 (based on Workmen Compensation Act) 100-228 R = Risk Factor 0.50 terminally ill patient (expected survival not more than [NMT] 6 months) 1.0 Patient with high risk (expected survival between 6 to 24 months)

Dr Gaurav Dahiya, Mission Director Government of Gujarat: “We are facing challenges in regulating the bordering districts where cross border illegal practice of sex selection could be happening.”

2.0 Patient with moderate risk 3.0 Patient with mild risk 4.0 Healthy Volunteers or subject of no risk.

Muscular dystrophy, covered under the GOI Disability Act, 1995, is a progressive neuromuscular genetic disorder where the muscles gradually lose their strength, leaving the patient completely immobile and dependent on others for every day to day activities. There is as on date no known cure/ treatment. Angiotensin-converting enzyme (ACE) inhibitor should be stopped if high potassium levels cannot be controlled or the serum kidney creatinine levels rise more than 30% above the baseline value within the first 6-8 weeks.

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Dry cough is seen up to 20% patients given ACE inhibitors. Treatment consists of lowering the dose or stopping the drug. Re-administration of the drug is associated with a high rate of recurrent cough.

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Angioedema is a rare but potentially fatal complication of ACE inhibitors and angiotensin receptor blockers (ARBs).

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Isoniazid-monoresistant tuberculosis (TB) include: Daily rifampin, ethambutol and pyrazinamide (with or without a fluoroquinolone) for 6-9 months (or 4 months after culture conversion). In HIVinfected patients prolong therapy for an additional 3 months.

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The government has announced an allocation of Rs. 10,000 crore for the government's ambitious health insurance program.

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University of Stanford spin-out PhysioWave has just received FDA clearance for its pulse wave velocity (PWV) cardiovascular analyzer scale, which measures the stiffness of the vessels transporting blood from the heart to the body.

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Capping on Compensation: Compensation Formula in case of Clinical Trial in Rule 122 DAB of Drugs and Cosmetics Rules: Compensation = BX (8 lac) F × R/ 99.37

Compensation amount will vary from a minimum of Rs. 4 lacs to a maximum of Rs. 48 lacs depending on the age of the deceased and the risk factor. (assuming factor 4 will not be applicable in diseased patients). In case of patients whose expected mortality is 90% or more within 30 days, a fixed amount of Rs. 2 lac should be given. ÂÂ

Antibiotics differ from almost every other class of drugs in one important and dangerous way: the more they are used, the less effective they become.

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The Trinamool Congress bagged four seats and the Congress got one in the Rajya Sabha polls from Bengal recently. Dr Santanu Sen prominent IMA leader emerged victorious in the vote count.

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Dubbing the Parliamentary Standing Committee report on the controversial National Medical Commission Bill as “worse than the bill itself”, the Indian Medical Association has threatened to go on a “warpath” if the contentious clauses are not removed from the proposed legislation.

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Indias largest body of doctors said recently, it was preparing to intensify its opposition to the Narendra Modi governments bill for a new regulatory structure for medicine and its proposal to allow practitioners of alternative healthcare systems to prescribe modern medicines. [Telegraph]

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A NIAID-led study found that a one-month antibiotic regimen to prevent active TB disease in people with latent TB infection was as safe and effective as the standard 9-month course in people living with HIV.

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A study carried out by the Indian Council of Medical Research (ICMR) showed that over 50% of female patients in India coming for in vitro fertilization (IVF) procedure have been reported to have genital TB.

IJCP Sutra 229: A theory can be proved by experiment; but no path leads from experiment to the birth of a theory. —Albert Einstein

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People with disabilities make up 15% of the world’s population. Half of those are over 60 years old, he said. Many of them don’t have the same opportunity as non-disabled people to socialize with their peers.

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In 2017, WHO classified antibiotics into three groups and issued guidance for how each class of drugs should be used to treat 21 of the most common infections. For example, the first of these groups consists of medicines that should always be available to patients, preferably by prescription. Amoxicillin, the preferred medicine for respiratorytract infections in children, is in this group. The second tier includes carbapenems. And the third group, including colistin and other “last resort” antibiotics, are drugs that must be used sparingly and only for medical emergencies.

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New research published in BMJ links dipeptidyl peptidase-4 (DPP-4) inhibitors used to treat type 2 diabetes to an increased risk for inflammatory bowel disease.

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India’s Red Line campaign–demands that prescription-only antibiotics be marked with a red line, to discourage the over-the-counter sale of antibiotics.

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“Last resort” antibiotics should never be used as growth promoters in livestock farming,

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March 24, 2018 was world TB day. Globally, the incidence of TB has been declining at about 2% per year. But, this decline is not enough to achieve the first 2020 milestone of the End TB Strategy and the target of ending the TB epidemic by 2030 under the Sustainable Development Goals (SDG 3). TB cases have to decline by 4-5% to achieve this target.

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A normal chest X-ray is possible even in active pulmonary TB. In one Canadian study of 518 patients with culture-proven pulmonary TB, 25 patients had normal chest X-ray. CT scan is more sensitive than plain chest X-ray for diagnosis, particularly for smaller lesions located in the apex of the lung (Radiology. 1993;186:653).

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Individuals who are on a gluten free diet are consuming more gluten than we actually imagined. Its not uncommon for them to be consuming on average a couple of 100 mg a day. Hidden gluten is ubiquitous in medications, food additives, seasonings, sauces, lipsticks and lip balms, fried foods and many other sources. (Reuters)

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Tooth loss in middle age is tied to a higher risk of cardiovascular disease, independent of traditional

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risk factors such as high blood pressure, poor diet, and diabetes. (Tulane University School of Public Health and Tropical Medicine in New Orleans) ÂÂ

Culture First: First-generation parenteral cephalosporins, including cefazolin, are active against most Gram-positive cocci except for enterococci, oxacillin-resistant staphylococci and penicillin-resistant pneumococci. They are also active against most strains of Escherichia coli, Proteus mirabilis and Klebsiella pneumoniae.

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For patients who are actively dying from a terminal illness, CPR constitutes a non-beneficial or harmful and inappropriate medical treatment.

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The identification of individuals with a terminal illness who are actively dying (life expectancy measured in hours to days) may be straightforward at times, but also can be difficult.

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The clinical signs of impending death: Five of the signs that emerged mostly during the last three days of life had both high specificity (>95% chance that the patient would not die within 3 days if the symptom was absent) were pulselessness of the radial artery, respiration with mandibular movement, decreased urine output, Cheyne-Stoke breathing and death rattle.

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Eight additional clinical bedside signs that were highly specific for impending death within three days were nonreactive pupils, decreased response to verbal stimuli, decreased response to visual stimuli, inability to close eyelids, drooping of the nasolabial fold, hyperextension of the neck, grunting of the vocal cords and upper gastrointestinal bleeding.

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In 2013 US FDA reported that olmesartan can produce a “sprue-like enteropathy” characterized by reversible severe chronic diarrhea and weight loss, occurring months to years after initiation of the drug. The corresponding number needed to harm was 12,550 treated to cause one additional case of severe enteropathy. Thus, patients starting olmesartan should be cautioned about the possibility of developing diarrhea and weight loss. The drug should be stopped if these symptoms occur and another cause is not found.

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Ramipril and telmisartan have similar rates of hyperkalemia, defined as a serum potassium >5.5 mEq/L (3.3% and 3.4%), acute renal failure, defined as a doubling of the serum creatinine (1.9% and 2.0%), and syncope requiring drug discontinuation (0.2% with both drugs).

IJCP Sutra 230: Permanence, perseverance and persistence in spite of all obstacles, discouragement and impossibilities: It is this, that in all things distinguishes the strong soul from the weak. —Thomas Carlyle

AROUND THE GLOBE ÂÂ

Multiple studies have demonstrated that patients who are treated with both an ACE inhibitor and an ARB are at higher risk for adverse effects.

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Saturday March 24th was celebrated as “IMA National Telemedicine Day”.

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WHO is coordinating efforts among 16 African countries in an attempt to contain the world’s largest ever Listeria outbreak, a preventable food born illness. Almost 200 people are confirmed to have died in the outbreak and almost 1,000 have been confirmed sick with listeriosis, according to South Africa’s health department. Listeria monocytogenes causes invasive disease, including central nervous system infection or bacteremia in immunosuppressed patients, individuals at the extremes of age including neonates and older adults, and pregnant women. The most common central nervous system (CNS) manifestation of listerial infection is meningoencephalitis, which ranges from a mild illness with fever and mental status changes to a fulminant course with coma.

to screen more than 1,000 drugs currently on the market. Of the 923 non-antibiotic drugs that were analyzed, 250 had disrupted the growth of at least one of the 40 species of gut bacteria in the panel. ÂÂ

The US CDC said that 13 people from eight states have been sickened in a Salmonella typhimurium outbreak linked to dried coconut.

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Phosphomycin is a safe and efficacious prophylaxis for those undergoing prostate biopsy. (Copenhagen, Denmark Dr. D’Elia, Bolzano General Hospital).

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National Human Right Commission has found doctors at 3 Delhi government hospitals negligent in providing treatment to a 22-year-old young man, resulting in his death on June 12 last year and recommended that the Delhi government pay Rs. 2 lac as compensation to the next of kin of the deceased.

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In a bid to curb quackery in the state, Health Minister C Vijayabaskar introduced the Tamil Nadu Private Clinical Establishments (Regulation) Amendment Act, 2018 in the Assembly recently.

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Transdermal nicotine treatment can decrease depressive symptoms in patients with late-life depression (Jason A. Gandelman, a medical student at Vanderbilt University School of Medicine, Nashville, Tennessee).

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Thoroughly cook raw food from animal sources to a safe internal temperature: ground beef 160°F (71°C), chicken 170°F (77°C), turkey 180°F (82°C), and pork 160°F (71°C).

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According to a notice by the Central Drugs Standard Control Organization (CDSCO) all pharma exporters can continue exporting without having to obtain no-objection certificates from the regulatory authorities.

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Bio Spectrum: Samsung India has initiated Samsung Smart Healthcare program at King George Hospital in Visakhapatnam to provide affordable and quality healthcare to financially and socially backward patients.

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The Cabinet has approved the launch of Ayushman Bharat—National Health Protection Mission, (also known as Modicare).

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The government announced increase in the seats reserved for people with disabilities for admission to post graduate medical courses from 3% to 5%.

Money control: The Madhya Pradesh Animal Husbandry Department has signed an MoU with Bharat Financial Inclusion Ltd (BFIL) to roll out an animal healthcare program.

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Economic Times: Healthcare Federation of India NATHEALTH recently said Fortis Healthcare president Daljit Singh has been elected as its president for the year 2018-19. He succeeds Dr Lal PathLabs chairman and MD Dr Arvind Lal, NATHEALTH said in a statement.

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This year, the focus of WNTD 2018 is “Tobacco and heart disease” with the campaign theme of ‘Tobacco breaks hearts’.

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ISA, IAP, FOGSI supported Doctors Mahapanchayat on 25.03.2018 at IGI Stadium, New Delhi.

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Last month, a study published in JAMA reported that many American medical schools don't offer

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US FDA has approved implants for increasing breast size in women (augmentation), for reconstruction after breast cancer surgery or trauma, and to correct developmental defects. Implants are also approved to correct or improve the result of a previous surgery. In a study research has revealed that a “few commonly used non-antibiotic drugs” are associated with changes in gut microbe composition. They compiled a panel of 40 species of gut bacteria that are typically found in the human gut and used it

IJCP Sutra 231: One resolution I have made, and try always to keep, is this: To rise above the little things. —John Burroughs

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the 12 weeks of maternity leave recommended by physicians.

the right to breathe, to live free from TB and AIDS.” said Michel Sidibé, Executive Director of UNAIDS.

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A yellow fever outbreak that began a year and a half ago in Brazil is spreading further, with additional cases since last July in the Brazilian states of Sáo Paulo, Minas Gerais and Rio de Janeiro, plus several cities in Bahia State.

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26th CSB (24th Jan 18): MOH have notified rules for manner of Appeal under the PC & PNDT Rules, 1996 vide no. GSR 492(E) dated 22.05.2017.

Tedros Adhanom Ghebreyesus, Director-General WHO said, “While the world has committed to end the TB epidemic by 2030, as part of the Sustainable Development Goals (SDGs), actions and investments do not match the political reality. World TB Day is an opportunity to mobilize political and social commitment for accelerated progress to end TB.” (UN, March 23, 2018)

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26th CSB (24th Jan 18): New rules will facilitate the states/ UTs to notify Appellate Authorities who will address the appeals against the orders passed by the States/ UTs Appropriate Authorities. Time lines have been provided for filing and disposal of appeals and requisite formats for submitting the appeal.

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26th CSB (24th Jan 18): States have also been requested to explore the possibilities of utilizing the sealed ultrasound machines under the PC&PNDT Act for the benefit of common public in the Government hospitals after seeking appropriate legal opinions from their concerned law departments. WP 34tl2008, Dr. Sabu Mathew George Vs Union of lndia in 2008 against the search engines- Google, Microsoft and Yahoo and UOI for the violation of Section 22 of the PC&PNDT Act that prohibits advertisement on sex selection through any medium including internet. The apex gave interim directions on 6.11.2016 to constitute a Nodal Agency to receive complaints against the violations of Section 22 for internet advertisements. Final judgment in the matter was pronounced on 13.12 2017. The apex Court has given final directions to UOI to constitute an inter-ministerial Expert Committee. Google, Microsoft and Yahoo are directed to appear before the Expert Committee for ensuring 100% compliance of the relevant provisions of the PC&PNDT Act accordingly.

‘Bold Action’ Needed to End TB, AIDS, Says UN Claiming more than 4,500 lives daily, tuberculosis (TB) continues to be the top infectious killer worldwide as well as the leading cause of death among people living with HIV. The UN has called on all partners to take unprecedented and bold action to advance efforts to end TB and AIDS by 2030. “The world has the resources to end the interlinked epidemics of TB and HIV, but political commitment and country action are lacking. Political, religious and civil society leaders need to step up to guarantee everyone

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Exposure to Loud Noise at Workplace Increases BP and Cholesterol According to a study published March 14, 2018 in the American Journal of Industrial Medicine, occupational noise exposure is associated with hypertension, elevated cholesterol and hearing difficulty. Hence, it is important to reduce workplace noise levels.

Depression Increases Risk of Atrial Fibrillation Depression may increase the risk for atrial fibrillation, which increases the risk of stroke, according to preliminary research presented at the American Heart Association’s Epidemiology and Prevention | Lifestyle and Cardiometabolic Health Scientific Sessions 2018 at New Orleans.

ESC Syncope Guidelines Recommend Filming the Attack and Recovery to Improve Diagnosis Guidelines on syncope from the European Society of Cardiology (ESC) have been published March 19, 2018 in the European Heart Journal. The guidelines recommend a new algorithm for emergency department (ED) to stratify patients and discharge those at low risk. Patients at intermediate or high risk should receive diagnostic tests in the emergency department or an outpatient syncope clinic. The value of video recording in hospital or at home to improve diagnosis has been emphasized. It recommends that friends and relatives use their smartphones to film the attack and recovery.

Poor Dental Health may Herald Risk of Diabetes Poor dental health may be a sign of increased risk for diabetes, according to a study presented March 19, at ENDO 2018, the 100th Annual Meeting of the Endocrine Society in Chicago, Illinois. A progressive increase in the number of patients with missing teeth was observed as glucose tolerance declined, from around 46% in patients with normal glucose tolerance, to around 68% in those with abnormal glucose tolerance, to about 83% in patients with diabetes.

IJCP Sutra 232: A mountain is not higher than our confidence. It will be under our feet if we reach the top.

AROUND THE GLOBE FDA Expands Use of Tasigna for Ph+ Chronic Myeloid Leukemia in Children The FDA has expanded the use of nilotinib to treat children aged 1 year or older, with Philadelphia chromosome-positive (Ph+) chronic myeloid leukemia in chronic phase in both the first- and second-line settings.

Older Adults Who Walk Slowly are More Prone to Dementia Older adults with slower walking speeds, and those who experienced a greater decline in their walking speed over time, were at increased risk for dementia independent of changes in cognition, according to results of the English Longitudinal Study of Ageing published online in the Journal of the American Geriatrics Society.

Health Ministry Launches New Initiatives to Combat TB on World TB Day "We are already aligned with world TB treatment protocols. It has a mission to End TB by 2025, through community participation, involving civil societies and other stakeholders.” This was stated by Smt. Preeti Sudan, Secretary (Health) at a function on the occasion of ‘World TB Day’. She further stated that the global target to end TB is 2030 but we will end it by 2025. “This is a tall order but I am confident that if we all work together, if all the partners combine together and we ensure full treatment is given on regular basis we can show the world this can be achieved. I am confident of this and my confidence is backed by our success in eradicating Polio,” she added.

in risk could be sustained every year for up to 5 years post-surgery.

Adjustable Gastric Banding Causes Fewer Fracture than Roux-en-Y Surgery As per a study presented March 17, 2018 at ENDO 2018, the 100th annual meeting of the Endocrine Society in Chicago, Illinois, patients undergoing Roux-en-Y gastric bypass (RYGB) surgery may be at greater risk for nonvertebral fracture than those having adjustable gastric banding (AGB).

Apixaban is a Safe Alternative to Warfarin During Catheter Ablation of AF Results of the AXAFA-AFNET 5 trial presented March 20, 2018 at EHRA 2018, a European Society of Cardiology (ESC) congress show that apixaban and warfarin had similar rates of stroke and bleeding and improvement in cognitive function up to 3 months after catheter ablation in patients with atrial fibrillation.

Genetic Screening Advised Before Dapsone Treatment in Asians A systematic review and meta-analysis reported online March 14 in JAMA Dermatology has recommended genetic screening before starting dapsone treatment in Asian populations because of the association of HLA-B*1301 with dapsone-induced cutaneous adverse reactions.

Venetoclax + Rituximab Improves Progression Free Survival in Refractory CLL

At the function, the Health Secretary also released the TB India 2018 Report and National Drug Resistance Survey Report. The NikshayAushadi Portal and shorter regimen for Drug Resistant TB were also launched… (Press Information Bureau, Ministry of Health and Family Welfare, March 24)

Treatment of patients with relapsed or refractory chronic lymphocytic leukemia (CLL) with a combination of venetoclax and rituximab resulted in significantly higher rates of progression-free survival compared to bendamustine + rituximab as demonstrated in a study published in the New England Journal of Medicine.

Bariatric Surgery Reduces Risk for Premature Heart Disease in Severely Obese Teens

Transmission of Infection in an Airplane is Higher within Two rows of an Infectious Passenger

Bariatric surgery is predicted to cut in half the 30-year risk of having a heart disease event, such as a heart attack or stroke in teens with severe obesity, according to preliminary research presented March 23, 2018 at the American Heart Association’s Epidemiology and Prevention | Lifestyle and Cardiometabolic Health Scientific Sessions 2018 in New Orleans. The reduction

A new research published online March 19, 2018 in the Proceedings of the National Academy of Sciences shows that passengers seated within one row or two seats on either side of an infected individual are at higher risk of acquiring the infection (80% or greater) compared to less than 3% risk for the remaining passengers.

IJCP Sutra 233: Man’s troubles are rooted in extreme attention to senses, thoughts and imagination. Attention should be focused internally to experience a quiet body and a calm mind. —Buddha

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Five Actions to Advance Efforts to End TB and AIDS by 2030

Perimenopausal Vasomotor Symptoms may Improve with Oral Micronized Progesterone

The UN is calling on all partners to take unprecedented and bold action to advance efforts to end TB and AIDS by 2030. While preventable and curable, persistent challenges remain, many of which are shared by the HIV response, including unequal access to services. Noting that both can be addressed effectively with integrated programs, UNAIDS outlined five important actions for partners.

Oral micronized progesterone (OMP) taken every day at bedtime may diminish vasomotor symptoms of hot flashes and night sweats in perimenopausal women, as per a new study presented March 19, 2018 at ENDO 2018, the annual meeting of the Endocrine Society, which concluded recently in Chicago, Illinois.

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Impelling political, religious and civil society leaders to champion the universal right to live free from TB and HIV.

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Communities must be empowered to call on governments to demand their right to health improving living standards to reduce the burden of TB and HIV.

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Promoting nondiscriminatory service delivery to protect all against catastrophic health expenditures in the context of universal health coverage extending care beyond health to include safe workplaces and places of detention.

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Finance ministers be engaged to approach health as an investment, not an expenditure, in which returns demonstrate their long-term value to societies and economies.

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Greater public-private sector partnerships to accelerate for innovative new medicines and vaccines. (UN, March 23, 2018)

Long-term Use of Antibiotics Increases Risk of Death in Women A new research presented at the American Heart Association’s Epidemiology and Prevention | Lifestyle and Cardiometabolic Health Scientific Sessions 2018 in New Orleans has said that compared to no antibiotic use, women who take antibiotics for 2 months or longer, especially in late adulthood, are at a higher risk of allcause mortality (27%) and death from heart disease (58%).

PFO Closure After Stroke Improves Prognosis Patients who underwent closure of patent foramen ovale (PFO) with a device after a stroke had a better prognosis at 2 years compared to those who were treated with stroke-preventing medications alone as shown in a study presented March 12, 2018 at the American College of Cardiology's 67th Annual Scientific Session in Orlando.

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Frist Trial of Empagliflozin for Treatment of NAFLD in Type 2 Diabetes Shows Promise Findings of the effect of empagliflozin on liver fat content in patients with type 2 diabetes (E-LIFT) presented March 19, 2018 at ENDO 2018: The Endocrine Society Annual Meeting in Chicago, Illinois show that empagliflozin may help in the treatment of nonalcoholic fatty liver disease (NAFLD).

Activity Status and Cardiac Size Predict Exercise Capacity in Patient with Diabetes Type 2 diabetes mellitus was associated with reduced exercise capacity, whereas active subjects with type 1 diabetes had preserved exercise capacity relative to healthy controls. In the study published March 23, 2018 in the journal Cardiovascular Diabetology, reduced physical activity and smaller left ventricle volumes, rather than subclinical cardiac dysfunction, were associated with impaired exercise capacity.

ACP Ethical Guidance for Individuals Volunteering for Medical Trips The American College of Physicians (ACP) has published a position paper on ethical decision making surrounding participation in short-term global health clinical care experiences or volunteer medical trips. Besides improving healthcare of the communities they will serve, participants also face several ethical challenges especially pertaining to local culture besides increased awareness of global health issues, practicing in low-technology settings, improved language skills. The position statement published online March 27, 2018 in the Annals of Internal Medicine describes five core positions that focus on ethics and the clinical care context supported by case scenarios. ÂÂ

Physicians' primary ethical obligation in short-term global health experiences is to improve the health and well-being of the individuals and communities they visit.

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The ethical principle of justice requires partnering with local leaders to ensure that the potential

IJCP Sutra 234: Betrayal is about learning not to idealize external sources. —Linda Talley

AROUND THE GLOBE burdens participants can place on local communities abroad are minimized and preparing for limited material resources. ÂÂ

The ethical principle of respect for persons, including being sensitive to and respectful of cultural differences, is essential to short-term global medical experiences.

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Predeparture preparation is itself an ethical obligation. It should incorporate preparation for logistical and ethical aspects of STEGHs, including the potential for ethical challenges and moral distress.

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Physicians should participate with organizations whose STEGHs are consistent with ethics and professionalism as exemplified in these positions.

Higher Waist Circumference before Pregnancy Increases Risk of Autism in Offspring A new study presented March 19, 2018 at ENDO 2018, the 100th annual meeting of the Endocrine Society in Chicago, Illinois has shown that children born to mothers who had a larger waist size before pregnancy were more likely to have autism than those whose mothers had a smaller pre-pregnancy waist.

ICMR Invites Suggestions on Draft Consensus Statement on Pancreatic Cancers ICMR has invited suggestions/comments on a draft consensus statement on pancreatic cancers by the 16th April 2018. Suggestions may be sent to Dr. Tanvir Kaur, Scientist 'F' at doctanvirkaur@gmail.com.

Monounsaturated Fats from Plants Reduce Risk of Death from Heart Disease and Other Causes

High-flow Oxygen Therapy in Infant Bronchiolitis Reduces Chances of Treatment Failure

Diets rich in monounsaturated fats from plants were associated with a lower risk of dying from heart disease and other causes compared to diets rich in monounsaturated fats from animals. The largest reductions in the risk of death were found when healthy fats from plant sources replaced saturated fats, trans fats and refined carbohydrates. These findings were presented March 21, 2018 at the American Heart Association’s Epidemiology and Prevention | Lifestyle and Cardiometabolic Health Scientific Sessions 2018 in New Orleans.

High-flow oxygen therapy given by nasal cannula to infants with bronchiolitis reduces chances of treatment failure and consequently significantly lower rates of escalation of care by nearly half compared to infants who were given standard oxygen therapy, according to a new study reported online March 21 in The New England Journal of Medicine.

Study Finds Atypical Brain Development in Preschoolers with ADHD Symptoms

Patients with kidney failure undergoing hemodialysis are at a greater risk of life-threatening infections and may also spread to others in dialysis facilities. A series of articles have been published online March 22, 2018 in the Clinical Journal of the American Society of Nephrology (CJASN) that provide important information on infections and their prevention in patients undergoing hemodialysis.

Children as young as 4 years old with symptoms of attention deficit hyperactivity disorder (ADHD) may have significant differences in brain structure, compared to children without such symptoms, according to a study published in the Journal of the International Neuropsychological Society.

Kidney Failure Patients Undergoing Hemodialysis are at Risk of Infections

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Rule of 20/10 for Hypertension ÂÂ

Every rise in 20 mmHg in upper BP and 10 mmHg in lower BP makes a higher grade of hypertension zz

120/80 Normal

140/90 Stage 1 hypertension

160/100 Stage 2 hypertension.

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For every 20/10 fall of BP, add one drug.

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Do not reduce more than 20/10 mmHg at one time in accelerated hypertension.

IJCP Sutra 235: Love is the only way to grasp another human being in the innermost core of his personality. —Viktor E. Frankl

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Spiritual Update

Spiritual Prescription: Yoga Nidra KK aggarwal

any people in the East and the West are attracted to yogic practices, for they think they can find a solution to every problem therein, be it physical, mental, emotional or spiritual. Hence, much importance is attached to relaxation techniques that one thinks might help a person in easing the tension caused due to chronic stressful lifestyle. Yoga Nidra is one such wonderful technique, not only for physical or mental relaxation but also to prepare the mind for spiritual discipline. It concerns mainly with pratyahara (withdrawing senses from sense-objects) and dharana (concentration). It is to be understood that ordinary sleep is not complete relaxation, for tension and stress cannot always be resolved completely in ordinary sleep. Yoga Nidra is qualitatively different relaxation. It is a ‘sleep’ where all the burdens are thrown off to attain a more blissful state of awareness, and hence it is a relaxation much more intense than ordinary sleep.

Group Editor-in-Chief, IJCP Group

As Swami Satyananda Saraswati (Preface to “Yoga Nidra”, 1982, Bihar School of Yoga, Monghyr, Bihar, India) says: “When awareness is separate and distinct from vrittis - mental modifications, when waking, dreaming and deep sleep pass like clouds, yet awareness of Atman remains, that is the experience of total relaxation. That is why, in Tantra, Yoga Nidra is said to be the doorway to samadhi!” Utility Yoga Nidra helps in restoring mental, emotional and physical health by way of relaxation, and makes the mind more conducive to pratyahara - (withdrawing senses from their objects), dharana - (concentration), and meditation. Such a practice helps to harmonize two hemispheres of the brain and the two aspects of autonomous nervous system viz. sympathetic and parasympathetic. The impressions in the subconscious are brought to the surface, experienced and removed. Thus, the fixation of awareness to the body is replaced with the awareness linked to subtler aspects of Prana and spiritual dimensions.

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Chat with Dr KK Zero Tolerance to Sex Determination

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IJCP Sutra 236: The height of your accomplishments will equal the depth of your convictions. —William F. Scolavino

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Indian Journal of Clinical Practice

January-February 2014, Pages 1-64 Peer Reviewed Journal

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In This Issue —

Emerging role of Cardiac MRI in Ischemic and Non-ischemic Cardiomyopathy

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Acute Renal Failure and Silent Myocardial Infarction Following Multiple Honey Bee Stings

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Asian Journal of Diabetology

Brachial Artery: Its Embryological Glucose Tolerance in Nondiabetic Patients after First Attack of Acute Myocardial Infarction and its Outcome

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A Case of Left Atrial Myxoma Presenting as Severe Pulmonary Hypertension

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Double-Chambered Right Ventricle with Transient 2:1 Atrioventricular Block: A Rare Presentation

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Cornary Artery Air Embolism

Volume 17, Number 5

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January-March 2015

Volume 1, Number 1

Asian Journal of Obs & Gynae Practice Asian Journal of Paediatric Practice

Volume 18, Number 3

Dr Swati Y Bhave

Dr KK Aggarwal

Editor

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lighter reading

HUMOR

Lighter Side of Medicine The Leave Application

Who Would Know?

From an employee who was performing the “mundan” ceremony of his 10-year old son: “as I want to shave my son’s head, please leave me for 2 days...”

The man passed out in a dead faint as he came out of his front door onto the porch. Someone called 911. When the paramedics arrived, they helped him regain consciousness and asked if he knew what caused him to faint.

Proportions

“It was enough to make anybody faint,” he said. “My son asked me for the keys to the garage, and instead of driving the car out, he came out with the lawn mower!”

One semester when my brother, Peter, attended the University of Minnesota in Minneapolis, an art-student friend of his asked if he could paint Peter’s portrait for a class assignment. Peter agreed, and the art student painted and submitted the portrait, only to receive a C minus.

Some Answers ÂÂ

Antibody - One who hates his body

ÂÂ

Artery - Study of Fine Paintings

ÂÂ

Bacteria - Back door of a Cafeteria

ÂÂ

Coma - Punctuation Mark

ÂÂ

Gallbladder - Bladder of a Girl

“The head is too big,” the professor explained.

ÂÂ

Genes - Blue Denim

“The shoulders are too wide, and the feet are enormous.” The next day, the art student brought Peter to see the professor. He took one look at my brother and said, “Okay, A minus.”

ÂÂ

Labour Pain - Hurt at Work

ÂÂ

Liposuction - A French Kiss

ÂÂ

Ultrasound - Radical Sound

ÂÂ

Cardiology - Advanced Study of Playing Cards

The art student approached the professor to ask why the grade was so poor. The teacher told him that the proportions in the painting were incorrect.

Under the Wagon A farm boy accidentally overturned his wagonload of wheat on the road. The farmer that lived nearby came to investigate. “Hey, Willis,” he called out, “forget your troubles for a while and come and have dinner with us. Then I’ll help you overturn the wagon.”

Dr. Good and Dr. Bad Situation: An individual with prediabetes was asked to join groups that promote diabetes self-management.

It will not help

Such groups are helpful

“That’s very nice of you,” Willis answered, “but I don’t think Dad would like me to.” “Aw, come on, son!” the farmer insisted.

After a hearty dinner, Willis thanked the host. “I feel a lot better now, but I know Dad’s going to be real upset.” “Don’t be silly!” said the neighbor. “By the way, where is he?” “Under the wagon,” replied Willis.

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IJCP Sutra 237: Medicines heal doubts as well as diseases. —Karl Marx

“Well, OK,” the boy finally agreed, “but Dad won’t like it.” Lesson: The ADA suggests that diabetes self-management

education and support programs may be beneficial for individuals with prediabetes for gaining knowledge and receiving support for developing and maintaining behaviors that can help in preventing or delaying the occurrence of diabetes. Diabetes Care. 2017;40(Suppl 1):S44-S47.

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ISSN number 0971-0876

RNI number 50798/1990.

The Medical Council of India (UGC, ICI)

Indian Journal of Clinical Practice is published by the IJCP Group. A multispecialty journal, it provides clinicians with evidence-based updated information about a diverse range of common medical topics, including those frequently encountered by the Indian physician to make informed clinical decisions. The journal has been published regularly every month since it was first launched in June 1990 as a monthly medical journal. It now has a circulation of more than 3 lakh doctors. IJCP is a peer-reviewed journal that publishes original research, reviews, case reports, expert viewpoints, clinical practice changing guidelines, Medilaw, Medifinance, Lighter side of medicine and latest news and updates in medicine. The journal is available online (http://ebook.ijcpgroup.com/IndianJournal-of-Clinical-Practice-January-2018.aspx) and also in print. IJCP can now also be accessed on a mobile phone via App on Play Store (android phones) and App Store (iphone). Sign up after you download the IJCP App and browse through the journal. IJCP is indexed with Indian Citation Index (ICI), IndMed (http://indmed.nic.in/) and is also listed with MedIND (http://medind.nic.in/), the online database of Indian biomedical journals. The journal is recognized by the University Grants Commission (20737/15554). The Medical Council of India (MCI) approves journals recognized by UGC and ICI. Our content is often quoted by newspapers. The journal ISSN number is 0971-0876 and the RNI number is 50798/1990. If you have any Views, Breaking news/article/research or a rare and interesting case report that you would like to share with more than 3 lakh doctors send us your article for publication in IJCP at editorial@ijcp.com. Dr KK Aggarwal Padma Shri Awardee Group Editor-in-Chief, IJCP Group

IJCP Sutra 238: When you are at a loss of what to do, do nothing. Doing nothing can be very wise. When you pause doing things, you become more aware of Godâ&#x20AC;&#x2122;s presence, and often an unexpected solution to your question will arise.

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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.

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.

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,

–

1096

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.

IJCP Sutra 239: Some of us think holding on makes us strong; but sometimes it is letting go. —Herman Hesse

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.

6. Suggestions for reviewers (name and postal address)

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. –

The legend must include enough information to permit interpretation of the figure without reference to the text.

Indian 1.____________Foreign 1._ _______________

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

IJCP Sutra 240: No matter how much you plan, it is tenacity, unyielding desire to succeed, and the ability to cope with change that will eventually prevail. —Perry Payne

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