Ijcp February 2014

Indexed with IndMED

ISSN 0971-0876

www.ijcpgroup.com

Volume 24, Number 9

February, Pages 801-900

Peer Reviewed Journal

zz American Family Physician zz Cardiology zz Community Medicine zz Dermatology zz Diabetology zz Drug zz ENT zz Gastroenterology zz Obstetrics and Gynecology

an i c i ys ians

zz Orthopedics

Phly Physic y l mi ami

zz Pediatrics zz Preventive and Social Medicine

Fademy of F n ica Aca

zz Respiratory Infections

er merican m A eA

zz Surgery

ingurnal of th t a or d Jo

zz Medilaw

rp-reviewe o c In eer AP

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

Dr KK Aggarwal Group Editor-in-Chief

Dr Veena Aggarwal MD, Group Executive Editor

IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma, Dr Kamala Selvaraj Cardiology Dr Praveen Chandra, Dr SK Parashar Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty ENT Dr Jasveer Singh Dr Chanchal Pal Dentistry Dr KMK Masthan Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar Dr Rajiv Khosla Dermatology Dr Hasmukh J Shroff Dr Pasricha Dr Koushik Lahiri Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan Dr Vineet Suri Journal of Applied Medicine & Surgery Dr SM Rajendran, Dr Jayakar Thomas Orthopedics Dr J Maheshwari

Anand Gopal Bhatnagar Editorial Anchor Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

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

Volume 24, Number 9, February 2014 from the desk of THE group editor-in-chief

805 Films Showing Smoking Scenes should be Certified as Adult Films

KK Aggarwal

Community health

808 Health Message in Water/Electricity Bills, a Unique Way to

Sensitize the Public KK Aggarwal

American Family Physician

811 Cluster Headache

Jacqueline Weaver-Agostoni

817 Practice Guidelines 818 Photo Quiz CARDIOLOGY

820 Prevalence of Metabolic Syndrome in Patients with Essential Hypertension

D Makwana, S Bagga, M Nandal

823 A Comparative Evaluation of Losartan/Hydrochlorothiazide

(Fixed Combination) versus Amlodipine Monotherapy on Left Ventricular Hypertrophy, Biochemical Parameters and Adverse Effects in Patients of Hypertension

Iram Shaifali, AK Kapoor, HK Singh

Community Medicine

830 Knowledge, Attitude and Practices Regarding Biomedical Waste Management among Healthcare Personnel in Lucknow, India

Gyan P Singh, Pratibha Gupta, Reema Kumari, Sneh Lata Verma

Dermatology

834 Erythematous Nodules on Face: A Dermatologist’s Dilemma

Kshama Talwar, Ankur Talwar, Suresh Talwar, Manisha Bindal

Diabetology

840 A Randomized Double-Masked Study of 50 mg of Acarbose versus 0.2 mg Voglibose in Overweight Type 2 Diabetes Patients Age Between 30 and 50 Years Having Isolated Postprandial Glycemia

Prem Kumar D, Pratap VGM

Drug

843 Tackling Antimicrobial Resistance: Optimizing Use of an Older Antibiotic-Amoxicillin

Rajiv Garg

ENT

846 Pleomorphic Adenoma of the Nose

Irfan Iqbal, Kanwaljeet Singh, Hardeep Singh

848 Intralesional Sclerotherapy Cures Unusual Presentation of Hemangioma in a Child

Bimal Kumar Mandal, Rina Das, Jayanta Bain

Gastroenterology

851 Jejunal Carcinoma – An Unusual Undiagnosed Cause of Anemia: A Case Report

Aswini K Pujahari, CR Praveen

Obstetrics and Gynecology

854 An Unusual Association of Aplasia Cutis Congenita with Twin Pregnancy and Maternal Varicella

R Gupta, Mukesh Kumar Gupta, M Kakkar

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

856 Multiple Fibroids in a Case of MRKH Syndrome with Absent Uterus: Recommendations for Management

Shalini Mahana Valecha, Prajakta Katdare, Uday Kargar, Prajakta Shende

859 Evaluation of Mifepristone and Misoprostol for Medical

Termination of Pregnancy Between 13-20 Weeks of Gestation

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

Neha Agarwal, Gauri Gandhi, Swaraj Batra, Rachna Sharma

Orthopedics

863 Bilateral Dupuytren’s Contracture

© Copyright 2014 IJCP Publications Ltd. All rights reserved.

Neelam Redkar, Sunil Pawar, Meenakshi Patil, Sameer Mahajan, Ajay Keur

865 Isolated Comminuted Fracture of the Scapula

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.

Amit Agrawal

867 Management of Fracture Neck of Femur with Cemented Bipolar Prosthesis

TS Raghavendra, BS Jayakrishna Reddy, Jithuram Jayaram

PEDIATRICS

872 Massive Fetomaternal Hemorrhage

Editorial Policies

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Kannan Venkatnarayan, Rajeev Thapar, Himanshu Sharma

Preventive and Social Medicine

875 Iron-Folic Acid Intake Among Pregnant Women in Anumanthai PHC of Villupuram, Tamil Nadu

Kumar S, Sitanshu Sekhar Kar, Sonali Sarkar, Ganesh Kumar S

RESPIRATORY INFECTIONs

879 Diagnosis and Management of Dry Cough: Focus on Upper Airway Cough Syndrome and Postinfectious Cough

N Huliraj

Surgery

884 Postoperative Wounds and their Antimicrobial Sensitivity

Pattern (Hospital-Based Surveillance of Aerobic Bacteria)

Irfan Iqbal, Aneesa Afzal, Sajad Majid Qazi

AROUND THE GLOBE

889 News and Views eMEDINEWS INSPIRATION

892 Vikramaditya’s Judgement MEDILAW

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.

893 When can Hospitals be Liable for Medical Negligence Deaths? eMEDI QUIZ

895 Quiz Time LIGHTER READING

896 Lighter Side of Medicine

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

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

Films Showing Smoking Scenes should be Certified as Adult Films

T

he connection between smoking in films and its influence on adolescent behavior is well-established.

Smoking is a killer as its connection to cancer, heart attacks and chronic lung disease is beyond doubt. Kids start to smoke before they’re old enough to think about the risks; after starting they rapidly become addicted to smoking and then regret it later on.

Hollywood and Bollywood play a role by making smoking look really good. As per a US report by Dr James Sargent, MD, co-director cancer control at Norris Cotton Cancer Center by eliminating smoking in movies marketed to youth, an R rating for smoking (in India equivalent to rating as an adult movie) would dramatically reduce exposure and lower adolescent smoking by as much as one-fifth.

As per the study, the movie industry should take smoking as seriously as they take profanity when applying the R rating. R rating for any film showing smoking could substantially reduce smoking onset in US adolescents - in fact, the effect would be similar if all parents took an active, authoritative stand with their teenage children against smoking.

The study, “Influence of Motion Picture Rating on Adolescent Response to Movie Smoking” published in the journal Pediatrics, Vol. 130, No. 2, August 2012, enrolled a total 6,522 US adolescents in a longitudinal survey conducted at 8-month intervals.

Movie smoking exposure (MSE) was estimated from 532 recent hit movies, categorized into three of the ratings brackets used by the Motion Picture Association of America to rate films by content – G, PG, PG-13 and R. Median MSE from PG-13 movies was approximately three times higher than median MSE from R-rated films but their relation to smoking was essentially the same.

The investigators were able to show that adolescent smoking would be reduced by 18% if smoking in PG-13 movies was largely eliminated, all else being equal.

In comparison, making all parents ‘maximally authoritative’ in their parenting with regard to smoking would reduce adolescent smoking by 16%, according to Sargent’s findings.

I personally feel that the Indian Central Board of Film certification should consider rating films as ‘adults’ if the same contains smoking scenes. The current practice is only to add a warning when the smoking scene comes.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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from the desk of THE group editor-in-chief Film Certification in the US and India Motion Picture Association of America zz

g-rating G: General Audiences. All ages admitted.

The picture contains nothing in theme, language, nudity, sex, violence or other matters that would offend parents whose younger children view the motion picture.

zz g-rating PG: Parental Guidance Suggested. Some material may not be suitable for children. The picture should be investigated by parents before they let their younger children attend. There is no drug use content in a PG-rated motion picture. zz pg-13-rating PG-13: Parents Strongly Cautioned. zz Some material may be inappropriate for children under 13. A PG-13 rating is a sterner warning by the Rating Board to parents to determine whether their children under age 13 should view the motion picture, as some material might not be suited for them. Any drug use will initially require at least a PG-13 rating. More than brief nudity will require at least a PG-13 rating. There may be depictions of violence in a PG-13 movie, but generally not both realistic and extreme or persistent violence. A motion picture’s single use of one of the harsher sexually-derived words, though only as an expletive, initially requires at least a PG-13 rating. More than one such expletive requires an R rating, as must even one of those words used in a sexual context. zz g-rating R: Restricted. Children under 17 require accompanying parent or adult guardian. The picture contains some adult material. An R-rated motion picture may include adult themes, adult activity, hard language, intense or persistent violence, sexually-oriented nudity, drug abuse or other elements, so that parents are counseled to take this rating very seriously. zz nc-17-rating NC-17: No one 17 and under admitted.

Most parents would consider patently too adult for their children 17 and under. No children will be admitted. The rating simply signals that the content is appropriate only for an adult audience. An NC-17 rating can be based on violence, sex, aberrational behavior, drug abuse or any other element that most parents would consider too strong and therefore off-limits for viewing by their children.

Central Board of Film Certification (India) U-Universal : Unrestricted public exhibition throughout India, suitable for all groups films under this category should not upset children over 4. Any nudity/drug innuendo is cut. Such films may contain mild profanity or crude humour, mild sexual content, educational or family-oriented themes and/or mild violence.

UA-Parental guidance: Unrestricted public exhibition but with parental guidance for children under the age of 12. Those aged under 12 years are only admitted if accompanied by an adult.

This rating is similar to the MPAA’s PG and PG-13. Such films may contain moderate coarse language or suggestive dialogue, references and use of soft drugs, people wearing minimal clothing (frontal or rear nudity is not permitted), moderate sexual content, mature themes and/or moderate violence (including brief or implied sexual violence).

A-Adults only: Public exhibition restricted to adults (18 years or over) only. Nobody younger than 18 may rent or buy an A-rated VHS, DVD, Blu-ray Disc, UMD or game, or watch a film in the cinema with this rating. Such films may contain references and use of hard drugs, explicit language or intensely suggestive dialogue, partial nudity (full-frontal or rear nudity is not permitted), strong and crude sexual content, adult/disturbing themes and/or intense/brutal violence (including strong sexual violence).

S-Specialized audience: Exhibition to restricted audience such as doctors etc.

Smoking in children ÂÂ In India, 36.9% of children initiate smoking before the age of 10 years. Almost 4.2% of students currently smoke

cigarettes, with the rate for boys significantly higher than girls, while 11.9% of students currently use other tobacco products. Cigarette smoking among youth is high in the central, southern and north-eastern regions of India. Exposure to second hand smoke in public places is also high.

ÂÂ A study conducted by Gururaj and colleagues showed point prevalence of tobacco use among 13-15 year olds

as 4.9%. One-third of current tobacco users (30.8%) purchased tobacco product in a store and one-fifth used it

806

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

from the desk of THE group editor-in-chief at home. Nearly half of the never smokers (43-56.7%) were exposed to tobacco smoke outside home and 83% favored a ban on smoking in public places. Only one-third (31.6%) reported that the reasons of tobacco usage among youth was discussed in formal school settings.1 ÂÂ A study conducted by Raj Narain and colleagues at Noida, India, in 2011 showed that any kind of tobacco

use was found in 537 (11.2%) students, 419 (8.8%) were ‘ever smokers (including current smokers)’, 219 (4.6%) were ‘ever tobacco chewers (including current chewers)’, 179 (3.7%) were ‘exclusive smokers’ and 118 (2.5%) were ‘exclusive tobacco chewers’. The mean age of initiation of these habits was around 12.4 year mainly from private school students as compared to government school students (p < 0.05).2

ÂÂ A community-based research, triangulation of qualitative (free list, focus group discussions) and quantitative

methods study by Deshmukh and colleagues at rural Wardha, India, revealed that about 68.3% boys and 12.4% girls had consumed any tobacco products in last 30 days. Among the main forms of tobacco, 79.2% consumed kharra and 46.4% consumed gutka. According to respondents, few adolescent boys taste tobacco by 8-10 years of age, while girls do it by 12-13 years.3

ÂÂ A study conducted by Awasthi and colleagues at Nainital, India, can be statistically summarized as (logistic

regression analysis) that students belonging to Grade 10 (adjusted odds ratio [OR] = 4.3; 95% confidence interval (CI): 2-9) and Grade 9 (adjusted OR = 2.2; 95% CI: 1.3-3) were more likely to use tobacco as compared to Grade 8 students. Students whose friends used tobacco were more likely to use than those whose friends were nonusers (adjusted OR = 3.4; 95% CI: 1.7-6.7).4

ÂÂ Kapil and colleagues at Delhi in 2007 showed that about 9.8% of the study children had at least once

experimented with any form of tobacco in their lifetime. The proportion of children who were ‘current users’ of tobacco products was 5.4% (boys: 4.6%, girls: 0.8%).5

References 1. Gururaj G, Girish N. Tobacco use amongst children in Karnataka. Indian J Pediatr 2007;74(12):1095-8.

2. Narain R, Sardana S, Gupta S, Sehgal A. Age at initiation and prevalence of tobacco use among school children in Noida, India: A cross-sectional questionnaire based survey. Indian J Med Res 2011;133:300-7.

3. Dongre AR, Deshmukh PR, Murali N, Garg B. Tobacco consumption among adolescents in rural Wardha: where and how tobacco control should focus its attention? Indian J Cancer 2008;45(3):100-6.

4. Awasthi S, Jha SK, Rawat CM, Pandey S, Swami SS. Correlates of tobacco use among male adolescents in schools of Haldwani, Nainital. Health and Population: Perspectives and Issues 2010;33(1):42-9.

5. Singh V, Pal HR, Mehta M, Kapil U. Tobacco consumption and awareness of their health hazards amongst lower income group school children in National Capital Territory of Delhi. Indian Pediatr 2007;44(4):293-5.

■■■■

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Community health

Health Message in Water/Electricity Bills, a Unique Way to Sensitize the Public kk Aggarwal

P

ublic health awareness is important to reduce the morbidity and mortality from common preventable lifestyle disorders. The principles of public awareness involve communicating to the public in easy to understand field tested health sutras. We, at Heart Care Foundation of India (HCFI), have been working towards creating low cost health awareness modules, which can be replicated.

Water and telephone bills are sent by the respective bodies in lakhs every month. This can be a useful way of creating health awareness without adding any extra cost.

HCFI on 15th December 2013 organized a CPR Utsav where thousands of people from all walks of life were trained on how to revive a person from sudden cardiac death. The event was organized by the Foundation in association with NDMC. The Foundation sensitized the Chairman, NDMC and got the following line inserted in every water and electricity bill of NDMC in the months of November and December. â&#x20AC;&#x153;Learn how to revive a person from sudden cardiac death on 15th December, 2013 at Talkatora Stadium from 8 am onwards (An Heart Care Foundation of India and NDMC initiative)â&#x20AC;?.

The Foundation field tested at random 300 recipients of the bill and found that 11% of them had read the advisory on the water and electricity bill. Normally, when you send a communication to the people, only 2% of them notice it but in a water/electricity bill, the response by 11% of the public makes it an important way of communicating health message to the public. The line was inserted immediately above the column which talks about the charges (Fig. 1 and 2).

All health activists in the country may use this and convince the respective State Governments so that every bill (water, electricity, house tax) can be used as a way of creating health awareness with no extra cost to the State Government.

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Community health Electricity Bills, a Unique Way to Sensitize the Public

Figure 1

Figure 1

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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Community health Water Bills, a Unique Way to Sensitize the Public

Figure 2

Figure 2

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

American Family Physician

Cluster Headache JACQUELINE WEAVER-AGOSTONI

Abstract Cluster headache causes severe unilateral temporal or periorbital pain, lasting 15 to 180 minutes and accompanied by autonomic symptoms in the nose, eyes, and face. Headaches often recur at the same time each day during the cluster period, which can last for weeks to months. Some patients have chronic cluster headache without remission periods. The pathophysiology of cluster headache is not fully understood, but may include a genetic component. Cluster headache is more prevalent in men and typically begins between 20 and 40 years of age. Treatment focuses on avoiding triggers and includes abortive therapies, prophylaxis during the cluster period, and long-term treatment in patients with chronic cluster headache. Evidence supports the use of supplemental oxygen, sumatriptan, and zolmitriptan for acute treatment of episodic cluster headache. Verapamil is first-line prophylactic therapy and can also be used to treat chronic cluster headache. More invasive treatments, including nerve stimulation and surgery, may be helpful in refractory cases.

Keywords: Cluster headache, periorbital pain, sumatriptan, zolmitriptan, verapamil, nerve stimulation, verapamil

nerve stimulation

A

bout one in 1,000 U.S. adults has experienced cluster headache.1 Studies estimate the one-year prevalence to be as high as 53 per 100,000 adults.1 The typical age of onset is usually 20 to 40 years.2 The overall male-to-female ratio is 4.3, but is much higher for chronic cluster headache than for the episodic form (15 and 3.8, respectively).1 Episodic cluster headache is six times more common than the chronic form.1 Cluster headache has a large socioeconomic impact and associated morbidity; almost 80% of patients report restricting daily activities.3 Clinical Features and Classifications Because of the location and associated symptoms, cluster headache is classified as a trigeminal autonomic cephalgia in the most recent diagnostic criteria from the International Headache Society (Table 1).2 Cluster headache is divided into chronic and episodic categories based on the duration and frequency of episodes.

Patients with the chronic form have at least one cluster period lasting at least one year, with no remission or remission of less than one month. Those with the episodic form have at least two cluster periods of at least one week but less than one year, with remission for at least one month. In addition to severe unilateral

JACQUELINE WEAVER-AGOSTONI, DO, MPH, is director of the Osteopathic Family Medicine Residency at the University of Pittsburgh (Pa.) Medical Center Shadyside Hospital.

Source: Adapted from Am Fam Physician. 2013;88(2):122-128.

headache, associated diagnostic symptoms can include ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, forehead and facial swelling, miosis, or ptosis. Patients who fulfill all but one of the diagnostic criteria are considered to have probable cluster headache. In one study, 64% of patients in the probable cluster headache group reported episodes exceeding three hours, or less often than every two days.4 A questionnaire combining headache duration of less than 180 minutes and conjunctival injection or lacrimation showed a sensitivity of 81.1% and a specificity of 100% for cluster headache diagnosis, and has been suggested as an effective screening tool.5 Triggers for cluster headache include vasodilators (e.g., alcohol, nitroglycerin) and histamine. Tobacco exposure

Table 1. Diagnostic Criteria for Cluster Headache Feature

Criteria

Associated symptoms

At least one ipsilateral symptom in the eye, nose, or face; restlessness or agitation

Duration

15 to 180 minutes (untreated)*

Frequency

One episode every other day to eight episodes per day*

Location

Unilateral in temporal or periorbital area

Pain quality

Severe, â&#x20AC;&#x153;suicide headacheâ&#x20AC;?*

Note: At least five episodes are required for diagnosis. Symptoms cannot be attributed to another condition. *Exceptions are allowed if they occur in less than one-half of instances Information from reference 2.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

811

American Family Physician (i.e., history of personal use or secondhand exposure in childhood) is a risk factor for the development of cluster headache.6 The unique pattern and constellation of symptoms usually makes the diagnosis of cluster headache fairly evident, but other headache disorders may present with overlapping or similar features (Table 27). Neuroimaging has not proved useful in the diagnosis of cluster headache, but is indicated in patients who have red flag headache features (e.g., sudden change in the nature of the headache, symptoms that suggest a pituitary mass) or abnormal findings on neurologic examination.

Etiology and Pathophysiology The pathophysiology of cluster headache is not fully understood. Current theories implicate mechanisms such as vascular dilation, trigeminal nerve stimulation, and circadian effects. Histamine release, an increase in mast cells, genetic factors, and autonomic nervous system activation may also contribute.

Acute cluster headache has been shown to involve activation of the posterior hypothalamic gray matter, and is inherited as an autosomal dominant condition in about 5% of patients.2 Having a first-degree relative with cluster headache increases the risk 14-to 39-fold.8

Table 2. Differential Diagnosis of Headache Diagnosis

Symptoms

Cluster headache

Sudden onset, unilateral severe headache lasting 15 to 180 minutes and occurring at the same time each day Unilateral throbbing More common in women; onset headache, often with sudden onset typically in adolescence or young adulthood

Migraine

Paroxysmal hemicrania

Patient characteristics More common in men; onset at 20 to 40 years of age

Unilateral headache More common lasting two to 30 in women; onset minutes typically at 34 to 41 years of age Unilateral headache More common in men; onset typically lasting five to at 35 to 65 years 240 seconds and of age occurring three to 200 times per day

Short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing Tension headache Gradually developing, constant bilateral dull ache or squeezing band-like headache Trigeminal neuralgia Paroxysmal, electrical, sharp, stabbing pain in trigeminal nerve distribution, lasting a few seconds; episodes last weeks to months

Activity, medication, oxygen, pacing

Lying in a dark room, medication, sleep

Reliably responds to indomethacin

Associated symptoms Ipsilateral cranial autonomic symptoms

Notes May begin during sleep

Fatigue, nausea, Worse with activity photo- or phonophobia, vomiting; 50 percent of patients have bilateral autonomic symptoms7 â&#x20AC;&#x201D; â&#x20AC;&#x201D;

Usually refractory to Ipsilateral eye treatment symptoms

Rare

Slightly more common in women

Analgesics, stress relief

Fatigue, pericranial muscle tenderness, sleep disturbance

Typically starts midday

Slightly more common in women; onset after 50 years of age

Carbamazepine

Inconsistent pattern of headaches

Often triggered by cold air or light touch in the nerve distribution area

Information from reference 7.

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

American Family Physician One study showed an association between cluster headache and the HCRTR2 gene.8 Disturbed circadian rhythms have been suggested as a possible contributor because headaches often begin during sleep.

Management Effective management of cluster headache requires the integration of several strategies. Patient education is important, and should focus on managing or avoiding triggers, with an emphasis on smoking cessation, alcohol counseling, and lifestyle modification. Abortive treatments should be used to alleviate acute headaches.

Prophylactic therapy should be started and continued for the duration of the expected cluster period, then tapered. Patients who have chronic cluster headache should continue maintenance medications indefinitely.

More invasive treatment options, including surgical interventions, are used only when other treatment modalities are ineffective. Complementary and alternative medicine approaches have provided inconclusive results.

Acute or Abortive Treatment Triptans and supplemental oxygen are first-line abortive therapies for cluster headache9 (Table 3 9,10). A doubleblind, randomized, placebo-controlled crossover trial

showed that inhaled high-flow oxygen (12 L per minute) was more effective than placebo in eliminating pain at 15 minutes.11 Complete pain relief was reported in 78% of patients. One low-power study suggested better outcomes from hyperbaric vs. normobaric oxygen, but cost and limited availability inhibit its use.12 No evidence indicates that supplemental oxygen prevents future cluster episodes.

One randomized, double-blind, placebo-controlled study found that a 6-mg subcutaneous dose of sumatriptan has a number needed to treat (NNT) of 2.4 for pain relief at 15 minutes, with response in 75% of patients vs. 32% in those who received placebo.13 A 12-mg dose did not provide significantly better outcomes than 6 mg, but was associated with more adverse effects.14 A multicenter, double-blind, randomized study of zolmitriptan showed significant pain improvement at 30 minutes in treated patients compared with those who received placebo.9 In this study, placebo was 30% effective, compared with 50% and 63.3%, respectively, for zolmitriptan nasal spray in 5-mg and 10-mg doses. A systematic review showed that a 10-mg intranasal dose of zolmitriptan has an NNT of 2.8 for pain relief at 30 minutes.13 Triptans are contraindicated in patients with vascular risks, including ischemic heart disease.

Table 3. Treatment of Acute Cluster Headache Therapy

Dosage and route of administration

Adverse effects

Oxygen

100% via nonrebreather face mask at 12 to 15 L per minute for 15 to 20 minutes10 6 mg subcutaneously; may repeat once at least one hour later

None

20-mg nasal spray; maximum of 40 mg per day

Nasal spray: bitter taste

5-mg nasal spray; may be repeated once after two hours

Nasal spray: mild adverse effects in approximately 25% to 33% of patients; bad taste, nasal cavity discomfort, somnolence

5 mg orally; maximum of 10 mg per day

Tablets: asthenia, dizziness, heaviness, nausea, chest tightness, paresthesias9

Lidocaine

1 mL of 10% solution applied bilaterally with a cotton swab for five minutes

Nasal congestion, unpleasant taste

Octreotide

100 mcg subcutaneously

Bloating, diarrhea, dull background headache, injection site reactions, lethargy, nausea

Ergotamine

2 mg sublingually, may repeat dose every 30 minutes to a maximum of 6 mg per day

Angina, fibrosis (cardiac valvular, retroperitoneal, pleuropulmonary), myocardial infarction, pruritus, vertigo; withdrawal is possible if abruptly stopped

Sumatriptan

Zolmitriptan

Mild to moderate; rarely lead to discontinuation Injections: dizziness, fatigue, injection site reactions, nausea, paresthesias, vomiting

Note: Treatments are listed in approximate order of use, with first-line agents listed first.

Information from references 9 and 10.

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American Family Physician Predicting response to these therapies by individual patients is difficult. Older age seems to negatively affect triptan response. Similarly, restlessness, nausea, and vomiting may be negative predictors of response to supplemental oxygen.15 Other treatment options with weaker supporting evidence include intranasal lidocaine, octreotide, and ergotamine.

One review concluded that there is insufficient evidence to endorse the use of dihydroergotamine, ergotamine, somatostatin, and prednisone for the acute treatment of cluster headache.9 Cluster headache is typically resistant to indomethacin. Some case reports suggest that, compared with other paroxysmal hemicranias, cluster headache may have a delayed

response to indomethacin, and that patients may respond to larger doses.16

Prophylaxis Verapamil at a minimum dosage of 240 mg per day is first-line prophylaxis for cluster headache9,17 (Table 418). Electrocardiographic monitoring is necessary because of potential cardiac effects. One randomized controlled trial reported statistically significant decreases in the number of headaches per day after two weeks of treatment.19 Another study comparing verapamil and lithium showed a 50% reduction in the number of headaches in the verapamil group.9 Oral steroids have been used, but their effectiveness

Table 4. Prophylaxis of Episodic Cluster Headache Drug Verapamil

Steroids

Dosage and route of administration Minimum of 240 mg orally per day, in single or divided doses 50 to 80 mg of oral prednisone per day, tapered gradually over 10 to 12 days

Adverse effects

Comments

Abdominal discomfort, bradycardia, constipation, edema, gum hyperplasia, hypotension Hyperglycemia, hypertension, increased appetite, insomnia, nervousness

Electrocardiography required to monitor for prolonged PR interval, change in cardiac axis, or broadening of QRS May be useful for bridging therapy; no adequate randomized controlled trials are available18

Transient injection site pain Suboccipital injection: 12.46 mg of betamethasone dipropionate plus 5.26 mg of betamethasone disodium phosphate plus 0.5 mL of lidocaine, 2% Alopecia, anorexia, dizziness, insomnia, nausea, somnolence, suicidal ideation, thrombocytopenia, weakness, weight gain Dizziness, paresthesias, slow speech; mostly well tolerated

Use with caution in patients with renal or hepatic insufficiency; can be used with sumatriptan

3 to 4 mg orally per day in divided doses for up to three weeks; maximum of 6 mg per day or 10 mg per week; give 30 to 60 minutes before anticipated headaches or at bedtime for nocturnal cluster headache 10 mg orally at bedtime

Angina, fibrosis (cardiac valvular, retroperitoneal, pleuropulmonary), myocardial infarction, pruritus, vertigo

Contraindicated in patients with peripheral vascular disease, hypertension, or cardiac disease; use with caution in patients with renal or hepatic insufficiency; should not be taken within 24 hours of a triptan; withdrawal is possible if abruptly stopped

None

â&#x20AC;&#x201D;

Intranasal application three or four times per day

Local irritation

â&#x20AC;&#x201D;

Valproic acid

600 to 2,000 mg per day

Topiramate

25 mg orally for seven days, then increase by 25 mg per day every week to a maximum of 400 mg per day

Ergotamine

Melatonin Capsaicin

Note: Treatments are listed in approximate order of use, with first-line agents listed first.

Information from reference 18.

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Contraindicated in patients with nephrolithiasis

American Family Physician is not supported by adequate randomized controlled trials. Steroids are probably most useful as bridging therapy until another prophylactic medication is established. Transitional bridging therapy is most often needed to reduce overuse of triptans and the need for supplemental oxygen in patients who have frequent headaches. Other prophylactic treatments that have limited evidence of success include suboccipital steroid injections, valproic acid, topiramate, ergotamine, melatonin, and capsaicin.18 A randomized, double-blind, placebo-controlled study of steroid injections showed that 85% of the 23 patients were pain-free in 72 hours, and 62% of responders remained headache-free for four to 26 months.9 Based on current evidence, one review suggested that sumatriptan, valproate, misoprostol, supplemental oxygen, cimetidine, and chlorpheniramine should not be used for preventive treatment, and found that there is insufficient evidence to recommend the use of intranasal capsaicin and prednisone.

Treatment of Chronic Cluster Headache Verapamil and lithium are the mainstays of treatment for chronic cluster headache9,17 (Table 5 20). A doubleblind crossover study comparing verapamil and lithium reported a 50% reduction in the headache index for the verapamil group and a 37% reduction for the lithium group.9 Deep brain stimulation is also an option for refractory chronic cluster headache, although it is not entirely clear how it works.20 A prospective crossover, double-blind, multicenter study comparing deep brain stimulation and sham treatment reported no effect in

the first month, but suggested benefit in more than onehalf of patients one year after treatment.21

Surgical and Other Invasive Options In a study of 14 patients, occipital nerve stimulation produced improvement in 71% of participants, and 62% of those who responded to the treatment remained headache-free for four to 26 months.17 The intensity of headaches was also decreased, although some patients had a lag of at least two months between the electrode implantation and clinical effect.3 Trigeminal nerve radiosurgical treatment is not recommended for patients with chronic cluster headache because of the lack of benefit and a high rate of new trigeminal nerve disturbances.22 Retrospective studies on radiofrequency treatment of the ganglion pterygopalatinum have shown inconsistent results and adverse effects including epistaxis, bleeding in the jaw, and loss of sensation of the palatum.3

Complementary and Alternative Medicine Approaches A systematic review of complementary and alternative therapies for nonmigraine headaches included studies of acupuncture, spinal manipulation, electrotherapy, physiotherapy, homeopathy, herbal heat rub, and therapeutic touch, but none of these studies specifically addressed cluster headache.23 There is some supporting evidence for the use of electrotherapy to cranial muscles in patients with nonmigraine headache, but not all of the studies are of high quality.24 Spinal manipulation may be more effective than massage or placebo to alleviate cervicogenic headache.24

Table 5. Treatment of Chronic Cluster Headache Therapy

Dosage and route of administration

Adverse effects

Comments

Verapamil

Minimum of 240 mg per day, in single or divided oral doses

Bradycardia, constipation, edema, gastrointestinal discomfort, gingival hyperplasia, hypotension

Electrocardiography should be performed to monitor for heart block

Lithium

800 to 900 mg with meals, in divided oral doses

Hypothyroidism, nephrogenic diabetes insipidus, polyuria, tremor

Serum lithium levels should be monitored at least every six months and with dosage changes; thyroid and renal function also should be monitored

Deep brain stimulation

â&#x20AC;&#x201D;

Micturition syncope, subcutaneous infection, transient loss of consciousness

Used only for refractory chronic cluster headache; the effect is not thought to be related to direct hypothalamic stimulation, and failure is not likely caused by electrode misplacement20

Note: Treatments are listed in approximate order of use, with first-line agents listed first.

Information from reference 20.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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American Family Physician Special Populations Cluster headache is rare during pregnancy, but treatment is challenging. Pregnant women should use the fewest medications possible, for the shortest amount of time, and at the lowest dosage that controls symptoms. Preferred treatments in pregnant women include supplemental oxygen and subcutaneous or intranasal sumatriptan for acute treatment, with verapamil or prednisone or prednisolone as prophylactic therapy. Gabapentin may be used as an alternative.

Supplemental oxygen, sumatriptan, and lidocaine are first-line therapies for acute treatment in women who are breastfeeding; verapamil, oral steroids, and lithium are recommended prophylactic medications.21 REFERENCES 1. Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: a meta-analysis of population-based studies. Cephalalgia. 2008;28(6): 614-618.

2. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004; 24(suppl 1):9-160.

3. van Kleef M, Lataster A, Narouze S, Mekhail N, Geurts JW, van Zundert J. Evidence-based interventional pain medicine according to clinical diagnoses. 2. Cluster headache. Pain Pract. 2009;9(6):435-442.

4. van Vliet JA, Eekers PJ, Haan J, Ferrari MD; Dutch RUSSH Study Group. Evaluating the IHS criteria for cluster headache—a comparison between patients meeting all criteria and patients failing one criterion. Cephalalgia.

2006;26(3):241-245.

5. Dousset V, Laporte A, Legoff M, Traineau MH, Dartigues JF, Brochet B. Validation of a brief self-administered questionnaire for cluster headache screening in a tertiary center. Headache. 2009;49(1):64-70.

6. Rozen TD. Cluster headache as the result of secondhand cigarette smoke exposure during childhood. Headache.

2010;50(1):130-132.

7. Lai TH, Fuh JL, Wang SJ. Cranial autonomic symptoms in migraine: characteristics and comparison with cluster headache. J Neurol Neurosurg Psychiatry. 2009; 80(10):1116-1119.

8. Rainero I, Rubino E, Valfrè W, et al. Association between the G1246A polymorphism of the hypocretin receptor 2 gene and cluster headache: a meta-analysis. J Headache Pain. 2007;8(3):152-156.

9. Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache.

Neurology. 2010;75(5):463-473.

10. Rozen TD. Inhaled oxygen for cluster headache: efficacy, mechanism of action, utilization, and

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economics [published ahead of print January 29, 2012].

Curr Pain Headache Rep. http://link.springer.com/ article/10.1007%2Fs11916-012-0246-2. Accessed July 30, 2012.

11. Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA. 2009;302(22):2451-2457.

12. Bennett MH, French C, Schnabel A, Wasiak J, Kranke P. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. Cochrane Database Syst Rev. 2008;(3):CD005219.

13. Law S, Derry S, Moore RA. Triptans for acute cluster headache. Cochrane Database Syst Rev. 2010;(4): CD008042.

14. Ekbom K, Monstad I, Prusinski A, Cole JA, Pilgrim AJ, Noronha D; The Sumatriptan Cluster Headache Study Group. Subcutaneous sumatriptan in the acute treatment of cluster headache: a dose comparison study. Acta Neurol Scand. 1993;88(1):63-69.

15. Schürks M, Rosskopf D, de Jesus J, Jonjic M, Diener HC, Kurth T. Predictors of acute treatment response among patients with cluster headache. Headache. 2007;47(7): 1079-1084.

16. Prakash S, Shah ND, Chavda BV. Cluster headache responsive to indomethacin: Case reports and a critical review of the literature. Cephalalgia. 2010;30(8):975-982.

17. Tyagi A, Matharu M. Evidence base for the medical treatments used in cluster headache. Curr Pain Headache Rep. 2009;13(2):168-178.

18. May A, Leone M, Afra J, et al.; EFNS Task Force. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol.

2006;13(10):1066-1077.

19. Leone M, D’Amico D, Frediani F, et al. Verapamil in the prophylaxis of episodic cluster headache: a double-blind study versus placebo. Neurology. 2000;54(6):1382-1385.

20. Fontaine D, Lazorthes Y, Mertens P, et al. Safety and efficacy of deep brain stimulation in refractory cluster headache: a randomized placebo-controlled double-blind trial followed by a 1-year open extension. J Headache Pain. 2010;11(1):23-31.

21. Jürgens TP, Schaefer C, May A. Treatment of cluster headache in pregnancy and lactation. Cephalalgia. 2009; 29(4):391-400.

22. Donnet A, Tamura M, Valade D, Régis J. Trigeminal nerve radiosurgical treatment in intractable chronic cluster headache: unexpected high toxicity. Neurosurgery.

2006;59(6):1252-1257.

23. Vernon H, McDermaid CS, Hagino C. Systematic review of randomized clinical trials of complementary/ alternative therapies in the treatment of tension-type and cervicogenic headache. Complement Ther Med. 1999; 7(3):142-155.

24. Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache.

Cochrane Database Syst Rev. 2004;(3):CD001878.

American Family Physician

Practice Guidelines Endocrine Society Releases Guidelines on Diagnosis and Management of Hypertriglyceridemia Elevated triglyceride levels typically occur in persons with other metabolic abnormalities. Contributing factors include overweight and obesity, physical inactivity, excessive alcohol intake, metabolic syndrome, type 2 diabetes mellitus, and certain genetic disorders (e.g., familial hypertriglyceridemia, familial combined hyperlipidemia, familial dysbetalipoproteinemia). The Endocrine Society recently published evidence-based recommendations on the diagnosis and management of hypertriglyceridemia in adults.

Diagnosis The diagnosis of hypertriglyceridemia should be based on fasting serum triglyceride levels. Cutoffs as defined by the Endocrine Society are 150 to 199 mg per dL (1.7 to 2.3 mmol per L) for mild hypertriglyceridemia; 200 to 999 mg per dL (2.3 to 11.3 mmol per L) for moderate; 1,000 to 1,999 mg per dL (11.3 to 22.6 mmol per L) for severe; and 2,000 mg per dL (22.6 mmol per L) or greater for very severe.

Mild or moderate hypertriglyceridemia may be a risk factor for cardiovascular disease, whereas severe and very severe hypertriglyceridemia increase the risk of pancreatitis. Of note, the National Cholesterol Education Program, Adult Treatment Panel III (NCEP ATP III) uses the following cutoffs: 150 to 199 mg per dL for borderline-high triglycerides; 200 to 499 mg per dL (2.3 to 5.6 mmol per L) for high; and 500 mg per dL (5.7 mmol per L) or greater for very high. Similar to NCEP ATP III, the Endocrine Society recommends that physicians screen adults for elevated triglyceride levels as part of a lipid panel at least every five years. Although persons with hypertriglyceridemia typically have smaller low- and high-density lipoprotein particles compared with persons who have normal triglyceride levels, lipoprotein particle size and density should not be routinely measured in these patients.

Measurement of apolipoprotein B or lipoprotein A levels may be useful in suggesting cardiovascular risk in patients with normal low-density lipoprotein levels, but measurement of other apolipoprotein levels has little clinical value.

Source: Adapted from Am Fam Physician. 2013;88(2)142-144.

Primary and Secondary Causes Patients with elevated fasting triglyceride levels should be evaluated for secondary causes of hyperlipidemia and treated accordingly. Secondary causes include excessive alcohol intake, untreated diabetes, endocrine conditions, renal or liver disease, pregnancy, autoimmune disorders, and use of certain medications (e.g., thiazides, beta blockers, estrogen, isotretinoin, corticosteroids, bile acidâ&#x20AC;&#x201C; binding resins, antiretroviral protease inhibitors, immunosuppressants, antipsychotics). It is unclear whether hypertriglyceridemia causes atherosclerosis; an elevated triglyceride level may, in some cases, be a marker for cardiovascular disease rather than a causal factor. However, because of the lack of clear data showing that reductions in triglyceride levels reduce the risk of cardiovascular disease, hypertriglyceridemia should be considered a marker for risk in some patients. Therefore, to assess genetic causes and cardiovascular risk, patients with primary hypertriglyceridemia should be evaluated for family history of dyslipidemia and cardiovascular disease. These patients also should be assessed for other cardiovascular risk factors, such as central obesity, hypertension, abnormal glucose metabolism, and liver dysfunction.

Management Much of the increase in serum triglyceride levels that occurs in adults is caused by weight gain, lack of exercise, and a diet rich in simple carbohydrates. Initial treatment of patients with mild to moderate hypertriglyceridemia should include dietary counseling and weight loss in patients who are overweight or obese. For patients with severe to very severe hypertriglyceridemia, reduced intake of dietary fat and simple carbohydrates is recommended, in combination with drug treatment to reduce the risk of pancreatitis. The treatment goal for patients with moderate hypertriglyceridemia is a nonâ&#x20AC;&#x2019;high-density lipoprotein cholesterol level of 30 mg per dL (0.78 mmol per L) higher than the low-density lipoprotein goal, as recommended by the NCEP ATP III (http://www.nhlbi.nih. gov/guidelines/cholesterol/atp_iii.htm). Fibrates are the first-line treatment in patients with hypertriglyceridemia who are at risk of pancreatitis. Fibrates, niacin, and n-3 fatty acids, alone or in combination, should be considered in patients with moderate to severe hypertriglyceridemia.

Statins have a modest triglyceride-lowering effect (typically 10% to 15%) and may be useful to modify cardiovascular risk in patients with moderately elevated triglyceride levels. However, they should not be used alone in patients with severe or very severe hypertriglyceridemia.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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American Family Physician

Photo Quiz Pigmented Lesion on the Sole in a Child A six-year-old boy had a pigmented lesion on the sole of his foot that appeared one month earlier. He had no chronic medical problems.

Physical examination showed an asymptomatic brown lesion measuring 7 mm (see accompanying figure).

The margins were not well defined, and a light-gray halo surrounded the lesion. A scratch test of the stratum corneum partially removed the pigmentation.

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

A. Acral melanoma.

B. Blue nevus.

C. Junctional melanocytic nevus.

D. Mycosis.

E. Subcorneal hematoma.

SEE THE FOLLOWING PAGE FOR DISCUSSION.

Source: Adapted from Am Fam Physician. 2013;88(2):135-136.

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

American Family Physician Discussion

Summary Table

The answer is E: subcorneal hematoma. Subcorneal hematomas are caused by traumatic rupture of the papillary capillaries, leading to extravasation of blood into the cornified layer of the sole of the foot. It can be difficult to clinically differentiate subcorneal hematoma from acral melanoma or melanocytic nevi. In children, it is especially difficult to connect the appearance of the lesion to a specific injury.

Condition

Characteristics

Acral melanoma

Rapidly growing, asymmetrical, flattened plaque; 5 to 12 mm; uneven edges, irregular borders, dark-brown or black color, and uneven pigmentation

Blue nevus

Blue, blue-gray, or blue-black papule or nodule; < 1 cm; appearance usually does not change

Junctional melanocytic nevus

Brown macule; < 1 cm; uniform pigmentation, round or oval shape, and smooth edges; generally does not regress spontaneously

Cutaneous or subcutaneous mycosis

Erythematous or desquamative plaques or nodules; single or multiple; usually located on extremities or other exposed area; slow growing; generally does not regress spontaneously

Subcorneal hematoma

Red-black, homogeneous pigmentation with light-gray halo; well-demarcated; round or irregularly shaped; sometimes linear, macular, nodular; regresses spontaneously

Dermoscopy can assist in the diagnosis.1,2 The presence of a red-black, homogeneous pigmentation combined with satellite globules (the light-gray halo) is a distinctive feature of subcorneal hematoma.3 The lesion is well-demarcated; round or irregularly shaped; and sometimes linear, macular, or nodular. A scratch test is another useful tool for the diagnosis of subcorneal hematoma and to exclude melanoma or melanocytic nevi. The scratch test involves using a scalpel to remove the erythrocytes located in the stratum corneum, which results in complete or partial removal of the lesion.

If the clinical history and dermoscopic features of a pigmented lesion are not diagnostic and the results of a scratch test are negative, the diagnosis should be confirmed by surgical excision and histopathologic examination.

Subcorneal hematomas regress spontaneously after a few months.

A rapidly growing pigmented lesion may suggest malignant acral melanoma. An acral melanoma may initially present as a 5- to 12-mm, asymmetrical, flattened plaque with uneven edges, irregular borders, dark-brown or black color, and uneven pigmentation.

In the advanced phase of vertical growth, it may look papular or nodular.

A blue nevus typically presents as a blue, blue-gray, or blue-black papule or nodule less than 1 cm. However, blue nevi usually do not change in appearance over time. A junctional melanocytic nevus typically appears as a macula that is smaller than 1 cm. It is brown with uniform pigmentation, has a round or oval shape, and has smooth edges. The lesion usually does not regress spontaneously.

Cutaneous or subcutaneous mycosis usually leads to erythematous or desquamative plaques or nodules.

They can be single or multiple, and are located at the site of infection, often on the extremities or other exposed areas. They are usually slow growing and do not regress spontaneously.4 REFERENCES 1. Saida T, Oguchi S, Miyazaki A. Dermoscopy of acral pigmented skin lesions. Clin Dermatol. 2002;20(3): 279-285.

2. Saida T, Oguchi S, Ishihara Y. In vivo observation of magnified features of pigmented skin lesions on volar skin using video macroscope. Usefulness of epiluminescence technique in clinical diagnosis. Arch Dermatol. 1995;131(3):298-304.

3. Zalaudek I, Argenziano G, Soyer HP, Saurat JH, Braun RP. Dermoscopy of subcorneal hematoma. Dermatol Surg. 2004;30(9):1229-1232.

4. Tambasco D, D’Ettorre M, Bracaglia R, et al. A suspected squamous cell carcinoma in a renal transplant recipient revealing a rare cutaneous phaeohyphomycosis by Alternaria infectoria. J Cutan Med Surg. 2011;16(2):131-134.

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CARDIOLOGY

Prevalence of Metabolic Syndrome in Patients with Essential Hypertension D Makwana, S Bagga, M Nandal

Abstract The objective of this study was to study the prevalence of metabolic syndrome among patients with essential hypertension and to correlate metabolic parameters. It was a noninterventional, observational study in which 172 patients having essential hypertension who fulfilled the inclusion criteria were included and all were subjected to a uniform questionnaire, medical examination and investigations. Prevalence of metabolic syndrome was 55.23% in patients with essential hypertension in this study, more common in females and most common in age group between 40 and 50 years (39.60%). Low high-density lipoprotein cholesterol (HDL-C) level was the most common metabolic abnormality detected in patients with metabolic syndrome followed by an abnormal fasting blood sugar (FBS), abnormal waist circumference and abnormal triglyceride (TG) level. The females had an abnormal HDL-C levels in 92.06% (z = 16.19, p < 0.05) followed by an abnormal waist circumference in 61.90% (z = 6.85, p < 0.05). The FBS and TG were abnormal in 60.3% (z = 3.34, p < 0.05) and 50.7% (z = 2.57, p < 0.05), of female patients, respectively, while in males, the most common abnormality was low HDL-C in 87.5% (z = 12.54, p < 0.05) followed by abnormal TG levels in 65.62% (z = 3.71, p < 0.05), abnormal FBS 62.5%, (z = 2.92, p < 0.05) and abnormal waist circumference 40.62% (z = 2.14, p < 0.05).

TG/HDL-C ratio of ≥3 was the variable that had the best correlation (p = 0.534) with the presence of metabolic syndrome.

Keywords: Metabolic syndrome, essential hypertension, metabolic parameters, high-density lipoprotein, waist circumference, triglycerides

T

he definition of metabolic syndrome refers to a cluster of metabolic abnormalities that are thought to occur due to insulin resistance and are associated with the presence of abdominal obesity. This cluster of metabolic abnormalities is known to increase the risk of coronary heart disease (CHD) and type 2 diabetes. Various abnormalities have been associated with metabolic syndrome. Here is a list of these abnormalities and the various metabolic derangements that are associated with each one of them. ÂÂ

Abdominal obesity

ÂÂ

Atherogenic dyslipidemia

ÂÂ

Hypertension Insulin resistance Impaired fasting glucose zz Impaired glucose intolerance Prothrombotic effect Increased fibrinogen proinflammatory effect Abnormal uric acid metabolism Endothelial dysfunction Reproductive zz

ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ

zz

zz

Increase in triglycerides (TGs)

zz

Decrease in high-density cholesterol (HDL-C)

zz

Increase in low-density lipoprotein (LDL) particle

zz

Postprandial lipidemia

lipoprotein

Dept. of Medicine, BJ Medical College, Ahmedabad, Gujarat Address for correspondence Dr D Makwana Dept. of Medicine BJ Medical College, Ahmedabad, Gujarat

820

ÂÂ

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Polycystic ovarian syndrome.

There is an increasing evidence that nonalcoholic steatohepatitis and several forms of cancer are more likely to occur in insulin-resistant individuals. It is important to note that not all insulin-resistant individuals will develop the entire cluster of abnormalities listed above and the number of manifestations present in an insulin-resistant individual will vary with the cut point used to separate normal from abnormal. Thus, detection of presence of insulin resistance along with other risk factor is more important.

Indians living in urban areas of the Indian subcontinent as well as those who have migrated to western countries have a high prevalence of CHD as compared to Caucasians.

CARDIOLOGY Material and Methods To achieve the above-mentioned aims and objectives, we carried out a noninterventional, observational study in 172 patients having essential hypertension attending the medicine outdoor patients department (OPD) of the tertiary care center from May 2010 to April 2011.

The study subjects were examined and their laboratory investigations were carried out in a fasting state.

Inclusion Criteria The study included patients between the age group of 25 and 70 years attending the medicine OPD having essential hypertension, that is, blood pressure (BP) >140/90 mmHg or on antihypertensive treatment.

Exclusion Criteria ÂÂ

Age > 70 years

ÂÂ

Age < 25 years

ÂÂ

Patient on medications like steroid treatment for any cause, decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants, monoamine oxidase inhibitors, erythropoietin, nonsteroidal anti-inflammatory agents and cocaine.

ÂÂ

Renal failure

ÂÂ

Obstructive sleep apnea

ÂÂ

Hypothyroidism, hyperthyroidism, hypercalcemia and acromegaly

ÂÂ

Pre-eclampsia/eclampsia

The metabolic syndrome in these patients was defined by the Adult Treatment Panel III (ATP III) criteria as the presence of any three or more of the following parameters: ÂÂ

Fasting blood glucose of ≥100 mg/dL

ÂÂ

Serum TGs ≥ 150 mg/dL

ÂÂ

Serum HDL-C <40 mg/dL (men) and 50 mg/dL (women)

ÂÂ

ÂÂ

BP of ≥130/85 mmHg (or on antihypertensive treatment) Waist circumference of >102 cm (men) and 88 cm (women)

family history and their correlation with the metabolic syndrome were studied. The percentage of patients having only LDL-C and the total cholesterol raised was also measured. The various variables of the metabolic syndrome were also correlated. The information thus obtained was analyzed using percentages; chi-square test and the variables correlated using Spearman’s correlation coefficient.

Observation and Analysis Overall prevalence of metabolic syndrome in our study population was 55.23%, out of which 31.97% patients were females (Table 1). The prevalence was found to Table 1. Distribution of Metabolic Syndrome Among the Cases Metabolic syndrome Yes Male

Number

Percent (%)

40

23.26

55

31.97

Male

43

25

Female

34

19.76

Total

172

100

Female No

Table 2. Prevalence of Metabolic Syndrome Among Various Age Groups Age groups (years)

<30

30-40

40-50

50-60

60-70

>70

Syndrome present

1.10

4.40

39.60

36.30

16.50

2.20

Syndrome absent

4.10

11.00

31.60

28.80

15.10

9.60

Table 3. Association of Waist Circumference (cm) with Metabolic Syndrome Waist circumference (cm) Abnormal

Outcomes Measured

Normal

The final outcome measured was prevalence of metabolic syndrome in patients with essential hypertension, using the above-mentioned criteria, attending the medicine OPD. The predisposing factors like the age and the sex of the patient, lifestyle and the

Total Chi-square test applied Pearson chisquare

Metabolic syndrome Yes No Number 57

% 60.0

Number 12

% 15.58

38

40.0

65

84.41

95 Value

55.23 df

77 p value

44.77 Significance

34.92

1

<0.000001

Significance

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

821

CARDIOLOGY Table 4. Association of FBS (mg/dL) with Metabolic Syndrome FBS (mg/dL)

Metabolic syndrome Yes No Number % Number % Abnormal 51 53.68 3 3.89 Normal 44 46.32 74 96.10 Total 95 55.23 77 44.77 Chi-square test Value df p value Significance applied Pearson 48.94 1 2.27E-11 Significance chi-square FBS = Fasting blood sugar.

Table 5. Association of TG with Metabolic Syndrome Triglyceride

Metabolic syndrome Yes

No

Number

%

Abnormal

54

Normal

41

Total

Number

%

56.84

9

14.29

43.16

68

62.39

95

55.23

77

44.77

Chi-square test applied

Value

df

p value

Significance

Pearson chisquare

37.35

1

1.04E-09

Significant

Table 6. Association of HDL-C with Metabolic Syndrome HDL-C

Metabolic syndrome Yes

No

Number

%

Number

%

Abnormal

87

82.07

27

17.93

Normal

8

13.79

50

86.21

Total

95

55.23

77

44.77

Value

df

p value

Significance

1

1.90E-15

Significant

Chi-square test applied Pearson chisquare

60.77

be highest in the middle age group of 40-50 years and the prevalence of metabolic syndrome did not increase with age (Table 2).

Discussion The findings of our study carried out in 172 patients with essential hypertension attending the Medicine OPD of tertiary care center indicate that the prevalence

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

of metabolic syndrome among hypertensive patients is around 55.23%, out of which 31.97% patients were females.

Thus, we concluded that the prevalence of metabolic syndrome is higher in patients with essential hypertension as compared to the normotensive patients.

Overall, metabolic syndrome in patients with essential hypertension was more prevalent among women than in men. The prevalence of metabolic syndrome in our study did not increase with age and the prevalence was found to be highest in the middle age group of 40-50 years.

The most common abnormal metabolic parameter detected was HDL-C (91.57%) among subjects with metabolic syndrome. This was also the most common abnormal parameter in males as well as in females.

Another parameter TG/HDL-C ratio has been shown to be a good surrogate marker for hyperinsulinemia as is FBS and it also provides an independent risk estimate for coronary artery disease. Our study showed that patient with TG/HDL-C ratio > 3.0 have higher chances of associated metabolic syndrome.

Patients with the syndrome had an almost double cardiovascular event rate than those without (3.23 vs 1.76/100 patient-years, p < 0.001). The ATP III too underlines this fact and recognizes the primary endpoint of metabolic syndrome as an increased risk of cardiovascular disease (CVD) and emphasizes the need of targeting metabolic syndrome and its individual components in preventing the CVD after targeting LDL-C. Conclusion It has been demonstrated in our study that all patients of essential hypertension should be screened for various parameters of metabolic syndrome, as it was found that this population is at a higher risk of developing metabolic syndrome and its associated complications. As the prevalence is more in younger age group, screening should start at an early age and further studies should be carried out in Indian population to support the same evidence.

References 1. McKeigue PM, Miller GJ, Marmot MG. Coronary heart disease in south Asians overseas: a review. J Clin Epidemiol 1989;42(7):597-609.

2. Chadha SL, Radhakrishnan S, Ramachandran K, Kaul U, Gopinath N. Epidemiological study of coronary heart disease in urban population of Delhi. Indian J Med Res 1990;92:424-30.

Contâ&#x20AC;&#x2122;d on page 829...

CARDIOLOGY

A Comparative Evaluation of Losartan/ Hydrochlorothiazide (Fixed Combination) versus Amlodipine Monotherapy on Left Ventricular Hypertrophy, Biochemical Parameters and Adverse Effects in Patients of Hypertension Iram Shaifali*, AK Kapoor**, HK Singhâ&#x20AC;

Abstract Background: Long-term administration of antihypertensives require better efficacy and tolerability. Moreover, the agent should regress left ventricular hypertrophy (LVH), which is an important predictor of cardiovascular events. Aims: To comparatively evaluate the effects of losartan/hydrochlorothiazide (LST/HCTZ) and amlodipine (AMLO) on LVH, biochemical parameters and adverse effects in hypertension. Material and methods: Two hundred fifty newly diagnosed hypertensive patients were randomly divided into two groups. LST 50 mg/HCTZ 12.5 mg and AMLO 5 mg once-daily, were administered. Biochemical parameters, adverse effects and ECG were recorded initially and after 6 months of therapy. Statistical analysis was done.

Results: Both regimens significantly reduced mean SBP and DBP in each of the six follow ups (p < 0.001). LST/HCTZ caused regression of LVH in greater number of cases (26) than AMLO (20) and also showed a significant increase in mean values of serum creatinine, serum uric acid and high-density lipoprotein (HDL) levels and a significant decrease in Serum cholesterol. In AMLO group only serum creatinine was raised. The most common adverse effects in LST/HCTZ was dizziness (4.5%) and in AMLO group pedal edema (22%). Conclusion: Comparatively LST/HCTZ therapy causes regression of LVH in larger number of cases, increases HDL and is better tolerated.

Keywords: Losartan, hydrochlorothiazide, amlodipine, hypertension, left ventricular hypertrophy

H

ypertension is a widely prevalent disease worldover and is responsible for cardiovascular morbidity and mortality. Phillips et al1 while comparing losartan (LST) with amlodipine (AMLO) in patients with mild-to-moderate hypertension noted that AMLO, LST and LST/HCTZ (hydrochlorothiazide) combination therapy are effective and safe treatments for hypertension. Hypertension has a major influence on the development of left ventricular hypertrophy (LVH), which is a strong independent predictor of cardiovascular events and all-cause mortality. Further,

*III Year Resident **Professor and Head â&#x20AC; Professor Dept. of Pharmacology Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh Address for correspondence Dr AK Kapoor Professor and Head Dept. of Pharmacology Rohilkhand Medical College, Bareilly, Uttar Pradesh E-mail: drakkapoor@rediffmail.com

prognosis of hypertensive patients who have LVH regression appears to be improved. It was demonstrated by the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study that left ventricular mass decreased significantly in mild-tomoderate hypertensive patients treated for 16 weeks with 50 mg LST/12.5 mg HCTZ, but not in patients treated with up to 10 mg of AMLO.2 Furthermore, the Losartan Intervention for Endpoint-Reduction in Hypertension (LIFE) study of hypertensives with LVH demonstrated a statistically significant 13% reduction in composite endpoint of cardiovascular death, stroke and myocardial infarction in LST-based therapy group compared with the atenolol-based therapy group.3 The goal of antihypertensive therapy is to prevent complications of hypertension. Several studies have mentioned no difference in blood pressure between AMLO group and LST/HCTZ group and a superior tolerability was observed in LST-based group.4,5 However, Asian populations respond more favorably to calcium channel blockers and less favorably to

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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CARDIOLOGY angiotensin-converting enzyme inhibitors compared to westerners.6 The present study was designed to compare the effects of LST/HCTZ with AMLO with respect to regression of left ventricular mass and to comparatively evaluate blood chemistry and adverse effects in patients of hypertension.

MATERIAL AND METHODS This prospective, observational study of 1 year duration (July 2012 to June 2013) was carried out by the Dept. of Pharmacology in collaboration with Dept. of Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh Ethical clearance from Institutional Ethical Committee was taken. Written informed consent from all enrolled hypertensive patients was undertaken.

Two hundred fifty newly diagnosed essential hypertension patients, of either sex conforming to Stage 1 JNC-7 criteria, who were 18 years and above, attending to medicine outdoor department were included and constituted the sample size. The patients were randomly divided into two groups. Of these, 128 patients were enrolled in LST/HCTZ group and 122 patients in AMLO group. Patients with secondary hypertension, patients with impaired liver and/or kidney function, pregnant and lactating females and those taking oral contraceptives were excluded from the study.

Demographic information was collected by using a structured pretested and predesigned questionnaire.

Blood pressure of all the patients was monitored initially and in all the subsequent follow-ups.

Of 250 patients, in only 100 randomly selected patients (50 each of LST/HCTZ group and AMLO group) ECG was done for evaluation of LVH, initially at the time of registration and after 6 months. The voltage criteria in ECG was used for assessment of LVH (R wave in V5 or V6 [whichever is greater] + S wave in V1 or V2 [whichever is greater] if > 35 mm denotes LVH).

The laboratory tests like random blood sugar (RBS), urine (routine and microscopic), serum creatinine, serum uric acid, serum potassium, serum bilirubin and lipid profile were carried out before the initiation of treatment and after 6 months of completion of treatment. The adverse effects observed during the therapy with both regimens were noted down. The patients were assessed at 2 weeks (first follow-up), 4 weeks, (second follow-up), 8 weeks (third follow-up) at 12 weeks (fourth follow-up), then at 18 weeks (fifth follow-up) and finally at 24 weeks (sixth follow-up) for evaluation of adverse effects.

Statistical analysis was done by using the Microsoft Excel and SPSS windows version 14.0 software.

OBSERVATION AND RESULTS Out of a total 250 newly diagnosed hypertensive patients conforming to Stage 1 JNC-7 criteria, 14 patients (10.9%) in LST/HCTZ group and 26 patients (21.3%) in AMLO group dropped out during the study.

The prevalence of hypertension was more common in females, M:F ratio being 0.92:1. The urban-rural ratio was 1.06:1. The incidence of hypertension was more in 41-50 years followed by 51-60 years age group. Mean systolic blood pressure (SBP) was 152.97 mmHg and mean diastolic blood pressure (DBP) was 95.05 mmHg in LST/HCTZ group. Similarly, mean SBP was 153.27 mmHg and mean DBP was 95.27 mmHg in AMLO group. Thus, mean SBP and mean DBP were comparable between the two groups (Table 1).

Following therapy, mean SBP and mean DBP were statistically significantly reduced in both LST/HCTZ as well as AMLO group in all of the six follow-ups (p < 0.001 for both groups). Of 100 randomly selected patients who were screened for LVH from the two groups, it was observed that only 32/50 patients in LST/HCTZ group and 26/50 patients in AMLO group had LVH initially, and following

Table 1. Baseline Characteristics of Randomized Patients

LST/HCTZ

AMLO

No. of patients

128

122

18-30

8

16

24

Male

66

54

31-40

35

24

59

Female

62

68

41-50

42

43

85

Mean SBP

152.97 mmHg

153.27 mmHg

51-60

37

30

67

Mean DBP

95.05 mmHg

95.27 mmHg

> 61

6

9

15

Total

128

122

250

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Age group

LST/HCTZ

AMLO

Total

CARDIOLOGY Table 2. Effect on Lab Parameters with LST/HCTZ Lab parameters

LST/HCTZ (n = 128)

t value

p value

Before (Mean ± SEM)

After (Mean ± SEM)

RBS

165.4 ± 7.04

144.81 ± 5.74

1.71

p > 0.05

S. creatinine

0.89 ± 0.02

0.95 ± 0.02

3.28

p < 0.05

S. cholesterol

224.89 ± 5.98

203.21 ± 5.26

2.56

p < 0.05

S. HDL

34.95 ± 0.57

45.49 ± 0.76

10.85

p < 0.05

S. LDL

185.39 ± 5.81

172.63 ± 5.25

1.28

p > 0.05

S. TG

167.5 ± 4.98

151.68 ± 4.67

1.92

p > 0.05

S. potassium

3.73 ± 0.04

3.76 ± 0.04

1.49

p > 0.05

S. bilirubin

0.53 ± 0.01

0.5 ± 0.99

1.19

p > 0.05

S. uric acid

4.51 ± 0.07

5.2 ± 0.06

7.31

p < 0.05

RBS = Random blood sugar; S. = Serum; HDL = High-density lipoprotein; LDL = Low-density lipoprotein; TG = Triglyceride. p < 0.05 = Significant

Table 3. Effect on Lab Parameters with AMLO Lab parameters

AMLO (n = 122)

t value

p value

Before (Mean ± SEM)

After (Mean ± SEM)

RBS

108.49 ± 3.27

104.04 ± 3.49

0.96

p > 0.05

S. creatinine

0.674 ± 0.01

0.732 ± 0.01

t = 2.52

p < 0.05

S. cholesterol

172.49 ± 4.98

168.87 ± 4.17

t = 0.72

p > 0.05

S. HDL

39.49 ± 0.82

41.54 ± 0.69

t = 1.10

p > 0.05

S. LDL

145.59 ± 5.00

147.02 ± 4.54

t = 0.17

p > 0.05

S. TG

139.37 ± 3.90

134.5 ± 3.54

t = 0.91

p > 0.05

S. potassium

3.25 ± 0.05

3.14 ± 0.04

t = 1.73

p > 0.05

S. bilirubin

0.55 ± 0.013

0.55 ± 0.01

t = 0.33

p > 0.05

S. uric acid

3.25 ± 0.05

3.14 ± 0.04

t = 1.73

p > 0.05

p < 0.05 = Significant.

Table 4. List of Adverse Effects Seen with LST/HCTZ and AMLO Adverse effects

Patients (%) in LST/HCTZ group

Patients (%) in AMLO group

Dizziness

4.5%

1.2%

Headache

1.4%

0.9%

1%

0.6%

Pedal edema

0.9%

22%

Palpitations

0.5%

2.2%

Cough

0.6%

0%

Emotional distress

0.6%

0.6%

Hot flushes

0.5%

0.6%

GI upset

GI = Gastrointestinal.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

825

CARDIOLOGY 6 months of therapy, LVH was reduced (between 25-40%) in 26 patients of LST/HCTZ group and in 20 patients of AMLO group.

Table 2 depicts effects on biochemical parameters in LST/HCTZ group. There was a significant increase (p < 0.05) in the mean values of serum creatinine, serum uric acid and high-density lipoprotein (HDL) levels along with significant decrease in serum cholesterol levels (p < 0.05). There were no significant changes in the levels of RBS, serum potassium, serum bilirubin, low-density lipoprotein (LDL) and triglycerides.

Table 3 shows effect on biochemical parameters in AMLO group. There was a significant increase in the levels of serum creatinine, (p < 0.05) following AMLO therapy. No other significant changes in mean values of any other laboratory parameters were noted.

Table 4 shows list of commonly encountered adverse effects with percentage of occurrence in LST/HCTZ and AMLO group. The most common adverse effect seen with LST/HCTZ was dizziness in 4.5% of cases followed by headache in 1.4% of patients and cough was seen in 0.6% of the patients. In the AMLO group, the commonest adverse effect was pedal edema in 22% of cases followed by palpitation in 2.2% and dizziness in 1.2% cases. Cough was not seen in any case.

DISCUSSION Affecting 1 billion population worldover, hypertension remains one of the leading causes of death worldwide making it a public health problem. Moreover, hypertension is also a leading cause for hospitalization and outpatients visits. Despite a large number of antihypertensives which are in current clinical use, in the present study, the two commonly used groups of agents were considered for comparative evaluation because of their efficacy in Asian population and in the doses applied they cause minimal adverse effect profile and are well-tolerated.

In the present study, majority of patients belonged to age group 41-50 and a predominance of females (M:F ratio 0.92:1) was noted. Our observations are in agreement with the serial epidemiological studies conducted by Gupta et al7, 8 who also reported a female predominance. The urban-rural ratio in our study is 1.06:1 suggesting a larger number of cases belonged to urban area. A number of workers9-11 have reported a similar trend. Baseline mean SBP and mean DBP were comparable between LST/HCTZ and AMLO groups initially. Following treatment, a statistically significant reduction of blood pressure, and similar response

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

rates and equal efficacy were noted in both groups thus facilitating and providing equal opportunities for a comparative evaluation in respect of LVH, adverse effects and laboratory parameters.

In hypertensive patients, LVH is a prognostically relevant target-organ damage feature associated with systolic and diastolic left ventricular dysfunction.

Patients with LVH are at increased risk for stroke, coronary heart disease, congestive heart failure and sudden cardiac death. Therefore, LVH regression is an important antihypertensive treatment goal. The rennin angiotensin-aldosterone system is implicated in LVH development in essential hypertension. Recent data suggest LVH is reduced more by angiotensin-II receptor antagonists than by antihypertensive drug of any other class.12-14 In the present study, LVH has been assessed electrocardiographically, as the electrocardiogram (ECG) has a high specificity to identify patients with LVH but the sensitivity is fairly low. Out of 100 randomly selected patients who were screened for LVH only 58/100 patients were positive for LVH in both groups. LVH had been reduced in both groups following 6 monthâ&#x20AC;&#x2122;s therapy; the regression was more with LST/HCTZ compared to AMLO group suggesting that LST/HCTZ therapy is more effective in regressing the left ventricular mass. Our observations were in agreement with the LIFE study, which had shown a superiority of LST-based therapy over atenolol-based therapy in reducing the composite primary end-point of cardiovascular death, myocardial infarction or stroke among 9,193 patients with severe hypertension and ECG signs of LVH.3 Krauser et al13 had observed a better LVH regression with LST/HCTZ than with AMLO therapy. Martina et al14 while investigating the effects of LST and AMLO on left ventricular mass by transthoracic echocardiographies had observed that following 16 weeks of active treatment, left ventricular mass decreased significantly (p = 0.003) with LST therapy. Though, left ventricular mass had also been decreased with AMLO but the decrease was not significant. Shibasaki et al12 had also observed that LST more effectively regresses LVH in patients with end-stage renal disease (ESRD) than do enalapril and AMLO despite a comparative antihypertensive effect between the three drugs.

In the present study, the LST/HCTZ group, a significant increase in the mean values of serum creatinine, serum uric acid and HDL levels had been noted along with significant decrease in serum cholesterol, whereas no other significant changes had been observed in other laboratory investigations. The clinical significance

CARDIOLOGY of raised serum uric acid seems to be trivial because the levels even after 6 months of therapy remained within normal range (normal range in our laboratory is 3-6.5 mg%). Similar results have been observed

by Hosoya et al15 who had also observed that the fluctuations remained within normal range but overall serum uric acid concentration increased (355 + 93 to 367 + 92 μmol/L, p < 0.05) and that the increase was significant in low uric acid group (315 + 65 to 333 + 77 μmol/L, p < 0.001). In contrast, in high uric acid group there was significant decrease in uric acid value (473 + 63 μmol/L, p < 0.005). Similar results had been observed by Kita et al.16 A recent post hoc analysis also confirmed that LST lowers serum uric acid levels compared with placebo in patients with diabetic nephropathy.17 The mechanism by which LST/HCTZ reduces uric acid levels in patients with hyperuricemia is largely attributed to uricosuric action of LST, which has been known to be mediated by the inhibition of URAT-1 in renal tubules.18,19 Our findings in respect to increase in serum uric acid concentrations contradicted those of Chung et al20 who have observed no significant uric acid elevation following LST/HCTZ combination therapy.

There was no significant effect (p > 0.05) on RBS following 6 months of therapy with LST/HCTZ, though there was slight reduction in RBS of euglycemic as well as diabetic hypertensive individuals. However, this did not necessitate any modifications in dietary habits of euglycemics or else a reduction in the dose of diabetic hypertensives. The mean serum creatinine levels were significantly increased; whereas, effects on serum potassium and serum bilirubin were not significantly (p > 0.05). Our observations with respect to the above mentioned laboratory parameters are in conformity with those of Minami et al21 and Hosoya et al.15 Regarding effect on lipid profile, a statistically significant reduction (p < 0.005) in serum cholesterol had been observed following therapy with LST/HCTZ but serum LDL and serum triglycerides levels had not shown a significant reduction (p > 0.05). However, serum HDL levels increased significantly (p < 0.05) following 6 months therapy with LST/HCTZ. This observation is in line with Minami et al21 who had also observed that following 12 months combination therapy of LST/HCTZ, serum HDL had increased significantly.

It was noted that low doses of HCTZ induce minimal, if any, adverse changes in lipid profile.22 However, angiotensin receptor blockers (ARBs) exert a beneficial effect on lipid profile and HDL levels are raised especially with LST.23 Lozano et al24 had reported

that combination therapy with LST/HCTZ for 6 months significantly increase serum HDL cholesterol in 422 hypertensive patients with type 2 diabetes.

In contrast, Hasoya et al15 reported no significant changes in lipid profile.

With AMLO regimen, serum RBS had decreased slightly following 6 months therapy but this reduction was not statistically significant (p > 0.05) Also, the values of serum potassium, serum bilirubin and serum uric acid were not significantly affected. Similar results have been noted by other workers in the field.15,20,21 Serum creatinine value was significantly increased (p < 0.05) following AMLO therapy and this finding is coherent with those of IIno et al,25 Saruta et al26 and FDA reports.27 The lipid profile notably was also not significantly altered. Our findings regarding minimal changes in lipid profile with AMLO regimen are in line with those of Ahmed et al28 and Hunninghake et al.29 It may be mentioned that in two large clinical trials, LIFE study3 and RENAAL Trial30 (combined >10,000 patients studied over 49,000 patients years of treatment) hypertension treatment based on LST therapy usually with a diuretic, had been shown to be superior to calcium channel blocker or β-blocker based treatment regimens in preventing some of the serious outcomes related to hypertension.

Since, antihypertensive therapy has to be continued almost throughout the life of an individual, therefore effect on laboratory parameters, tolerability and adverse effects between two regimens are quite important, while comparing the two regimens. In the present study, the combination of LST/HCTZ had caused a low incidence of adverse effects both at short interval and following 6 months of therapy, thus exhibiting better tolerability for this regimen. It may be mentioned that thiazides including HCTZ often induce adverse effects such as hypokalemia, impaired glucose tolerance and an increase in serum uric acid levels. These side effects of HCTZ can be minimized if prescribed in lower doses. Thus, fixed-dose combination of LST 50 mg plus HCTZ 12.5 mg is worth prescribing as it has blood pressure-lowering potency and avoids or minimizes adverse effects. Adverse effects of LST/ HCTZ have been charted out in Table 4. It is worth noting that no severe adverse effects requiring special treatment or hospitalization have been recorded.

Chung et al,20 LOA study group4 and Volpe et al31 have observed dizziness as the most common adverse effect and this corroborates our observations.

A better tolerability in respect to AMLO therapy was also observed. The incidence of gastrointestinal

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

827

CARDIOLOGY upset, emotional stress and hot flushes were found to be minimal with AMLO therapy. Significantly, the occurrence of cough in contrast to LST/HCTZ therapy was not observed. However, the incidence of pedal edema was fairly high (22%) with AMLO group.

The drop outs were basically due to pedal edema.

Volpe et al31 and Wilson et al32 had also reported high incidence of pedal edema 25% and 24%, respectively in their studies. Other workers1,31-33 had also reported pedal edema as a commonest adverse effect with AMLO monotherapy and a variable incidences of other side effects.

A total number of 14 patients of LST/HCTZ regimen and 26 patients of AMLO regimen dropped out. The probable reasons may be adverse events, lack of efficacy, cost of treatment and the poor awareness that despite adequate blood pressure control the treatment has to be continued lifelong. Other workers1,31-33 have also observed that adverse effects due to therapy resulted in drop outs but the incidence of dropped outs varied in different studies. Though, the overall frequency of adverse effects between the two treatment regimens are similar and consistent with the known safety profile of the two groups, yet the drug related adverse effects and withdrawal from the study are more common for amolodipine.

CONCLUSION In conclusion, comparatively speaking, LST/HCTZ therapy provides comparable antihypertensive efficacy, superior tolerability and unequivocal benefits for clinical outcomes in hypertensive patients. It significantly raises serum HDL cholesterol and causes regression of LVH in larger number of patients as compared to AMLO regimen.

REFERENCES 1. Phillips RA, Kloner RA, Grimm RH Jr, Weinberger M. The effects of amlodipine compared to losartan in patients with mild to moderately severe hypertension. J Clin Hypertens (Greenwich) 2003;5(1):17-23.

2. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288(23):2981-97.

3. Dahlöf B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, de Faire U, et al; LIFE Study Group. Cardiovascular morbidity

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and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002;359(9311):995-1003.

4. Dahlöf B, Lindholm LH, Carney S, Pentikäinen PJ, Ostergren J. Main results of the losartan versus amlodipine (LOA) study on drug tolerability and psychological general well-being. LOA Study Group. J Hypertens 1997;15(11):1327-35.

5. Oparil S, Barr E, Elkins M, Liss C, Vrecenak A, Edelman J. Efficacy, tolerability, and effects on quality of life of losartan, alone or with hydrochlorothiazide, versus amlodipine, alone or with hydrochlorothiazide, in patients with essential hypertension. Clin Ther 1996;18(4):608-25.

6. Jamerson K, DeQuattro V. The impact of ethnicity on response to antihypertensive therapy. Am J Med 1996;101(3A):22S-32S. 7. Gupta R, Prakash H, Majumdar S, Sharma S, Gupta VP. Prevalence of coronary heart disease and coronary risk factors in an urban population of Rajasthan. Indian Heart J 1995;47(4):331-8.

8. Gupta R, Gupta VP, Sarna M, Bhatnagar S, Thanvi J, Sharma V, et al. Prevalence of coronary heart disease and risk factors in an urban Indian population: Jaipur Heart Watch-2. Indian Heart J 2002;54(1):59-66.

9. Chadha SL, Gopinath N, Shekhawat S. Urban-rural differences in the prevalence of coronary heart disease and its risk factors in Delhi. Bull World Health Organ 1997;75(1):31-8.

10. Padmavati S, Gupta S. Blood pressure studies in rural and urban groups in Delhi. Circulation 1959;19(3):395-405.

11. Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18(2):73-8.

12. Shibasaki Y, Masaki H, Nishiue T, Nishikawa M, Matsubara H, Iwasaka T. Angiotensin II type 1 receptor antagonist, losartan, causes regression of left ventricular hypertrophy in end-stage renal disease. Nephron 2002;90(3):256-61.

13. Krauser DG, Devereux RB. Ventricular hypertrophy and hypertension: prognostic elements and implications for management. Herz 2006;31(4):305-16.

14. Martina B, Dieterle T, Weinbacher M, Battegay E. Effects of losartan titrated to Losartan/Hydrochlorothiazide and amlodipine on left ventricular mass in patients with mildto-moderate hypertension. A double-blind randomized controlled study. Cardiology 1999;92(2):110-4.

15. Hosoya T, Kuriyama S, Ohno I, Kawamura T, Ogura M, Ikeda M, et al. Antihypertensive effect of a fixed-dose combination of losartan/hydrochlorothiazide in patients with uncontrolled hypertension: a multicenter study. Clin Exp Nephrol 2012;16(2):269-78.

16. Kita T, Yokota N, Ichiki Y, Ayabe T, Etoh T, Tamaki N, et al.

One-year effectiveness and safety of open-label losartan/ hydrochlorothiazide combination therapy in Japanese patients with hypertension uncontrolled with ARBs or ACE inhibitors. Hypertens Res 2010;33(4):320-5.

CARDIOLOGY 17. Miao Y, Ottenbros SA, Laverman GD, Brenner BM, Cooper ME, Parving HH, et al. Effect of a reduction in uric acid on renal outcomes during losartan treatment: a post hoc analysis of the reduction of endpoints in noninsulin-dependent diabetes mellitus with the Angiotensin II Antagonist Losartan Trial. Hypertension 2011;58(1):2-7.

(JLIGHT) Study Investigators. Renoprotective effect of losartan in comparison to amlodipine in patients with chronic kidney disease and hypertension - a report of the Japanese Losartan Therapy Intended for the Global Renal Protection in Hypertensive Patients (JLIGHT) study.

Hypertens Res 2004;27(1):21-30.

18. Enomoto A, Kimura H, Chairoungdua A, Shigeta Y, Jutabha P, Cha SH, et al. Molecular identification of a renal urate anion exchanger that regulates blood urate levels.

Nature 2002;417(6887):447-52.

26. Saruta T, Ishii M, Abe K, Iimura I. Efficacy and safety of amlodipine in hypertensive patients with renal dysfunction. Clin Cardiol 1994;17(6):317-24.

19. Anzai N, Ichida K, Jutabha P, Kimura T, Babu E, Jin CJ, et al.

Plasma urate level is directly regulated by a voltagedriven urate efflux transporter URATv1 (SLC2A9) in humans. J Biol Chem 2008;283(40):26834-8.

20. Chung JW, Lee HY, Kim CH, Seung IW, Shin YW, Jeong MH, et al. Losartan/Hydrochlorothiazide fixed combination versus amlodipine monotherapy in Korean patients with mild to moderate hypertension. Korean Circ J 2009;39(4):151-6.

21. Minami J, Abe C, Akashiba A, Takahashi T, Kameda T, Ishimitsu T, et al. Long-term efficacy of combination therapy with losartan and low-dose hydrochlorothiazide in patients with uncontrolled hypertension. Int Heart J 2007;48(2):177-86.

22. Weir MR, Moser M. Diuretics and beta-blockers: is there a risk for dyslipidemia? Am Heart J 2000;139(1 Pt 1):174-83.

23. Kyvelou SM, Vyssoulis GP, Karpanou EA, Adamopoulos DN, Zervoudaki AI, Pietri PG, et al. Effects of antihypertensive treatment with angiotensin II receptor blockers on lipid profile: an open multi-drug comparison trial. Hellenic J Cardiol 2006;47(1):21-8.

24. Lozano JV, Llisterri JL, Aznar J, Redon J; Spanish Working Group. Losartan reduces microalbuminuria in hypertensive microalbuminuric type 2 diabetics. Nephrol Dial Transplant 2001;16 Suppl 1:85-9.

25. Iino Y, Hayashi M, Kawamura T, Shiigai T, Tomino Y, Yamada K, et al; Japanese Losartan Therapy Intended for the Global Renal Protection in Hypertensive Patients

27. FDA reports: Amlodipine besylate and blood creatinine increased, eHealthmed, 2013.

28. Ahmed AH, Al-Hayali RMA. Effects of amlodipine on serum lipid profile in hypertensive patients. Ann Coll Med Mosul 2009;35(1):8-12.

29. Hunninghake DB. Effects of celiprolol and other antihypertensive agents on serum lipids and lipoproteins.

Am Heart J 1991;121(2 Pt 2):696-701.

30. Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, et al; RENAAL Study Investigators.

Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001;345(12):861-9.

31. Volpe M, Junren Z, Maxwell T, Rodriguez A, Gamboa R, Gomez-Fernandez P, et al; CDSP-944 Study Group.

Comparison of the blood pressure-lowering effects and tolerability of Losartan- and Amlodipine-based regimens in patients with isolated systolic hypertension. Clin Ther 2003;25(5):1469-89.

32. Wilson TW, Lacourcière Y, Barnes CC. The antihypertensive efficacy of losartan and amlodipine assessed with office and ambulatory blood pressure monitoring. Canadian Cozaar Hyzaar Amlodipine Trial Study Group. CMAJ 1998;159(5):469-76.

33. Wu SC, Liu CP, Chiang HT, Lin SL. Prospective and randomized study of the antihypertensive effect and tolerability of three antihypertensive agents, losartan, amlodipine, and lisinopril, in hypertensive patients.

Heart Vessels 2004;19(1):13-8.

■■■■ ...Cont’d from page 822 3. Balarajan R. Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales. BMJ 1991;302(6776):560-4.

4. Beckles GL, Miller GJ, Kirkwood BR, Alexis SD, Carson DC, Byam NT. High total and cardiovascular disease mortality in adults of Indian descent in Trinidad, unexplained by major coronary risk factors. Lancet 1986;1(8493):1298-301.

7. Ramachandran A, Snehalatha C, Dharmaraj D, Viswanathan M. Prevalence of glucose intolerance in Asian Indians. Urban-rural difference and significance of upper body adiposity. Diabetes Care 1992;15(10):1348-55.

8. McKeigue PM, Pierpoint T, Ferrie JE, Marmot MG. Relationship of glucose intolerance and hyperinsulinaemia to body fat pattern in south Asians and Europeans. Diabetologia 1992;35(8):785-91.

5. McKeigue PM, Shah B, Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians.

Lancet 1991;337(8738):382-6.

9. Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 1988;37(12):1595-607.

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

11. Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994;17(9):961-9.

10. Meigs JB. Epidemiology of the metabolic syndrome, 2002.

Am J Manag Care 2002;8(11 Suppl):S283-92; quiz S293-6.

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Community Medicine

Knowledge, Attitude and Practices Regarding Biomedical Waste Management among Healthcare Personnel in Lucknow, India Gyan P singh*, Pratibha Gupta†, Reema Kumari‡, Sneh Lata Verma#

Abstract Background: Biomedical waste (BMW) is waste generated during diagnosis, treatment or immunization of human beings or animals, or in research activities pertaining thereto, or in the production and testing of biologicals, and is contaminated with human fluids.

Objective: To assess the Knowledge, Attitude and Practices (KAP) regarding healthcare waste management among healthcare personnel in Lucknow District, Uttar Pradesh, India. Material and methods: A cross-sectional study was conducted amongst medical, dental, paramedical staff and graduate and postgraduate students of King George’s Medical and Dental University, Lucknow, Uttar Pradesh, India. A total of 28 healthcare personnel consented for interview. Simple random sampling technique was used to select the study unit. A predesigned and pretested questionnaire for KAP study was used for data collection. Data were collected, compiled and tabulated using Microsoft Excel and analyzed using SPSS 17.0 version for calculation of percentages.

Results: In present study, 83.3% of medical and dental doctors and students had knowledge about waste management plan and its authorization. Majorities of the medical doctors (83.3%), paramedics (80%) and students (66.7%) had knowledge about place of waste disposal. On practice level, most of the healthcare personnel were using autoclave and lesser number of personnel were using dry heat sterilization. Conclusion: The healthcare personnel were observed to be good in theoretical knowledge as well as practices. The need of comprehensive training programs regarding BMW management is highly recommended to all hospital staff. Wherever, generated, a safe and reliable method for handling of BMW is essential.

Keywords: Biomedical waste, knowledge, practice, healthcare personnel

B

iomedical waste (BMW) is waste-generated during diagnosis, treatment or immunization of human beings or animals, or in research activities pertaining thereto, or in the production and testing of biologicals, and is contaminated with human fluids.1 The waste produced in the course of healthcare activities carries a higher potential for infection and injury than any other type of waste.2 It is estimated that annually about 0.33 million tons

*Assistant Professor, Dept. of Orthodontics and Dentofacial Orthopedics Faculty of Dental Sciences, KGMU, Lucknow, Uttar Pradesh †Associate Professor, Dept. of Community Medicine Era’s Lucknow Medical College, Lucknow, Uttar Pradesh ‡Associate Professor Upgraded Dept. of Community Medicine KGMU, Lucknow, Uttar Pradesh #Reader Dept. of Orthodontics and Dentofacial Orthopedics BBDCODS, Lucknow, Uttar Pradesh Address for correspondence Dr Pratibha Gupta D-4, Doctor's Residence Era’s Lucknow Medical College, Sarfarazganj, Hardoi Road Lucknow, Uttar Pradesh - 226 003 E-mail: pratibha_jayant@yahoo.co.in

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

of hospital waste is generated in India and, the waste generation rate ranges from 0.5 to 2.0 kg bed-1 day-1.3 All BMW generated in the hospital should be disposed off strictly in accordance with Biomedical Waste Management and Handling Rule 1998. Schedule I of which describes the categories of BMW; their treatment and disposal methods.2 BMW differs from hospital waste in the sense that it is “any solid, fluid or liquid waste, including its container and any intermediate product. These products could be generated during the diagnosis, treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals and the animal waste from slaughter houses or any other establishments.4 In persuasion of the aim of reducing health problems, eliminating potential risks and treating sick people, healthcare services inevitably create waste, which itself may be hazardous to health. The waste produced in the course of healthcare activities carries a higher potential for infection and injury than any other type of waste.

Inadequate and inappropriate knowledge of handling

Community Medicine of healthcare waste may have serious health consequences and a significant impact on the environment as well.3 Although, there is an increased global awareness among health professionals about the hazards and also appropriate management techniques but the level of awareness in India is found to be unsatisfactory.5

A total of 28 healthcare personnel consented for interview. Simple random sampling technique was used to select the study unit. A predesigned and pretested questionnaire for KAP study was used for data collection. Data were collected, compiled and tabulated using Microsoft Excel and analyzed using SPSS 17.0 version for calculation of percentages.

Results

Objective The objective of the study was to assess the Knowledge, Attitude and Practices (KAP) regarding healthcare waste management among healthcare personnel in Lucknow District, Uttar Pradesh, India. The hospital chosen for the study is a premier tertiary level Institute in India. Therefore, the current status of employeeâ&#x20AC;&#x2122;s awareness regarding BMW management will help the authorities to develop the strategy for improving the situation in future.

Material and Methods A cross-sectional study was conducted amongst medical, dental, paramedical staff and graduate and postgraduate students of King Georgeâ&#x20AC;&#x2122;s Medical and Dental University, Lucknow, Uttar Pradesh, India.

A total of 28 healthcare personnel consented for interview, which included six medical doctors, six dentists, 10 paramedicals and six graduate and postgraduate students.

In present study, 83.3% of medical and dental doctors and students had knowledge about waste management plan and its authorization. So, majorities of healthcare personnel have knowledge about waste management plan and its authorization and guidelines (Table 1).

Majorities of the medical doctors (83.3%), paramedicals (80%) and students (66.7%) had knowledge about place of waste disposal and they used to dispose it in any authorized waste collection. However, percentage of dental doctors (50%) was found to be low for using authorized waste collection (Table 2).

Table 1. Knowledge Regarding BMW Management Plan, Guidelines and Authorization among Healthcare Personnel Person interviewed

Waste management plan

Authorization

Waste management guidelines

Total

No (%)

No (%)

No (%)

No (%)

Medical

5 (83.3)

5 (83.3)

4 (66.7)

6 (100)

Dental

5 (83.3)

5 (83.3)

4 (66.7)

6 (100)

9 (90)

9 (90)

7 (70)

10 (100)

Students

5 (83.3)

4 (66.7)

4 (66.7)

6 (100)

Total

24 (85.7)

23 (82.1)

19 (67.9)

28 (100)

Paramedics

Table 2. Knowledge Regarding Place of BMW Disposal among Healthcare Personnel Person interviewed

Dumping in corporation bin

Any authorized waste collection

Total

No (%)

No (%)

No (%)

Medical

1 (16.7)

5 (83.3)

6 (100)

Dental

3 (50)

3 (50)

6 (100)

Paramedics

2 (20)

8 (80)

10 (100)

Students

2 (33.3)

4 (66.7)

6 (100)

Total

8 (28.6)

20 (71.4)

28 (100)

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

831

Community Medicine Table 3. Attitude Towards BMW Management among Healthcare Personnel Person interviewed

Medical

Dental

Paramedics

Students

Total

Agree/ Disagree(%)

Agree/ Disagree(%)

Agree/ Disagree(%)

Agree/ Disagree(%)

Agree/ Disagree(%)

Acceptance about universal precaution

83.3/0

83.3/0

60/10

66.7/16.7

71.4/7.1

Responsibility of government

83.3/0

50/16.7

60/10

66.7/16.7

64.3/10.7

83.3/16.7

66.7/16.7

60/30

83.3/0

71.4/17.9

Requires segregation of waste

83.3/0

83.3/0

80/0

66.7/16.7

78.6/3.6

Waste management is a team work

83.3/0

83.3/0

90/0

83.3/0

85.7/0

Question

Increases financial burden on waste management

Table 4. Practices Regarding Methods of Sterilization of BMW among Healthcare Personnel Person interviewed

Methods of Sterilization

Total

Autoclave

Dry heat sterilization

Cold chemical solution

Boiling water

Medical

83.3

16.7

0

0

6 (100.0%)

Dental

50

33.3

0

16.7

6 (100.0%)

80

10

10

0

10 (100.0%)

Students

Paramedics

33.3

33.3

0

33.3

6 (100.0%)

Total

64.3

21.4

3.6

10.7

28 (100.0%)

Attitude-based questions were well-responded by all the healthcare personnel. About 83.3% of doctors were aware about universal precaution, responsibility of government, requirement of segregation of waste and also that waste management was a team work. Almost majority of healthcare personnel were in agreement with the facts associated with waste management.

(Table 3).

On practice level most of the medical doctors (83.3%), dental doctors (50%), paramedicals (80%) and students (33.3%) were using autoclave and a lesser number were using dry heat sterilization. A very few percentages of paramedicals (10%) were using cold chemical solution for sterilization (Table 4).

Discussion In the present study, knowledge about BMW management plan, its authorization and guidelines among all the healthcare personnel was high but was low among the sanitary staff; this was similar to the

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

findings from other studies.5,6 Similar findings were also observed by Mathur et al, in a study conducted in Allahabad, India.7 In a study conducted by Bathma et al in Bhopal, it was also observed that the knowledge about BMW management and handling rule was much better in doctors (92.1%) as compared to nurses (54.5%) and other staff as well as knowledge about disease spread by improper waste management was more in doctors (92.1%) as compared to nurses (84%).8 In this study, majority of the medical doctors (83.3%), paramedicals (80%) and students (66.7%) had knowledge about place of waste disposal and they used to dispose it in authorized waste collection. In a study conducted by Bathma in Bhopal, knowledge of color container used in hazardous waste and storage time of waste was higher in nurses (72.7%) as compared to doctors (47.4%).8 Similar observations were noted in other studies. Saini et al, in their study showed that consultants, residents and the scientists, respectively had (85%, 81% and 86%) knowledge about the BMW management rule as compared to nurses

Community Medicine (60%), and that of sanitary staff, operation theater and laboratory staff was 14%, 14% and 12%, respectively.6 Attitude-based questions were well-responded by all the healthcare personnel. About 83.3% of doctors were aware about universal precaution, responsibility of government, requirement of segregation of waste and also that waste management is a team work.

Similarly in a study conducted by Pallavi V. Tenglikar in Gulbarga city, it was observed that the attitude towards any health behavior depended primarily on the knowledge level of the subject by the individual and in proportion with the knowledge score.9 In this study too, the positive attitude towards healthcare waste management was commensurate with knowledge level i.e., highest amongst doctors followed by nursing staff and housing staff. This was in conformity with the similar study done by Deepali Deo et al.10 On practice level, most of the medical doctors (83.3%), dental doctors (50%), paramedics (80%) and students (33.3%) were using autoclave and lesser number were using dry heat sterilization. Mathur et al, in a study conducted in Allahabad, India found that regarding practices related to BMW management, sanitary staff were ignorant on all the counts.7 Saini et al, in his study shows that residents were rated 89%, 81% and 78% and scientists were at the rate of 82%, 73% and 82%, respectively practicing as per rules. In regards to the nurses it is shown to be the best i.e., 100% of them were practicing according to the rules.6

Acknowledgment

Conclusion

8. Bathma V, Likhar SK, Mishra MK, Athavale AV, Agarwal S, Shukla US. Knowledge assessment of hospital staff regarding biomedical waste management in a tertiary care hospital. Nat J Commun Med 2012;3(2):197-200.

The healthcare personnel were observed to be good in theoretical knowledge as well as practices. The need of comprehensive training programs regarding BMW management is highly recommended to all hospital staff. Wherever, generated, a safe and reliable method for handling of BMW is essential. Effective management of BMW is not only a legal necessity but also a social responsibility. A step forward has been made in India in the field of medical waste management but there remains much scope for improvement in the field.

We acknowledgment the KGMU doctors, students and hospital staff for their cooperative coordination and support during the study.

References 1. Das NK, Prasad S, Jayaram K. A TQM approach to implementation of handling and management of hospital waste in Tata Main Hospital. Issued by Hospital Waste Management Committee, TMH. 2001;11-12:75-8.

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

21st edition, Bhanot Publishers: Jabalpur 2011:p.730.

3. Patil AD, Shekdar AV. Health-care waste management in India. J Environ Manage 2001;63(2):211-20.

4. Satpathy S, Pandhi RK. Manual for Hospital Waste Management at AIIMS Hospital, New Delhi, 1998.

5. Pandit NB, Mehta HK, Kartha GP, Choudhary SK. Management of bio-medical waste: awareness and practices in a district of Gujarat. Indian J Public Health 2005;49(4):245-7.

6. Saini S, Nagarajan SS, Sarma RK. Knowledge; attitude and practices of bio-medical waste management amongst staff of a tertiary level hospital in India. J Acad Hosp Adm 2005;17:1-12.

7. Mathur V, Dwivedi S, Hassan M, Misra R. Knowledge, attitude, and practices about biomedical waste management among healthcare personnel: a crosssectional study. Indian J Community Med 2011;36(2): 143-5.

9. Tenglikar PV, Kumar GA, Kapate R, Reddy S, Vijayanath V. Knowledge attitude and practices of health care waste management amongst staff of nursing homes of Gulbarga city. J Pharm Biomed Sci 2012;19(19):1-3.

10. Deepali Deo, Tak SB, Munde SS. A study of knowledge regarding biomedical waste management among employees of a teaching hospital in rural area. J ISHWM 2006;5:12-5.

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Meditation ‘Works Just as Well as Antidepressants’ Meditating for just half an hour a day can offer people with depression as much relief as taking pills, researchers have claimed. The report, published in JAMA Internal Medicine, found an 8-week training program in mindfulness meditation reduced symptoms of anxiety, depression, stress and pain as well as improving the participants’ quality-of-life.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

833

Dermatology

Erythematous Nodules on Face: A Dermatologist’s Dilemma Kshama Talwar*, Ankur Talwar, Suresh Talwar, Manisha Bindal

Abstract Granuloma faciale (GF) is a chronic inflammatory disease of unknown origin characterized by nodular or granulomatous lesions on the face in adults. It is now regarded as a variant of vasculitis in which eosinophils are particularly numerous.

It remains a benign, though chronic condition, not associated with systemic lesions like other forms of vasculitis. We report a case of 24-year-old male who presented with multiple erythematous nodules on photoexposed areas since past 2 years. The patient had been previously treated for Hansen’s disease for 3 months but with no relief. The patient responded wonderfully to intralesional triamcinolone and topical tacrolimus after two initial failed attempts with intralesional cryotherapy.

Keywords: Granuloma faciale, vasculitis, erythematous nodules, intralesional triamcinolone, topical tacrolimus

E

rythematous nodular and plaque lesions on face always pose a challenge to the treating dermatologist. The dermatologist is confronted with wide array of differential diagnosis, which may include sarcoidosis, histoid leprosy, tumid lupus erythematosus, lymphocytoma cutis, Jessner’s lymphocytic infiltrate, leishmaniasis, granuloma faciale (GF) and Sweet’s syndrome. The final diagnosis depends upon an accurate dermatological and systemic examination, which may include history of photoaggravation, residence in endemic area, examination for any areas of sensory loss, thickened or tender nerves, pulmonary symptoms, enlarged lymph nodes and current or past history of prolonged fever. The clincher is unsurprisingly histopathologic examination with all the above conditions presenting with distinct and pathognomonic histopathological features.

in consistency, nontender with succulent appearance (Fig. 2), totally asymptomatic and progressively increasing in number and size. On closer examination, there were prominent follicular openings on the surface of the lesion (Figs. 2 and 3). Few lesions healed with mild atrophy. Mucosal examination was normal and no nerves were thickened.

There was no history of photoaggravation. Systemic examination was unremarkable. A differential diagnosis of sarcoidosis, GF, histoid leprosy, tumid lupus erythematosus, pseudolymphoma and Sweet’s syndrome was kept in mind. Complete blood count, liver function tests and basic metabolic panel were normal. Histopathology revealed dense mixed inflammatory exudate below an area of grenz zone

Case Report A 24-year-old male patient presented with complaints of multiple erythematous papules and nodules on forehead and temples, varying in size from 0.5 to 4 cm in diameter (Fig. 1) since three years. Lesions were firm

*Dept. of Dermatology Talwar Skin Institute, Lucknow, Uttar Pradesh Address for correspondence Dr Kshama Talwar Dept. of Dermatology Talwar Skin Institute, Lucknow, Uttar Pradesh E-mail: kshama.arora@gmail.com

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Figure 1. Multiple erythematous papules and nodules on the forehead and temple.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

835

Dermatology

Figure 2. Closer view of the lesions demonstrating the shiny, succulent appearance.

Figure 3. Further close-up view demonstrating prominent follicular orifices on the surface of the lesion.

Figure 4. Histopathology (H&E, 10X) revealing a clear grenz zone separating a dense polymorphous infiltrate in lower two-third of the dermis.

Figure 5. (H&E, 40X) Polymorphous infiltrate of eosinophils, neutrophils, plasma cells and lymphocytes.

(Fig. 4). Eosinophils, neutrophils, plasma cells and lymphocytes were present diffusely in the upper two-third of dermis (Fig. 5). Endothelial swelling was observed. Deep dermis and panniculus were unaffected, hence, a diagnosis of GF was made. The patient was started on oral dapsone together with intralesional cryotherapy (introducing a hypodermic needle through the lesion followed by passing of liquid nitrogen through the needle). However, there was no significant improvement after two sessions, so patient was started on topical tacrolimus together with intralesional triamcinolone acetonide. There was a significant reduction (>80%) of the lesions in a single session and patient was then maintained on topical tacrolimus subsequently.

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Discussion Granuloma faciale is an uncommon benign condition seen in adult males and females, with male preponderance. Lesions can be solitary or multiple, disseminated, and occur on sun-exposed areas, most often on the face. Sites of predilection include the nose, periauricular area, cheeks, forehead, eyelids and ears.

It was suggested that actinic damage plays a role in causing GF. However, GF is also reported to occur on extrafacial areas of the body, such as trunk and extremities. GF is usually symptomless. Some patients may complain of tender itching or stinging lesions. The skin is the primary organ system that is affected.

The diagnosis of GF can be established by skin biopsy. The term granuloma in GF is a misnomer as

Dermatology granulomas are never present histologically. Diffuse dermal infiltration with neutrophils, lymphocytes and eosinophils with subepidermal narrow grenz zone is highly characteristic of GF. There is usually an associated vasculitis. GF has to be differentiated from other conditions that have similar clinical appearance and/or are characterized by vasculitis. The clinical conditions to be differentiated include sarcoidosis, cutaneous lupus erythematosus, polymorphous light eruption, Jessner lymphocytic infiltration, lymphocytoma cutis and mycosis fungoides. There are both clinical and histological similarities between extrafacial GF and erythema elevatum diutinum (EED) and some authors suggest an association between the two conditions.

However, the symmetrical and acral involvement clinically, as well as the absence of grenz zone with notable fibrosis histologically, helps distinguishes EED from GF. GF is notoriously resistant to treatment. Many different medical therapies, including topical or intralesional corticosteroids, dapsone, antimalarials, isoniazid, clofazimine and topical nitrogen mustard have been tried with variable results. Recently, a successful

treatment of GF with pulse dye laser was reported.

Cryotherapy has been advocated as the first-line of treatment but our patient did not respond to the same.

Hence, we switched over to intralesional triamcinolone and topical tacrolimus and there was significant flattening of the lesions within a month of starting treatment.

Suggested Reading 1. Koplon BS, Wood MG. Granuloma faciale. First reported case in a Negro. Arch Dermatol 1967;96(2):188-92.

2. Crowson AN, Mihm MC Jr, Magro CM. Cutaneous vasculitis: A review. J Cutan Pathol 2003;30(3):161-73.

3. Carlson JA, LeBoit PE. Localized chronic fibrosing vasculitis of the skin: an inflammatory reaction that occurs in settings other than erythema elevatum diutinum and granuloma faciale. Am J Surg Pathol 1997;21(6):698-705.

4. Ackerman AB, Mones JM, Petronic-Rosic V. Ackerman’s Resolving quandaries in dermatology, pathology, and dermatopathology. Ardor Scribendi: New York; 2001.

5. Sewell L, Elston D. Extrafacial granuloma faciale successfully treated with 595-nm pulse dye laser. J Amer Acad Dermatol 2008;58(2):141.

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Corrigendum In the October issue of IJCP, the sequence of authors’ name for the article “Unusual Presentation of a Rare Case of Acrochordon” and name of the main author was wrongly published. The correct sequence should read as: Jaya K Gedam*, Disha A Rajput*, Arti Patel**, Meenal Bhalerao† *Associate **Senior

Professor

Resident

†Registrar

Dept. of Obstetrics and Gynecology ESIC, PGIMSR, MGM, Hospital, Parel, Mumbai Address for correspondence Dr Jaya K Gedam Flat no. 1501, Plot no. 412, 413 A & B, Shivthar Tower Sector 31A, Vashi Goan, Vashi, Navi Mumbai, Maharashtra - 400 703 Email id : jayagedam@gmail.com

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

837

Diabetology

A Randomized Double-Masked Study of 50 mg of Acarbose versus 0.2 mg Voglibose in Overweight Type 2 Diabetes Patients Age Between 30 and 50 Years Having Isolated Postprandial Glycemia Prem Kumar D*, Pratap VGMâ&#x20AC;

Abstract Objective: To compare the efficacy of 50 mg acarbose versus 0.2 mg of voglibose in treating postprandial hyperglycemia.

Material and methods: A randomized double-masked study was conducted at the Hassan Obesity and Diabetes Wellness Centre, Hassan, Karnataka, in coordination with Rajiv Gandhi University of Health Sciences, Karnataka. Sixty cases of isolated high postprandial blood sugar (PPBS > 200 mg/dL FBS < 126 mg/dL), including both males and females between age group 30 and 50 years, were included in the study group. Observation and results: Out of 30 patients in the group treated with acarbose 50 mg, the mean reduction of glycosylated hemoglobin (HbA1C) to their baseline values was 0.8% and mean reduction in the postprandial values was 64 mg/dL. Out of 30 patients in the group treated with voglibose 0.2 mg, the mean reduction in the HbA1C was 0.6% and mean reduction in the postprandial values was 57 mg/dL. Conclusions: Reduction of postprandial blood glucose and HbA1C were more in the group treated with acarbose with the difference of 0.2% in HbA1C and 7-8 mg/dL (mean) in postprandial plasma glucose. The side effects were more in the group treated with acarbose when compared with group treated with voglibose.

Keywords: Acarbose, voglibose, overweight type 2 diabetes, isolated postprandial glycemia

P

hyperglycemia exerts its effects may be identified in the production of free radicals. Correcting the postprandial hyperglycemia may form part of the strategy for the prevention and management of CVD.

ostprandial glycemia is one of the most common problems that are encountered in diabetes practice. Postprandial rise in the sugars is a contributing factor to the development of atherosclerosis.

The postprandial phase is characterized by a rapid and large increase in the blood sugar levels, the possibility that the postprandial 'hyperglycemic spikes' may be relevant to the onset of cardiovascular complications that has recently received much attention.

Epidemiological studies and preliminary intervention studies have shown that postprandial hyperglycemia is a direct and independent risk factor for cardiovascular disease (CVD). The mechanisms through which

Strict control of glycosylated hemoglobin (HbA1C) can prevent the microvascular complications of diabetes mellitus. According to the American Diabetes Association, fasting blood glucose should be < 110 mg/dL and postprandial blood glucose should be <140 mg/dL. Isolated postprandial hyperglycemia increases the risk of death from CVD. These observations imply that strict glycemic control is required to prevent macrovascular disease than microvascular disease.

*Professor Dept. of Internal Medicine, Hassan Institute of Medical Sciences Hassan, Karnataka *Registrar Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka â&#x20AC; Consultant Diabetologist Hassan Obesity and Diabetes Wellness Centre, Hassan, Karnataka Address for correspondence Dr Prem Kumar D Dept. of Internal Medicine Hassan Institute of Medical Sciences, Hassan, Karnataka

Acarbose is a complex oligosaccharide that delays the digestion of ingested carbohydrates thereby resulting in smaller rise in blood glucose concentration following meals. Acarbose reduces the levels of HbA1C in patient with type 2 diabetes mellitus. The antihyperglycemic action of acarbose results from a competitive reversible inhibition of pancreatic alpha-amylase and membranebound intestinal alpha-glucoside hydrolase enzymes that results in delayed glucose absorption and wavering of postprandial hyperglycemia. Acarbose blocks the

840

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Diabetology additional pancreatic amylase in addition to alphaglucosidase inhibitors.

Table 1. Analysis Done for Acarbose and Voglibose Groups

Voglibose is the newest alpha-glucosidase inhibitor that delays the absorption of glucose in intestines by inhibiting the alpha-glucosidase. It is a synthetic molecule that carries the same role as others in the group but it is designed to cause little side effects when compared to acarbose.

Side effects

Material and Methods The study was conducted at the Hassan Obesity and Diabetes Wellness Centre, Hassan, Karnataka, in coordination with Rajiv Gandhi University of Health Sciences, Karnataka.

Sixty cases of isolated high postprandial blood sugar (PPBS > 200 mg/dL; FBS < 126 mg/dL), including both males and females between age group 30 and 50 years, were included in the study group. This study was a drug-based study, where patients were divided into two random groups consisting of 30 patients each, irrespective of sex and age group. Each patient’s HbA1C and 2-hour postprandial sugars were measured.

All the patients were screened for dyslipidemia, impaired liver functions and impaired renal functions, and were excluded accordingly. Individuals were selected according to body mass index (BMI) >24 (overweight). Thyroid function tests were performed to rule out hypothyroidism. Group A consisting of 30 patients were initiated with acarbose 50 mg once-daily, which was increased twice-daily after a week; Group B consisting of 30 patients were initiated with voglibose 0.2 mg once-daily, which was increased twice-daily after a week as monotherapy. Analysis was performed after 3 months of therapy with HbA1C values and monthly postprandial glucose values.

Observation and Results Out of 30 patients in the group treated with acarbose 50 mg, the mean reduction of HbA1C to their baseline values was 0.8% and significant reductions in postprandial plasma glucose was 70 mg/dL in the first month, 62 mg/dL in the second month and 60 mg/dL in the third month. Mean reduction in the postprandial values was 64 mg/dL. Out of 30 patients in the group treated with voglibose 0.2 mg, the mean reduction in the HbA1C was 0.6% and significant reductions in the

Acarbose group (No. of patients)

Voglibose group (No. of patients)

Abdominal distention

6

3

Nausea

1

1

Diarrhea

3

1

Bloating and flatulence

4

2

Hypoglycemia

Nil

Nil

postprandial plasma glucose was 52 mg/dL in the first month, 58 mg/dL in the second month and 61 mg/dL in the third month. Mean reduction in the postprandial values was 57 mg/dL. The common side effects related to alpha-glucosidase inhibitors are gastrointestinal such as abdominal distention, diarrhea, nausea and flatulence. Analysis was done for both groups and the results are given in Table 1.

The undesirable effects were more in the group treated with acarbose, 14 out of 30 patients, than voglibose, seven out of 30 patients. Thus, the incidence of side effects associated with acarbose was around 48% and with voglibose it was around 22%. So, the overall side effects associated with voglibose are less when compared with acarbose.

Conclusions Reduction of postprandial blood glucose and HbA1C were more in the group treated with acarbose with the difference of 0.2% in HbA1C and 7-8 mg/dL (mean) in postprandial plasma glucose. The side effects were more in the group treated with acarbose when compared with group treated with voglibose.

Suggested reading 1. Gerich JE. Clinical significance, pathogenesis and management of postprandial hyperglycemia. Arch Intern Med 2003;163(11):1306-16.

2. RSSDI Text book of Diabetes. 2nd edition. Management of Type 2 diabetes mellitus. Oral hypoglycemic drugs.

3. Type 2 Diabetes Mellitus, an evidence based approach.

Postpranidial hyperglycemia.

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

841

Amoxicillin Trihydrate â&#x20AC;&#x201C; Enzymatic API

Drug

Tackling Antimicrobial Resistance: Optimizing Use of an Older Antibiotic-Amoxicillin Rajiv Garg

Abstract Antimicrobial resistance has become a major clinical and public health problem today. It not only poses a serious threat to human health and welfare but also undermines national economies worldwide. There are major international efforts to tackle the challenge of antimicrobial resistance. Similarly, being seriously concerned about the high resistance rate in our country, ‘Chennai Declaration’ was an initiative to formulate a national policy to control the rising trend of antimicrobial resistance.

In such a scenario, it is prudent to focus on first-generation antibiotics such as amoxicillin. In this review, we have highlighted the efficacy and usefulness of amoxicillin in clinical practice.

Keywords: Antimicrobial resistance, older antibiotics, antibiotic smart use, amoxicillin, respiratory tract infections

A

fter saving countless lives, antibiotics are in danger of losing their effectiveness.1 The reason is an alarming increase in bacterial resistance that has become a major clinical and public health problem within the lifetime of most people living today. Confronted by increasing amounts of antibiotics over the past 60 years, bacteria have responded to the deluge with the propagation of progeny no longer susceptible to them.2 Antimicrobial resistance not only poses a serious threat to human health and welfare but also undermines national economies worldwide. Every continent and country is facing the menace of antibioticresistant ‘super bugs,’ although the extent and the severity of the problem varies.3 According to a recent study in Thailand, in 2010, antimicrobial resistance was responsible for at least 3.2 million extra hospitalization days and 38,481 deaths, and for losses amounting to US$ 84.6-202.8 million in direct medical costs and more than US$ 1,333 million in indirect costs. Annual losses stemming from antimicrobial resistance are estimated to range from US$ 21,000 to 34,000 million in the United States and about € 1,500 million in Europe.4 In Indian hospitals also, very high gram-negative resistance rates have been reported, with very high prevalence of extended-spectrum beta-lactamases (ESBLs) producers and also high carbapenem resistance rates. Increasing carbapenem resistance invariably results in increased usage of colistin, currently the last-line of defense, with

Senior Medical Specialist and Head Dept. of Medicine, ESI Hospital, Noida, Uttar Pradesh

a potential for colistin-resistant and pandrug-resistant bacterial infections.3 Global Efforts for Tackling AntiMicrobial Resistance There are major international efforts to tackle the challenge of antimicrobial resistance. Antibiotics Smart Use (ASU) was introduced in 2007 as an innovative model to promote the rational use of medicines and counteract antimicrobial resistance.4 The World Alliance against Resistance to antibiotics (WAAR) is an action plan designed by a small group of professionals and by the patient support group LIEN to deal with the current emergency. The scientific committee is composed of 80 international physicians of considerable renown.

The Alliance receives support from 50 learned societies or professional groups in France and throughout the world.1 To cope with this growing problem and the consequent treatment failures, the European Commission has also come up with a comprehensive Action Plan on Antimicrobial Resistance that unveiled 12 concrete actions to be implemented in close cooperation with the Member States.5 Similarly, being seriously concerned about the high resistance rate in our country, a joint meeting of ‘Medical Societies in India’ was organized as a preconference symposium of the 2nd Annual Conference of the Clinical Infectious Disease Society (CIDSCON 2012) at Chennai with a plan to formulate a roadmap to tackle the global challenge of antimicrobial resistance from the Indian perspective. ‘Chennai Declaration’ was an initiative to formulate a national policy to control the rising trend

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Drug of antimicrobial resistance after consultation with all relevant stakeholders and to take all possible measures to implement the strategy.3 The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Antibiotic Policies (ESGAP) performed a review in 2006, which showed that shortages of narrow-spectrum antibacterial drugs forced clinicians to use broadspectrum drugs, adversely influencing the policies of prudent use.6 The reasons for shortages and market withdrawals of older antibiotics are incompletely understood. However, the lack of profit for drugs in limited market areas (small countries) and increasing regulatory requirements and bureaucracy appear to play a role. Several older, potentially useful, sometimes ‘forgotten,’ antibiotics were not available in many countries, either never having been introduced or having but now been withdrawn.6 Appropriate Use of Antibiotics The majority of antibiotics are prescribed in general practice and most prescriptions are attributable to treatment of respiratory tract infections. In many cases of infections, microorganisms are now fully-resistant to commonly used newer generation antibiotics such as ESBL producers, and cephalosporins and carbapenems.

Today, the world is facing a crisis due to antimicrobial resistance emerging as a major concern. In such a scenario, it is prudent to focus on first-generation antibiotics such as amoxicillin. Promoting the rational use of antibiotics among prescribers and the general public are key to combating the unnecessary use of these drugs. We need to take the following steps: ÂÂ

We should try to isolate the causative pathogen whenever a patient comes for treatment, so that we start a specific first-generation antibiotic.

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Sensitivity test should be undertaken to choose the antibiotic that will be most effective against the pathogen isolated.

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Treatment should be started with older firstgeneration antibiotics such as amoxicillin, ampicillin, cloxacillin and cephalexin.

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Antibiotics should be given in proper doses and treatment durations should be kept as short as possible, and when appropriate, antibiotics should be stopped after a careful reappraisal (based on the clinical course and new results from the microbiology laboratory).

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Preference should be given to antibiotics that have limited ecological effects.

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The second- and third-generation antibiotics such as ceftriaxone and oral azithromycin should be used only when treatment with older antibiotics fail.

Older Antibiotics: Amoxicillin in Clinical Practice In an era, where there is a gap between the current worldwide spread of multi-resistant bacteria and the development of new antimicrobial drugs, there is a growing need to optimize the use of older antibiotics to treat infections.6 Amoxicillin is a gold standard antibiotic and a drug of choice in various infections.

In this review, we would highlight the efficacy and usefulness of amoxicillin in clinical practice. It is an humble effort to ignite the reuse of such a wonderful molecule. Moreover, amoxicillin, which was earlier manufactured by chemical processes and was not eco-friendly, is now being produced by unique enzymatic technology and is available as an environmentally friendly antibiotic.

Group A Streptococcal Pharyngitis Group A streptococcal (GAS) pharyngitis is a significant cause of community-associated infections.

Inappropriate antimicrobial use for upper respiratory tract infections, including acute pharyngitis, has been a major contributor to the development of antimicrobial resistance among common pathogens. Based on their narrow-spectrum of activity, infrequency of adverse reactions and modest cost, penicillin or amoxicillin is the recommended drug of choice for those nonallergic to these agents. A 10-day course of an oral cephalosporin is recommended for most penicillinallergic individuals. Narrow-spectrum cephalosporins, such as cefadroxil or cephalexin, are much preferred to broad-spectrum cephalosporins, such as cefuroxime, cefixime, cefdinir and cefpodoxime.7 Although acute rheumatic fever is now uncommon in most developed countries, it continues to be the leading cause of acquired heart disease in children in areas such as India, sub-Saharan Africa and parts of Australia and New Zealand. Even after decades of use, phenoxymethylpenicillin (penicillin V) is first choice because it remains effective against Group A beta-hemolytic streptococci (GABHS). It is the only antibiotic that has been shown to effectively prevent primary and secondary attacks of rheumatic fever. Two or three daily doses are as effective as four daily doses but, when the indication for treatment is to eradicate GABHS for rheumatic fever prevention, a 10-day course is required. It must be taken on an empty

Drug stomach. Amoxicillin at higher doses 500 mg to 1.0 g three times daily is a useful alternative.

Acute Otitis Media Streptococcus pneumoniae and Haemophilus influenzae are usually implicated in bacterial acute otitis media (AOM). Antibiotic use is indicated in the following clinical situations: ÂÂ

Children with systemic symptoms

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Children under 3 years with severe or bilateral AOM

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Children under 6 months.

Amoxicillin is the drug of choice if an antibiotic is to be used. High doses are used to combat nonsusceptible S. pneumoniae. The recommended dose is 15 mg/kg (up to 500 mg) three times a day or 30 mg/kg (up to 1,000 mg) twice-daily for 5 days. Cotrimoxazole and cefaclor are effective alternatives.

Community-Acquired Pneumonia Community-acquired pneumonia (CAP) can be diagnosed clinically when a patient acquires a lower respiratory tract infection in the community and has the following: ÂÂ

New focal chest signs

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Systemic illness such as sweating, aches and pains, or temperature >38°C

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No other explanation for the illness.

People with nonsevere CAP can be given empirical antibiotic treatment at home without the need for microbiological and radiological investigations. It is seen that only a small range of pathogen cause CAP, the commonest being S. pneumoniae. Amoxicillin at higher doses 500 mg to 1.0 g three times daily remains the preferred agent for community-managed CAP.

Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. Patient with exacerbations of COPD with clinical signs of infection (increased

volume and change in color of sputum and/or fever, leukocytosis) benefit from antibiotic therapy.

The patients should have a home supply of antibiotics so that they can initiate treatment themselves because earlier the antibiotics are started, early the better it is.

Amoxicillin 500 mg to 1.0 g three times daily for 7-10 days is appropriate as first-line therapy.

Conclusion In conclusion, we would like to emphasize that it is high time that we start reusing the gold standard amoxicillin as the first-line of treatment before it is too late and there is no pool of antibiotics left for the use of our future generations.

References 1. Carlet J, Rambaud C, Pulcini C; WAAR, International Section of the Alliance Contre le Dévelopement des Bactéries Multi-résistantes (AC-de-BMR). WAAR (World Alliance against Antibiotic Resistance): Safeguarding antibiotics. Antimicrob Resist Infect Control 2012;1(1):25.

2. Levy SB. The 2000 Garrod lecture. Factors impacting on the problem of antibiotic resistance. J Antimicrob Chemother 2002;49(1):25-30.

3. Ghafur A, Mathai D, Muruganathan A, Jayalal JA, Kant R, Chaudhary D, et al. The Chennai Declaration: a roadmap to tackle the challenge of antimicrobial resistance. Indian J Cancer 2013;50(1):71-3.

4. Sumpradit N, Chongtrakul P, Anuwong K, Pumtong S, Kongsomboon K, Butdeemee P, et al. Antibiotics Smart Use: a workable model for promoting the rational use of medicines in Thailand. Bull World Health Organ 2012;90(12):905-13.

5. Available at: http://ec.europa.eu/health/antimicrobial_ resistance/policy/index_en.htm.

6. Pulcini C, Bush K, Craig WA, Frimodt-Møller N, Grayson ML, Mouton JW, et al; ESCMID Study Group for Antibiotic Policies. Forgotten antibiotics: an inventory in Europe, the United States, Canada and Australia. Clin Infect Dis 2012;54(2):268-74.

7. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.

Clin Infect Dis 2012;55(10):1279-82.

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ENT

Pleomorphic Adenoma of the Nose Irfan Iqbal*, Kanwaljeet Singh†, hardeep Singh‡

Abstract Pleomorphic adenoma is the most common benign tumor of the major or minor salivary glands. The incidence in the other parts of the head and neck region is very low and in most of the cases, the lesion is located in the upper aerodigestive tract, namely, the oral and pharyngeal and occasionally, in the nasal cavity. Cases involving regions where minor salivary glands are not normally present are extremely rare. We report a 35-year-old female who presented with progressive swelling at nasal vestibule of 9 months duration. The mass was excised and the histopathological report revealed it to be pleomorphic adenoma.

Keywords: Neoplasm, nose, benign

P

leomorphic adenoma is the most common benign tumor of the salivary gland. It occurs primarily in the major salivary glands. Incidence in the minor salivary glands is very rare and very few reported cases are located in the larynx, pharynx, trachea and lacrimal glands. Primary pleomorphic adenomas located at sites other than aerodigestive tract, for example, external nose, is extremely rare. Although, several intranasal pleomorphic adenomas have been described but this is first reported case to our knowledge arising from nasal vestibule.

and covered by a thinned but intact skin. Swelling was protruding out of nasal vestibule (Fig. 1).

There was no other deformity in major salivary glands or cervical lymphadenopathy.

Case Report A 35-year-old female presented with history of painless and gradual increasing swelling coming from the nasal vestibule of nose for 9 months duration. There was occasional history of nasal obstruction initially that used to get relieved only once the mass used to get dislodged on side either by herself or on forced respiration; but with progressive increase in the size of swelling, there was complete unilateral obstruction and there was no history of bleeding or pain. The patient was more concerned about the deformity caused by swelling. Examination revealed painless, firm and lobulated mass approximately 1.6 × 1.9 cm in size

*Registrar †Consultant, Dept. of ENT HNS Government Medical College, Srinagar, Kashmir ‡Assistant Professor, Dept. of Medicine Government Medical College, Srinagar, Kashmir Address for correspondence Dr Irfan Iqbal Dept. of ENT HNS Government Medical College, Srinagar, Kashmir E-mail: irfaniqbal0809@yahoo.com.in

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Figure 1. Swelling protruding out of nasal vestibule.

Figure 2. Surgical excision of the mass.

ENT Pleomorphic adenoma of the skin in head and neck region may originate from sebaceous glands, sweat glands or ectopic salivary glands. In the present case, the tumor seemed to develop from the sebaceous or sweat glands of the skin of the face.

The treatment of pleomorphic adenoma of the nose like in other location is surgical, which is total removal with a margin of surrounding healthy tissue. In our patient, no local recurrence was observed during 13-month follow-up. Pleomorphic adenoma located in the nose and paranasal sinuses should be considered as potential malignant and treated with radical surgery.

Recurrence may occur as with pleomorphic adenoma of major salivary glands.

Figure 3. Gross appearance of the mass.

Radiologically, there was a mass confined to nasal vestibule without any cartilaginous or bony involvement.

Differential diagnosis confirmed dermoid, chondroma and epidermoid cyst. Surgical excision of the mass was performed under local anesthesia that was removed in toto with intact capsule (Figs. 2 and 3).

Postoperative period was uneventful. Histopathological examination of the mass revealed a pleomorphic adenoma.

Discussion Pleomorphic adenomas are benign, epithelium-derived tumors that have biphasic appearance resulting from a mixture of epithelium and stroma. Pleomorphic adenoma or mixed tumor is the most common neoplasm (50%) involving both the major and minor salivary glands. Approximately 85% of pleomorphic adenoma occur in the parotid gland, 8% in the submandibular salivary gland and 7% in the minor salivary glands.

They can rarely occur at other sites in the upper aerodigestive tract including the nasal cavity, pharynx, larynx, trachea and lacrimal glands. The nasal cavity is the most common site of the involvement of pleomorphic adenoma in the upper respiratory tract.

While pleomorphic adenoma in the skin is rare, it can be seen at various sites in the head and neck region including scalp, eyelid, nose, cheek, upper lip, external ear and external auditory canal.

The risk of malignant transformation of pleomorphic adenoma is time dependent, with a risk of 1.6% for those present for less than 5 years rising to 9.6% for those present for more than 15 years. The risk is increased by delayed diagnosis.

Conclusion In conclusion, it is important to consider pleomorphic adenoma in the presence of a slow-growing unilateral mass of the nose even if not frequently encountered in clinical practice. Early diagnosis offers the possibility of a more complete excision. Long follow-up, both clinically and radiologically, is mandatory to exclude malignancy, even if the tumor is to be clinically benign with complete resection.

Suggested Reading 1. Clauser L, Mandrioli S. Pleomorphic adenoma of the palate. J Craniofac 2004;15:1026-9.

2. Dubey SP, Banerjee S, Ghosh LM, Roy S. Benign pleomorphic adenoma of the larynx: report of a case and review and analysis of 20 additional cases in the literature.

Ear Nose Throat J 1997;76(8):548-50.

3. Okura M, Hiranuma T, Shirasuna K, Matsuya T. Pleomorphic adenoma of sublingual gland: report of a case. J Oral Maxillofac Surg 1996;54(3):363-6.

4. Nishimura S, Murofushi T, Sugasawa M. Pleomorphic adenoma of the auricle. Eur Arch Otorhinolaryngol 1999;256(1):22-4.

5. Cho KJ, el-Naggar AK, Mahanupab P, Luna MA, Batsakis JG. Carcinoma ex-pleomorphic adenoma of the nasal cavity: a report of two cases. J Laryngol Otol 1995;109(7):677-9.

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ENT

Intralesional Sclerotherapy Cures Unusual Presentation of Hemangioma in a Child Bimal Kumar Mandal*, Rina Das†, Jayanta Bain‡

Abstract Hemangiomas are benign tumors made up of blood vessels. They usually regress spontaneously within 9 years of age.

Hemangioma of retropharyngeal space is a rare entity. History, digital palpation, computed tomography (CT) and fine-needle aspiration cytology (FNAC) clinches the diagnosis. We want to report a case of retropharyngeal hemangioma in a 33-month-old female child who presented with respiratory distress. She was diagnosed and treated successfully in our department.

Keywords: Retropharyngeal hemangioma, CT scan, aspiration, sclerotherapy CASE REPORT NK, a 33-month-old Muslim female child from Jharkhand presented in early August 2010 to the local doctor with fever, cough and cold who treated her symptomatically (Fig. 1).

She used to have frequent episodes of upper respiratory tract infection (URTI) until last week of January 2011, when she got first attack of breathing difficulty during sleep. Her parents took her to Dept. of ENT, Ranchi Medical College, where she was admitted and stayed for 2 days. X-ray and computed tomography (CT) scan of nasopharynx revealed a retropharyngeal space occupying lesion (SOL) (Fig. 2) and they referred the case to a higher center.

Subsequently, they came to Dept. of ENT, Calcutta National Medical College and Hospital (CNMCH), Kolkata. Her parents complained of sleepless nights for a fortnight because of the breathing difficulty she felt each time she desired to sleep. Only in prone position she got some relief of the distress, but unknowingly during sleep her posture change to supine and again she felt the distress. On examination, her general condition was poor, her cry sounded a bit hoarse and she was very much apprehensive.

*RMO cum Clinical Tutor Dept. of ENT and Head-Neck Surgery †Demonstrator, Dept. of Microbiology Calcutta National Medical College, Kolkata ‡Senior Resident, Dept. of Surgery, SVB Patel Hospital, New Delhi Address for correspondence Dr Bimal Kumar Mandal 3E, Mansatala Lane, Kidderpore, Kolkata - 700 023, West Bengal E-mail: dr.bmandalrkm@gmail.com

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Figure 1. Photography shows 33-month-old girl admitted in our female ward.

Figure 2. Shows retropharyngeal space occupying lesion.

She was admitted on 22nd February 2011 and planned for examination of the SOL under general anesthesia.

In operation theater (OT), digital palpation was done under general anesthesia. A cystic retropharyngeal mass was diagnosed. About 15 ml of altered blood from the cystic mass was aspirated (Fig. 3).

ENT

Figure 3. Shows aspiration of altered blood from retropharyngeal mass.

Cytologic examination of that fluid showed RBC-5.5 million/dL, WBC-6,400/dL, platelets-1,50,000/mL and no pus cells.

She was kept under observation for 5-6 days and was discharged. In late March 2011, she was readmitted in our department with the same complaints. Digital palpation and aspiration was done under general anesthesia. At this time 10 ml of fluid was aspirated followed by injection of sclerosing agent sodium tetradecyl sulfate (2 ml of the sclerosing agent was mixed with 4 ml of distilled water). She was asked to come for follow-up 2-3 weeks later. For approximately 3 months she did well. On 6th June 2011, again she got admitted but there was mild breathing problem and examination under general anesthesia was done. This time no fluid came out of the aspiration but 2 ml of the same diluted sclerosing agent was injected into the site. Follow-up CT scan of neck was found normal. The patient is under regular follow-up and leading a normal life.

DISCUSSION The retropharyngeal space lies between the buccopharyngeal fascia covering posterior pharyngeal wall anteriorly and cervical vertebra with prevertebral muscles covered by prevertebral fascia posteriorly. This space is divided into two compartments (right and left) by its attachment with the median raphe. Types of retropharyngeal SOL: 1) Congenital (brachial cleft cyst, ectopic thyroid); 2) inflammatory (retropharyngeal abscess and retro-pharyngeal cellulitis); 3) neoplastic (cystic hygroma, neurofibroma, neuroblastoma, hemangioma); 4) traumatic (foreign body, hematoma) and 5) metabolic (hypothyroidism). Of them, the hemangioma is a rare cystic mass in this space, a benign tumor that grows within the blood vessels.

Hemangiomas are the most common childhood tumor. A hemangioma (comes from the Latin words hemangio meaning blood vessel and oma meaning tumor with active cell dividing activity) is a benign

self-involuting tumor of endothelial cells. This tumor is most often found on the head or neck. However, they may occur anywhere on the skin or internal organs. It is usually found at 2-4 months of age. In most cases, hemangioma appears during the first days or weeks of life and resolve at the latest by age 10. Hemangiomas never develop in an adult. There is no reason in this day to accept that the only option available is to ‘leave it alone’ and wait for the hemangioma to ‘go away’ or allow to attaining mega size. Secondly, the most appropriate treatment plan needs to be individualized for each patient and each lesion. Therefore, similar lesions in different patients may be treated differently.1,2 Sclerotherapy is a procedure used to treat blood vessels or blood vessel malformations (vascular malformations) and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink.

It is used for children and young adults with vascular or lymphatic malformations.

In adults, sclerotherapy is often used to treat varicose veins and hemorrhoids. Sclerosant is diluted with blood as it diffuses away from the site of injection, thus if a strong sclerosant is injected there will be three zones of action. In zone 1, vascular endothelium is irreversibly injured: The vessel will be fully sclerosed and eventually will be completely replaced by a fibrous tissue. In zone 2, vascular endothelium is injured, and the vessel will be partially or completely thrombosed but will eventually recanalize. In zone 3, the sclerosant will be diluted below its injurious concentration, and there will be no endothelial injury. Sclerosants are polidocanol, 5% phenol, absolute alcohol, hot water, hypertonic saline and sodium teradecyl sulfate.3 In our case, we unanimously thought that sclerothrapy would be the best treatment option and accordingly we did it.

We used sodium teradecyl sulfate as sclerosant.

Being a detergent-based chemical, its action is on the lipid molecules in the cells of the vein wall, causing destruction of the internal lining of the vein and causing them to shed, leading to thrombosis, fibrosis and obliteration (sclerosis). It is used in concentrations ranging from 0.1 to 3% for this purpose. Until now, the patient is relieved of the distress with this treatment (1 and half years follow-up) and we expect no recurrence in future. There are various types of treatment protocol like sclerotherapy, laser, interferon a2, intralesional corticosteroid therapy3-6 but we used sclerotherapy with successful result without any complication.

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ENT CONCLUSION Hemangioma of retropharyngeal space is a rare entity.

CT scan followed by digital palpation and fine-needle aspiration cytology (FNAC) can clinch the diagnosis in case of retropharyngeal hemangioma presented with respiratory distress. Repeated aspiration of collected fluid and sclerotherapy in hemangioma is a preferable treatment option.

REFERENCES 1. Fishman SJ, Mulliken JB. Hemangiomas and vascular malformations of infancy and childhood. Pediatr Clin North Am 1993;40(6):1177-200.

2. McCook TA, Felman AH. Retropharyngeal masses in infants and young children. Am J Dis Child 1979;133(1): 41-3.

3. Woods JE. Extended use of sodium tetradecyl sulfate in treatment of hemangiomas and other related conditions.

Plast Reconstr Surg 1987;79(4):542-9.

4. Landthaler M, Hohenleutner U, el-Raheem TA. Laser therapy of childhood haemangiomas. Br J Dermatol 1995;133(2):275-81.

5. Gawrych E, Walecka A, Rajewska J, Juszkiewicz P. Intralesional corticosteroid therapy in infantile hemangiomas. Ann Acad Med Stetin 2009;55(1):15-21.

6. Ezekowitz RA, Mulliken JB, Folkman J. Interferon alfa2a therapy for life-threatening hemangiomas of infancy.

N Engl J Med 1992;326(22):1456-63.

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Head, Neck Cancer Survival Better with IMRT Patients with head and neck cancers had significantly better cancer-specific survival when treated with intensitymodulated radiation therapy (IMRT) instead of conventional RT, a review of a large database showed.

Although, this is a retrospective analysis rather than a prospective trial of the two strategies, the results do confirm what has become a generally accepted clinical regimen.

After a median follow-up of 40 months, patients treated with IMRT had a cause-specific survival of 84% compared with 66% for patients treated with other types of RT. Analysis of data by cancer site showed a survival advantage for IMRT in all subgroups.

Multivariable analyses showed that IMRT reduced the survival hazard by 30-40%, Beth M. Beadle, MD, PhD, of the University of Texas MD Anderson Cancer Center, and co-authors reported online in Cancer.

Ear Infections: Treat All Kids All children younger than 2 with acute otitis media diagnosed according to current American Academy of Pediatrics guidelines should receive antibiotics, researchers said.

Among children age 6 months to 2 years with unilateral, nonsevere acute otitis media given amoxicillinclavulanate, treatment failures were seen in 14% compared with failure rates of 40% in those given placebo, for an adjusted relative risk of 0.27 (95% confidence interval [CI] 0.13-0.41), according to Alejandro Hoberman, MD, of the University of Pittsburgh and colleagues.

In contrast, children with bilateral, severe otitis media - those for whom treatment currently is recommended had failure rates of 25% with antimicrobial treatment and 59% with placebo, giving an adjusted relative risk of 0.34 (95% CI 0.18-0.48), Hoberman and colleagues wrote online in a research letter in JAMA Pediatrics.

Tonsil Surgery Not Just for Kids?

Tonsillectomy may be the best option for adults with recurrent, severe sore throat.

Tonsillectomy cut in half the number of patients with any degree of pharyngitis over the subsequent 5 months compared with watchful waiting (39% vs 80%), Timo Koskenkorva, MD, of Finland’s University of Oulu and Oulu University Hospital, and colleagues found.

But the trial failed due to lack of an impact on severe pharyngitis, which was rare without any episodes in the surgery group and just one in the control group over 5 months, the group reported online in CMAJ.

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Gastroenterology

Jejunal Carcinoma – An Unusual Undiagnosed Cause of Anemia: A Case Report Aswini K Pujahari*, CR Praveen†

Abstract A 46-year-old male presented with features of anemia. On evaluation, there was iron deficiency. No source of bleeding could be located by upper and lower gastrointestinal endoscopy. Computed tomography (CT) scan and Mantoux test had evidence of tuberculosis. He deteriorated with antitubercular therapy. He improved only after laparotomy, a diagnostic laparoscopy and resection of the bleeding malignant lesion. It turned out to be jejunal cancer. Seven years after chemotherapy, he is surviving disease free. In undiagnosed iron-deficiency anemia, small bowel growth should be considered and diagnostic laparoscopy should be done to avoid confusion in diagnosis.

Keywords: Anemia, abdominal pain, jejunal cancer

C

ancer of the small bowel is rare and comprises 2.4% of all gastrointestinal (GI) malignancies.1 Due to unusual symptoms, the rarity of the disease and the difficulty in small bowel imaging, a correct diagnosis is often delayed and common diagnosis like tuberculosis is entertained in developing countries. Early case may at times confuse with tubercular lesion and adds to delay.2 A similar case has been reported here.

Case Report A 46-year-old male presented with easy fatigability and abdominal discomfort since 3 months. There was no history of chronic diarrhea or fever. On evaluation, he was found to be having severe iron-deficiency anemia as evidenced by low hemoglobin (5.6 g/dL), low serum iron level 17 µg/dL (normal: 200-300), elevated total iron-binding capacity 489 µg/dL (up to 400) and reduced stored iron in the marrow.

The upper GI endoscopy and colonoscopy were normal. The stool for occult blood was negative.

Computed tomography (CT) scan with oral and

*Professor †Resident Dept. of Surgery Armed Forces Medical College, Pune, Maharashtra Address for correspondence Air Commodore (Dr) Aswini K Pujahari Dept. of Surgery Armed Forces Medical College, Pune - 40, Maharashtra E-mail: akpuja@rediffmail.com

intravenous contrast showed evidence of small bowel thickening. Mantoux test was positive with 12 mm indurations at 72 hours. The chest X-ray was normal.

He was diagnosed as a case of small bowel tuberculosis with occult bleeding and was given antituberculosis therapy (ATT) along with iron supplementation.

He came back without any improvement after 3 months with increasing abdominal pain. He had lost 6 kg of weight over the last 6 months in spite of ATT; he was re-evaluated. Clinically, he had marked pallor and a vague tender mass at the left upper quadrant of the abdomen. On investigation, his hemoglobin was 4.9 g/dL. Other parameters were within normal limits. m99Tc-labeled red blood cell (RBC) scan was negative for any active GI bleed; repeat CT scan of the abdomen demonstrated a 75 × 65 × 30 mm mass lesion with cavitation of the mesentery at small bowel (Fig. 1).

There was no evidence of metastasis of liver or lung.

Other parameters were within normal limit. Hence, a diagnostic laparoscopy was done. After the laparoscopic finding, it was converted to open exploration. A mass at the mesentery opposite to jejunum at 20 cm from the duodenojejunal flexor with inversion of the jejunum toward the mass was found (Fig. 2).

Intraoperatively, it was diagnosed as a case of leiomyoma of the jejunum/mesentery. Resection was done with 10 cm on either side with complete excision of the mesenteric lesion. Bowel continuity was maintained by side-to-side jejujno-jejunostomy. On opening the specimen, the cavity was clear (Fig. 3).

Postoperatively, the patient’s hemoglobin went up to 11.0 g in 3 weeks time with iron therapy. Histological

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Gastroenterology findings reported this as well-differentiated adenocarcinoma (T3N0M0). He was given chemotherapy, oxaliplatin/5-fluorouracil/leucovorin (FOLFOX4) during the 80-month follow-up. He underwent incisional hernia repair after 60 months and is still disease free at 80 month.

Discussion

Figure 1. CT scan of the abdomen demonstrating a 75 Ă&#x2014; 65 Ă&#x2014; 30 mm mass lesion with cavitation of the mesentery at small bowel.

Figure 2. Mass at the mesentery opposite to the jejunum at 20 cm from the duodenojejunal flexor with inversion of the jejunum toward the mass.

Primary adenocarcinoma of the small bowel is rare, in spite of constituting 75% of the entire length of the GI tract. The rarity has been attributed to various factors such as faster transit, alkaline pH, lower bacterial content and higher lymphoid tissue.1 Several genetic and environment factors have been documented to predispose to small bowel carcinoma.

These include Crohnâ&#x20AC;&#x2122;s disease, familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, inflammatory bowel disease and lifestyle parameters (alcohol consumption, smoking, high-fat diet and animal protein diet).3,4 In one retrospective study of 197 patients with small bowel adenocarcinoma, the highest was noted at duodenum 55%, followed by the jejunum in 30% and the ileum in 15%.5 Anemia is one of the commonest presentation seen in 35% of cases6 like the present case. Even though small bowel endoscopy is ideal,7 its nonavailability is the problem. Imaging studies like enteroclysis and CT are the mainstay.8 At times it is confusing, like the present case, that may lead to the delay in the diagnosis.

Fecal occult blood test and the Tc RBC scan were even negative.

The severe anemia, with low serum iron, forced us to do a diagnostic laparoscopy and the diagnosis was suspected. Even though laparoscopic diagnosis is reported,9 laparotomy was the commonest mode of final diagnosis7 like in our case.10 Complete surgical resection remains the only potentially curative treatment for nonmetastatic tumors. The main prognosis factor is the involvement of the lymph nodes.1,10 Adjuvant chemotherapy has a response rate of 36% with improved survival in a retrospective study.11 Our case received six cycles of (FOLFOX4), and long survival can be attributed to this besides other histological factors.12 Conclusion

Figure 3. Opened specimen showing the cavity.

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Anemia is one of the commonest presentation seen in 35% of cases of cancer of small bowel. Therefore, in patients with undiagnosed iron-deficiency anemia, small bowel growth should be considered.

Gastroenterology References 1. Zaanan A, Afchain P, Carrere N, Aparicio T. Small bowel adenocarcinoma. Gastroenterol Clin Biol 2010;34(6-7): 371-9.

2. Sood GK, Chaudhary A, Kumar N, Jain SK, Broor SL. Small bowel adenocarcinoma mimicking tubercular stricture. Role of enteroscopy in early diagnosis. J Assoc Physicians India 1991;39(3):284-5.

3. Talamonti MS, Goetz LH, Rao S, Joehl RJ. Primary cancers of the small bowel: analysis of prognostic factors and results of surgical management. Arch Surg 2002;137(5):564-70; discussion 570-1.

4. Agostini M, Tibiletti MG, Lucci-Cordisco E, Chiaravalli A, Morreau H, Furlan D, et al. Two PMS2 mutations in a Turcot syndrome family with small bowel cancers. Am J Gastroenterol 2005;100(8):1886-91.

5. Chang HK, Yu E, Kim J, Bae YK, Jang KT, Jung ES, et al; Korean Small Intestinal Cancer Study Group. Adenocarcinoma of the small intestine: a multi-institutional study of 197 surgically resected cases. Hum Pathol 2010;41(8):1087-96.

6. Yang YS, Huang QY, Wang WF, Sun G, Peng LH. Primary jejunoileal neoplasmas: a review of 60 cases. World J Gastroenterol 2003;9(4):862-4.

7. Nabeshima K, Machimura T, Wasada M, Takayasu H, Ogoshi K, Makuuchi H. A case of primary jejunal cancer diagnosed by preoperative small intestinal endoscopy. Tokai J Exp Clin Med 2008;33(1):42-5.

8. Horton KM, Fishman EK. Multidetector-row computed tomography and 3-dimensional computed tomography imaging of small bowel neoplasms: current concept in diagnosis. J Comput Assist Tomogr 2004;28(1):106-16.

9. Soeda J, Sekka T, Hasegawa S, Ishizu K, Ito E, Saguti T, et al.

A case of primary small intestinal cancer diagnosed by laparoscopy. Tokai J Exp Clin Med 2004;29(4):159-62.

10. Ito H, Perez A, Brooks DC, Osteen RT, Zinner MJ, Moore FD Jr, et al. Surgical treatment of small bowel cancer: a 20-year single institution experience. J Gastrointest Surg 2003;7(7):925-30.

11. Fishman PN, Pond GR, Moore MJ, Oza A, Burkes RL, Siu LL, et al. Natural history and chemotherapy effectiveness for advanced adenocarcinoma of the small bowel: a retrospective review of 113 cases. Am J Clin Oncol 2006;29(3):225-31.

12. Chen CW, Wang WM, Su YC, Wu JY, Hsieh JS, Wang JY. Oxaliplatin/5-fluorouracil/leucovorin (FOLFOX4) regimen as an adjuvant chemotherapy in the treatment of advanced jejunal adenocarcinoma: a report of 2 cases. Med Princ Pract 2008;17(6):496-9.

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Cinnamon in Nonalcoholic Fatty Liver Disease Cinnamon (dalchini) helps improve lipid profiles and improve nonalcoholic fatty liver disease (NAFLD), according to a new Iranian trial reports Medscape. The report found that 12 weeks consumption of 1.5 g cinnamon/day plus a balanced diet improves insulin resistance and NAFLD characteristics. The study by Dr Azita Hekmatdoost is published online December 9 in the journal Nutrition Research.

Cinnamon has antioxidant and insulin-sensitizer properties.

In the study, 50 patients were randomized to two 750 mg capsules of cinnamon or placebo daily for 12 weeks.

All patients were given advice on a balanced diet and physical activity. In both groups, low-density lipoprotein (LDL) cholesterol dropped significantly but there was no significant change in serum high-density lipoprotein (HDL) cholesterol levels. After 12 weeks, LDL levels were 55.8 mg/dL in the treatment group and 90.3 mg/dL in the placebo group (p = 0.032).

In the active treatment group there were also significant decreases in the Homeostatic Model Assessment (HOMA) index, fasting blood glucose, total cholesterol, triglyceride, serum glutamic-oxaloacetic transaminase (SGOT) and serum glutamic-pyruvic transaminase (SGPT) levels. This was also true of γ-glutamyl transferase (GT) and high-sensitive C-reactive protein (CRP).

Polyp and adenoma detection rates were highest when the colonoscopy withdrawal time was 9 minutes long, near the upper limit of the recommended 6-10 minutes withdrawal time in a study in the American Journal of Gastroenterology. For each minute of normal withdrawal time above 6 minutes, incident rate ratios for detection of adenomas or clinically significant serrated polyps increased by 50% and 77%, respectively, with a leveling benefit at 9 minutes.

The US Food and Drug Administration (FDA) has approved diclofenac sodium topical solution 2% w/w (Pennsaid 2%) for knee pain caused by osteoarthritis (OA). Pennsaid 2% is supplied in a metered dose pump bottle and has been approved for twice-daily dosing. It is contraindicated in patients with a known hypersensitivity to diclofenac sodium or any other component of Pennsaid and in patients who have experienced asthma, urticaria, or allergic-type reactions after taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).

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An Unusual Association of Aplasia Cutis Congenita with Twin Pregnancy and Maternal Varicella R Gupta*, Mukesh kumar Gupta†, M Kakkar*

Abstract We report an unusual case of aplasia cutis congenita associated with twin pregnancy and history of maternal varicella in first trimester, occurring over the extremity of one of the twins while other twin was perfectly normal.

Keywords: Aplasia cutis congenita, fetus papyraceous, maternal varicella

A

plasia cutis congenital (ACC) is part of a heterogeneous group of disorders first reported by Cordon in 1767 and is characterized by the absence of a portion of skin at birth.1 Majority of the cases present as a solitary lesion on the scalp. It has also been reported in a twin pregnancy where it occurs in the surviving twin, the other twin being fetus papyraceous.1-3 However, ACC has not been reported in a twin pregnancy with survival of both the twins.4,5 Here, we report a rare case of ACC occurring over the extremity of one of the twins while the other twin was clinically normal.

Case Report Index case was male baby, product of monozygotic twin (monoamniotic, monochorionic placenta and identical) pregnancy, born to a primigravida mother delivered by normal delivery at 36 weeks of gestation weighing 2.62 kg at birth. Mother had suffered from chickenpox at 8 weeks of gestation lasting for 10 days.

Antenatal period was normal otherwise and there was no history of teratogenic drug intake, consanguinity or similar lesions in the family.

On examination, the baby had absence of skin (6 × 3 cm) over the right thigh extending from groin to knee (Fig. 1).

The margins of the lesion were well-defined with some

*Associate Professor †Assistant Professor Dept. of Pediatrics, Mahatma Gandhi Medical College and Hospital Sitapura Institutional Area, Jaipur, Rajasthan Address for correspondence Dr Mukesh Kumar Gupta 61/226, Pratap Nagar, RHB, Sanganer Jaipur, Rajasthan 302 022 E-mail: drmukeshgupta.pediatrics@gmail.com, mukesh_dhonkaria@yahoo.co.in

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Figure 1. Baby showing absence of skin (6 x 3 cm) over the right thigh extending from groin to knee.

fibrosis and epithelialization and the base was clean, glistening red, with visible capillaries covered with a thin transparent membrane. There were no other abnormalities on physical examination. Second twin was clinically normal weighing 2.53 kg and was handed over to the mother soon after birth.

Lesion was managed with application of emollients and silver sulfadiazine ointment and it was left open without any dressing. It started healing with epithelialization starting at the edges by Day 5 of birth.

It healed completely within 2 weeks and at followup after 4 months, the overlying skin was normal without any contractures. The baby was found to be developmentally normal at 1 year of age when we followed him last.

Discussion ACC most commonly manifests as a solitary defect on the scalp vertex just lateral to the midline, but

Obstetrics and Gynecology sometimes it may occur as multiple lesions and symmetrically. The exact incidence of the ACC is not known due to underreporting of the condition. The lesions are noninflammatory and well-demarcated, and they range in size from 0.5 to 10 cm. They may be superficial involving only epidermis and the upper dermis, resulting in minimal alopecic scarring, or the defect may extend to the deep dermis, the subcutaneous tissue, or rarely the periosteum, the skull, and the dura. Prognosis is usually excellent; they heal with epithelialization and leave an atrophic scar. Complications are usually due to the associated abnormalities.1-5 Frienden has classified ACC into nine groups based on the etiology and associated anomalies.

defect through ischemic and thrombotic events.

The intrauterine death of one of the fetuses should cause the release of the thrombosis promoting material from the dead fetus. These substances can cause placental infarction, disseminated intravascular coagulation, and cutaneous lesions.6-8 Twin pregnancy in our case was not associated with fetus papyraceous; other twin was absolutely normal and there was no evidence of placental infarcts on gross examination.

The defect was unilateral on right thigh rather than being bilateral or over the scalp.

ACC in Group 8 has been reported with primary varicella zoster infection in the mother during the first trimester of pregnancy and associated features are mental retardation, chorioretinitis and limb hypoplasia.

In our case, there was history of maternal varicella occurring at 8 weeks of gestation; but there were no other features suggesting varicella as underlying cause of ACC. Thus, index case is unique having association with maternal varicella infection as well as twin pregnancy but this association is probably coincidental rather than being causative.

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Group 1: ACC of scalp without multiple anomalies.

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Group 2: ACC of scalp with limb anomalies.

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Group 3: ACC of scalp with epidermal and sebaceous nevi.

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Group 4: ACC overlying deeper embryonic malformations, for example, spinal dysraphism, porencephaly and others.

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Group 5: ACC associated with twin pregnancy and fetus papyraceous.

References

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Group 6: ACC associated with epidermolysis bullosa.

1. Crowe MA. Aplasia Cutis Congenita. Available at: http:// emedicine.medscape.com/article/1110134-overview

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Group 7: ACC of the extremities without epidermolysis bullosa.

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Group 8: ACC associated with teratogens and intrauterine infections, for example, methemizole, herpes simplex virus and varicella zoster virus.

The lesions in this group are usually at the scalp.

2. Kruk-Jeromin J, Janik J, Rykala J. Aplasia cutis congenita of the scalp. Report of 16 cases. Dermatol Surg 1998;24(5):549-53.

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Group 9: ACC associated with malformation syndromes, for example, trisomy 13, JohansonBlizzard syndrome and others.

ACC in Group 5 results in death of one of the twin during the first or second trimester. The surviving twin usually remains normal except ACC of scalp. Affected patients show linear areas of absence of skin that have bilateral pattern of distribution along the flanks and the lateral aspect of the limbs.6-8 The cause of the symmetrical ACC is vascular disruption inducing abnormal dermoepidermal development and cutaneous

3. Evers ME, Steijlen PM, Hamel BC. Aplasia cutis congenita and associated disorders: an update. Clin Genet 1995;47(6):295-301.

4. Shirvany TE, Zahedpasha Y, Lookzadeh D. Aplasia cutis congenita: a case report. Iran J Pediatr 2009;19(2):185-8.

5. Frieden IJ. Aplasia cutis congenita: a clinical review and proposal for classification. J Am Acad Dermatol 1986;14(4):646-60.

6. Maccario S, Fasolato V, Brunelli A, Martinelli S. Aplasia cutis congenita: an association with vanishing twin syndrome. Eur J Dermatol 2009;19(4):372-4.

7. Classen DA. Aplasia cutis congenital associated with fetus papyraceous. Cutis 1999;64(2):104-6.

8. Mannino FL, Jones KL, Benirschke K. Congenital skin defects and fetus papyraceous. J Pediatr 1977;91(4):559-64.

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Obstetrics and Gynecology

Multiple Fibroids in a Case of MRKH Syndrome with Absent Uterus: Recommendations for Management Shalini Mahana Valecha*, Prajakta Katdare†, Uday Kargar†, Prajakta Shende‡

Abstract Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare congenital anomaly characterized by aplasia or hypoplasia of uterus and vagina in women with normal development of secondary sex characteristics. It affects one in 4,000-5,000 female births. Women with this syndrome present in their teens with primary amenorrhea. MRKH syndrome may be associated with renal, skeletal, cardiac and auditory anomalies. Although, very rare women with MRKH syndrome may develop leiomyomas from a rudimentary uterus. Initial investigation in women having MRKH syndrome with leiomyoma is ultrasonography (USG).

However, magnetic resonance imaging (MRI) is more accurate for diagnosis. Complete removal of the masses with the uterine remnant is recommended.

Keywords: MRKH syndrome, leiomyoma, MRI, laparotomy

M

ayer-Rokitansky-Küster-Hauser (MRKH) syndrome or mullerian agenesis syndrome is a rare congenital anomaly characterized by aplasia or hypoplasia of uterus and vagina in women with normal development of secondary sex characteristics and normal 46 XX karyotype.1 It affects one in 4,500 female births.2 Women with this syndrome present with primary amenorrhea early in life.

Association of pelvic mass with mullerian agenesis can pose a diagnostic dilemma. The uterine remnant, even though rudimentary and either absent or grossly underdeveloped, retains its potential to form tumors.

Notably, if MRKH is rare, masses in this scenario are a rarest of rare association.3 Since adnexa are normal, masses originating from them are other possibilities.4 The initial investigation is usually ultrasonography (USG), although computed tomography (CT) and magnetic resonance imaging (MRI) are more accurate in diagnosis.

*Professor †Senior Resident ‡Assistant Professor Dept. of Obstetrics and Gynecology of Employees State Insurance Postgraduate Institute of Medical Sciences and Research and Model Hospital Mumbai, Maharashtra Address for correspondence Dr Shalini Mahana Valecha 606, Panchleela, Near SM Shetty School, Powai, Mumbai - 400 072, Maharashtra E-mail: shalini.mahana@gmail.com

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Case Report Mrs XYZ, 35 years, presented with complaints of abdominal distension, urinary urgency, ‘big ball moving around in stomach’ and pain in the lower abdomen for 6 months. Patient had never menstruated. Interestingly, she was married and enjoyed an active sex life.

She was of average height and weight with welldeveloped secondary sex characters. A freely mobile, irregular, firm, nontender mass, roughly 6 × 6 cm in size lying on the left psoas muscle was palpated. Such was its mobility that on subsequent examination it had disappeared in the pouch of douglas. External genitalia were normal with a blind vaginal pouch of 4 cm length and absent cervix. On bimanual examination, a hypermobile, firm, globular mass approximately 6 × 6 cm was felt sitting in the midpelvis, with two smaller masses of few centimeters on the other side. Uterus was not felt as a separate structure.

Rectal examination confirmed absence of uterus.

Except for raised follicle-stimulating hormone (34.64 mIU/mL), hormone profile was unremarkable.

USG abdomen/pelvis showed a hypoplastic uterus with multiple subserosal pedunculated fibroids, largest 6 × 5 cm. Both ovaries were normal. Of note was the fact that urogenital system was normal.

MRI revealed absent uterus, atretic structure in the region of cervix and the upper part of vagina. Lower vagina ended in a blind pouch. Multiple hypointense masses were seen of 7 × 7 cm at the site of the missing uterus. Also there was a soft tissue mass in right adnexa

Obstetrics and Gynecology

F I B R O I D S

Uterine Band Blind Vaginal Pouch

Figure 1. MRI showing multiple fibroids with rudimentary uterine band and blind vaginal pouch.

Ovaries

Fibroids Uterine Band

Fibroids

Figure 2. In situ findings during laparotomy showing multiple masses (fibroids), rudimentary uterine band and both ovaries.

with preserved zonal anatomy of uterus suggestive of right uterine remnant. Both ovaries were unremarkable and there were no renal anomalies (Fig. 1).

On the basis of USG and MRI findings, a provisional diagnosis of multiple leiomyomas with MRKH syndrome was made. Chromosomal study of the patient revealed a normal karyotype of 46 XX. Laparotomy revealed a mere band, where the uterus should have been. A large fibroid of 6 Ă&#x2014; 6 cm was seen arising from the left horn. Also the right horn showed multiple fibroids. Left ovary showed a hemorrhagic cyst and the right ovary was normal (Fig. 2). All the myomas, uterine remnant and left-side tube and ovary were removed. The normal right adnexa was retained considering her young age. She recovered uneventfully.

Uterine horns on cut section were noncommunicating.

Endometrial lining was compressed. The leiomyomas did not show features of degeneration. Histology revealed typical features of leiomyoma with hypoplastic uterus. Sections from left ovary showed hemorrhagic corpus luteal cyst. Left fallopian tube was normal and cervix could not be identified.

Discussion MRKH syndrome is a rare disorder described as aplasia or hypoplasia of uterus and upper two-third of vagina due to early arrest in development of mullerian duct. Women with this syndrome have normal 46 XX karyotype, normal female secondary sex characters, normal ovarian functions and underdeveloped vagina.1 In addition, women with MRKH syndrome may have renal, skeletal, hearing and cardiac anomalies.

The incidence of MRKH syndrome has been estimated as one in 4,500 female births.2 Leiomyomas in the rudimentary uteri of MRKH patients are exceedingly rare and only few cases have been reported.3 MRKH syndrome can be of two types depending on the extent of uterine hypoplasia, type 1 being completely absent as was the case in this patient.5,6 Leiomyomas of uterus are estrogen-dependent tumors.

Although, mullerian ducts are primarily endodermal in origin, some smooth muscle cells exist at their proximal ends. These may be where leiomyomas arise from.

However, the exact etiopathogenesis of leiomyoma from the rudimentary uterus in MRKH syndrome is not known.

The usual symptoms are primary amenorrhea, infertility and pain, accompanied by large mobile mass that, most of the times, are ovarian in origin. Uterine masses are unexpected and rarely thought of USG followed by MRI helps to delineate the masses as well as evaluate the urogenital system.

MRI allows an accurate evaluation of the uterine aplasia, as well as a clear visualization of the rudimentary horns and ovaries.7 MRI has nearly 100% accuracy in diagnosis of mullerian duct anomalies because of its excellent soft tissue resolution.8 Diagnostic laparoscopy is the gold standard for definitive diagnosis of MRKH syndrome.9 Differential diagnosis of leiomyoma of rudimentary uterus in MRKH syndrome includes ovarian fibroma, gastrointestinal stromal tumor of intestine and extravesical leiomyoma of urinary bladder.10 Management Extreme anxiety and psychological distress accompany this rare condition making counseling advisable.11

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Obstetrics and Gynecology Treatment for patients of MRKH syndrome with leiomyomas is removal of the fibroids with removal of adjacent uterine remnant.12 While no reports of leiomyosarcoma in fibroid associated with MRKH have been reported in the literature, it can well be construed that like other myomas these can also turn malignant, further making removal of the fibroid associated with absent uterus imperative.

Conclusion In summary, we recommend the following guidelines for management of MRKH patients: ÂÂ

Any associated masses should be thoroughly evaluated keeping fibroid as a remote but possible differential.

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MRI is an investigation of choice.

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Complete removal of all masses is recommended.

References 1. Morcel K, Guerrier D, Watrin T, Pellerin I, Levêque J. The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: clinical description and genetics. J Gynecol Obstet Biol Reprod (Paris) 2008;37(6):539-46.

2. Folch M, Pigem I, Konje JC. Müllerian agenesis: etiology, diagnosis, and management. Obstet Gynecol Surv 2000;55(10):644-9.

3. Deligeoroglou E, Kontoravdis A, Makrakis E, Christopoulos P, Kountouris A, Creatsas G. Development of leiomyomas on the uterine remnants of two women with Mayer-Rokitansky-Küster-Hauser syndrome. Fertil Steril 2004;81(5):1385-7.

4. Silva GRC, Wickramasinghe WUS, Gange VP. MayerRokitansky-Kuster-Hauser syndrome associated with serous papillary cystadenocarcinoma of the ovary. Sri Lanka J Obstet Gynaecol 2010;32(4):91-2.

5. Jones KL. Rokitansky sequence. In: Smith’s Recognizable Patterns of Human Malformations. 4th edition, Saunders WB (Ed.), Saunders: Philadelphia 1988:p.570-1.

6. Strübbe EH, Willemsen WN, Lemmens JA, Thijn CJ, Rolland R. Mayer-Rokitansky-Küster-Hauser syndrome: distinction between two forms based on excretory urographic, sonographic, and laparoscopic findings. AJR Am J Roentgenol 1993;160(2):331-4.

7. Maubon A, Ferru JM, Courtieu C, Mares P, Rouanet JP. Gynecological malformations. Classification and contribution of different imaging methods. J Radiol 1996;77(7):465-75.

8. Mueller GC, Hussain HK, Smith YR, Quint EH, Carlos RC, Johnson TD, et al. Müllerian duct anomalies: comparison of MRI diagnosis and clinical diagnosis. AJR Am J Roentgenol 2007;189(6):1294-302.

9. Fiaschetti V, Taglieri A, Gisone V, Coco I, Simonetti G. Mayer-Rokitansky-Kuster-Hauser syndrome diagnosed by magnetic resonance imaging. Role of imaging to identify and evaluate the uncommon variation in development of the female genital tract. J Radiol Case Rep 2012;6(4):17-24.

10. Rawat KS, Buxi T, Yadav A, Ghuman SS, Dhawan S. Large leiomyoma in a woman with Mayer-Rokitansky-KusterHauser syndrome. J Radiol Case Rep 2013;7(3):39-46.

11. Weijenborg PT, ter Kuile MM. The effect of a group programme on women with the Mayer-Rokitansky-KusterHauser syndrome. Br J Obstet Gynecol 2000;107:365-8.

12. Powell B, Cunnane MF, Dunn LK, Corson SL. Leiomyoma uteri in a rudimentary uterine horn in a woman with the Rokitansky-Kuster-Hauser syndrome. A case report.

J Reprod Med 1988;33(5):493-4.

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Tobacco, Drug Use in Pregnancy can Double Risk of Stillbirth Smoking tobacco or marijuana, taking prescription painkillers or using illegal drugs during pregnancy is associated with double or even triple the risk of stillbirth, according to research funded by the National Institutes of Health.

Researchers based their findings on measurements of the chemical byproducts of nicotine in maternal blood samples; and cannabis, prescription painkillers and other drugs in umbilical cords. Taking direct measurements provided more precise information than did previous studies of stillbirth and substance use that relied only on women’s self-reporting. The study findings appear in the journal Obstetrics and Gynecology.

“Smoking is a known risk factor for stillbirth, but this analysis gives us a much clearer picture of the risks than before,” said senior author Uma M. Reddy, M.D., MPH, of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the NIH institute that supported the study. “Additionally, results from the latest findings also showed that likely exposure to second-hand smoke can elevate the risk of stillbirth.” Stillbirth occurs when a fetus dies at or after 20 weeks of gestation.

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Obstetrics and Gynecology

Evaluation of Mifepristone and Misoprostol for Medical Termination of Pregnancy Between 13-20 Weeks of Gestation Neha Agarwal*, Gauri Gandhi†, Swaraj Batra‡, Rachna Sharma#

Abstract Aim: To assess the efficacy, safety and acceptability of mifepristone followed by vaginal misoprostol for medical termination of pregnancy (MTP) between 13-20 weeks of gestation. Material and methods: Forty women who fulfilled the criteria of MTP Act of India, were given 200 mg oral mifepristone, followed after 36-48 hours by 800 µg vaginal misoprostol and subsequently 400 µg vaginal misoprostol 3-hourly (maximum 2,400 µg). Success was taken as complete expulsion of fetus and placenta within 15 hours of first dose of misoprostol. Results: Success rate of complete abortion was 92.5%, which increased to 95% at 24 hours and successful expulsion of fetus was seen in 100% cases within 24 hours of first dose of misoprostol. Median induction-abortion interval was 6 hours. There were no major side effects. Nulliparous women took significantly longer time to abortion and required more analgesia than multiparous women. Conclusion: Mifepristone followed by vaginal misoprostol is a safe, effective and acceptable method for second trimester termination of pregnancy.

Keywords: Mifepristone, misoprostol, second trimester termination of pregnancy

M

id-trimester (13-20 weeks) abortion constitutes 10-15% of all induced abortions.1 There has been a gradual increase in second trimester termination of pregnancies because of the widespread introduction of prenatal screening programs, which detect serious fetal anomalies. The Medical Termination of Pregnancy (MTP) Act of India (1971) provides for the termination of certain pregnancies up to 20 weeks of gestation, by a registered medical practitioner, provided all the prerequisites are fulfilled. The medical methods for mid-trimester abortion, especially prostaglandins, have become increasingly popular as they avoid the risks of surgical methods. When prostaglandin E1 analogs gemeprost or misoprostol are used alone for second trimester MTP, the mean induction-abortion interval (IAI) can be as long as 12-16 hours.2,3 Pretreatment with mifepristone, an antiprogesterone, prior to prostaglandin administration, reduces the IAI,

*Ex-Resident †Director Professor ‡Director Professor and Ex-Head #Senior Specialist Dept. of Obstetrics and Gynecology, Maulana Azad Medical College, New Delhi Address for correspondence Dr Neha Agarwal F-56, Professor Colony, Kamla Nagar, Agra, Uttar Pradesh E-mail: its_my_ishtyle@yahoo.com

the total dose of prostaglandins required as well as the analgesia requirement.3,4 The combination of mifepristone followed by misoprostol has been found safe and effective for first trimester termination of pregnancy. In the last decade, this combination has been studied for second trimester MTP.3-8 Among the various routes of misoprostol, vaginal route has better systemic bioavailability, is more sustained and has lower side effects than oral route.9 The ideal dose schedule of this combination is still being investigated.

Aim To assess the efficacy, acceptability and side effects of this combination of mifepristone and vaginal misoprostol for MTPs between 13-20 weeks of gestation.

MATERIAL AND METHODS Forty women presenting to the Family Planning Clinic, seeking MTP between 13 to 20 weeks of gestation and fulfilling the prerequisites specified in the MTP Act were included in this prospective clinical study after proper informed consent. The exclusion criteria were anemia (hemoglobin <9 g/dL), multiple pregnancy, previous cesarean section or previous surgery on uterus or cervix, history of coagulation disorder, anticoagulant and

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Obstetrics and Gynecology corticosteroid therapy, history of thromboembolism, cardiac disease or severe hypertension and allergy to misoprostol or mifepristone. Ethical approval was taken from the Institutional Ethical Committee.

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All women were given 200 mg mifepristone, to be swallowed under supervision. They were allowed to go home and were admitted to the hospital after 36-48 hours, when 800 µg misoprostol was inserted in the posterior vaginal fornix. This was followed by 3-hourly vaginal insertion of 400 µg misoprostol till the woman aborted or for a maximum of four doses of 400 µg (total 5). Maximum misoprostol inserted if required was 2,400 µg. The women were given sterile vulval pads weighed previously and were told to save all pads and any expelled products. The time of onset of expulsion of fetus and placenta was noted. Any side effects observed were recorded. After abortion, the placenta was checked for its completeness. Blood loss was estimated by weighing the soaked pads and subtracting the original weight of the pads used, plus the estimated additional blood loss during abortion.

The hemoglobin and hematocrit levels were repeated the next day. All the women aborted within 24 hours.

Follow-up was done after 15 days when duration of bleeding, any side effects observed and acceptability of the regimen were noted.

Secondary outcome measures were amount of blood loss, duration of bleeding, fall in hemoglobin and hematocrit levels, side effects and acceptability of this regimen.

Statistical Analysis All continuous efficacy parameters were presented as mean ± standard deviation and median (range) and were analyzed using the independent t-test or nonparametric Mann-Whitney U-test. The Chi-square and Fisher’s exact test were used as appropriate for independent nominal data. Statistical significance was taken at p ≤ 0.05.

OBSERVATION AND RESULTS The mean age of women included in the study was 29.9 years and the mean parity was 3.2. The mean period of gestation was 15.9 weeks. The women were distributed in two equal groups according to their gestational age; Group A with gestational age 13-16 weeks and Group B with gestational age 16.1-20 weeks. Both these groups were similar with respect to baseline characteristics (Table 1).

Success rate (complete abortion within 15 hours of first dose of misoprostol) of the study was 92.5%.

The primary outcome measures were: ÂÂ

Induction-abortion interval (IAI), calculated from the time of administration of first dose of misoprostol to complete expulsion of fetus and placenta.

Success rate, defined as complete abortion occurring with a maximum of total 5 doses of misoprostol, i.e., within 15 hours of first dose.

Table 1. Outcome Measures in Relation to Period of Gestation Total (n = 40)

Group A (13-16 weeks) (n = 20)

Group B (16.1-20 weeks) (n = 20)

P value between Group A and B

Mean age (years)

29.9

30.4

29.5

0.546

Mean parity

3.2

3.4

3.1

0.613

92.5%

95%

90%

0.548

5%

5%

5%

-

6.0 hours

5.0 hours

6.9 hours

0.106

2.5

2.1

2.9

0.054

186.5 ml

199.8 ml

173.3 ml

0.198

Fall in hemogram (gm%)

0.72

0.74

0.71

0.989

Fall in hematocrit (%)

2.7

2.9

2.5

0.473

Duration of bleeding (days)

8.6

7.9

9.3

0.099

Success rate (complete abortion in 15 hours) Surgical intervention Median IAI Mean no. of doses of misoprostol Blood loss

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Obstetrics and Gynecology Table 2. Cumulative Rate of Complete Abortion and Fetal Expulsion According to IAI IAI (hours)

Complete abortion

Fetal expulsion

No. (n = 38)

%

Cumulative (%)

No. (n = 40)

%

Cumulative (%)

0-3

5

12.5

12.5

5

12.5

12.5

3-6

18

45

57.5

18

45

57.5

6-9

8

20

77.5

8

20

77.5

9-12

6

15

92.5

6

15

92.5

12-15

0

0

92.5

1

2.5

95

15-24

1

2.5

95

2

5

100

Total

38

95

40

100

Effect of Nulliparity The study included two nulliparous women at 18 weeks and 19.4 weeks gestation with ultrasound diagnosis of congenital anomalies in the fetus.

They took significantly longer time to abort, with a median IAI of 15.17 hours compared to 5.75 hours by multiparous women (p = 0.030) and required significantly higher number of doses of misoprostol (4.50 vs 2.38; p = 0.004) as well as more analgesia.

None of the two nulliparous women required surgical evacuation, which is a big advantage because chances of infection are minimized if there is no surgical intervention (Fig. 1).

15.17

31.50% 100%

Median of IAI

5.30% 0%

Mean Mean no. gestational of doses of age (weeks) misoprostol

5.75

2.38 4.5

20 18 16 14 12 10 8 6 4 2 0

Nulliparous women (n = 2)

94.70% 50%

The median IAI of the study was 6.0 hours. Most women (67.5%) required 2 or 3 doses (1,200 or 1,600 Âľg) of misoprostol. One woman aborted with only mifepristone, prior to administration of misoprostol. The mean blood loss was 186.5 ml and none of the women required blood transfusion.

The mean fall in hemoglobin and hematocrit was 0.72 gm% and 2.7%. The mean duration of bleeding was 8.6 days. There was no statistically significant effect of gestational age on any outcome (Table 1). The regimen was acceptable to all the women in the study.

Multiparous women (n = 38) 15.75 18.72

In Group A, success rate was 95%. One woman was considered as failure because she required surgical evacuation of retained placental bits, although the fetus aborted within 15 hours. In Group B, success rate was 90%. Two cases were considered as failure because they aborted later at 18.5 and 19.8 hours. One of these also needed surgical evacuation. The total success rate for complete abortion increased to 95% at 24 hours and successful expulsion of fetus was in 100% cases within 24 hours of first dose of misoprostol (Table 2).

Success rate

Surgical evacuation

Analgesia requirement

Figure 1. Outcome in relation to parity.

Side Effects There were no major side effects. Pain was an unavoidable component of natural abortion process.

Most women had mild pain not requiring any analgesia.

About 25% women had moderate pain, which settled with oral analgesics and 10% had severe pain requiring injectable analgesia. Fever (25%), headache (7.5%) and vomiting (5%) were the other side effects seen, but they were temporary and subsided as the effect of misoprostol weaned off.

DISCUSSION Several dose schedules of the combination of mifepristone and misoprostol have been studied for second trimester termination of pregnancy. The present study was compared with other studies using a similar protocol of 200 mg mifepristone with minor variations in routes of misoprostol.

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Obstetrics and Gynecology Gupta et al5 gave the second dose of misoprostol vaginally or sublingually after 4-6 hours of first dose.

The success rate was 91.42% at 15 hours, which is very close to our success rate of 92.5%.

Ashok et al3 used vaginal route for the first dose and oral for subsequent doses of misoprostol. Success rate, taken as expulsion of fetus with or without placenta within 15 hours, was 97.1%, which remained the same at 24 hours. Taking the same criteria, our success rate would be 95% at 15 hours and 100% at 24 hours.

Bartley et al8 used similar routes of misoprostol as Ashok et al.3 About 94% women aborted the fetus within 24 hours versus 100% in the present study. Thus, there is a slightly higher success rate at 24 hours if all the doses of misoprostol are given vaginally. Hamoda et al6 and Goh et al7 used the same protocol as the present study and got a similar fetus expulsion rate of 100% and 97.9% at 24 hours respectively. In the present study, on increasing the period of observation to 24 hours, complete expulsion is increased from 92.5 to 95% and expulsion of fetus with or without placenta is seen in 100% women. Thus, if more observation time is given with this five dose (total 2,400 µg) schedule, the success rate increases. The IAI in these studies ranges from 5.4 to 6.7 hours, which is comparable to six hours in the present study.3,5-8 The mean number of doses of misoprostol required for complete abortion (2.49) was also comparable.3,6 In the present study, one woman (2.5%) aborted completely with only mifepristone, prior to administration of misoprostol. She was multiparous with a gestational age of 13 weeks 1 day. Other studies have reported that 0.2-0.5% women abort with mifepristone alone.3,5,6 Similar to the present study, Ashok et al3 and Goh et al7 also found that nulliparous women had a longer IAI than multiparous women, requiring higher number of doses of misoprostol as well as higher analgesia requirement. There is a slightly lower incidence of surgical intervention in nulliparous women possibly due to more efficient establishment of pregnancy in multiparous women. This further emphasizes the advantage of this medical method in nulliparous women.

CONCLUSION It is concluded that for MTP between 13-20 weeks gestation, the drug protocol of mifepristone and misoprostol used in the present study is highly effective and has 92.5% complete abortion rate at 15 hours and 95% complete abortion rate at 24 hours. It is an acceptable and safe method and has only few minor side effects. There are no major side effects and blood loss is within acceptable limits. Surgical intervention with its risk of subsequent infection is avoided in 95% women, which is of special importance in nulliparous women.

REFERENCES 1. Lalitkumar S, Bygdeman M, Gemzell-Danielsson K. Mid-trimester induced abortion: a review. Hum Reprod Update 2007;13(1):37-52.

2. Hammond C. Recent advances in second-trimester abortion: an evidence-based review. Am J Obstet Gynecol 2009;200(4):347-56.

3. Ashok PW, Templeton A, Wagaarachchi PT, Flett GM. Midtrimester medical termination of pregnancy: a review of 1002 consecutive cases. Contraception 2004;69(1):51-8.

4. Nagaria T, Sirmor N. Misoprostol vs mifepristone and misoprostol in second trimester termination of pregnancy.

J Obstet Gynaecol India 2011;61(6):659-62.

5. Gupta N, Mittal S. Is mifepristone needed for second trimester termination of pregnancy? J Turkish-German Gynecol Assoc 2007;8(1):58-62.

6. Hamoda H, Ashok PW, Flett GM, Templeton A. A randomized trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion at 13-20 weeks gestation. Hum Reprod 2005;20(8):2348-54.

7. Goh SE, Thong KJ. Induction of second trimester abortion (12-20 weeks) with mifepristone and misoprostol: a review of 386 consecutive cases. Contraception 2006;73(5):516-9.

8. Bartley J, Baird DT. A randomised study of misoprostol and gemeprost in combination with mifepristone for induction of abortion in the second trimester of pregnancy.

BJOG 2002;109(11):1290-4.

9. Tang OS, Schweer H, Seyberth HW, Lee SW, Ho PC. Pharmacokinetics of different routes of administration of misoprostol. Hum Reprod 2002;17(2):332-6.

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Orthopedics

Bilateral Dupuytren’s Contracture Neelam Redkar*, Sunil Pawar†, Meenakshi Patil‡, Sameer Mahajan†, Ajay Keur#

Abstract Dupuytren’s contracture (DC) is painless flexion contracture of ulnar side of palm where fingers bend towards palm and cannot be straightened. It is a fibrosing disorder that results in slowly progressive thickening and shortening of the palmar fascia, leading to the debilitating digital contractures. The prevalence of DC is found to be higher in patients with cirrhotic or noncirrhotic alcoholic liver disease. We report the case of a 56-year-old male chronic alcoholic who presented with distention of abdomen, yellow discoloration of sclera since 1 month and altered sensorium since 1 day. He had bilateral contractures on ulnar side of hands, suggestive of DC.

Keywords: Dupuytren’s contracture, fibrosing disorder, alcoholic liver disease, cirrhosis Case Report A 56-year-old male chronic alcoholic presented with distention of abdomen, yellow discoloration of sclera since 1 month and altered sensorium since 1 day.

On examination, he had icterus, pallor, fetor hepaticus, spider naevi, ascites and had bilateral contractures on ulnar side of hands, suggestive of Dupuytren's contracture (DC) (Fig. 1). Ultrasonography of abdomen revealed cirrhosis of liver with ascites. Our patient had alcoholic liver cirrhosis with bilateral DC. We rarely get to see this classic sign of alcoholic liver cirrhosis. discussion Dupuytren’s contracture is painless flexion contracture of ulnar side of palm where fingers bend towards palm and cannot be straightened. It is named after the surgeon who described release procedure for such contracture.1 Ring and little fingers are commonly affected and incidence increases after the age of 40. There are various theories regarding the etiology of DC such as genetic, microinjury, immunological, toxic and ischemic.

The condition is a fibrosing disorder that results in slowly progressive thickening and shortening of the palmar fascia, leading to the debilitating digital

*Professor †Senior Resident ‡Assistant Professor #Junior Resident Dept. of Medicine, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra Address for correspondence Dr Meenakshi Patil Flat No. 702, Awesome Heights Society, Off Military Road, Marol Andheri (East), Mumbai - 400 072, Maharashtra E-mail: meenakshi.patil90@gmail.com

Figure 1. Bilateral contractures on ulnar side of hands.

contractures. Clinically, it starts with a nodule on palmar aspect of hand, which progresses to form cords along tendons, and this thickening progresses up to fingers.

There is local fascial fibroplasia and development of a nodule, in which myofibroblasts proliferate and later, leaving acellular tissue and thick bands of collagen.

It belongs to group of plantar fibromatosis (Ledderhose disease), penile fibromatosis (Peyronie disease) and fibromatosis of the dorsal proximal interphalangeal joints.2 DC is known to recur even after correction.

Although, many cases appear to be idiopathic and without coexisting conditions, a variety of associated diseases have been reported. Family history, manual labor with vibration exposure, prior hand trauma, alcoholism, smoking, diabetes mellitus, hyperlipidemia, Peyronie disease and complex regional pain syndrome.2 The prevalence of DC is found to be higher in patients with cirrhotic or noncirrhotic alcoholic liver disease

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Orthopedics than it is in patients with nonalcoholic liver disease, but it was not significantly different in alcoholic patients with or without liver disease.3 No specific test is required for diagnosis and contracture can be made out by table top test where patient has to put his hand straight palm down on table top. This condition if mild and hand function not compromised treatment is not required. If severe can be treated by fasciotomy, aponeurotomy, collagenase injection and radiation.

REFERENCES 1. Van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in Dupuytren's disease. Hand Surg Br 2006;31(5):498-501.

2. Hindocha S, McGrouther DA, Bayat A. Epidemiological evaluation of Dupuytren's disease incidence and prevalence rates in relation to etiology. Hand (NY).

2009;4(3):256-69.

3. Attali P, Ink O, Pelletier G, Vernier C, Jean F, Moulton L, et al. Dupuytren's contracture, alcohol consumption and chronic liver disease. Arch Intern Med 1987;147(6): 1065-7.

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Low Back Pain and Surgery Low back pain is back in the news. There are newer modalities of surgical and nonsurgical management now available. Fusion rules the day but indications for fusion keep getting redefined. Motion-sparing technologies are also in vogue; disc replacement and posterior interspinous spacers promise to retain motion, while restoring pain-free function. It has never been conclusively proved what is the best mode of management for chronic back pain. It has however been proved beyond doubt that back pain costs a large amount of time and money in lost work hours.

There have been a number of articles on the efficacy of surgery versus a number of nonsurgical modalities in chronic back pain. These nonsurgical modalities may vary from physical therapy to ozone therapy. Each of these has been subject to the analysis of randomized trials and that of the meta-analysis. Definitive conclusions have been raised in favor of the conservative as well as the surgical modalities. The surgeon, however, remains as confused as ever, and the patient with chronic pain as miserable as before. A Cochrane database search for reviews in low back pain revealed about 200 studies. These are related to efficacy of modalities as diverse as massage, herbal medicines, multidisciplinary modalities and antidepressants in low back pain.

The systematic review on massages yielded 13 randomized controlled trials of which only five had a high bias.

Massage has a beneficial effect as foretold by the authors, especially in concurrence with other modalities in nonspecific low back pain. Now, in my opinion, it is this problem that is more difficult to tackle, the problem of labeling a patient as nonspecific back pain. Which back pain is specific and which is nonspecific. A battery of investigations are probably necessary or is it gut instinct?

Suggested Reading 1. Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev 2008;(4):CD001929.

2. Kleinstück F, Dvorak J, Mannion AF. Are “structural abnormalities” on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain? Spine (Phila Pa 1976) 2006;31(19):2250-7.

3. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low back pain and sciatica. Cochrane Database Syst Rev 2000;(2):CD001254. Update in: Cochrane Database Syst Rev 2004;(4):CD001254.

4. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain.

Cochrane Database Syst Rev 2005;(3):CD000335.

5. van Duijvenbode IC, Jellema P, van Poppel MN, van Tulder MW. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev 2008;(2):CD001823.

6. Fritzell P, Hägg O, Wessberg P, Nordwall A; Swedish Lumbar Spine Study Group. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976) 2001;26(23):2521-32; discussion 2532-4.

7. Singh K, Ledet E, Carl A. Intradiscal therapy: a review of current treatment modalities. Spine (Phila Pa 1976) 2005;30(17 Suppl):S20-6.

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Orthopedics

Isolated Comminuted Fracture of the Scapula Amit Agrawal

Abstract Fractures of the scapula are relatively rare and constitute 3-5% of all shoulder girdle injuries and 1% of all fractures. Isolated scapular fractures are uncommon because the scapula is well-protected by large muscle masses and by virtue of its mobility about the posterolateral aspect of the thorax. We report a case of a 65-year-old man fell from an auto and presented with swelling and tenderness over the right scapula with painful and restricted right shoulder movements. Radiographs revealed an unusual stellate fracture of the body of the scapula with an involvement of the neck of the scapula.

Keywords: Isolated scapular fractures, high-energy vehicular trauma, broad arm sling, conservative management

F

ractures of the scapula are relatively rare and constitute 3-5% of all shoulder girdle injuries and 1% of all fractures.1,2 Scapular fractures are usually caused by high-energy vehicular trauma or by falling from a height and can be associated with injuries of the ipsilateral limb, shoulder girdle and thorax.2 Isolated scapular fractures are uncommon because the scapula is well-protected by large muscle masses and by virtue of its mobility about the posterolateral aspect of the thorax.3 Case Report A 65-year-old man fell from an auto and sustained a direct injury to the right shoulder. On examination, the patient had swelling and tenderness over the right scapula with painful and restricted right shoulder movements, especially protraction and retraction of the shoulder. Radiographs revealed an unusual stellate fracture of the body of the scapula with an involvement of the neck of the scapula (Fig. 1).

A

There were no associated fractures of the shoulder, which was in joint. He was admitted for cardiac monitoring and analgesia. He was discharged

Associate Professor (Neurosurgery) Dept. of Surgery Datta Meghe Institute of Medical Sciences Sawangi (Meghe), Wardha, Maharashtra Address for correspondence Dr Amit Agrawal Associate Professor (Neurosurgery) Clinical and Administrative Head Division of Neurosurgery Datta Meghe Institute of Medical Sciences Sawangi (Meghe), Wardha - 442 004, Maharashtra E-mail: dramitagrawal@gmail.com

B

Figure 1. Comminuted fracture of right scapula that is better seen in Fig. 1(b).

24 hours later with a broad arm sling and physiotherapy exercises to mobilize the shoulder as much as pain allowed.

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Orthopedics Discussion In patients with multiple injuries, scapular fractures may be overlooked or neglected because other lifethreatening problems are the focus of attention.4 Extensive chest injuries overshadowing the scapula on the chest trauma radiographs, inappropriately performed computer tomography or an unusual mechanism of injury can all lead to delay in the diagnosis of scapular fractures.3,5 It is recommended that the presence of ipsilateral regional skeletal injuries and soft-tissue injuries after major blunt chest trauma should prompt a diligent search for concomitant scapular fractures.3 As the supine chest radiograph is obtained routinely in patients who sustain major blunt chest trauma, it provides the earliest opportunity to detect scapular fractures.3,5 When a scapular fracture is clinically suspected and the patient’s condition permits, an axial (‘V view’) of the scapula identifies the fracture and establishes the magnitude of fragment separation.3 Most of the scapular fractures need conservative management with good to excellent results and operative treatment is recommended only when bone and soft-tissue damage are such that with conservative measures function would not be restored and there

is a risk of post-traumatic osteoarthritis.1,6 Early identification and proper management are integral to decrease symptoms, for example, scapular snapping syndrome and we should be aware of scapular injuries that will need further investigations particularly scapular Y views.

References 1. Goss TP. Fractures of the scapula. In: The Shoulder. 3rd edition, Rockwood CA Jr, Matsen FA, Wirth MA, Lippitt SB (Eds.), Saunders: Philadelphia 2004:p.413-54.

2. Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma 2006;20(3): 230-3.

3. Harris RD, Harris JH Jr. The prevalence and significance of missed scapular fractures in blunt chest trauma. AJR Am J Roentgenol 1988;151(4):747-50.

4. Hardegger FH, Simpson LA, Weber BG. The operative treatment of scapular fractures. J Bone Joint Surg Br 1984;66(5):725-31.

5. Tadros AM, Lunsjo K, Czechowski J, Abu-Zidan FM. Causes of delayed diagnosis of scapular fractures. Injury 2008;39(3):314-8.

6. DePalma AF. Fractures and dislocations of the scapula.

In: Surgery of the Shoulder. 3rd edition, Lippincott: Philadelphia/London/New York 1983:p.362-71.

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Orthopedic Injuries Fractures can produce large blood losses. Stabilization of fractures can minimize the amount of bleeding.

Fractures of the spine are multiple in 10% of cases. Complete radiographic evaluation of the spine is necessary, therefore, when a single fracture is discovered. Extremity trauma can result in devastating injuries requiring the coordination of multiple specialists to perform complex reconstructions. The goal of management is limb preservation and restoration of function, and it should focus on ensuring vascular continuity, maintaining skeletal integrity and providing adequate soft-tissue coverage.

In conclusion, the four main features of effective trauma care: ÂÂ

Comprehensive therapy extending from the initial field evaluation through the completion of rehabilitation

ÂÂ

Multidisciplinary therapy involving the coordination of a dedicated team of health professionals

ÂÂ

Systematic therapy providing a framework for the timely and accurate identification of all injuries and comorbidities

ÂÂ

Rapid therapy resulting in the proper prioritization of injuries and the interventions required to treat them.

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Orthopedics

Management of Fracture Neck of Femur with Cemented Bipolar Prosthesis TS Raghavendra*, BS Jayakrishna Reddy†, Jithuram Jayaram‡

Abstract Background: In this clinical study, 20 cases of intracapsular fracture neck of femur in elderly patients of age 60 years and above were treated by hemiarthroplasty using cemented bipolar endoprosthesis. This study was conducted at the Dept. of Orthopedics, Sri Siddhartha Hospital, Tumkur, Karnataka, between October 2010 and March 2012. The results and follow-up were evaluated. Material and methods: The cases were followed-up for 6 months and the short-term functional results were analyzed by using modified Harris hip scoring system. Results: At the end of 6 months after surgery, the functional results were analyzed in 20 cases. All patients were in the age group of 60-82 years with mean average age of 75 years. Thirty-five percent of the patients had a Garden type III fracture radiologically, while 60% had a Garden type IV and one patient was diagnosed with a nonunion fracture neck of femur. In 75% of cases, the mode of injury was trivial trauma. Some of the complications observed were superficial infection of the wound or a limb length discrepancy, following the procedure. There were 50% excellent results and 30% good results. Conclusions: The success of hemiarthroplasty no doubt depends on preoperative planning and proper attention to surgical details to achieve the optimum biomechanical stability. This study showed that the final functional outcomes were dependent on the presence of associated comorbidities and the optimum postoperative rehabilitation of the patient following surgery.

Keywords: Bipolar, hemiarthroplasty, cement, femoral neck fracture

I

ntracapsular fractures of the proximal femur account for a major share in hospital inpatients. Treatment of fracture neck of femur has always remained a debate, especially in the elderly.

Prosthetic replacement of the femoral head with Austin Moore or Thompson prosthesis hemiarthroplasty has undoubtedly played an important role. However, acetabular erosion is a significant long-term complication. To overcome these problems, cemented bipolar hemiarthroplasty has emerged as a good option for:

ÂÂ

Active elderly patients who need a stable fixation so as to return to the prefracture level of activity and also an independent ambulation.

*Assistant Professor †Professor and Head ‡Orthopedic Surgery Resident Dept. of Orthopedics Sri Siddhartha Medical College, Tumkur, Karnataka Address for correspondence Dr TS Raghavendra Dept. of Orthopedics Sri Siddhartha Medical College, Agalakote, BH Road, Tumkur - 572 107, Karnataka E-mail: drragavendra@gmail.com

ÂÂ

Patients who had developed nonunion of the fracture or avascular necrosis of the femoral head with osteosynthesis.1

Bipolar hemiarthroplasty thus appears to be the best option for acute fracture neck femur in the elderly in our population.

The aims of this study was to analyze the postoperative time required for mobilization of the patient, complications and quality-of-life after hemireplacement arthroplasty using cemented bipolar thereby assessing endoprosthesis and its functional outcome.

Material and Methods Patients who had sustained an intracapsular femoral neck fracture and were admitted to Sri Siddhartha Medical College and Research Centre, Tumkur, Karnataka, were taken up for this study after obtaining their consent. This was a prospective study from October 2010 to March 2012 and the number of cases were 20.

Inclusion Criteria ÂÂ

Intracapsular fracture neck of femur in patients of age 60 years and above.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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Orthopedics ÂÂ

Ununited fracture neck of femur.

ÂÂ

Fracture neck of femur with avascular necrosis.

Exclusion Criteria ÂÂ

Patients below 60 years.

ÂÂ

Avascular necrosis of femoral head with acetabular changes.

ÂÂ

Pathological fractures of neck of femur.

ÂÂ

Patients medically unfit for surgery.

All study patients were put on skin traction and 3-5 kg of weight was applied to maintain the length of the lower limb and facilitate subsequent hemiarthroplasty procedure. Adequate medical management of associated comorbid conditions like diabetes mellitus, systemic hypertension and heart diseases were initialized to optimize patient’s fitness for anesthesia.

All cases were done under regional anesthesia that included spinal or epidural anesthesia. The patients were placed in lateral position on the operating table with the affected side facing up. A curved incision was taken from 8 cm distal to the posterior superior iliac spine, extended distally and laterally, parallel with fibers of gluteus maximus muscle to the posterior margin of the greater trochanter. The incision was then directed distally 5-8 cm along the femoral shaft.

By blunt dissection, the fibers of the gluteus maximus were separated taking care not to disturb the superior gluteal vessels in the proximal part of the exposure.

The gluteus maximum muscle was split and short external rotators were exposed. A tenotomy of the short external rotators was done close to their insertion on the inner surface of the greater trochanter.

The capsule was incised by a T-shaped incision. Using a head extractor and bone levers, head was delivered out of the acetabulum and the acetabulum was cleared of debris.

The neck was trimmed leaving 1.5 cm of the medial calcar, on which the flare of the prosthesis would eventually sit. The proximal femur was over-reamed with rasp; for the insertion of bone cement, the cement was inserted into the medullary cavity by the method of manual cement packing until it was completely packed firmly in the canal with a finger before the stem was introduced.

The appropriate-sized prosthesis was inserted into the reamed canal taking care to place it in 10-15° of anteversion. Adequate seating of the prosthesis on the calcar was visualized directly. The bone cement was allowed to set, following which the hip joint was

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

reduced by gentle traction with external rotation of the hip and simultaneous manipulation of the head of the prosthesis into the acetabulum. The range of movement in all directions was checked by taking the joint through the whole range of movements. Great care was taken to achieve adequate closure of the posterior capsule and anatomical reattachment of the short external rotators.

The rest of the wound was closed in layers. Hemostasis was maintained throughout the procedure.

All the patients who were operated were kept in supine position with the involved lower limb in 20-30° abduction using an abduction pillow.

All the patients were advised to sit with backrest from the second postoperative day and were advised deep breathing exercises. Mobilization with a walker was started between third and fifth postoperative day.

Patients were initially advised toe-touch down weight bearing with the help of a walker and later advised progress to full weight-bearing with the aid of a walker as tolerated. Active hip and quadriceps exercises for the knee were advised for a period of 6 weeks.

Regular follow-up of all cases was done at 6 weeks, 3 months and at the end of 6 months. At each follow-up, patients were evaluated clinically using the Harris hip score1,2 and radiologically with appropriate X-rays.3,4 Harris hip score was used to evaluate the functional outcome in the present study. Results were rated as – Excellent: 90-100; Good: 80-89; Fair: 70-79; Poor: < 70.

Results Data was collected based on detailed patient evaluation with respect to history, clinical examination and radiological evaluation. The postoperative evaluation was done both clinically and radiologically. Out of 20 patients treated in this manner, all cases were available for follow-up period of 6 months. Patients of age 60 years and above, diagnosed with fracture neck of femur, were included in the study. The average age was noted to be 75 years (60-89). Patients sustaining fracture neck of femur included 11 females (55%) and 9 males (45%). Laterality pattern was 50% both right and left.

The mechanism of injury in majority of patients (75%) was tripping/slipping. Garden type IV fracture pattern was observed in 12 cases while Garden type III pattern was observed in seven patients and one patient was diagnosed with nonunion fracture neck of femur.

Systemic comorbidities was present in 11 of 20 patients, 20% patient had heart disease, 10% had diabetes, 5% had hypertension, 10% had heart disease as well as diabetes, 5% had heart disease with hypertension and 5% had hypertension and diabetes mellitus.

Orthopedics All the patients were operated under spinal or epidural anesthesia in lateral decubitus position by the posterior approach of Moore. In all patients, the average blood loss during surgery was below 750 mL. Intraoperatively, technical difficulties were encountered in six patients, while hypotension was observed in five patients. There were two cases of superficial wound infection and five cases with limb length discrepancy. There were no late postoperative complications.

At final 6 months follow-up by Harris hip scoring system, 50% had excellent result, 30% had good results, 15% had fair results and 5% had poor results. The results of our study are comparable with standard studies of bipolar hemiarthroplasty performed for fracture neck of femur. Final functional outcome of the patients was affected to an extent by the presence of associated systemic comorbities and by the pain component that was present in many patients. No radiological changes were observed at the end of 6 months.

Discussion The aim of replacement surgery in fracture neck femur is early return to daily activities. This is particularly applicable to the elderly age group where complications due to long periods of immobilization have to be prevented.

The mean age of the patients in the present study was 75 years, the youngest being 60 years and the eldest being 82 years. Age distribution is an important factor in the management of hip fractures. The results of our study showed that age of the patient had minimal influence on the final functional outcome.

As in most standard studies, the present study also had a higher number of females who sustained a fracture neck of femur as compared to the male population.

Elderly females are more prone to fracture neck of femur due to osteoporosis.5

presented for treatment within 24-72 hours; 10% were brought to the hospital between 72 hours and 1 week and the remaining 5% presented for treatment after 1 week. Difficulty in postoperative rehabilitation was particularly noticed in the patient who presented after 90 days following trauma, probably due to bony and soft tissue changes that would occur in this duration that finally gave a poor outcome.

All of our study patients had a displaced fracture of the neck of femur. Majority of the patients (60%) had a Garden type IV fracture, while seven patients (35%) had Garden type III fracture and one patient (5%) was diagnosed with a nonunion fracture neck of femur.

Even in a comparison study by Krishnan et al,5 between the outcomes following cemented and uncemented bipolar prosthesis, 29 patients were of Garden type IV, while five patients sustained a Garden type III fracture type.5 However, the type of fracture and the displacement did not have any bearing on the final function.

Heart disease was found to be the most common comorbidity seen in 20% of the study patients.

Two patients had type II diabetes and were on oral hypoglycemic agents or human actrapid injection.

They were shifted to insulin preoperatively and blood sugar values optimized before taking up for surgery.

Five percent of the patients were hypertensives, while 10% of the patients had both heart disease and diabetes mellitus, 5% had heart disease and hypertension and another 5% of the patients were diagnosed with both hypertension and diabetes mellitus. It was observed that the postoperative rehabilitation of patients was significantly affected by the presence of the above comorbidities. This also had an effect on the final functional result of the procedure. Similar observations have been made by Koval and Zuckerman6 and Bath.7

Majority of our study patients (75%) sustained the injury due to a trivial trauma like tripping or slipping. This is a very common occurrence in elderly population where poor vision and lack of neuromuscular coordination is a problem. Most of such injuries can be classified as â&#x20AC;&#x2DC;indirectâ&#x20AC;&#x2122; trauma. Ten percent patients sustained the injury due to a fall from a height and 15% due to a road traffic accident.

All the study patients were taken up for the surgical procedure between the second and fourth day after the trauma, the average delay to surgery being 4 days. Delay in taking up for surgery was usually for optimizing the medical condition of the patient.

Deep vein thrombosis (DVT) prophylaxis was given for all patients, using low molecular weight heparins, on admission and was stopped 12 hours before the surgery. All cases were performed on an elective basis and were scheduled as the first surgery in the morning.

A little more than half of our study patients were brought to the hospital within 3 days of sustaining the injury. Fifty-five percent of the patients were brought to the hospital within 24 hours of the injury, while 30%

All patients were operated after being put into lateral decubitus position by the posterior approach of Moore.

The posterior approach was preferred because of the familiarity of most of the surgeons at our institution

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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Orthopedics with this approach. Although, the dislocation rate is reported to be more with the posterior approach, none of our study patients had a postoperative dislocation of the prosthesis.2,7 This was because meticulous attention was given to suturing the posterior capsule and the short external rotators and keeping the limb in slight abduction using an abduction pillow, after the procedure. In the immediate postoperative period, patients were also explained about the risk of dislocation with excessive flexion or adduction of the hip.

Both the patients were managed by antibiotic treatment, debridement and secondary suturing with adequate control of the diabetic status. The infection resolved without any sequelae and there was no late reactivation of the same. Infection rate of 3.9% after bipolar hemiarthroplasty is reported by Nottage and McMaster.11 No complications of DVT was noticed in any patient due to the administration of low molecular weight heparins, preoperatively and for 5 days postoperatively.3

In 50% of the cases, 45 mm prostheses were used that was followed by 43 mm (30%), 47 mm (15%) and 41 mm (5%) prostheses in the order of frequency. Following calcar preparation and over-reaming of the medullary cavity using the rasps that were provided, manual packing of cement and insertion of the prosthesis was done.

Pain following hemiarthroplasty is a major concern.

Hinchey and Day12 in their series of 294 patients found pain following hemiarthroplasty in 22 patients in the early postoperative period. They could not find any definitive cause in them. Lunceford13 stated that the causes of pain could be due to infection, improper prosthetic seating, metallic corrosion and tissue reaction, improper-sized femoral head, contractures and periarticular ossification. In our study, 13 patients had complaints of pain on the final follow-up. These patients were however advised exercises and were reassured about the condition, along with which medications were prescribed and advised to be consumed only when the pain was intolerable.

Technical difficulties encountered with the procedure, first, was calculating the angle of the neck osteotomy required and the amount of calcar to be retained for the correct placement of the prosthesis. Second, a difficulty in cement insertion by the technique of manual packing was also encountered. Intraoperative hypotension was encountered in five patients during cement insertion but was corrected on table by the anesthetist.

In up to half of the cases, the blood loss was < 500 mL for the whole procedure and in most of the others it was between 500 and 750 mL. Only 13.63% of cases had a blood loss of > 750 mL requiring a blood transfusion. It has been reported in literature that the average blood loss with hip hemiarthroplasty is less in the anterior approach as compared to the posterior approach.7,8 Most of the surgeries were completed between 90 and 120 minutes of starting the procedure.

Similar duration of the procedure has been reported by Haidukewych et al9 and Drinker and Murray.10 Neither the intraoperative blood loss nor the duration of the procedure had any effect on the final function. Most of our study patients were mobilized in bed on day one of surgery and with weight-bearing as tolerated within the 72 hours postoperative period. Delay if at all was due to medical reasons.

Limb length discrepancies were observed in five patients (25%) postoperatively, of which four patients had a lengthening of 1 cm each, probably due to the less amount of calcar resection, while one patient had a shortening of 1.5 cm postoperatively, probably due to excessive resection, during preparation of the calcar.

Superficial infection in the form of a wound dehiscence was seen in two patients (10%) who were diabetic.

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In our study, the final Harris hip score as evaluated at 6 months follow-up averaged 87.2 with the maximum score being 100 and the minimum score being 55.

Of 20 patients, 10 patients (50%) achieved excellent result, 6 patients (30%) achieved good result, 3 patients (15%) achieved fair result and one patient (5%) achieved poor result. Overall, 80% of the patients achieved either an excellent or a good result. Our results are comparable with standard studies of bipolar hemiarthroplasty performed for fracture neck femur. The poor result in one patient may be attributed to the late presentation following trauma, which had an effect on the surgical procedure and postoperative rehabilitation, probably due to soft tissue and bony changes that must have occurred.

No radiological changes or complications were noticed in any patients, at the end of 6 months follow-up.

Our study is not without its own shortcomings.

First, our duration of follow-up of 6 months is very less in assessing the longevity and functional endurance of the prosthesis used and hence coming to definitive conclusions. Second, we have not evaluated the degree of intraprosthetic motion at the inner-bearing at each follow-up. Such studies are complicated and beyond the facilities available at our institution. Such studies are indicated because there are claims that the motion

Orthopedics at the inner-bearing reduces over time and most prostheses behave as unipolar prostheses over a period of time.

femoral neck fractures - a comparison of cemented and uncemented prosthesis placement. Malaysian Ortho J 2010;4(1):26-31.

6. Koval KJ, Zuckerman JD. Functional recovery after fracture of the hip. J Bone Joint Surg Am 1994;76(5):751-8.

Acknowledgment The first author would like to extend a wholehearted gratitude to the Dept. of Orthopedics, Sri Siddhartha Medical College, Tumkur, Karnataka, for providing a platform for conducting the studies. The author would also like to thank his colleagues, staff and postgraduates students for lending him a helpful hand in whatever way possible. The author would like to give a special vote of thanks to Dr JKSY Reddy for his cooperation in reviewing the patients and valuable guidance.

References 1. LaBelle LW, Colwill JC, Swanson AB. Bateman bipolar hip arthroplasty for femoral neck fractures. A five- to ten-year follow-up study. Clin Orthop Relat Res 1990;(251):20-5.

2. Malhotra R, Arya R, Bhan S. Bipolar hemiarthroplasty in femoral neck fractures. Arch Orthop Trauma Surg 1995;114(2):79-82.

3. Maini PS, Talwar N, Nijhawan VK, Dhawan M. Results of cemented bipolar hemiarthroplasty for fracture of the femoral neck - 10 year study. Indian J Ortho 2006;40(3):154-6.

4. Choudhary, Mohite. Pathology of fracture neck of femur.

Clinic Ortho India 1987;1:45-8.

5. Krishnan H, Yoon TR, Park KS. Bipolar hemiarthroplasty in patients presenting with displaced intracapsular

7. Barnes R. Problems in the treatment of femoral neck ractures. Proc R Soc Med 1970;63(11 Pt 1):1119-20.

8. Kenzora JE, Magaziner J, Hudson J, Hebel JR, Young Y, Hawkes W, et al. Outcome after hemiarthroplasty for femoral neck fractures in the elderly. Clin Orthop Relat Res 1998;(348):51-8.

9. Haidukewych GJ, Israel TA, Berry DJ. Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res 2002;(403):118-26.

10. Drinker H, Murray WR. The universal proximal femoral endoprosthesis. A short-term comparison with conventional hemiarthroplasty. J Bone Joint Surg Am 1979;61(8):1167-74.

11. Nottage WM, McMaster WC. Comparison of bipolar implants with fixed-neck prostheses in femoral-neck fractures. Clin Orthop Relat Res 1990;(251):38-43.

12. Hinchey JJ, Day PL. Primary prosthetic replacement in fresh femoral neck fractures. JBJS 1960;42B:633-40.

13. Lunceford EM Jr. Use of the moore self-locking vitallium prosthesis in acute fractures of the femoral neck. J Bone Joint Surg Am 1965;47:832-41.

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Common Surgery Practices that should Stop American Academy of Orthopaedic Surgeons made the following five evidence-based recommendations: ÂÂ

Avoid performing routine postoperative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.

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Don't use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.

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Don't use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.

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Don't use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.

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Don't use postoperative splinting of the wrist after carpal tunnel release for long-term relief.

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871

PEDIATRICS

Massive Fetomaternal Hemorrhage Kannan Venkatnarayan*, Rajeev Thapar†, Himanshu Sharma

Abstract Massive fetomaternal hemorrhage (FMH) is a rare entity and the diagnosis needs to be determined by performing a KleihauerBetke test (KBT) of the maternal blood. We present a case of massive FMH presenting as severe neonatal anemia. The varied presentations of FMH and its management are discussed.

Keywords: Fetomaternal hemorrhage, Kleihauer-Betke test

T

he ability of fetal red cells passing the placental membrane was demonstrated by Chown in 1954.1 Fetal red cells in the maternal circulation can be detected with the Kleihauer acid-elution method by relative acid resistance from fetal hemoglobin to adult hemoglobin.2 About 40-50% of pregnancies usually in late gestation have fetal red cells in the maternal circulation.3 In 98% of the cases, the loss of blood is minimal, usually only <0.1 ml.4 Fetomaternal hemorrhage (FMH) of a significant volume is rare with a frequency of about 0.2 per 1,000 pregnancies.5 Massive FMH has been defined as bleeding in which >150 ml of fetal blood is found in maternal circulation.6 Diagnosis is difficult and is usually made postpartum.

CASE Report A male neonate weighing 2,700 g was born by normal spontaneous delivery to a 36-year-old gravida II para I mother at 36 weeks three days of gestation at a nursing home. Mother was a known case of hypothyroidism, on treatment for last 6 years. Ultrasound evaluation done in the second trimester showed a single fetus with evidence of a small fibroid over the anterior wall.

Both parents had blood group O positive. However, there was no history of any trauma or any vaginal bleed occurring in any of the trimesters. The baby cried immediately after birth with Apgar scores of 7 and 8 at

*Assistant Professor Dept. of Neonatology, AIIMS, New Delhi †Postdoctoral Fellow Dept. of Pediatrics Command Hospital (Eastern Command), Alipore, Kolkata Address for correspondence Dr Kannan Venkatnarayan Assistant Professor Dept. of Pediatrics Command Hospital (Eastern Command), Alipore, Kolkata - 700 027 E-mail: venkatnarayan_kannan@yahoo.co.in

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

1 and 5 minutes, respectively and did not require any active resuscitation. Baby was noticed to have significant pallor immediately after delivery and advised treatment at a higher center equipped with neonatal intensive care unit (NICU) facility. The baby was brought to our hospital at around 12 hours of age. At presentation, there was noticeable pallor and mild generalized edema along with tachypnea with normal temperature and heart rate. Blood pressure was also found to be normal.

The most significant finding was the oxygen saturation, which was very low, ranging 35-40% on room air. This responded dramatically to hood box oxygen of 6 L/ min. Tissue perfusion as measured by capillary refill time was <3 seconds and evidence of any hematoma or bruise was lacking. Also, there was a Grade II/VI systolic murmur heard best in the apical area. There was presence of bilateral nontender, nonmatted axillary lymphadenopathy. Liver or spleen was not palpable.

A complete blood count revealed that hemoglobin (Hb) was 6.6 g/dL, hematocrit 22.1%, white blood cell count 24 × 10³/mm3, differential cell count: Neutrophils 54%, lymphocytes 41%, monocytes 03%, eosinophils 02%, corrected reticulocyte count 7.9%, platelets 280 × 10³/ mm³.

Peripheral smear showed marked anisocytosis with red blood cells (RBCs) being predominantly macrocytic and presence of polychromasia and nucleated RBCs (28 nRBC/100 WBC) few fragmented and dysmorphic RBCs were also noticed. Features of sepsis were present in the form of IT ratio of 22%, polymorphonuclear leukocytosis with some polymorphs showing cytoplasmic vacuolations and occasional toxic granules.

Blood culture showed growth of coagulase-negative Staphylococcus aureus. Cerebrospinal fluid (CSF) study was normal. The baby’s blood group (type O Rh+) was the same as the mother’s. Both the direct Coombs’ test of the baby and the indirect Coombs’ test of the mother

PEDIATRICS were negative. Ultrasonography of brain as well as abdomen was unremarkable. 2D-echo done in view of the cardiac murmur was a normal study. The maternal peripheral blood smear with Kleihauer-Betke stain (Fig. 1) showed 13.34% fetal cells, which represented 620 ml of fetal blood loss in the maternal circulation on the basis of 55 kg of mother’s weight. This contrasted with no visible fetal cells on Kleihauer-Betke test (KBT) from a control, with the maternal RBCs appearing as ‘ghost cells’ (Fig. 2).

Antibiotics were started on Day 1 in view of generalized edema and presence of features of sepsis on peripheral

Figure 1. Fetal red cells derived from leakage of the infant’s blood into the maternal circulation rich in hemoglobin F and stained darkly in the index case.

Figure 2. Kleihauer-Betke acid-elution preparation of maternal postpartum peripheral blood. The maternal RBCs from a control appear as ‘Ghost cells’.

(Courtesy: Dr Bhaskar Mukerjee)

smear, which were continued for a period of 2 weeks.

Baby was transfused with 80 ml of packed RBCs (40 ml on Day 1 and 40 ml on Day 18) with improvement in the clinical status. Baby was discharged on Day 22 with normal physical and neurological examination.

DISCUSSION Neonatal anemia can be induced by fetal hemorrhage (internal, external or intraplacental), fetal hemolysis or failure of RBC production. Anemia may be compensated at birth, or be only minimal if FMH has been <50 ml. De Almeida and Bowman defined massive FMH as fetal blood loss of 80-150 ml and reported an incidence of 0.2 per 1,000 pregnancies from a large cohort.7 Most of the case reports have not explained the causes of the massive FMH. The risk factors of FMH include, antepartum fetal death, cesarean delivery, abruptio placentae, placenta previa, manual removal of the placenta, intrapartum manipulation, antepartum genital bleeding, thirdtrimester trauma and third-trimester amniocentesis.5 Bowman and Pollock concluded that the risk of FMH of 20 ml or more in third-trimester amniocentesis was about 0.7%.8 Manifestation of FMH depends on the magnitude and the acuity of blood loss. Generally, the nonstress test and ultrasound are useless for early diagnosis of FMH except in unusual cases.9 However, sinusoidal heart rate pattern and decrease in fetal movement are considered important signs of FMH.10 Prenatal ultrasound studies could sometimes identify the presence of hydrops fetalis11 or fetal growth retardation with a low biophysical score.12 In fact, fetal anemia in these cases can be diagnosed by measuring the peak systolic velocity of the middle cerebral artery (MCA PSV) of the fetus.

Diagnosis of FMH can be confirmed by fetal RBC cells in the maternal blood with KBT.2 Alternatively, the fetal RBCs can be detected by flow cytometry studies. However, flow cytometry studies are not easily available and in fact, are being currently used only in 4% of laboratories in the United States.7 Estimates of the actual amount of fetal blood loss into maternal circulation from KBT can be derived based on published formulae13,14 and generally correspond to 140 ml of FMH for every 3% KBT count. In addition to KBT, elevated serum α-fetoprotein has also been found to be a surrogate marker of FMH. Although such an association is found in a number of pregnancies associated with complications like intrauterine growth

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PEDIATRICS retardation, preterm delivery, late vaginal bleeding, pre-eclampsia, abruptio placentae, fetal death, placenta sonolucencies and fetal malformations, especially neural tube defects, thus leading to high false-positive rates.12 In our case, the estimated volume of fetal blood in maternal circulation was approximately 620 ml, which represented a loss of triple amount of the infant’s entire blood volume. Although a great amount of blood was lost, the patient only demonstrated pallor with mild edema, which indicated a chronic FMH with good compensation. A similar case has been earlier reported

by Tsai et al.15 Neonatal deaths due to FMH are associated with shock at birth or soon after. Massive FMH that occurs on a more chronic basis and that allows fetal hemodynamic compensation usually has a good prognosis. As for massive FMH, the rapidity of the hemorrhage is probably a more important prognostic factor than the amount of fetal blood loss to the maternal circulation.

Treatment of the anemic newborn following FMH depends primarily on the presence or absence of signs of circulatory failure. For those cases with chronic massive FMH, partial exchange transfusion is a better option.16 In our case, in spite of the massive blood loss, the baby was born without shock and with normal Apgar scores. Since, the baby gradually developed edema and tachypnea, he was treated with packed RBC transfusion and the condition improved.

As massive FMH accounts for a significant portion of unexplained fetal deaths,12 this condition needs to be considered when there is an anemic newborn without clues of hemolytic disease, obstetric hemorrhage, decreased RBC production or neonatal hemorrhage. A Kleihauer-Betke stain should be performed for consideration of FMH. References 1. Chown B. Anaemia from bleeding of the fetus into the mother’s circulation. Lancet 1954;266(6824):1213-5.

2. Kleihauer E, Braun H, Betke K. Demonstration of fetal hemoglobin in erythrocytes of a blood smear. Klin Wochenschr 1957;35(12):637-8.

3. Clayton EM Jr, Feldhaus W, Phythyon JM, Whitacre FE. Transplacental passage of fetal erythrocytes during pregnancy. Obstet Gynecol 1966;28(2):194-7.

4. Jørgensen J. Feto-maternal bleeding. During pregnancy and at delivery. Acta Obstet Gynecol Scand 1977;56(5): 487-90.

5. de Almeida V, Bowman JM. Massive fetomaternal hemorrhage: Manitoba experience. Obstet Gynecol 1994;83(3):323-8.

6. Hoag RW. Fetomaternal hemorrhage associated with umbilical vein thrombosis. Case report. Am J Obstet Gynecol 1986;154(6):1271-4.

7. Wylie BJ, D’Alton ME. Fetomaternal hemorrhage. Obstet Gynecol 2010;115(5):1039-51.

8. Bowman JM, Pollock JM. Transplacental fetal hemorrhage after amniocentesis. Obstet Gynecol 1985;66(6):749-54.

9. Tsuda H, Matsumoto M, Sutoh Y, Hidaka A, Imanaka M, Miyazaki A. Massive fetomaternal hemorrhage: a case report. Int J Obstet Gynecol 1995;50:47-9.

10. Clark SL, Miller FC. Sinusoidal fetal heart rate pattern associated with massive fetomaternal transfusion. Am J Obstet Gynecol 1984;149(1):97-9.

11. Cardwell MS. Successful treatment of hydrops fetalis caused by fetomaternal hemorrhage: a case report. Am J Obstet Gynecol 1988;158(1):131-2.

12. D’Ercole C, Boubli L, Chagnon C, Nicoloso E, Leclaire M, Cravello L, et al. Fetomaternal hemorrhage: diagnostic problems. Three case reports. Fetal Diagn Ther 1995;10(1):48-51.

13. Kleihauer E. Beihefte zum. Arch Kinderheilk 1966;53: 234-5.

14. Creasy RK, Resnik R, Iams JD (Eds.). Maternalfetal medicine. 5th edition, Saunders: Philadelphia (PA) 2004:p.541.

15. Tsai YG, Hung CH, Cheng SN, Hua YM, Yuh YS. Chronic massive fetomaternal hemorrhage: a case report. Clin Neonatol 1998;5(1):35-7.

16. Moya FR, Perez A, Reece EA. Severe fetomaternal hemorrhage. A report of four cases. J Reprod Med 1987;32(3):243-6.

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A new study presented at the American Epilepsy Society (AES) 67th Annual Meeting shows that epilepsy surgery doesn’t appear to have a major effect on mood or anxiety in children‚ and some kids even do better.

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The diabetes drug metformin is only modestly effective for promoting weight loss when combined with lifestyle intervention in nondiabetic children and teens, and the benefits do not appear to be long lasting‚ as reported in a new meta-analysis in JAMA Pediatrics‚ published online Dec. 16.

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Preventive and Social Medicine

Iron-Folic Acid Intake Among Pregnant Women in Anumanthai PHC of Villupuram, Tamil Nadu Kumar S*, Sitanshu Sekhar Kar†, Sonali Sarkar‡, Ganesh Kumar S$

Abstract Background: Prevalence of anemia in India is among the highest in the world. Apart from other causes of anemia, iron or folate deficiency is the most common cause, especially during pregnancy. Although, supplementation of diet with iron and folic acid (IFA) tablets has been a part of the Ministry of Health and Family Welfare Program for over three decades, levels of IFA intake during pregnancy remain low. Material and methods: A descriptive study was conducted among 132 postnatal women registered in Anumanthai primary health center (PHC), Villupuram, Tamil Nadu, catering to a population of 56,142 through eight subcenters to explore factors affecting compliance to IFA. One hundred thirty-two postnatal women were interviewed after taking informed consent in local language using a pretested structured proforma. Statistical analysis was done using SPSS Version 16.

Results: Majority of the study subjects (134; 98%) were in the age group of 20-29 years. First-trimester registration was 99.4% and 99.3% received at least three antenatal visits at the PHC. Fifty-four (40%) of the study subjects did not consume any IFA tablet at all. Only 31.1% of the study subjects were aware that IFA tablets should be consumed for 100 days. About 25.9% consumed at least above 90 IFA tablets and only 5.9% consumed more than 100 IFA tablets. Nausea and vomiting 85 (63%) and counseling by village health nurse 115 (89%) were reported to be the most common hindering and facilitating factors, respectively. Conclusion: Despite high rates of antenatal visits, the intake of IFA was low.

Keywords: Anemia in pregnancy, compliance, iron and folic acid tablets

I

ron-deficiency anemia is a serious public health problem that affects health and well-being. It is one of the most prevalent and preventable nutritional deficiencies in the world with prevalence being as high as 60% among pregnant women.1 Anemia burden among pregnant women in India is also high with 59% of the pregnant women being affected with the condition.2 It is estimated that about 20-40% of maternal deaths in India are due to anemia; India contributes to about 50% of global maternal deaths due to anemia.1,2 Apart from other causes of anemia, iron or folate deficiency is the most common cause, especially during pregnancy. Although, supplementation of diet with iron and folic acid (IFA) tablets has been a part of the Ministry of Health and Family Welfare Program for over three decades, levels of IFA intake during pregnancy

*PGDPHM Trainee †Assistant Professor Dept. of Preventive and Social Medicine JIPMER, Puducherry, Tamil Nadu Address for correspondence Dr Sitanshu Sekhar Kar Assistant Professor Dept. of Preventive and Social Medicine JIPMER, Puducherry - 605 006, Tamil Nadu E-mail: drsitanshukar@gmail.com

remain low.3 As per the National Family Health Survey (NFHS)-3, only 23% of women consumed IFA for at least 90 days in India.2 There has been a wide variation regarding IFA intake for 90 days among pregnant women in Kerala being the highest (75.1%) and lowest in Nagaland (3.5%).3 In Tamil Nadu, more than 90% of pregnant women were anemic despite very high antenatal check-up (ANC) (96.5% of pregnant women had three or more ANC visits) and 91.1% were given or bought IFA tablets, however, only 43.2% took IFA for at least 90 days.4 District Level Household and Facility Survey (DLHS)-3 (2007-2008) showed that the percentage of mothers who consumed 100 IFA tablets was 54.7% (rural 51.0% and urban 60.6%) and mothers who had received ANCs was 98.8% (rural 98.6% and urban 99.3%) in Tamil Nadu.5 This study was planned to find out the compliance of IFA intake and to identify facilitating and hindering factors associated with intake of iron in a rural primary health center (PHC) of Villupuram district, Tamil Nadu.

Material and Methods A descriptive study was conducted in Anumanthai PHC of Villupuram that provides comprehensive care to a population of 56,142 through eight subcenters.

The study subjects were the postnatal women registered

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Preventive and Social Medicine during November 2009 to December 2010. Out of eight, four subcenters were selected by convenient sampling as the subcenters were similar in sociodemographic parameters. Considering the prevalence of intake of iron to be 43.2%2 and with 20% allowable error, the sample size was calculated to be 132. Thirty-five postnatal women registered during the reference period from each of these four subcenters were selected randomly using a random number table from the postnatal case register with the help of a village health nurse (VHN).

All interviews were conducted in the local language after taking informed consent.

A structured questionnaire after pretesting was used to collect information on demographic variables, socioeconomic variables, awareness, regularity of intake of IFA, facilitating factors (motivation by VHN/husbands/community; availability of IFA) and hindering factors (side effects and packaging). Analysis was done by SPSS Version 16. All statistical analyses were carried out at 5% level of significance and the p value <0.05 was considered significant. This study was approved by the Institute of Research Council and the Institute of Ethics Committee. The compliance to IFA intake was defined as daily intake of IFA for at least 90 days from the second trimester of pregnancy.

Table 1. IFA Tablets Consumed by the Study Population IFA tablets consumed

No. of responses

Percentage (%)

Did not consume at all

54

40

1-30

25

18.5

61-90

14

10.3

91-100

35

25.9

101-120

7

5.9

Table 2. Facilitating Factors as Reported by Study Subjects for Intake of IFA Tablets Motivation

No. of responses

Percentage (%)

Counseling by village health nurse

115

85.2

Doctors

11

8

Private nursing homes

7

5

Husband

2

1.8

Table 3. Hindering Factors Reported by Study Subjects for Not Consuming IFA Tablets Reasons

No. of responses

Percentage (%) 63

Nausea and vomiting

85

Results

Abdominal cramps

34

25

Majority of the study subjects (134; 98%) were in the age group of 20-29 years and were Hindus (129; 95%); 83 (61.5%) of them belonged to most backward caste and 98 (72%) were educated up to primary level (1-4 years of schooling). First-trimester registration was 99.4% and 99.3% who received at least three antenatal visits at the PHC. Hundred percent of them who visited PHC were checked for blood pressure, height, weight, abdominal examination and blood and urine examination.

Constipation

2

1.5

The IFA tablet consumption pattern is given in Table 1.

Fifty-four (40%) of the study subjects did not consume any IFA tablet at all. Only 31.1% of the study subjects were aware that IFA tablets should be consumed for 100 days. The facilitating and hindering factors are reported in Tables 2 and 3. It was found that 95.6% felt good about the package of IFA tablets; 82.2% of the pregnant women felt that the smell was good.

It was found that 88.9% of the pregnant women felt good about the taste of the IFA tablets.

Mrs P said, “My mother-in-law told, don’t take iron tablets.

If you take iron tablets, your baby will be black in color.”

Discussion The study showed that 99.3% of postnatal women were registered with auxiliary nurse midwife (ANM). About 99.3% received at least three ANC visits to the PHC. In Tamil Nadu, 96.5% had three or more antenatal visits.4 DLHS-3 (2007-2008) showed that mothers who had received ANC were 98.8% (rural 98.6% and urban 99.3%) that is close to the result of the study.5

Some of the quotes during the interviews are as follows:

A community-based cross-sectional study on utilization of antenatal care facilities in a rural population in Tamil Nadu showed that 95% of the women received at least one antenatal visit. The median number of visits was four. High utilization of antenatal care was due to low parity and adverse obstetric history, short distance to healthcare facilities and literacy.6,7

Mrs R said, “I feel nausea, giddiness and vomiting as soon as I took the tablets. So, I didn’t take any iron tablets.”

Despite high rate of antenatal visits, the intake of IFA was low. Our study showed that 18.5% of

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Preventive and Social Medicine them consumed at least 30 IFA tablets and 25.9% consumed at least above 90 IFA tablets. Only 5.9% consumed more than 100 IFA tablets. This result is quite less than the NFHS-3 data showing that 91.1% were given IFA tablets and only 43.2% took IFA tablets for at least 90 days.4 DLHS-3 (2007-2008) showed that the percentage of mothers who consumed 100 IFA tablets was 54.7% (rural 51% and urban 60.6%).5 Evaluation of the National Nutritional Anemia Control Program in Dharwad, Karnataka, showed that IFA tablets were not distributed regularly by the ANMs and 10% subjects did not receive any tablets even once.

The tablets supplied were not consumed due to side effects and blind beliefs.6 Our study also depicts the similar findings.

The awareness about the IFA tablets was only 31.1% among the pregnant women; whereas, 68.9% were not aware about the IFA tablets. In a study conducted by Abel et al8 from June 1996 to August 1998, a significant decrease in the prevalence of anemia (19.9%) was observed in the post-intervention period between the study and control area; therefore, awareness is one of the important factors in iron supplementation that is very close to our study.8,9 In our study, only 34.1% of the subjects were told by the VHNs about the importance and need for IFA tablets. In other studies, nonadherence was due to lack of motivation resulting from the lack of information about beneficial effects and some misconception about IFA therapy.10,11 In our study, only 12.6% of postnatal women received house visits by the VHNs. House visits done by the VHNs were not up to the expected level.

It is a matter of concern that with almost near 100% antenatal registration, the IFA intake rate is quite low.

Still misconceptions regarding iron tablets exist in the community. It will be apt to initiate the communitybased educational campaign to increase awareness regarding beneficial effects and dispel myths.

References 1. de Benoist B, McLean E, Egli I, Cogswell M (Eds.).

Worldwide Prevalence of Anaemia 1993–2005: WHO Global Database on Anaemia. Available at: http://whqlibdoc.who. int/publications/2008/9789241596657_eng.pdf 2. Agarwal KN, Agarwal DK, Sharma A. Anemia in pregnancyinterstate differences. Nutrition Foundation of India; Scientific Report 16, 2005.Available at: http://nutritionfoundationofindia. res.in/pdfs/Scientific-report-16.pdf 3. International Institute for Population Sciences (IIPS) and Macro International 2007. National Family Health Survey (NFHS-3), 2005-06: India: Volume I. Mumbai: IIPS. 4. International Institute for Population Sciences (IIPS) and Macro International 2007. National Family Health Survey (NFHS-3), 2005-06: India. Fact sheet Tamil Nadu. Available at: http://www.nfhsindia.org/pdf/Tamil%20Nadu.pdf 5. International Institute for Population Sciences (IIPS), 2010.

District Level Household and Facility Survey (DLHS-3), 2007-08: India. Mumbai: IIPS. 6. Iyenger L. Effects of dietary supplements late in pregnancy on the expectant mother and her newborn. Indian J Med Res 1967;55(1):85-9.

7. Assessment of Nursing Management Capacity in Tamil Nadu, National Institute of Health and Family Welfare in Collaboration with Indian Institute of Management Ahmedabad. Available at: http://nihfw.org/pdf/Nsg%20 Study-Web/Tamil%20Nadu%20Report.pdf.

8. Abel R, Rajaratnam J, Sampathkumar V. Anemia in Pregnancy: Impact of Iron Supplementation, Deworming and IEC. Reproductive Health Focus. Report on Projects for Reduction of Maternal Anemia. MotherCare/John Snow Inc. 1999: IDPAS# 532.

9. Prevalence of Micronutrient Deficiencies. National Nutrition Monitoring Bureau (NNMB) Technical Report No. 22, 2003. National Institute of Nutrition, Indian Council of Medical Research. Available at: http://nnmbindia.org/ NNMB%20MND%20REPORT%202004-Web.pdf 10. Kalaivani K. Prevalence & consequences of anaemia in pregnancy. Indian J Med Res 2009;130(5):627-33.

11. Agarwal KN, Agarwal DK, Sharma A, Sharma K, Prasad K, Kalita MC, et al. Prevalence of anaemia in pregnant & lactating women in India. Indian J Med Res 2006; 124(2):173-84.

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RESPIRATORY INFECTIONs

Diagnosis and Management of Dry Cough: Focus on Upper Airway Cough Syndrome and Postinfectious Cough N Huliraj

Abstract Cough is an important complaint of respiratory disease and normal defense mechanism of the lungs. It helps in clearing excessive secretions, fluids, infections or foreign material from the airway. In most of the cases, cough occurs as part of a brief, self-limiting illness. However, it can become a persistent symptom in several cases. The etiology of cough is very diverse and commonly includes environmental causes (cigarette smoke, pollutants, dust mites, etc.) and several disease entities, including both respiratory and nonrespiratory causes. Postnasal drip syndrome and postinfectious cough are the most common respiratory causes of chronic cough. The objective of this article is to highlight the importance and consequences of cough and discuss the effective diagnosis and management of upper airway cough syndrome and postinfectious cough. For this article, PUBMED was searched for studies and guidelines published in the English language using the medical subject heading terms cough, causes of cough, etiology of cough, postinfectious cough, post-viral cough, upper airway cough syndrome, and postnasal drip.

Keywords: Cough, causes of cough, etiology of cough, postinfectious cough, post-viral cough, upper airway cough syndrome, postnasal drip

C

ough is the most common complaint of patients who present to primary care physicians.1 It has been recently identified as the sixth common reason for hospital outpatient department visits.2 In most of the cases, cough occurs as part of a brief, self-limiting illness. However, it can become a persistent symptom in several cases.1 A cough can be arbitrarily classified as acute (that lasts for <3 weeks), subacute (that lasts between 3 and 8 weeks) and chronic (that lasts for >8 weeks). The estimated prevalence of chronic cough is between 11% and 20%.3 In a survey of members of the American Academy of Allergy, Asthma and Immunology in 2008, it was observed that chronic cough was the chief complaint in about 20-40% of new patients.3 Chronic cough occurs more often in females than males. It has been observed that women have a heightened cough reflex sensitivity compared to men.4 In most of the cases, chronic cough is dry or minimally productive in nature.5 The etiology of cough is diverse and commonly includes environmental causes (cigarette smoke, pollutants, etc.) and several respiratory and nonrespiratory disease entities.6 The objective of this article

Professor and HOD of TB and Chest Medicine KIMS Hospital, Bangalore E-mail: nhuliraj@gmail.com

is to highlight the importance and consequences of cough and the effective diagnosis and management of postnasal drip syndrome/upper airway cough syndrome and postinfectious cough. In preparing this article, PUBMED was searched for studies/guidelines published in the English language using the medical subject heading terms cough, causes of cough, etiology of cough, postinfectious cough, post-viral cough, upper airway cough syndrome and postnasal drip.

Importance of the Cough Reflex and Complications of Chronic Cough Cough is an important defense mechanism of the lungs. It helps in clearing excessive secretions, fluids, noxious substance or foreign material from the airway.

Both excess as well as a shortfall of cough can have harmful effects on the body. While absence of cough can cause frequent aspirations leading to infection and pneumonia, an excessive cough is associated with a variety of physical and psychological complications (Table 1)7,8 This ultimately reduces the health-related quality-of-life of patients.8 Spectrum and Frequency of Etiologies Chronic cough can be the key symptom of many respiratory and nonrespiratory conditions. Postnasal drip syndrome, postinfectious cough and asthma are the most common respiratory causes of chronic cough,

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RESPIRATORY INFECTIONs Table 1. Potential Complications from Excessive Cough7,8 Central nervous system

Cough syncope, headache, cerebral air embolism, cerebrospinal fluid rhinorrhea, acute cervical radiculopathy, malfunctioning ventriculoatrial shunts, seizures , stroke due to vertebral artery dissection

Respiratory system

Pulmonary interstitial emphysema, laryngeal trauma, tracheobronchial trauma, exacerbation of asthma, intercostal lung herniation, pneumothorax, pneumomediastinum, subcutaneous emphysema

Cardiovascular system

Arterial hypotension, loss of consciousness, rupture of subconjunctival, nasal and anal veins, dislodgement/malfunctioning of intravascular catheters, bradyarrhythmias, tachyarrhythmias

GI system

Gastroesophageal reflux events, hydrothorax in peritoneal dialysis, malfunction of gastrostomy button, splenic rupture, inguinal hernia, esophageal perforation

Genitourinary system

Urinary incontinence, inversion of bladder through urethra

Musculoskeletal system

Rupture of rectus abdominis muscles, rib fractures, intercostal muscle rupture, cervical disc prolapse

Miscellaneous

Disruption of surgical wounds, constitutional symptoms, self-consciousness, hoarseness, dizziness, fear of serious disease, decrease in the quality-of-life, social embarrassment, depression, petechiae

Table 2. Causes of Chronic Cough9 Respiratory conditions Common causes

Postnasal drip syndrome (upper airway cough syndrome), postinfectious cough, asthma, acute bronchitis

Other causes

Allergic or vasomotor rhinitis, abscess, sinusitis, allergic inflammation, aspiration, bronchiectasis, bronchitis, chronic obstructive pulmonary disease, cystic fibrosis, eosinophilic bronchitis, interstitial lung disease, pertussis, primary or metastatic lung tumors, sarcoidosis, tuberculosis

Nonrespiratory conditions Common causes

Gastroesophageal reflux disease, recurrent aspiration

Other causes

Left ventricular failure, mitral stenosis, psychological response, pulmonary infarction

Postnasal drip syndrome is considered as one of the most common causes of chronic cough with reported incidence between 6% and 73% of a studied population (see Fig 1).10 It is also commonly associated with the common cold (acute cough).11 Postnasal drip syndrome has been renamed upper airway cough syndrome by the

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Number of patients (%)

60 50 40 30 20 10

41 38 29 26

33 24

26.7

22 12

18

17

24.4 18.6

6

0 R S Po (1 Irw e 98 in (1 0) R 98 S 9) ( M C el 199 a Br rn lo 0 ig ey (1 ) ht 9 lin IK 96 g (1 ) C 9 Jo E 97 o (19 ) J A H 99 Bi yik (20 ) rri S 02 Ka ng (20 ) st SS 03 Fu elik (2 ) jim JA 00 4) u ( Ya ra M 200 5) ng ( Z 20 La M ( 05 i K 20 ) Lu F ( 05) G 200 La L (2 6) i K 00 F 9 (2 ) 01 2)

In general, adults produce about 20-30 mL of nasal mucus every day, which is either expectorated or swallowed with saliva. Very often, patients complain of a sensation of secretions from the nose or paranasal sinuses into the pharynx, leading to throat clearing, coughing or both.3

73

70

in

Postnasal Drip Syndrome/Upper Airway Cough Syndrome: Diagnostic Approaches

80

Irw

while gastroesophageal reflux disease is a common nonrespiratory cause. The respiratory and nonrespiratory etiologies of chronic cough are summarized in Table 2.9

Figure 1. Postnasal drip syndrome as the cause of chronic cough in various epidemiological studies.10

guideline committee of the American College of Chest Physicians (ACCP) because it is not clear whether the cough is caused by irritation from direct contact with

RESPIRATORY INFECTIONs postnasal drip or by inflammation of cough receptors in the upper airway.11 Upper airway cough syndrome may result from a number of distinct etiologies, but it commonly arises from rhinitis or rhinosinusitis.11

Diagnosis As postnasal drip is not a disease, but a symptom, the diagnostic approach should take into consideration a combination of criteria, including symptoms, physical examination findings (including deviated nasal septum, turbinate hypertrophy, polyps, sinusitis), radiographic findings and response to specific therapy.11 ÂÂ Common symptoms suggestive of upper airway cough syndrome include throat clearing, sensation of postnasal drip, nasal congestion or discharge, cobblestone appearance of the oropharyngeal mucosa and previous history of upper respiratory illness (e.g., cold).11 ÂÂ Other symptoms that may help in diagnosing upper airway cough syndrome include cough triggered by deep breath, laughing or prolonged talking; nasal quality of voice due to concomitant nasal blockade, congestion and hoarseness of voice. ÂÂ An empiric trial of antihistamine/decongestant therapy with a first-generation antihistamine should be administered. Improvement or resolution of cough with this therapy helps in confirming the diagnosis of upper airway cough syndrome.11 ÂÂ Topical administration of corticosteroid spray with concomitant use of antibiotics is also recommended.

Antibiotics should be initiated in case of sinusitis or mucopurulent sinusitis. ÂÂ Plain sinus radiography and computed tomography imaging are used for the evaluation of postnasal drip if it is the suspected cause for chronic cough.12 Postinfectious Cough: Diagnostic Approaches Postinfectious cough is suspected when a patient with a normal chest radiograph complains of persistent cough (>3 weeks) after an upper respiratory tract infection. It occurs in about 11-25% of patients with persistent cough. Increased frequency of postinfectious cough (between 25% and 50%) has been observed during outbreaks of Mycoplasma pneumoniae and Bordetella pertussis infections. Common pathogens that cause chronic cough in children include respiratory viruses (particularly respiratory syncytial virus and parainfluenza), M. pneumoniae, Chlamydia pneumoniae (strain TWAR), and B. pertussis.13

Pertussis, also called whooping cough, is a severe and debilitating disease that can last for weeks to months and can occur in both children and adults. The cough in adult patients with B. pertussis infection is spasmodic in nature and occurs more frequently at night. Although cough generally lasts for 4-6 weeks, it can persist longer in some patients.13 Although, the exact pathophysiology of postinfectious cough is not known, it is believed to occur as a result of airway inflammation with or without transient airway hyperresponsiveness.13

Diagnosis Although, the clinical diagnosis of postinfectious cough is by exclusion, a careful history, physical examination, as well as serology and sputum culture (if positive) can provide important clues to the diagnosis.13-15 ÂÂ When a patient complains only of cough after a respiratory tract infection for at least 3 weeks, but not more than 8 weeks and has a normal chest radiograph, a diagnosis of postinfectious cough should be considered. ÂÂ In case of suspected M. pneumoniae infection, a high cold agglutinin titer or acute and convalescentspecific serologic studies could help confirm the diagnosis. ÂÂ When a patient has a cough lasting for >2 weeks without any other apparent cause and is associated with, post-tussive vomiting and/or an inspiratory whooping sound, the diagnosis of B. pertussis infection should be made.

The confirmatory diagnosis of B. pertussis infection can be made by detection of the organism from nasopharynx secretions.

Management of Dry Cough Recent guidelines published by the ACCP recommend the use of a first-generation antihistamine in combination with a decongestant for the treatment of chronic cough due to upper airway cough syndrome.11 Nonpharmacological approach such as nasal breathing exercises may also be useful in patients with upper airway cough syndrome. In patients with postinfectious cough, ACCP recommends that if cough persists despite use of inhaled ipratropium, then use of inhaled corticosteroids can be considered. Use of macrolides is recommended in patients with B. pertussis or M. pneumoniae infection.

ACCP also recommends use of antitussive agents such as codeine and dextromethorphan in the management of postinfectious cough when the cough adversely affects the patient’s quality-of-life despite all other measures.15

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RESPIRATORY INFECTIONs Antitussive agents including codeine, pholcodine and dextromethorphan are widely used alone or in combination with antihistamines, decongestants and expectorants for effective symptomatic relief of dry cough. Codeine, in addition to antitussive effect, possesses analgesic and minor sedative effects, which can be especially beneficial in relieving painful cough.16

4. Kelsall A, Decalmer S, McGuinness K, Woodcock A, Smith JA. Sex differences and predictors of objective cough frequency in chronic cough. Thorax 2009;64(5):393-8.

Conclusion

7. Singh S, Singh V. Combating cough–etiopathogenesis.

Supplement to JAPI 2013;61:6-7.

Cough, a common symptom for which patients visit primary care physicians, is normally a self-limiting illness. However, it can become a persistent symptom in several cases. Persistent cough is associated with several physical and psychological complications.

Upper airway cough syndrome, postinfectious cough, asthma and acute bronchitis are the most common respiratory causes of chronic cough. Diagnosis of upper airway cough syndrome requires consideration of a combination of criteria, including symptoms, physical examination findings, radiographic findings and response to specific therapy. The clinical diagnosis of postinfectious cough is usually made by exclusion.

A first-generation antihistaminic agent in combination with a decongestant is recommended for the treatment of chronic cough due to upper airway cough syndrome.

When cough adversely affects a patient’s quality-of-life, centrally-acting antitussive agents such as codeine and dextromethorphan should be considered.

8. Irwin RS. Complications of cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl): 54S-58S.

References 1. Simpson CB, Amin MR. Chronic cough: state-of-the-art review. Otolaryngol Head Neck Surg 2006;134(4):693-700.

2. National Hospital Ambulatory Medical Care Survey: 2010 Outpatient Department Summary Tables. Available a t : h t t p : / / w w w. c d c . g o v / n c h s / d a t a / a h c d / n h a m c s outpatient/2010_opd_web_tables.pdf.

Accessed on Jan. 8, 2014.

3. Goldsobel AB, Kelkar PS. The adults with chronic cough.

J Allergy Clin Immunol 2012;130:825e1-825e6.

5. O’Connell F. Management of persistent dry cough. Thorax 1998;53(9):723-4.

6. Vaishnav KV. Diagnostic approach to cough. Supplement to JAPI 2013;61:8.

9. D’Urzo A, Jugovic P. Chronic cough. Three most common causes. Can Fam Physician 2002;48:1311-6.

10. Lai K, Pan J, Chen R, Liu B, Luo W, Zhong N. Epidemiology of cough in relation to China. Cough 2013;9(1):18.

11. Pratter MR. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl): 63S-71S. 12. Morice AH, Fontana GA, Sovijarvi AR, Pistolesi M, Chung KF, Widdicombe J, et al; ERS Task Force. The diagnosis and management of chronic cough. Eur Respir J 2004;24(3):481-92.

13. Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM, Hoffstein V, et al. Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest 1998;114(2 Suppl Managing):133S-181S. 14. Malowany J, Popat N, Kirchhof M. Chronic cough is a common symptom in children – What is the cause?

UWOMJ 2006;74(2):7-10.

15. Braman SS. Postinfectious cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl): 138S-146S. 16. Padma L. Current drugs for the treatment of dry cough.

Supplement to JAPI 2013;61:9-13.

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Surgery

Postoperative Wounds and their Antimicrobial Sensitivity Pattern (Hospital-Based Surveillance of Aerobic Bacteria) Irfan Iqbal*, Aneesa Afzal, Sajad Majid Qaziâ&#x20AC;

Abstract Surgical site infections are an important cause of hospital-acquired infections among surgical patients and is the commonest troublesome reason for poor wound healing. They continue to be a major problem even in hospitals with the most modern facilities and standard protocols of preoperative preparation and antibiotic prophylaxis.

Keywords: Surgical wound infections, microbiological etiology, antimicrobial sensitivity, aerobic organisms

S

urgical wound infections has plagued surgeons since time immemorial.1 This postoperative complication has at times brought about embarrassment to the surgeon with considerable financial burden and undue discomfort to the patient.

Surgical site infections are an important cause of hospital-acquired infections among surgical patients and is the commonest troublesome reason for poor wound healing.2 In fact, they are the third most commonly reported nosocomial infection and account for approximately a quarter of all nosocomial infections.3 They continue to be a major problem even in hospitals with the most modern facilities and standard protocols of preoperative preparation and antibiotic prophylaxis.4 Surgical site infection rate has varied from a low of 2.5% to a high of 41.9%.5-12 A nosocomial surgical wound infection lengthens the hospitalization by an average of 7.4 days.13

*Registrar â&#x20AC; Assistant Professor Dept. of Otorhinolaryngology Head and Neck Surgery, Government Medical College Srinagar, Jammu and Kashmir Address for correspondence Dr Irfan Iqbal Dept. of Otorhinolaryngology Head and Neck Surgery Government Medical College Srinagar, Jammu and Kashmir E-mail: irfaniqbal0809@yahoo.com

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Material and Methods This descriptive observational study was designed and carried out in the Postgraduate Dept. of ENT and HNS and in the Dept. of Microbiology, Government Medical College, Srinagar, Jammu and Kashmir, in order to survey the common microbiological etiology of surgical wound infections and to establish their antimicrobial sensitivity pattern. This study was carried from October 2010 to March 2012 on 50 cases that underwent major surgical procedures.

Tip of drains secured in during surgical procedures and swabs from surgical drain site were collected aseptically and were subsequently processed for isolation and identification of aerobic bacterial pathogens. Antimicrobial sensitivity to the cultured aerobic organisms was also recorded.

Emergency procedures (2%)

Elective procedures (98%)

Figure 1. Percentage distribution of elective and emergency procedures included in the study.

Surgery

40

36.36

30

27.27

20 10

18.18 4

0 P. aeruginosa

3

2

S. aureus

18.18 2

E. coli

1

Klebsiella

9.09

Enterobacter

Figure 2. Distribution of the bacterial isolates obtained from 12 cases of infected surgical wounds.

Table 1. The Susceptibility Pattern of P. aeruginosa

Table 4. The Susceptibility Pattern of Klebsiella

Antibacterial

Antibacterial

Percentage of susceptibility

Imipenem

86.3

Cefoperazone/sulbactam

73.1

Ceftazidime/clavulanate

65.0

Piperacillin/tazobactam

40.7

Ciprofloxacin

36.0

Ceftazidime

30.3

Cefepime

20.6

Percentage of susceptibility

Imipenem

70.0

Piperacillin/tazobactam

63.7

Levofloxacin

60.5

Amikacin

60.0

Ceftriaxone

41.0

Exclusion Criteria Table 2. The Susceptibility Pattern of S. aureus Antibacterial Linezolid Vancomycin Amikacin Levofloxacin Clindamycin

Percentage of susceptibility 100 94 80 79.7 63.8

Table 3. The Susceptibility Pattern of E. coli Antibacterial Imipenem Cefoperazone/sulbactam Ceftazidime/clavulanate Piperacillin/tazobactam Ciprofloxacin Ceftazidime Cefepime

Percentage of susceptibility 70.3 66.1 65.0 40.7 36.0 30.3 20.6

Inclusion Criteria ÂÂ

Patients undergoing ENT/head and neck surgical procedure necessitating surgical drains.

ÂÂ

Patients of either sex.

ÂÂ

Patients of any age.

ÂÂ

Refusal to participate in the study.

ÂÂ

Preoperative infected cases.

Results A total of 50 specimens were obtained from postoperative wounds of patients under study hospitalized in the ENT ward. Among these patients, 20 (40%) were males and 30 (60%) were females.

Elective operations (n = 49) were 98% of all operative procedures while emergency operations (n = 1) that was a firearm injury constituted 2% (Fig. 1).

In the study, 12 cases of infected surgical wounds were recorded with an infection rate of 24%. Pseudomonas aeruginosa (4 isolates, 36.36%) was the most common isolated organism followed by Staphylococcus aureus (3 isolates, 27.27%), Escherichia coli (2 isolates, 18.18%), Klebsiella (2 isolates, 18.18%) and Enterobacter (1 isolate, 9.09%) (Fig. 2). There was no growth in 38 (76%) samples.

The susceptibility of P. aeruginosa, S. aureus, E. coli and Klebsiella to various antibiotics is shown in Tables 1-4, respectively.

Discussion Despite advances in the operative techniques and better understanding of the pathogenesis of wound infection, postoperative wound infection continues to be a

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Surgery major source of morbidity and mortality for patients undergoing operative procedures. Its rate varies in different countries, different areas and even in different hospitals. Our overall incidence was 24%. Ahmed et al14 has observed incidence of 11% whereas Damani and Ahmed15 has quoted a figure of 40%. The predominant bacterial isolates recovered in our study included P. aeruginosa (36.36%). Our results were consistent with similar studies carried out by Anupurba et al,16 which showed that P. aeruginosa was isolated in 32% of isolates.

Oguntibeju and Nwobu17 in their study concluded it as 33.3% and Hani and colleagues (2009) found a prevalence rate of 27.78%. The maximal susceptibility of P. aeruginosa isolates was against imipenem (86.3%).

Navaneeth et al18 noted a susceptibility of 88% to imipenem. S. aureus was the next most common bacterial isolate obtained in 27.27% followed by E. coli in 18.18% and Klebsiella in 18.18%. The isolation of S. aureus (27.27%) agrees with the findings of earlier work carried out by Enweani et al.19 This finding is not surprising as it forms the bulk of the normal flora of the skin and nails.20 In our study, 100% susceptibility of S. aureus to linezolid was recorded. Malik et al21 also noted 100% susceptibility of S. aureus to linezolid.

Conclusion Despite modern surgical and sterilization techniques and prophylactic use of good antibiotics, postoperative wound infection remains a major contributory factor of patient’s morbidity. The universally acceptable rate of 2% can be achieved by taking proper measures to improve the environment of our operation theaters and wards and the method of sterilization and prophylactic gram-negative coverage.

References 1. Siguan SS, Laudico AV, Isaac MP. Aerobic surgical wound infection: microbiology and antibiotic antimicrobial activity. Philipp J Surg Spec 1987;42(1).

2. Nicholas RL. Wound infection rates following clean operative procedures. Infect Contr Hosp Epidemiol 1992;13:455.

3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Contr Hosp Epidemiol 1999;20:250-78.

4. Yalcin AN, Bakir M, Bakici Z, Dokmetas I, Sabir N. Postoperative wound infections. J Hosp Infect 1995;29:305-9.

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5. Berard F, Gandon J. Postoperative wound infections: the influence of ultraviolet irradiation of the operating room and of various other factors. Ann Surg 1964;160:1-192.

6. Agarwal SL. Study of postoperative wound infection.

Indian J Surg 1972;34:314-20.

7. Rao AS, Harsha M. Postoperative wound infections.

J Indian Med Assoc 1975;64:90-3.

8. Cruse PJ, Foord R. The epidemiology of wound infection.

A 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980;60:27-40.

9. Tripathy BS, Roy N. Post-operative wound sepsis. Indian J Surg 1984;47:285-8.

10. Kowli SS, Nayak MH, Mehta AP, Bhalerao RA. Hospital infection. Indian J Surg 1985;48:475-86.

11. Olson MM, Lee JT Jr. Continuous, 10-year wound infection surveillance. Results, advantages, and unanswered questions. Arch Surg 1990;125:794-803.

12. Anvikar AR, Deshmukh AB, Karyakarte RP. A one year prospective study of 3,280 surgical wounds. Indian J Med Microbiol 1999;17:129-32.

13. Lilani SP, Jangale N, Chowdhary A, Daver GB. Surgical site infection in clean and clean-contaminated cases.

Indian J Med Microbiol 2005;23:249-52.

14. Ahmed M, Alam SN, Khan O, Manzar S. Post-operative wound infection: a surgeon’s dilemma. Pak J Surg 2007;23:41-7.

15. Damani NN, Ahmed MU. Prevention of surgical wound infection. Ann Abbasi Shaheed Hosp Karachi 1999;4:131-2.

16. Anupurba S, Bhattacharjee A, Garg A, Sen MR. Antimicrobial susceptibility of Pseudomonas aeruginosa from wound infections. Indian J Dermatol 2006;51:286-8.

17. Oguntibeju OO, Nwobu RAU. Occurrence of Pseudomonas aeruginosa in post-operative wound infection. Pak J Med Sci 2004;20:187-92.

18. Navaneeth BV, Sridaran D, Sahay D, Belwadi MR. A preliminary study on metallo-beta-lactamase producing Pseudomonas aeruginosa in hospitalized patients. Indian J Med Res 2002;116:264-7.

19. Enweani IB, Esumeh FI, Akpe RA, Taffeng MY, Isibor JO. Bacteria associated with post-operative wounds. J Contem Issues 2003;1:183-8.

20. Junet SB, Geo FB, Stephen AM. Candida albicans.

In: Jawetz, Melnick, Adelberg’s and Medical Microbiology.

23rd edtion. McGraw-Hill 2004:p.645.

21. Malik S, Gupta A, Singh KP, Agarwal J, Singh M. Antibiogram of aerobic bacterial isolates from post-operative wound infections at a tertiary care hospital in India. J Infect Dis Antimicrob Agents 2011;28:45-51.

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News and Views ÂÂ Patients receiving preoperative chemotherapy for

rectal cancer do not have to undergo the hassle and discomfort of intravenous infusion any longer, according to the results of a major randomized trial sponsored by the National Cancer Institute.

Investigators found that in patients with stage II or III disease, outcomes and toxicity were similar with an oral drug, capecitabine and with the current standard of care, which is continuous intravenous infusion of 5-fluorouracil (5-FU). All patients also received concurrent radiation therapy before undergoing curative surgery.

ÂÂ Gavin Churchyard, MBBCh, PhD, of the Aurum

Institute in Johannesburg, South Africa and colleagues report in the January 23 issue of the New England Journal of Medicine that preventive tuberculosis (TB) therapy had no lasting effect on TB incidence among South African gold miners ––a group hard-hit by the disease. In a cluster-randomized trial, the therapy –– 9 months of isoniazid (Nydrazid) –– also did not cut prevalence of TB among the miners. On the other hand, while miners were actually taking the drug, they were less likely to develop TB.

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Clinical Outcomes Utilizing Revascularization and

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(MSCs) into the meniscus after knee surgery is safe, relieves osteoarthritis (OA) pain, and may facilitate regeneration, according to results of a small study published in the January 15 issue of the Journal of Bone and Joint Surgery.

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February issue of the Journal of Nutrition suggests that consuming high levels of flavonoids, including compounds found in berries, tea, grapes and wine, could potentially lower the risk of type 2 diabetes.

ÂÂ Statins may have a role in reducing mortality in

patients with heart failure and preserved ejection fraction (HFpEF). In pooled results of observational studies, statin use was associated with a 40% reduction in the risk of dying through up to 10 years of follow-up (RR 0.60, 95% CI 0.49-0.74), according to Xiao-Hong Huang, MD, PhD, of Fu Wai Hospital in Beijing and colleagues. The reduction was significant both for studies that followed patients for less than 5 years (RR 0.34, 95% CI 0.15-0.77) and for those that followed patients for longer (RR 0.64,

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Around the Globe 95% CI 0.47-0.89), the researchers reported online in the American Journal of Cardiology.

warfarin metabolism, such as metronidazole and trimethoprim-sulfamethoxazole.

ÂÂ In a new study, 5-year overall survival was

ÂÂ New research shows that previously reported

ÂÂ New findings suggest that self-expandable metal

ÂÂ A new study in Pediatrics found that children

significantly better in patients with gastric cancer who did not experience any perioperative complications than in those who did (43% vs 27%; p < .001). Preoperative characteristics associated with complications included older age, elevated American Society of Anesthesiologists class, previous gastrectomy and upper gastrointestinal bleed. stents (SEMS) are a safe and effective approach to treating colorectal obstruction due to malignant disease. Stents can be used as a bridge to surgery or as a palliative treatment. In the study reported in Digestive and Liver Diseases, the technical success rate was 99% and the clinical success rate was 94.6%.

ÂÂ Mechanical bowel preparation before reconstructive

vaginal prolapse surgery offers no advantages and makes patients unhappy, according to a randomized controlled trial published online January 7 in Obstetrics and Gynecology.

ÂÂ After a slow fall season, China has seen a recent

wave of H7N9 avian influenza cases, according to the World Health Organization. The United Nations agency listed 23 new cases, bringing the total reported in January to 58, including four deaths. In contrast, the agency reported just eight cases from Aug. 11 through Dec. 31. But the picture supports fears expressed earlier in 2013 that the virus –– first identified in March of last year –– would return during the 2013-2014 flu season in China.

ÂÂ Eating brown rice instead of white rice may

help prevent and control diabetes in rice-eating populations. In the first randomized controlled trial to compare the two in India, substituting brown rice for white rice in a population of overweight/obese individuals helped significantly reduce glucose levels and lower serum insulin. The findings were presented at the International Diabetes Federation World Diabetes Conference 2013 last month.

ÂÂ In a retrospective study in JAMA Internal Medicine,

the presence of a respiratory infection untreated by an antibiotic, as well as exposure to an antibiotic, after accounting for other factors, were both associated with more than twice the likelihood of having an INR reading of 5.0 or higher (ORs 2.46 and 2.12, respectively) in patients taking warfarin.

Excessive anti-coagulation was significantly more likely to occur with antibiotics that interfere with

differences in gray matter volume (GMV) in individuals with dyslexia are not the root cause of the disorder. Instead, it is likely that some of these differences come about because typical readers grow brain areas as they acquire reading skills, whereas those with dyslexia do not grow them at the same pace. The study was published in the January 15 issue of the Journal of Neuroscience. admitted to the hospital for wheezing or asthma commonly show signs of exposure to tobacco smoke, even when caregivers say there is no exposure, new research indicates. Second-hand smoke exposure was also associated with risk for readmission.

ÂÂ Chronic damage in the small intestine is a risk

factor for hip fracture in patients with celiac disease (CD), according to a cohort study published online January 16 in the Journal of Clinical Endocrinology and Metabolism.

ÂÂ Neoadjuvant chemoradiation with an oral agent

worked just as well as infusional therapy for patients with Stage II and III rectal cancer, as per results of a randomized trial reported at the Gastrointestinal Cancers Symposium.

ÂÂ Extensively drug-resistant tuberculosis (XDR-TB)

appears to be spreading in South Africa, fueled by patients who are discharged despite failing therapy.

In a prospective cohort of patients with XDR-TB in The Lancet, about 40% were eventually discharged into the community and of those, almost half had failed treatment and remained alive and contagious for a median of 19.8 months.

ÂÂ More than 90% of patients with neuroendocrine

tumors had objective responses or stable disease when treated with an off-the-shelf chemotherapy doublet. In a study presented at the Gastrointestinal Cancers Symposium (GiCS), the combination of capecitabine and temozolomide led to a median progression-free survival of almost 2 years among 28 patients, including more than 40 months in the subgroup of patients with pituitary tumors.

ÂÂ Women with early-stage invasive breast cancer who

undergo breast-conserving therapy (BCT) have a higher rate of disease-specific survival than those who undergo mastectomy, according to an analysis published online January 15 in JAMA Surgery.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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emedinews inspiration

Vikramaditya’s Judgement

O

nce there lived an old and pious man, renowned for his honesty. One day his neighbor, a rich merchant comes to him with a request. The merchant was leaving on a voyage and wants the old man to safeguard his wealth, until his return. The old man agrees and with God as witness promises to protect and safeguard the merchant’s wealth.

is innocent of the actual theft, he is guilty of dereliction of duty. The son’s crime was a straight forward one, the old man’s was a graver crime. He did nothing to protect the merchant’s wealth. Far from being vigilant he failed to take action even when he was warned of his son’s misdeeds. Because of his laxity the merchant is condemned to a life of penury. He should be punished.”

The old man then entrusts the safe keep of the merchant’s wealth to his son, from whom he takes an oath of propriety and honesty. Slowly the son starts dipping into the merchants’ wealth; people notice this and warn the old man of the son’s misdeeds.

The old man calls his son asks him to explain, he also reminds him of his oath on following the right path. The son rubbishes the accusations as rumors and the idle gossip of jealous people, who could not bear to see his prosperity. The old man accepts the son’s explanation and things go on as before.

The merchant returns and demands his wealth. The old man calls his son, who hands over a quarter of the merchant’s wealth saying that is all there was. The merchant realizing that he has been cheated approaches the King. The King listens to the merchant’s complaint and summons the old man. The old man comes to the court with his son and handing him over to the King says “your majesty, the merchant is right. My son has confessed to the crime. Please punish him.”

NOW TRY TO SEE THE HAPPENINGS IN INDIA and 2G SCAM IN LIGHT OF THE ABOVE STORY

The king has the son flogged and imprisoned. He then praises the old man’s honesty and dismisses the case.

But the merchant demands punishment for the old man saying, “I have still not received justice. I had entrusted my wealth to the old man which he swore

by God to safeguard. The old man’s integrity is intact, but what of me, I have been robbed of my life’s savings, and made a pauper. It was the old man’s decision to entrust my wealth to his son for safe keeping that has caused this loss. As far as I am concerned the old man is the real culprit, and should be punished.”

The king is astounded by this demand. The old man, was neither a party to the theft nor did he benefit from it. In fact, he had sent his son to jail. Yet, the merchant was asking for the old man’s punishment. The Betal asks Vikramaditya, “What should be the King’s decision.” Vikramaditya’s replies, “Though the old man

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India 2010, Dr Manmohan Singh, esteemed economist, former Governor of RBI, Deputy Chairman of Planning Commission, former Finance Minister, a man whose personal ethics and integrity are unblemished, takes oath to protect and safeguard the Nation and its assets.

He appoints Raja, as his Cabinet Minister for IT and Telecom. Unlike the story, this heist of a precious national asset is carried out in full view of Dr Manmohan Singh and his cabinet colleagues. Newspapers across the country cry out at this outrage in front page headlines.

The Indian Constitution grants the Prime Minister absolute power in running the country. He is the head of the Government and the Union Cabinet functions at his pleasure. As per the Transaction of Business Rules the Prime Minister has the unrestricted right to demand and get any file, any record from any Ministry. Dr. Man Mohan Singh could have at any time stopped this heist of a National asset, yet he chose to remain silent.

The Minister’s failure to exercise his constitutional rights has caused irreparable loss to the Nation.

Dr Singh did not profit personally from Raja’s shenigans, but his failure to act, to honor the oath of office, to protect and safeguard the nation and its wealth is unforgivable. Like the old man, he has sacked Raja from his ministerial berth, but does his culpability end there.

The people of India had entrusted their faith and the future of the Nation in Dr Manmohan Singh, believing him to be a man of integrity and honesty, and not to Raja. Does dismissing Raja absolve Dr Singh or like the old man is he guilty of dereliction of duty and failure to safeguard the Nation and its citizens. Does he deserve punishment? Who can decide here?

mediLAW

When can Hospitals be Liable for Medical Negligence Deaths?

I

f a patient dies due to medical negligence in a hospital then its management cannot be prosecuted and it is only the doctors who should be penalized, the Delhi High Court has ruled. However, the court held that the management of the hospital would be liable in case of administrative negligence and failure to provide basic infrastructure to patients.

petitioner Indraprastha Medical Corporation Limited was a company incorporated under Companies Act and the company being only a juristic person was incapable of committing a crime of medical negligence, because it involved personal negligent act.

Setting aside the trial court order, Justice Dhingra said: “The hospital or company cannot be held liable for the personal negligence of the doctor in giving wrong treatment.”

A complaint was filed before the learned M.M. against the petitioner company and the Doctors involved in the treatment of deceased wherein it was alleged that deceased died due to gross medical negligence of the Doctors. It is also submitted that Doctors involved in treatment advised wrong/superfluous treatments in order to extract extra money. The petitioner’s counsel stated that petitioner is not assailing the order as against Doctors but is assailing it so far as company was concerned on the ground that the company running the hospital, could not have acted in the manner in which it is assailed by the complainant.

“If there is an administrative negligence or a negligence of not providing basic infrastructure, which results into some harm to an aggrieved person or such negligence which is impersonal, the hospital can be held liable”.

In Standard Chartered Bank Vs. Directorate of Enforcement, 2005 SCC (Cri.) 961, SC made following observations regarding criminal liability of the Corporation:

Justice SN Dhingra passed the order on a petition filed by Indraprastha Medical Corporation Limited challenging a metropolitan magistrate’s order for registration of a first information report against it for alleged medical negligence resulting in the death of a patient in 2007.

The court, said that it is the doctor who treats the patients and hospitals should not be punished due to error on part of its medical staff. “The offence of medical criminal negligence cannot be fastened on the company since the company can neither treat nor operate a patient of its own.”

“It is the doctor working in the hospital who treats and performs operations. It is the doctors who examines the patients and prescribe medicines. If there is a deliberate or negligent act of the doctor working in the hospital, it is the liability of the doctor and not of the hospitals for criminal negligence,” the court said.

In the present case, the company contended that the hospital could not be held responsible as the patient was being treated by three doctors from the Dept. of Cardiology a few years back.

Judgment: Present petition has been filed by the petitioner for quashing of order dated 19th December, 2007, passed by learned Metropolitan Magistrate in a complaint case under section 336/337/471 read with section 34 IPC qua the petitioner. It is submitted that

“There is no dispute that a company is liable to be prosecuted and punished for criminal offences. Although there are earlier authorities to the effect that corporations cannot commit a crime, the generally accepted modern rule is that except for such crimes as a corporation is held incapable of committing by reason of the fact that they involve personal malicious intent, a corporation may be subject to indictment or other criminal process, although the criminal act is committed through its agents.

Inasmuch as all criminal and quasi-criminal offences are creatures of statute, the amenability of the corporation to prosecution necessarily depends upon the terminology employed in the statute. In the case of strict liability, the terminology employed by the legislature is such as to reveal an intent that guilt shall not be predicated upon the automatic breach of the statute but on the establishment of the actus reus, subject to the defence of due diligence. The law is primarily based on the terms of the statutes. In the case of absolute liability where the legislature by the clearest intendment establishes an offence where liability arises instantly upon the breach of the statutory prohibition, no particular state of mind is a prerequisite to guilt. Corporations

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mediLAW and individual persons stand on the same footing in the face of such a statutory offence. It is a case of automatic primary responsibility. It is only in a case requiring mens rea, a question arises whether a corporation could be attributed with requisite mens rea to prove the guilt. But as we are not concerned with this question in these proceedings, we do not express any opinion on that issue.”

In Kalpnath Rai Vs. State, 1998 AIR (SC) 201, SC made following observations: “The company is not a natural person. We are aware that in many recent penal statutes, companies or corporations are deemed to be offenders on the strength of the acts committed by persons responsible for the management of affairs of such company or corporations e.g. Essential Commodities Act, Prevention of Food Adulteration Act etc. But there is no such provision in TADA which makes the company liable for the acts of its officers. Hence, there is no scope whatsoever to prosecute a company for the offence under Section 3(4) of TADA. The corollary is that the conviction passed against A-12 is liable to be set aside.” In Standard Chartered Bank Vs. Vinay Kumar Sood & Ors, 2009 (1) JCC 756, this court had observed as under: “Undisputedly, the petitioner is a bank incorporated in England with limited liability by Royal Charter, 1853 and, therefore, is a corporation/company. A company cannot be in any case held to have committed an offence under Section 500 IPC because; most essential ingredient of the said offence i.e. ‘mens rea’ would be missing as a company is a juristic entity or an artificial person, whereas a Director is not a company. The company may be made liable for offences, however, if there is anything in the definition or context of a particular Section or a particular statute which would prevent the application of the said section to a limited company, the limited company cannot be proceeded against.

There are number of provisions of law in which it would be physically impossible by a limited company to commit the offence. A limited company, therefore, cannot generally be tried for offences where mens rea is essential. Similarly, a company cannot face the punishment of imprisonment for obvious reasons that company cannot be sent to prison by way of a sentence.”

The offence of criminal negligence requires a specific state of mind in respect of the person committing the offence. The offence of medical criminal negligence cannot be fastened on the company since the company can neither treat nor operate a patient of its own. It is the Doctor working in the company who treats and

performs operations. It is the Doctor who examines the patients and prescribes medicines. If there is a deliberate or negligent act of the Doctor working in the Corporation/Hospital, it is the liability of the Doctor and not of the Corporation for criminal negligence despite the fact that due to the act of the Doctor of treating patients the Corporation was getting some revenue. These days, all Doctors with big hospitals, are on panels where they have fixed fee for examination of patients and for conducting operations. Out of this fee, a percentage is paid to the hospital. The hospital/ company cannot be held liable for the personal negligence of the Doctor in giving wrong treatment.

However, if there is an administrative negligence, or a negligence of not providing basic infrastructure, which results into some harm to an aggrieved person or such negligence which is impersonal, the hospital can be held liable. But, in the case of medical negligence, which is personal to the Doctor who gave treatment, the Corporation would not be liable and it is the Doctor who can be indicted for medial criminal negligence.

I therefore, allow this petition in respect of the petitioner. The order passed by learned M.M. qua the petitioner is hereby quashed.

(August 02, 2010 SN Dhingra, J) Comments 1. Is an important judgement.

2. Needs to be read in totality.

3. Is applicable mainly for the criminal act and not for compensation purposes.

4. A criminal negligence on the part of a resident will be the responsibility of the resident and not the hospital.

5. But a fault of a resident where compensation is awarded will have to be paid by the hospital as he is the full time salaried staff of that hospital.

6. The judgment lines “However, if there is an administrative negligence, or a negligence of not providing basic infrastructure, which results into some harm to an aggrieved person or such negligence which is impersonal, the hospital can be held liable” Covers a lot of situations. A mistake by the nurse, resident, pathology services, radiology services etc. will come under the “providing basic infrastructure services”.

■■■■

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

eMedi Quiz

Quiz Time 1.

He has been a chronic smoker for 30 years.

On examination, a reddish area of mucosal irregularity overlying a portion of both cords was seen. Management would include all except:

A vascular necrosis can be possible sequelae of fracture of all the following bones, except:

A. Femur neck B.

Scaphoid

C.

Talus

D. Calcaneum 2.

A 10-year-old girl presents with swelling of one knee joint. All of the following conditions can be considered in the differential diagnosis, except:

A. Cessation of smoking B.

Bilateral cordectomy

C.

Microlaryngeal surgery for biopsy

D. Regular follow-up.

5.

A 5-year-old boy passed 18 loose stools in last 24 hours and vomited twice in last 4 hours. He is irritable but drinking fluids. The optimal therapy for this child is:

A.

Intravenous fluids

B.

Oral rehydration therapy

C.

Intravenous fluid initially for 4 hours followed by oral fluids

A. Tuberculosis B.

Juvenile rheumatoid arthritis

C.

Hemophilia

D. Villonodular synovitis 3. Thirty-eight children consumed eatables procured from a single source at a picnic party.

Twenty children developed abdominal cramps followed by vomiting and watery diarrhea 6-10 hours after the party. The most likely etiology for the outbreak is:

D. Plain water ad libitum 6.

A couple, with a family history of beta thalassemia major in a distant relative has come for counseling. The husband had HbA2 of 4.8% and the wife has HbA2 of 2.3%. The risk of having a child with beta thalassemia major is.

A. Rotavirus infection.

B.

Entero-toxigenic Escherichia coli infection

C.

Staphylococcal toxin

D. Clostridium perfringens infection 4.

A middle-aged male comes to the outpatient department (OPD) with the only complaint of hoarseness of voice for the past 2 years.

A. 50% B.

25%

C.

5%

D. 0%

Answers to eMedi Quiz Published in January 2014 Issue Q1. C. Loss of overhead abduction Q2. D. Protein folding Q3. B. Corticosteroid Q4. A. Transitional Q5. D. Oxygen affinity of hemoglobin

Send your answers to the Editor-Indian Journal of Clinical Practice.

E-mail: editorial@ijcp.com The correct answers will be published in the next issue of IJCP.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

895

lighter reading

Old age secret Grandpa was celebrating his 100th birthday and everybody complimented him on how athletic and well-preserved he appeared.

“Gentlemen, I will tell you the secret of my success,” he cackled. “I have been in the open air day after day for some 75 years now.”

The celebrants were impressed and asked how he managed to keep up his rigorous fitness regime.

“Well, you see my wife and I were married 75 years ago. On our wedding night, we made a solemn pledge. Whenever we had a fight, the one who was proved wrong would go outside and take a walk.”

Quote

LAUGH-A-WHILE

Lighter Side of Medicine “Difficulties increase the nearer we get to the goal” −Johann Wolfgang von Goethe

“The bad news is time flies. The good news is you’re the pilot.”

−Michael Altshuler

Make Sure

During Medical Practice An elderly patient taking diphenhydramine develops urinary retention.

Oh! My god, I forgot that this drug has anticholinergic side effects

Science Lesson

©IJCP Academy

Miss Jones had been giving her second-grade students a lesson on science. She had explained about magnets and showed how they would pick up nails and other bits of iron. Now it was question time, and she asked, “My name begins with the letter ‘M’ and I pick up things. What am I?” A little boy on the front row proudly said, “You’re a mother!”

Make sure that in elderly patients with suspected BPH first generation H1 antihistamines are not prescribed, since they can cause acute urinary retention due to anticholinergic side effects.

New antihistamines like loratadine do not have this side effect.

Dr. Good and Dr. Bad Situation: A diabetic patient with CKD wanted to know if he should exercise.

KK Aggarwal

ILLUSION Yes, it will help

©IJCP Academy

NO

Lesson: The effect of exercise is well-established, in the treatment of CKD in the presence of diabetes mellitus (DM/CKD). A recent study revealed that exercise, at the recommended level or more, is associated not only with lower odds of DM/CKD but also with a 26% lower mortality risk among DM/CKD patients.

KK Aggarwal

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Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767).

Indian Journal of Clinical Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.

The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript.

Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper.

Covering letter –

– –

The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper.

Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors.

Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript Three complete sets of the manuscript should be – submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures).

–

The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

–

All pages should be numbered consecutively beginning with the title page.

Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.

Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed,

name of the corresponding authors, acknowledgment of financial support and abbreviations used.

– The title should be of no more than 80 characters and should represent the major theme of the manuscript.

A subtitle can be added if necessary.

– A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

– The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page.

– A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary – The summary of not more than 200 words. It must convey the essential features of the paper.

– It should not contain abbreviations, footnotes or references.

Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives.

Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others.

– Ethical guidelines followed by the investigations should be described.

Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected.

– Method of selecting the sample (cases, subjects, etc. from the statistical universe).

– Method of allocating the subjects into different groups.

– Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

–

Confidence intervals for the measurements should be provided wherever appropriate.

Results – These should be concise and include only the tables and figures necessary to enhance the understanding of the text.

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

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Discussion –

This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g., practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses).

At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution.

Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes.

Q. J. Expt. Physiol. 1955;40:89-111.

Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat.

– All photomicrographs should indicate the magnification of the print.

– Special features should be indicated by arrows or letters which contrast with the background.

– The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen.

– Color illustrations will be accepted if they make a contribution to the understanding of the article.

–

Do not use clips/staples on photographs and artwork.

–

Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”.

Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________ 2. Total number of pages ________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________

Books

5. Special requests _____________________________

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

Indian 1.____________Foreign 1.________________

Articles in Books

2.____________ 2.________________

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

3.____________ 3.________________

4.____________ 4.________________

Tables –

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends – These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text.

–

898

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

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014

6. Suggestions for reviewers (name and postal address)

7. All authors’ signatures________________________ 8.

Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Online Submission Also e- Issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Indian Journal of Clinical Practice E-219, Greater Kailash, Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com

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R.N.I. No. 50798/90 Date of Publication 13th of Same Month Date of Posting 13-14 Same Month

DL (S)-01/3200/2012-2014 Posted in N.D. PSO New Delhi