Ijcp june 2015 by IJCP

Indexed with IndMED

ISSN 0971-0876

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Volume 26, Number 1

June 2015, Pages 01–100

Anesthesiology

Cardiology

Clinical Psychology

Community Medicine

Critical Medicine

Dentistry

Dermatology

Diabetology

ENT

Internal Medicine

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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, Dr BC Roy & National Science Communication 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

Volume 26, Number 1, June 2015 FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

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.

KK Aggarwal

ANESTHESIOLOGY

15 To Evaluate the Effectiveness of Oral Tablet Clonidine as a Premedicant Drug: A Prospective Study of 100 Cases

B Brinda, S Chakravarthy, S Manjunatha Prasad

CARDIOLOGY

23 Complete Heart Block in Rheumatoid Arthritis

Kavina Marian Fernandes, Vivek GC

CLINICAL PSYCHOLOGY

26 Impact of Perceived Stress and Locus of Control on Conflict Resolution Styles

Sachin, Krishan Kumar, Rajeev Dogra

COMMUNITY MEDICINE

40 Global Pathway, Current Condition and Challenges in the Management of Dengue

Sathish Amirthalingam

CRITICAL MEDICINE

44 Incidence, Susceptibility Profiles and Risk Factors of

Multidrug-resistant Nonfermenting Gram-negative Bacilli Causing Ventilator-associated Pneumonia in a Tertiary Care Hospital

Kalidas Rit, Bipasa Chakraborty, Udayan Majumder, Parthasarathi Chakrabarty, Saswati Chattopadhyay, Hirak Jyoti Raj

DENTISTRY

48 Multidisciplinary Management of a Patient with Idiopathic

Gingival Enlargement and Congenitally Missing Mandibular Lateral Incisors

Raghu Devanna, Chandrashekar Sajjan, Shivanand Aspalli, Siddanth Jajoo

DERMATOLOGY

56 Recalcitrant Plaque Psoriasis Cleared with 308 nm Excimer Light

Sanjeev J Aurangbadkar

DIABETOLOGY

59 Gender-related Difference in Socioeconomic and Behavioral Factor in Relation to BP and BMI of Type 2 Diabetic Workers from Match Factories and Fireworks in Sivakasi, Tamil Nadu

Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

Natural Disasters

V Priya, Mazher Sultana, Babuji, Kamaraj

ENT

67 Facial Necrotizing Fasciitis: A Rare Complication of Maxillary Sinusitis

N Gupta, S Varshney, P Gupta

INTERNAL MEDICINE 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

70 Multisystem Involvement in Melioidosis: A Case Report

Priyadarshini Gunaseelan, Swamikannu M, Vaidehi R, Sarveswari KN

NEUROSURGERY

73 Pneumocephalus after Ventriculoperitoneal Shunt:

Diagnostic Dilemma and its Endoscopic Management

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

Hanish Bansal, Rakesh Kaushal, Manish Munjal

OBSTETRICS AND GYNECOLOGY

77 A Comparative Study to Assess the Interference of Calcium Lysinate

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.

with Iron Absorption When it is Co-administered with Iron Supplements

N Vijayalakshmi, SB Joshi, PN Kasture, KH Nagabhushan

OPHTHALMOLOGY

83 Adult Unilateral Chorioretinal Atrophy Secondary to Acquired Rubella

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Meenakshi Patil, Neelam Redkar, Maruti Karale, Manish Dodmani

EXPERTSâ&#x20AC;&#x2122; VIEW

86 What are the Risks of Myocardial Infarction and/or Death in a Patient with Unstable Angina During Hospital Admission?

TS Kler, KK Aggarwal

ALGORITHM

88 Fever in the ICU Patient CPA

90 Medical Negligence and Consumer Protection Act

Justice NV Ramana

AROUND THE GLOBE

93 News and Views LIGHTER READING

95 Lighter Side of Medicine

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FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

Prof. Dr KK Aggarwal

Padma Shri, Dr BC Roy & National Science Communication Awardee Sr. Physician and Cardiologist, Moolchand Medcity President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS

Natural Disasters ÂÂ A natural disaster is always unpredictable and requires crisis management. ÂÂ The role of medical doctors is very important. Disaster Management and Crisis Management should be made

compulsory subjects in MBBS and Post Graduation courses. There are protocols for medical crisis management in a war. Similar protocols should be followed during any natural disaster.

ÂÂ Disaster Management is based on the following principles: One cannot live for more than 3 minutes without

air, one cannot live for more than 3 days without water and one cannot live for more than 3 weeks without food.

ÂÂ Triage management is the basic principle to be adopted in disaster management. ÂÂ Most people who reach the hospital within the first hour are the ones who are usually not injured much. The

real emergencies or critical patients start coming in after one hour.

ÂÂ Number of people reaching for medical help at the end of one hour can be multiplied by two to calculate the

total requirement.

ÂÂ In Triage management, priority should be given to people who require emergent and urgent care based on the

facilities available in the set-up.

ÂÂ Everybody in the team should know how to resuscitate a person. The senior most person should become the

team leader and be responsible for management.

ÂÂ Medical profession faces a lot of problems during the natural disaster such as scarcity of medical supply,

unavailability of specialists, and scarcity of safe water. They often have to manage patients in stop gap arrangements like a hospital in the tent.

ÂÂ The main diseases which spreads after disaster are water-borne diseases, especially cholera. If not prevented,

it can also end up in another disaster. The prevention is safe water supply.

ÂÂ Any doctor who wants to help and wishes to provide his/her services during the disaster, should go through

Medical Associations like the IMA so that there is a rational use of medical resources available.

ÂÂ Commercialization of medical profession does not mean that the medical profession will not remain noble.

Corporatization is by the commercial bodies for the purpose of profit. The difference between the corporate hospital and trust hospital is that in corporate hospital money earned can be used by the Board of Directors for their personal use and in a trust, the money earned has to be used only for the purpose for which the trust was made.

ÂÂ As far as doctors are concerned, whether they work in trust or in corporate hospital, their job is to provide

services which are transparent, ethical and full of seva.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

EMINIENT EDITORS

r Alka Kriplani is an Indian gynecologist, medical writer and academic, known for her contributions to the fields of reproductive endocrinology and gynecological endoscopy. A recipient of the Dr BC Roy National Award in 2007, she was honored by the Government of India in 2015 with Padma Shri, the fourth highest Indian civilian award.

Prof Alka Kriplani Professor & HOD Dept. of Obstetrics and Gynecology Director in-charge WHO-CCR HRRC & Family Planning All India Institute of Medical Sciences, New Delhi

She is the editor of Asian Journal of Obstetrics and Gynecology practice for more than one decade. She is actively associated and occupies official positions with various national and international associations including Federation of Obstetricians and Gynecologists of India (FOGSI). She is an honorary Fellow of Royal College of Obstetricians and Gynecologists (FRCOG) of London and holds the Fellowships of Academy of Medicine, Singapore (FAMS), Indian College of Obstetricians and Gynecologists (FICOG), Indian College of Maternal and Child Health (FICMCH) and the Federation of Immunological Societies of AsiaOceania (FIMSA). Dr Kriplani is the president of the Gynecological Endocrine Society of India (GESI) since 2011 and a former Vice President of the Federation of Obstetricians and Gynecological Societies of India and the Delhi Gynecological Endoscopists Society. Dr Kriplani is reported to have been involved in research and clinical trials in the field of gynecology. She is a recipient of several awards and honors such as CL Jhaveri (1995), Dr Neera Agarwal Gold Medal (1999), KP Tamaskar Award (2002), DMA Medical Teachers Award (2005), Jagadishwari Mishra Award (2006), Rashtriya Gaurav Award (2007), IMAAMS Distinguished Service Award (2007), and DGF Women of the Year Award (2010).

ight in the heart of the city of Chennai is Dr Kamala Selvaraj’s dream project, the “Fertility Research Centre”, pioneering assisted reproductive technology with a state-of-the-art IVF laboratory. She is the daughter of the famous yesteryear cine star late Mr Gemini Ganesan. She got trained in “In vitro Fertilization and Embryo Transfer” techniques at the Monash University in 1985 followed by several training programs in Singapore and Monash University. Dr Kamala Selvaraj commissioned the first test tube baby of South India in August 1990 and since then had many achievements to her credit. In 2001, she was awarded PhD for her thesis on “Premature ovarian failure and its management”. She is known for having operated for first Gamete Intrafallopian Tube transfer (GIFT) twins in South India, first Pronucleus Stage Transfer (PROST) baby in South India. First Surrogate Baby of India, first test tube baby to a 50-year-old woman put on HRT in India. First test tube baby to a patient with premature ovarian failure donor oocyte program with HRT, Programmed and delivered the first baby in India with the Fallopian Replacement of Oocyte with Timed Insemination (FROOTI) Technique invented by her. First pregnancy in a single woman in India - first Intracytoplasmic Sperm Injection (ICSI) baby of South India. South India’s first baby (triplets) from frozen embryo, Asia’s first (twins) born to a patient with Mayer-Rokintansky-Küstner-Hauser syndrome through a surrogate. India’s first frozen oocyte baby-male, India’s first twin baby by vitrification method.

Dr Kamala Selvaraj Associate Director GG Hospital, Chennai

She has received many national awards.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

EMINIENT EDITORS

r Sameer Shrivastava is a very familiar name in the field of Noninvasive Cardiology with an experience of more than 25 years. He heads the Dept of Noninvasive cardiology at Fortis Escorts Heart Institute (FEHI).

His keen interest in teaching and training distinguishes him from his peers. Also to his credit is the running of PGDCC at FEHI. He is a teacher and guide for superspeciality course in cardiology (DNB) at FEHI. He has to his credit being an integral part of first cardiac transplant at FEHI. Dr Sameer's strong inclination towards research has added several academic publications to his work. He has edited books “Cardiology Update” “Advanced Cardiovascular Medicine”.

Dr Sameer Shrivastava Director and HOD Non-Invasive Cardiology Fortis Escorts Heart Institute & Research Centre, Delhi

r Swati Yashwant Bhave is the Executive Director of AACCI (Association of Adolescent and Child Care in India) and was senior Visiting Consultant at Indraprastha Apollo Hospital, New Delhi.

She trained in USA in Adolescent Medicine in 2001 and is an office bearer in many International Adolescent Health Associations and also WHO committees of Adolescent Health. She has won many awards both for academics and extracurricular activities and written many books on adolescent and mental health issues. During 1989-1990, Dr Bhave was a Visiting Professor at Harvard Medical College & Massachusetts General Hospital (USA). In the last few years she has conducted a large number of workshops for parents, teachers, students both from school and college in many cities of India. She has also published and presented research surveys done on the participants of the workshops. Dr Bhave is Past President of the Indian Academy of Pediatrics. International positions held - Co-coordinator of Development International Pediatric Association (IPA) 2007-2014, Vice President International Association of Adolescent Health (IAAH) 2009-2011, Member of WHO Technical Steering Committee on Child and Adolescent Health 2007-2009.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

Dr Swati Y Bhave Issue Editor Asian Journal of Pediatrics Practice

EMINIENT EDITORS

r Mithal has achieved a landmark by being awarded Padma Bhushan 2015 for his outstanding contribution in the field of Medicine.

Dr Mithal was the first DM in Endocrinology from the All India Institute of Medical Sciences (1987), and subsequently served on the faculty at Sanjay Gandhi PGI, Lucknow (1988-1998) where he was instrumental in setting up the Dept. of Endocrinology. From December 1998, Dr Mithal has been Senior Consultant at Apollo Hospital, New Delhi, where he established DNB (Endocrinology) training program. Dr Mithal is immediate Past President, Endocrine Society of India and the Chairperson, Bone and Joint Decade, India. He is the founder, Past President and currently Chief Advisor to the Indian Society for Bone and Mineral Research (ISBMR).

Dr Ambrish Mithal Chairman, HOD Division of Endocrinology and Diabetes Medanta the Medicity

He chairs the Nutrition Working Group of the Committee of Scientific Advisors, and has recently been elected Chairperson of the Asia Pacific Advisory Council of the International Osteoporosis Foundation (IOF, Switzerland). He is the issue editor of Asian Journal of Diabetology, esteemed journal by IJCP group of publications.

r Jasveer Singh is the editor of Asian Journal of Ear, Nose and Throat, esteemed journal by IJCP Group of Publications.

He is a Visiting Consultant at City Hospital affiliated with Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi. He also serves as Chief ENT Consultant, Dept. of ENT, Central Hospital, New Delhi. Dr Singh is Chief & Senior Resident, Dept. of Oto-Rhino-Laryngology, King George’s Medical College, Lucknow; Registrar & Lecturer, Dept. of Oto-RhinoLaryngology, Christian Medical College, Ludhiana. He is ENT Consultant in Indian Railways, since 1983 in Divisional Hospital Asansol, West Bengal. He got accreditation of DNB studies in Northern Railway Central Hospital, New Delhi in 1991. He had many published papers in National & International journals. He is the author of book “Examination preparatory manual for ENT”.

Dr Jasveer Singh Visiting consultant City Hospital affiliated with Sir Ganga Ram Hospital, Rajinder Nagar New Delhi

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

EMINIENT EDITORS

r Pal has built a large national and international clientele. She has been actively involved in organizing various ENT workshops and has been at the forefront of all academic activities at Moolchand.

Dr Pal is a distinguished ENT surgeon with 20+ years of experience. She holds expertise in a wide range of ENT surgeries and has perfected upon Endoscopic Sinus Surgery (2,000+ surgeries done till date).

Dr Chanchal Pal Senior Consultant Moolchand General Hospital Moolchand Medcity New Delhi

r KMK Masthan, MDS is Professor & Head, Dept. of Oral Pathology & Microbiology, Sree Balaji Dental College & Hospital, Chennai. He has an extensive 17 years of experience in teaching BDS and MDS students and 21 years of experience in clinical practice. He is the Editor-in-Chief of Indian Journal of Multidisciplinary Dentistry (IJMD). He has authored thirteen books, ten in English and three in Tamil. He has published many articles in the National & International Journals. He is a Peer-Reviewer for several Journals on Dentistry, Oral Health and Oral Pathology. He is a member of the Advisory Board of Journal of Applied Medicine & Surgery (JAMS). He is also a member of Indian Dental Association and Indian Association of Oral Pathology. Dr KMK Masthan Professor & HOD Department of Oral Pathology & Microbiology Sree Balaji Dental College & Hospital, Chennai

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

EMINIENT EDITORS

r Ajay Kumar is a Senior Consultant in Gastroenterology and Hepatology at Indraprastha Apollo Hospital in New Delhi, India and recipient of the prestigious Dr BC Roy National Award.

Dr Kumar is a medical graduate from GGS Medical College, Faridkot. Postgraduate in Medicine from PGI, Chandigarh, and post-doctoral training in Gastroenterology at GB Pant Hospital, New Delhi. After establishing the Dept. of Gastroenterology and Hepatology at Moolchand Medcity, New Delhi, in 1996, he moved on to Indraprastha Apollo Hospital, New Delhi, the premier tertiary-care hospital in India.

Dr Ajay Kumar Gastroenterologist & Hepatologist Indraprastha Apollo Hospitals New Delhi

This now has developed into the key referral center for Therapeutic Endoscopy and Hepatology services in India and South Asia. He has more than thirty five publications in the national and international journals. He has made significant contributions to the research in the area of corrosive esophageal strictures and nomenclature of gastric varices. Dr Ajay Kumar is known for his administrative skills. In addition to many responsibilities, he has been President of Society of GI endoscopy of India and has been its Hony Secretary for three years.

r JS Pasricha is the Ex-Head of the Dept. of Dermatology at the All India Institute of Medical Sciences (AIIMS) and is a renowned dermatologist, held in high regard.

Research Papers 190 papers in national/international journals on contact dermatitis, urticaria, drug eruptions, pemphigus and pulse therapy, vitiligo, acne, hair diseases and others.

Editorship Chief Editor Indian Journal of Dermatology, Venereology and Leprology 1984-1990 (6 years).

Industrial surveys ÂÂ 25000 industrial workers around Delhi for skin diseases ÂÂ Silk workers in Bangalore and Guwahati ÂÂ Cashewnut workers around Manipal ÂÂ Prawn workers around Manipal ÂÂ Tea-Coffee plantations in Coorg and Dibrugarh.

Dr JS Pasricha Professor and Head (Retd.) Department of Dermatology and Venereology All India Institute of Medical Sciences, New Delhi

The other fields of interest include allergic diseases (especially contact dermatitis, physical urticaria and drug eruptions especially TEN), acne and hair diseases especially pre-mature grey hairs and telogen effluvium. Currently, managing a private dermatology clinic in New Delhi since 1998.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

EMINIENT EDITORS

r Rajat Kandhari completed his MBBS from Pune university and his MD in Dermatology from Sri Ramachandra University and Medical College, where he topped the university.

He has 3 years of working experience in Safdarjung Hospital, New Delhi. He has authored and co-authored articles in national textbooks and national journals, and is the recipient of the EADV fellowship award, the International Congress of Dermatology Global education award, the Imrich Sarkany Memorial Scholarship and the Prof. Patrick Yesudian award. He has received training in various fields of leprosy from the reputed Schieffelin Institute of Health, Research & Leprosy Center, Karigiri, Tamil Nadu and has received training in botox, dermal fillers and lasers at Kasemrad Hospital, Bangkok under Dr Niwat Polnikorn.

Dr Rajat Kandhari Consultant Dermatologist New Delhi

He has been an invited speaker at various national forums and has also presented papers in international conferences. He takes keen interest in General Dermatology and Dermatological procedures and Aesthetic Dermatology (Botulinum Toxin, Restylane/Juvederm, Chemical Peels).

r JS Rajkumar graduated from Madras Medical College, Chennai with 32 gold medals. After that, he went on to do his post graduation and got four FRCS to his credit.

He is a prolific surgeon with a huge volume of laparoscopic and open surgeries in Chennai since 1993. He is also one of the International Examiners for the Royal College of Surgeons, Edinburgh. He is the Chairman of the Lifeline Group of Hospitals, founded by him in 1997, with two tertiary hospitals and two primary hospitals. He was also responsible for setting up the first ever stem cell unit in Chennai and also for reporting the first successful case after stem cell therapy. The hospital has done clinical trials on various fields like spinal cord injury, liver diseases, neuro etc. on about 650 patients. Dr Rajkumar is the Chairman of the Association of Surgeons of India, TN & P chapter for the year 2011-12. He is totally committed towards treating HIV patients and patients with advanced cancer. He founded a trust in 1997 called "Dr Rajarathnam Medical and Educational Foundation" by means of which he continues to render free service to hundreds of HIV and cancer patients. He is the recipient of several awards for his vocational excellence from organizations like Rotary, Lions, Public Relations Syndicate, Ved Vyas Trust etc. Dr Rajkumar is a very good singer and enjoys writing and has written many poetries and articles for several magazines. He is a voracious reader and a very good orator. He has many publications to his credit both in national and international journals.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

Dr JS Rajkumar Chairman â&#x20AC;&#x201C; Lifeline Group of Hospitals, Chennai

ANESTHESIOLOGY

To Evaluate the Effectiveness of Oral Tablet Clonidine as a Premedicant Drug: A Prospective Study of 100 Cases B BRINDA*, S CHAKRAVARTHY†, S MANJUNATHA PRASAD‡

ABSTRACT Introduction: Premedication is used to provide sedation and anxiolysis and to enhance the quality of induction, maintenance and recovery from anesthesia. The ideal premedicant should be orally effective, possess sedative, analgesic, antianxiety, antisialogogue and antiemetic properties. It should maintain cardiovascular stability and normal respiration. No single drug has all the forementioned features. Hence search continues for an ideal premedicant. Recently emphasis has shifted to a2- adrenoceptor agonists, because of their properties, which are of potential benefit in anesthesia. Objectives: To evaluate the effectiveness of oral clonidine as a preanesthetic medicant and as a drug to attenuate the hemodynamic responses associated with laryngoscopy and endotracheal intubation. Material and methods: Study was performed on 100 patients of the age group 18-65 years in whom 4 µg/kg body weight of oral clonidine (max 0.2 mg) was administered 90 minutes prior to induction of anesthesia. Degree of sedation, anxiolysis, antisialagogue effect and changes in heart rate, systolic blood pressure (BP), diastolic BP, mean arterial pressure and ECG changes before and after premedication with oral clonidine were evaluated. Statistical methods: Descriptive statistical analysis has been carried out in the present study. Results on continuous measurements are presented on mean ± SD (Min-Max) and results on categorical measurements are presented in number (%). Statistical software: The statistical software namely SPSS 15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables, etc. Results: Clonidine produced significant sedation with a p value of <0.05; before premedication, 61% of patients had anxiety score of 1 and 27% had a score of 2 and after premedication, 77% had a score of zero and 19% had score 1, which is significant anxiolysis. The association that is observed between clonidine as antisialogogue is mildly significant statistically. Premedication with clonidine produced decrease in pulse rate; decrease in systolic, diastolic and mean arterial pressure was highly significant statistically (p < 0.001). These values remained lower than the basal value after 1 minute up to 5 minutes after intubation. Conclusion: The premedication with oral clonidine produces significant sedation, anxiolysis, mild antisialagogue effect and hemodynamic stability during laryngoscopy and endotracheal intubation with no adverse effects. Thus oral clonidine may be used as an ideal preanesthetic medication.

Keywords: Premedication, oral clonidine, hemodynamic response

reanesthetic medication forms an integral part of anesthetic management and is universally administered before any anesthesia. The ideal premedicant should be effective and pleasant to be

*Professor of Anesthesiology Dept. of Emergency Medicine KIMS, Bangalore, Karnataka †Registrar in Anesthesiology ‡Resident in Anesthesiology SSMC, Tumkur, Karnataka Address for correspondence Dr B Brinda Professor of Anesthesiology and Critical Care, Chief of ICU Dept. of Emergency Medicine KIMS Hospital, KR Road, VV Puram, Bangalore - 560 004, Karnataka E-mail: brindapaddu@rediffmail.com

taken orally; have sedative, analgesic antiemetic, antisialagogue and antianxiety properties. Also it, should not impair cardiovascular stability or depress respiration.1 clonidine is a mixed a1- and a2- adrenoceptor agonist with a predominant a2 action (a2:a1 = 220:1), which is mainly used as an antihypertensive agent, but has many properties of an ideal premedicant and also has beneficial effects by blunting hemodynamic response to laryngoscopy and intubation.2,3 Laryngoscopy and intubation is a noxious stimulus which provokes a sympathoadrenal response characterized by rise in arterial blood pressure (BP) and pulse rate which is attenuated by clonidine. This study was undertaken to evaluate the effectiveness of oral

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

ANESTHESIOLOGY clonidine as a preanesthetic medicant and as also a drug to attenuate the hemodynamic responses associated with laryngoscopy and endotracheal intubation.4 MATERIAL AND METHODS One hundred patients of both sexes between 18-65 years scheduled for various elective surgeries under general anesthesia were taken in the study after ethical clearance and informed consent had been taken from them. Patients with central nervous system (CNS) disorders (UMN lesions, LMN lesions) and patients taking drug treatments known to affect heart rate, BP or hormonal stress responses were excluded. All patients scheduled for the study were kept nil by mouth and neither premedicated the previous night nor on the morning of surgery. Tablet clonidine 4 µg/kg body weight (max. 0.2 mg) was given 90 minutes prior to induction of anesthesia with sips of water. No anticholinergic drug was given either before or at the time of induction of anesthesia. Assessment was done just before and 90 minutes after administration of the drug. Assessment of degree of sedation was evaluated by sedation score (0 - patient awake and talkative, 1 - patients awake but not communicative, 2 - patients drowsy, quiet and easily arousable, 3 - patient asleep). Assessment of degree of anxiolysis and dryness of tongue was evaluated by anxiety scoring (0 - patient quiet and comfortable, 1 - patient uneasy, 2 - patient worried and anxious, 3 - patient very worried or very upset, 4 - patient frightened or terrified) status of tongue: moist/dry. Baseline heart rate, BP (systolic and diastolic and mean arterial pressure) and ECG were recorded by noninvasive monitor (Datex) in preanesthetic room. On arrival in OT, an IV line with appropriate fluid was started. General anesthesia was induced by injection of thiopentone 2.5%, 4-6 mg/kg body weight followed by injection succinylcholine 2 mg/kg body weight intravenously. Once there was cessation of fasiculation induced by succinylcholine, laryngoscopy was performed and appropriate size ETT was passed.

During laryngoscopy and intubation HR, BP (systolic, diastolic and mean arterial pressure) with continuous ECG recording done at a time interval of 1 minute continuously for 5 minutes there after. Any patient who strained or took >15 seconds for intubation or required second attempt to laryngoscopy and intubation were excluded from the study. Anesthesia was maintained with O2 and N2O only (without narcotic and inhalation agent) up to 5 minutes after endotracheal intubation. After 5 minutes of monitoring, NDMR (injection atracurium) and inhalation anesthetic (halothane) were supplemented uniformly to all the cases. After completion of surgery, NDMR was antagonized by neostigmine and glycopyrrolate. Once the patient satisfied extubation criteria – extubation was done and the patient was shifted to recovery room; drugs like injection atropine and injection ephedrine diluted and loaded were kept ready in case the patient developed complications like bradycardia or hypotension during the study. Any complication like undesirable effect or rebound phenomenon or untoward hemodynamic event was noted and treated. RESULTS In our study, maximum patients were in the age group of 31-40 years followed by 41-50 years (mean ± SD of 41.04 ± 12.61). Before premedication, all 100 patients were of sedation score 0 and after premedication

Moist (99%)

Dry (1%)

Before premedication

Dry (29%) Moist (71%)

After premedication

Figure 1. Percentage of patients having moist tongue before and after premedication.

Table 1. Sedation Score Before and After Premedication Sedation score Before premedication After premedication Inference

Mean ± SD

45%

50%

Sedation score is significantly increased after premedications with p < 0.05

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

0.74 ± 0.58

ANESTHESIOLOGY Table 2. Anxiety Score Before and After Premedication Anxiety score

Mean ± SD

Before premedication

10%

60%

27%

1.21 ± 0.64

After premedication

77%

19%

0.27 ± 0.52

Inference

Anxiety score is significantly reduced after premedication with p < 0.001

Table 3. Hemodynamic Response Score Before and After Premedication Events

Heart rate

SBP (mmHg)

DBP (mmHg)

MAP (mmHg)

Before premed

80.29 ± 6.69

127.34 ± 9.27

81.04 ± 5.71

96.47 ± 6.37

After premed

74.39 ± 6.67

119.66 ± 9.07

73.82 ± 5.91

89.09 ± 6.43

Laryngoscopy and endotracheal intubation Ι0 min

87.58 ± 7.07

128.17 ± 7.79

82.12 ± 5.21

97.04 ± 6.28

Ι1 min

80.87 ± 6.44

125.47 ± 7.94

79.53 ± 5.07

94.46 ± 6.32

Ι2 min

79.03 ± 6.14

122.59 ± 7.79

77.13 ± 5.18

91.79 ± 6.16

Ι3 min

77.42 ± 6.29

119.33 ± 7.76

74.38 ± 5.21

88.97 ± 6.23

Ι4 min

75.76 ± 6.05

116.38 ± 7.59

71.52 ± 5.32

86.06 ± 6.15

Ι5 min

73.89 ± 6.11

113.26 ± 7.61

68.43 ± 5.27

83.07 ± 6.02

% change from basal value Before premed- after premed

-7.3%

-6.1%

-8.9%

-7.7%

Before premed- Ι0 min

+9.1%

+0.6%

+1.3%

+0.6%

Before premed- Ι1 min

+0.8%

-1.5%

-1.9%

-2.1%

Before premed- Ι2 min

-1.5%

-3.7%

-4.8%

-4.9%

Before premed- Ι3 min

-3.5%

-6.3%

-8.2%

-7.8%

Before premed- Ι4 min

-5.6%

-8.6%

11.7%

-10.8%

Before premed- Ι5 min

-7.9%

-11.1%

-15.6%

-13.9%

Table 4. Significance of Hemodynamic Response Score Before and After Premedication Significance Before premed- after premed

t = 18.02; p <0.001**

t = 22.88; p <0.001**

t = 26.52; p <0.001**

t = 28.89; p <0.001**

Before premed- Ι0 min

t = 34.47; p <0.001**

t = 1.25; p = 0.212

t = 1.52; p = 0.108

t = 0.86; p = 0.390

Before premed- Ι1 min

t = 2.80; p <0.001**

t = 2.74; p = 0.007

t = 2.46; p = 0.016*

t = 3.03; p = 0.003**

Before premed- Ι2 min

t = 5.68; p <0.001**

t = 6.68; p <0.001**

t = 6.16; p <0.001**

t = 7.27; p <0.001**

Before premed- Ι3 min

t = 10.57; p <0.001**

t = 11.90; p <0.001**

t = 10.50; p <0.001**

t = 11.391; p <0.001**

Before premed- Ι4 min

t = 16.13; p <0.001**

t = 15.70; p <0.001**

t = 14.95; p <0.001**

t = 15.79; p <0.001**

Before premed- Ι5 min

t = 21.13; p <0.001**

t = 19.47; p <0.001**

t = 20.37; p <0.001**

t = 20.50; p <0.001**

45% had score 0, 50% had score 1, 3% had score 2 and 2% had score 3, showing a statistically significant sedation with clonidine premedication, p < 0.05 (Table 1). Before premedication 61% of patients had anxiety score of 1 and 27% had a score of 2 and after premedication 77% had a score of 0 and 19% had score 1. P value was <0.001 thereby concluding that premedication with

clonidine had very significant antianxiety effect (Table 2). Before premedication 99% of patients had moist tongue and 1% had dry tongue. But after premedication with clonidine 71% remained to have moist tongue, while 29% had dry tongue (Fig. 1). This shows that though there is antisialagogue effect, it is not very significant. From the above Tables 3 and 4, it can be concluded that

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

ANESTHESIOLOGY Age in years 15-30 31-50

100 95 90 85 80 75 70 65 60 55 50

Age in years 15-30 31-50

100 95 90 85 80 75

B pr efo em re ed pr Afte em r ed 10 m i 11 n m in 12 m in 13 m in 14 m in 15 m in

Heart rate (beats/min)

MAP (mmHg)

Figure 2. Mean values (beats/min) of pulse rate at various intervals.

Age in years 15-30 31-50 >50

130 125 120 115 110 105

B pr efo em re ed pr Afte em r ed 10 m i 11 n m in 12 m in 13 m in 14 m in 15 m in

100

Systolic BP (mmHg)

Figure 3. Mean values of systolic arterial pressure (mmHg) at various intervals.

Age in years 15-30 31-50

B pr efo em re ed pr Afte em r ed 10 m i 11 n m in 12 m in 13 m in 14 m in 15 m in

100 95 90 85 80 75 70 65 60 55 50

Diastolic BP (mmHg)

Figure 4. Mean values of diastolic arterial pressure (mmHg) at various intervals.

after premedication with clonidine, the decrease in the pulse rate is statistically highly significant. But, the rise in pulse rate during laryngoscopy and endotracheal intubation from basal value is not significant clinically

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

Figure 5. Mean values of mean arterial pressure (mmHg) at various intervals.

though some significance was seen statistically. After 1 minute of intubation, pulse rate returned to basal value and remained lower than the basal value up to 5 minutes of intubation (Fig. 2). After premedication with clonidine, there was decrease in systolic, diastolic and mean arterial pressure (Figs. 3-5). But the rise in systolic, diastolic and mean arterial pressure from basal value during laryngoscopy and endotracheal intubation was not significant clinically, though some significance was seen statistically. These values remained lower than the basal value upto 5 minutes of intubation. DISCUSSION The Îą2 agonists are assuming greater importance as anesthetic adjuvants and analgesics. Their primary effect is sympatholytic. They reduce peripheral noradrenaline release by stimulation of prejunctional Îą2 inhibitory adrenoceptors. They inhibit central neural transmission in the dorsal horn by presynaptic and postsynaptic mechanisms and directly in spinal preganglionic sympathetic nerves. Traditionally, they have been used as antihypertensive drugs, but doses based on sedative, anxiolytic and analgesic properties are being developed. Clonidine hydrochloride is an imidazole derivative. It was synthesized in early 1960â&#x20AC;&#x2122;s; as a derivative of the known alpha sympathomimetic drug naphazoline and talazonine. It was originally developed as a nasal vasoconstrictor. During clinical trials, it was found to cause hypotension; sedation and bradycardia. It was introduced as an antihypertensive first in Europe in 1966 and subsequently in the United States of America. It was the first antihypertensive known to act on the central nervous system. Clonidine

ANESTHESIOLOGY

H N

H N N

C I

is chemically 2-(2,6 - dichlorophenyl amino) 2- imidazole monohydrochloride. a2 adrenergic receptors are G proteins, which when activated inhibit adenylate cyclase. The result in decrease in accumulation of cyclic AMP attenuates the stimulation of cyclic AMP-dependent protein kinase and hence the phosphorylation of target regulatory proteins. Efflux of potassium through an activated channel can hyperpolarise the excitable membrane and provide an effective means of suppressing neuronal firing. a2 adrenoreceptor stimulation also suppresses calcium entry into nerve terminals, which may be responsible for its inhibitory effect on secretion of neurotransmitters. a2 adrenergic agonists produce clinical effects by binding to a2 receptors of which there are 3 subtypes: a2a, a2b and a2c, a2a receptors mediate sedation, analgesia and sympatholysis. a2h receptors mediate vasoconstriction and possibly antishivering mechanisms. The startle response reflects activation of a2c receptors.5 Clonidine is rapidly and almost completely absorbed from gastrointestinal tract. After oral intake, onset of action starts within 30-60 minutes and peak plasma concentration is reached within 60-90 min. The elimination half-life ranges from 6 to 24 hours with a mean of about 12 hours. Clonidine is metabolized mainly by the liver to produce p-hydroxyclonidine which subsequently undergoes glucuronidation to produce 0-glucuronide and is excreted in urine. Forty to 60% of an orally administered dose is excreted unchanged in urine within 24 hours. Effects of clonidine on different systems: There is no prejunctional α2 receptor in the myocardium. Hence, a direct effect on heart is unlikely. It causes hypotension due to centrally-mediated reduction in sympathetic flow. Clonidine exerts vagomimetic effect on heart by stimulating nucleus tractus solitarious, which can be attenuated completely by highly selective muscarinic M2 receptor antagonists. It can cause bradycardia and reduction in cardiac output without affecting the cardiac contractility and peripheral vascular resistance. Clonidine effectively inhibits the firing rate of locus ceruleus which mediates the normal response and exerts its hypotensive action by a net reduction in central sympathetic outflow. The α2 agonists hyperpolarize and

depress the locus ceruleus through potassium channel and markedly reduce the nor adrenaline concentration. Clonidine causes vasodilatation by the release of endothelium-derived relaxing factors (EDRF). a2 receptors are found densely in the pontine locus coeruleus which is an important source of sympathetic nervous system innervations. The sedative effects evoked by a2 agonists most likely reflect inhibition of this nucleus. Clonidine causes dose related sedation. In small doses it causes anxiolysis almost comparable to that seen with benzodiazepines. It has a powerful analgesic action both at supra spinal and spinal levels. Its potency is enhanced synergistically by opiods, acting through independent receptors. Clonidine by its action on α2 receptors reduces the anesthetic requirements. It reduces the minimum alveolar concentration of halothane and isoflurane. Clonidine is devoid of respiratory depressant action and lacks the negative effects on cognition, memory and behaviour as seen with midazolam. Thus it may be substituted for premedication.6,7 It does not potentiate the respiratory depression caused by opiods. Clonidine inhibits the centrally-mediated sympathoadrenal outflow as seen by the decreased levels of catecholamines in circulation and decreased level of metabolites in urine. Clonidine has a prominent antisialagogue effect by a direct action. Activation of prejunctional α2 adrenoreceptors inhibit the vagally-mediated release of gastric acid from the parietal cells and also reduces the gastric motility. It does not alter the gastric pH significantly. The most commonly seen adverse effects are dry mouth, drowsiness, hypotension and bradycardia, if large doses are used. Withdrawal phenomenon is reported after chronic clonidine treatment. There is no evidence of sympathetic over reactivity after single dose therapy. It probably takes about 6 days of continuous therapy to produce adaptive changes. In single dose preanesthetic therapy such rebound phenomenon are not seen. The hypertensive rebound, if occurs, is effectively treated with labetalol.8-12 Several studies have shown the efficacy of clonidine as a premedicant and also to suppress the hemodynamic responses to intubation. Das AK, studied clinical efficacy of oral clonidine as preanesthetic medicant and found that the central action of clonidine reduces sympathetic outflow and produces sedation, anxiolysis and smooth induction of

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

ANESTHESIOLOGY anesthesia. It also reduces salivation, sleeping dose of IV anesthetics, requirements of inhalation anesthetics and postoperative shivering moreover it provides cardiovascular stability.13 Nishikawa T, studied the effects of oral clonidine on the hemodynamic changes associated with laryngoscopy and endotracheal intubation. They observed that when clonidine was given in a dose of 5 µg/kg orally, the increase in mean BP was significantly smaller as compared to that in the control group.3 Sympathoadrenal activation associated with laryngoscopy and endotracheal intubation cause rise in arterial BP and tachycardia. Carabine et al suggested that cardiovascular responses by short lasting laryngoscopies can be attenuated with very low doses of oral clonidine.14 Study conducted by Orko et al, to evaluate the effect of clonidine on hemodynamic responses to endotracheal tube intubation and on gastric acidity found that the means of the systolic and diastolic arterial pressures just before and immediately after tracheal intubation were lower in the clonidine group (p < 0.001). The maximal increase in heart rate at intubation was lower in the clonidine group (p < 0.01).15 Study done to evaluate the effect of clonidine as preanesthetic medication by Weight et al16 found that clonidine produced a significant reduction in anxiety (p < 0.05) and caused sedation. Tachycardia in response to intubation was attenuated by clonidine (p < 0.05). Study done to evaluate the low-dose oral clonidine as premedication before intraocular surgery in retrobulbar anesthesia by Weindler et al17 found that after clonidine 86% of the patients showed sedation. Clonidine produced effective anxiolysis before the operation (p < 0.01). By the present study conducted, it can be concluded that Tab clonidine can be used as an effective premedicant drug as it produces good sedation, anxiolysis and also blunts the cardiovascular response to laryngoscopy and intubation significantly. However, the antisialagogue effect was not significant with the dosage we used. REFERENCES 1. Raval DL, Mehta MK. Oral clonidine premedication for the attenuation of haemodynamic response to laryngoscopy and intubation. Indian J Anaesth 2002;46(2):124-9.

3. Nishikawa T, Taguchi M, Kimura T, Taguchi N, Sato Y, Dai M. Effects of clonidine premedication upon hemodynamic changes associated with laryngoscopy and tracheal intubation. Masui 1991;40(7):1083-8. 4. Corbett JL, Kerr JH, Prys-Roberts C. Cardiovascular responses to aspiration of secretions from the respiratory tract in man. J Physiol 1969;201(1):51P-52P. 5. Stoelting RK, Hillier SC (Eds.). Antihypertensive drugs. In: Pharmacology and Physiology in Anesthetic Practice. 4th edition, Lippincott Williams& Wilkins: Philadelphia 2006:p.338-51. 6. Bergendahl H, Lönnqvist PA, Eksborg S. Clonidine: an alternative to benzodiazepines for premedication in children. Curr Opin Anaesthesiol 2005;18(6):608-13. 7. Bergendahl H, Lönnqvist PA, Eksborg S. Clonidine in paediatric anaesthesia: review of the literature and comparison with benzodiazepines for premedication. Acta Anaesthesiol Scand 2006;50(2):135-43. 8. Morgan GE, Michael MS, Murray MJ. Adrenergic agonists and antagonists. In: Clinical Anesthesiology. 3rd edition, McGraw-Hill: New York 2002:p.216-7. 9. Collins VJ. Principles of preanesthetic medication. In: Principles of Anesthesiology. 3rd edition, Lea & Febiger: Malvern 1993:p.292. 10. Stoelting RK, Hillier SC. Antihypertensive drugs. In: Pharmacology and Physiology in Anesthetic Practice. 4th edition, Lippincott Williams & Wilkins: Philadelphia 2006:p.340-3. 11. Moss J, Glick D. The Autonomic nervous system. In: Miller’s Anesthesia. 6th edition, Miller RD (Ed.), Churchill Livingstone: Philadelphia 2005:p.650-1. 12. Maze M, Tranquilli W. Alpha-2 adrenoceptor agonists: defining the role in clinical anesthesia. Anesthesiology 1991;74(3):581-605. 13. Das AK, Rudra R. Clinical efficacy of oral clonidine as preanaesthetic medicant. Indian J Anaesth 1995;43: 133-9. 14. Carabine UA, Wright PM, Howe JP, Moore J. Cardiovascular effects of intravenous clonidine. Partial attenuation of the pressor response to intubation by clonidine. Anaesthesia 1991;46(8):634-7. 15. Orko R, Pouttu J, Ghignone M, Rosenberg PH. Effect of clonidine on haemodynamic responses to endotracheal intubation and on gastric acidity. Acta Anaesthesiol Scand 1987;31(4):325-9. 16. Wright PM, Carabine UA, McClune S, Orr DA, Moore J. Preanaesthetic medication with clonidine. Br J Anaesth 1990;65(5):628-32.

2. Ghignone M, Quintin L, Duke PC, Kehler CH, Calvillo 17. O. Effects of clonidine on narcotic requirements and hemodynamic response during induction of fentanyl anesthesia and endotracheal intubation. Anesthesiology 1986;64(1):36-42. ■■■■

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

Weindler J, Kiefer RT, Rippa A, Wiech K, Ruprecht KW. Low-dose oral clonidine as premedication before intraocular surgery in retrobulbar anesthesia. Eur J Ophthalmol 2000;10(3):248-56.

CARDIOLOGY

Complete Heart Block in Rheumatoid Arthritis KAVINA MARIAN FERNANDES*, VIVEK GC*

ABSTRACT Rheumatoid arthritis (RA) can affect all parts of the heart. The pericardium, endocardium, valves, myocardium and the conduction system can get involved separately or in combination. However, complete heart block is very uncommon. We describe a case of a 65-year-old lady with RA presenting with complete heart block because of its rarity and unusual feature like negative rheumatoid factor.

Keywords: Rheumatoid arthritis, complete heart block, conduction disturbances, sudden cardiac death

hythm and conduction disturbances and sudden cardiac death (SCD) are important manifestations of cardiac involvement in autoimmune rheumatic diseases (ARDs). Complete heart block (CHB) is a rare complication of rheumatoid arthritis (RA) with an approximate incidence of 1 in 1,000 patients with RA.1 CHB in RA occurs generally in patients with established erosive RA.2 It can develop suddenly, being discovered after syncope or found unexpectedly on routine physical and electrocardiographic examination.2 In patients with high activity of RA, the decrease of heart rate variability reflects severity of inflammation. Decreased heart rate variability in degree I-II RA activity, is predictor for ventricular arrhythmias, SCD and acute myocardial infarction (MI). Antibodies to cardiac conducting tissue were found significantly more often in these patients than in those without conduction abnormalities.

The patient did not complain of giddiness, syncopal attacks, chest pain and palpitation. She had been on ayurvedic treatment. There was no history of oral ulcers, photosensitive rash, hair loss or abortions. She did not suffer from hypertension, diabetes mellitus or ischemic heart disease. There was no family history of autoimmune disorders. On examination, she was afebrile, pulse rate was 40/min, regular, blood pressure of 100/70 mmHg and respiratory rate of 14/min, jugular venous pressure (JVP) was raised and showed cannon a waves and SaO2 was 98% at room air. She had pallor and bilateral pitting pedal edema. There was no icterus, clubbing, lymphadenopathy or goiter. She had Boutonnieres deformity, swan neck deformity of index finger, ring finger of both hands, z-deformity of thumb, ulnar deviation of wrist and hallux valgus (Fig. 1). Trophic ulcers were present in the sole of the right and left foot. No nodules were palpable. Systemic examination was otherwise

CASE PRESENTATION A 65-year-old female presented to our department with low-grade fever and fatigue on exertion (Class III New York Heart Association [NYHA]) of 2-week duration. She also had deforming polyarthritis since 20 years. She had stiffness in joints on getting up in the morning, which would last till late morning.

*Dept. of General Medicine Vijayanagar Institute of Medical Sciences Bellary, Karnataka Address for correspondence Dr Vivek GC No. 210, 7th A Main, Vijayanagar 2nd Stage Bangalore - 560 104 E-mail: gc.vivek@gmail.com

Figure 1. Picture showing the Boutonnieres deformity, swan neck deformity of index finger, ring finger of both hands, z-deformity of thumb, ulnar deviation of wrist and hallux valgus.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CARDIOLOGY

Figure 2. ECG showing complete heart block.

Figure 3. X-ray of both hand and wrist (AP view) showing Boutonnieres deformity at 4th DIP joint, left wrist X-ray also showed hitch hikers thumb, swan neck deformity of 2nd finger.

Figure 4. X-ray of right foot (AP/oblique) showing narrowing of joint spaces involving tarsometatarsal joint and intertarsal joint, medial deviation of 2nd to 5th toes, lateral deviation of great toe.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

normal. Investigations revealed hemoglobin - 8 g/ dL, total leukocyte count (TLC) - 14,300 cells/mm3; differential leukocyte count (DLC) was polymorphs - 69%, lymphocytes - 13%, eosinophils - 12%, monocytes - 6%. Erythrocyte sedimentation rate (ESR) was 65 mm/hour, platelet count - 3.17 lac/mm3; liver function tests (SGOT - 33 IU/L, SGPT - 30 IU/L), renal function tests (urea - 25 mg/dL, creatinine - 1.2 mg/dL, sodium - 140 mEq/L, potassium - 4.2 mEq/L, chloride - 102 mEq/L), blood glucose (RBS - 94 mg/dL), uric acid and thyroid function tests were normal. Urine routine showed traces of albumin. ECG showed CHB (Fig. 2). 2-D echocardiography showed LA - 3.37 cm, AO - 2.27 cm, dilated RA and RV, mild mitral regurgitation (probably functional as there was no thickening of leaflets or chordae), left ventricular ejection fraction (LVEF) - 40%, no regional wall motion abnormality. Right ventricle systolic pressure (RVSP) by tricuspid regurgitation jet 45 mmHg, and no evidence of clot, vegetation or pericardial effusion. X-ray of both wrists anteroposterior (AP) view showed juxta articular osteopenia, Boutonnieres deformity at 4th distal interphalangeal (DIP) joint and narrowing of radiocarpal, intercarpal joint spaces. Left wrist X-ray also showed hitch hikers thumb, swan neck deformity of 2nd finger, Boutonnieres deformity in 4th finger (Fig. 3). X-ray of bilateral feet (AP/oblique view) showed diffuse osteopenia of the bones, narrowing of joint spaces involving tarsometatarsal joint and intertarsal joint, medial deviation of 2nd to 5th toes, lateral deviation of great toe (Fig. 4). Chest X-ray was normal. Troponin I - 0.011 ng/mL (negative), rheumatoid factor/ RA test - 18 IU/mL (negative) CRP - 150.8 mg/L (raised), anti-CCP antibodies - 0.60 U/mL (negative), ANA >125 U (strongly positive); SS-A 3+, RO-52 3+, centromere B 3+. Arterial Doppler study of both lower limbs was normal, venous Doppler did not show any signs of deep venous thrombosis (DVT). The patient was administered injection atropine 0.6 mg intravenous (IV) initially and repeated 3 times. However, there was no change in the rhythm or heart rate. The patient has undergone a pacemaker implantation and continues to be well. The patient was started on methotrexate (10 mg/ week)and hydroxychloroquine (400 mg/day) along with anti-inflammatory drugs. DISCUSSION RA is a chronic inflammatory disease of unknown etiology marked by a symmetric, peripheral

CARDIOLOGY polyarthritis. It is the most common form of chronic inflammatory arthritis and often results in joint damage and physical disability. Because it is a systemic disease, RA may result in a variety of extra-articular manifestations, including fatigue, subcutaneous nodules, lung involvement, pericarditis, peripheral neuropathy, vasculitis and hematologic abnormalities.4 The clinical diagnosis of RA is largely based on signs and symptoms of a chronic inflammatory arthritis, with laboratory and radiographic results providing important supplemental information. In 2010, a collaborative effort between the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) revised the 1987 ACR classification criteria for RA in an effort to improve early diagnosis.4 The most frequent site of cardiac involvement in RA is the pericardium. Cardiomyopathy, another clinically important manifestation of RA, may result from necrotizing or granulomatous myocarditis, coronary artery disease or diastolic dysfunction. Mitral regurgitation is the most common valvular abnormality in RA, occurring at a higher frequency than the general population.2 Right bundle branch block (RBBB), hemiblocks or AV blocks of any degree could occur. CHB is a rare complication of RA.1 Connective tissue diseases are responsible for <2% of cases of CHB. The transition from sinus rhythm to CHB usually appears to be sudden and permanent. However, there may be progression from first-degree heart block or blocks of the bundles or their fascicles to second-degree heart block and finally CHB. The conduction disturbances are usually mild, asymptomatic and incidentally diagnosed by electrocardiography. There is a female preponderance. In addition to standard 12-lead ECG, 24-hour Holter monitoring is most widely applied for evaluation of patients with arrhythmias and conduction abnormalities. The mean duration of RA prior to the development of the block is 10-12 years. In the case series published by Ahern et al,5 the average age for development of CHB was about 60 years, which matches our case. CHB can be due to following mechanisms: 1) Direct involvement of conducting system with granuloma; 2) extension of the inflammatory process from base of aorta to mitral valve to conduction pathways; 3) amyloidosis; 4) hemorrhage into rheumatoid nodule; 5) coronary arteritis causing ischemia of the conduction tissue; 6) focal myocarditis due to RA and 7) premature coronary artery disease due to accelerated atherosclerosis in patients with

RA.6 Conduction blocks once established in the disease do not respond to anti-inflammatory treatment.6 If patient is symptomatic pacemaker implantation helps improve.7 CONCLUSION CHB is a rare complication of RA. It usually occurs in patients with established erosive nodular rheumatoid disease and in rheumatoid factor positive cases but can also occur in those who are seronegative although rarely. CHB usually suggests active disease though it can occur in patients with well-controlled disease.8 The transition from sinus rhythm to CHB usually appears to be sudden and permanent. Spontaneous recovery is possible, but extremely rare. If patient is symptomatic, pacemaker implantation helps improve symptoms and prognosis. The indications for a permanent pacemaker are the same as any patient of CHB without RA. Once a pacemaker has been installed, the prognosis is good in the absence of other cardiac complications such as congestive cardiac failure. REFERENCES 1. Seferović PM, Ristić AD, Maksimović R, Simeunović DS, Ristić GG, Radovanović G, et al. Cardiac arrhythmias and conduction disturbances in autoimmune rheumatic diseases. Rheumatology (Oxford) 2006;45 Suppl 4:iv39-42. 2. Harris M. Rheumatoid heart disease with complete heart block. J Clin Pathol 1970;23(7):623-6. 3. Parnes EIa, Krasnosel’skiĭ MIa, Tsurko VV, Striuk RI. Long-term prognosis in patients with rheumatoid arthritis depending on baseline variability of cardiac rhythm. Ter Arkh 2005;77(9):77-80. 4. Shah Ankoor E. William St. Clair. Rheumatoid arthritis. In: Harrison’s Principles of Internal Medicine. 18th edition, Vol. 2, Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J (Eds.), McGraw-Hill Company: 2012:p.2738-52. 5. Ahern M, Lever JV, Cosh J. Complete heart block in rheumatoid arthritis. Ann Rheum Dis 1983;42(4):389-97. 6. Mandell BF, Villa-Forte A. Rheumatic diseases and the cardiovascular system. In: Heart Disease: A Text Book of Cardiovascular Medicine. 9th edition, Braunwald E, Zipes DP, Libby P (Eds.), WB Saunders Company p.1876-904. 7. Spragg D, Tomaselli GF. The bradyarrythmias. In: Harrison’s Principles of Internal Medicine. 18th edition, Vol. 2, Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J (Eds.), McGraw-Hill Company 2012:p.1867-70.

8. David-Chaussé J, Blanchot P, Warin J, Dehais J, Bullier R, Texier JM. Atrioventricular blocks and rheumatoid arthritis. Rev Rhum Mal Osteoartic 1976;43(3):177-83. ■■■■

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CLINICAL PSYCHOLOGY

Impact of Perceived Stress and Locus of Control on Conflict Resolution Styles SACHIN*, KRISHAN KUMAR†, RAJEEV DOGRA‡

ABSTRACT Modern life is full of hassles, deadlines, frustrations and demands. These stressful challenges not only pose a threat to one’s ability but also their cumulative effects lead to physical, emotional and mental breakdown. Stress is the body’s automatic response to any physical or mental demand placed on it. It may turn someone on (eustress), or may wear someone out (distress). Infact life without stress is death. Stress may have positive and negative effects. Perception is basically a common source of stress i.e., how one perceives the situation. The locus of control (LOC) governs the person’s decision, making ability, which may be governed by him (internal loci) or influenced by others (external loci). The present study examined the impact of perceived stress and LOC on conflict resolution styles. The study was carried over on 300 adolescents with a mean age of 15-18 years. The results indicated more perceived stress, agitation and anxious behavior in girls as compared to their male counterparts. Avoiding coping styles showed a positive correlation with the level of stress. External LOC also showed a positive correlation with high level of perceived stress.

Keywords: Perceived stress, locus of control, conflict resolution styles, external locus, internal locus, adolescents

tress is part of life in a fast-paced society. Stress is the physical, mental and chemical adjustments that our body makes in accordance to the circumstances of our life. In other words, stress is a response to what is happening around us. Too much stress results in uncomfortable and prolonged emotions. This causes psychological and physiological problems like loss of confidence, sleeplessness, raised blood pressure, back pain, rapid loss or gain of weight, heart disease and stroke, digestive disorders and irrational fears. The word ‘stress’ is derived from the Latin term ‘Stringers’ which means, ‘to draw tight’. Some define stress as the nonspecific response of the body to any demands made on it. When the demands on an individual exceed his capability and adjustment resources stress occurs. All situations positive and negative that require adjustment can be stressful. Neufeld (1990) has pointed out that “stress is a by product of poor or inadequate coping”. There are various definitions of stress, and this is further complicated because we all intuitively

*Research Scholar, University of Rajasthan, Jaipur †Clinical Psychologist, National Brain Research Centre, Manesar, Haryana ‡Associate Professor, PGIMS, Rohtak, Haryana

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

understand what stress is–although different people feel stress very differently. The most commonly accepted definition (mainly attributed to Richard S Lazarus) is that “Stress is experienced when a person perceives that demands exceed the personal and social resources that the individual is able to mobilize”. Stress is different from anxiety which is a state of uncertainly. It is also different from agitation, which is the physical part of anxiety. Stress also differs from frustration, which is blocked goal attainment. Stress is a pressure condition causing hardship; it is an internal phenomenon and a mental attitude. If stress is an imbalance in condiment salt relationship, the result is implantable. Stress is generally believed to have a deleterious effect on health and performance. But a minimum level of stress is necessary for effective functioning and peak performance. It is the individual’s reaction to stress which makes all the difference. Whether something is felt to be stress or not depends on the individual’s point of view. The common symptoms of stress can be physical, mental, emotional or behavioral:ÂÂ

Physical: Tiredness, headache, difficulty in sleeping, muscle aches, chest pain, stomach cramps, nausea, trembling, feeling cold, flushing or sweating, and frequent colds.

ÂÂ

Mental: Difficulty in concentrating, poor memory, confusion and loss of sense of humor.

CLINICAL PSYCHOLOGY ÂÂ

Emotional: Anxiety, nervousness, depression, anger, frustration, worry, fear, irritability, impatience or short temper.

shifts towards internal LOC (e.g., outdoor education programs; Hans, 2000; Hattie, Marsh, Neill & Richards, 1997).

ÂÂ

Behavioral: Pacing, fidgeting, increased eating, smoking, drinking, crying or yelling.

However, its important to warn people against lapsing in the naive notion that internal LOC is good and external LOC is bad (two legs good, four legs bad). There are important subtleties and other factors involved. For example, if one has internal orientation it usually needs to be matched by skills and competence so that the person is able to act successfully on their sense of personal responsibility. Overly internal people who lack confidence and efficacy in their abilities can become neurotic, anxious and depressed. On the other hand, there are many people with an external orientation who lead easy-going, relaxed, happy lives. It seems to psychologically healthy to perceive that one has control over those things which one is capable of influencing. In general, psychological research has found that people with a more internal LOC seem to be better off, e.g., they tend to be more achievement oriented and to get better-paid jobs. Sometimes LOC is seen as a personality construct, but this may be misleading, since the theory and research indicates that LOC is largely learned. Seligman’s research on learned helplessness is an example, where he found that animals and people would learn to simply give up trying when they experience having no control over what happens to them. In prolonged circumstances without control, developing an external LOC is an adaptive response. However, if circumstances change, having learned helplessness (external LOC) is maladaptive.

LOCUS OF CONTROL Locus of control (LOC) is a concept in psychology, originally developed by Julian Rotter in 1950s. The core of his approach is called Expectancy Value Theory. The two ‘loci’, as established by the theory, are the internal and external loci. The LOC represents how a person’s decision-making ability is influenced; essentially, those who make choices primarily on their own are considered to have internal loci, while those who make decisions based more on what others desire are said to have external loci. People with external loci are generally more apt to be stressed and suffer from depression as they are more aware of work situations and life strains. Women tend to have more of an external locus than men. A more internal LOC is generally seen as desirable. Having an internal LOC can also be referred to as ‘personal control’, ‘self-determination’, etc. Males tend to be more internal than females; as people get older they tend to become more internal; people higher up in organizational structures tend to be more internal. Internal locus protects against submission to authority- more resistant to others influence (but tend to be more premature and less sympathetic than externals). LOC is related to, but distinct from, several other social psychological constructs related to control. LOC refers to an individual’s generalized expectations concerning where control over subsequent events resides. In other words, who or what is responsible for what happens. It is analogous to, but distinct from, attributions.

Internal vs External In simplistic terms, a more internal LOC is generally seen as desirable. Having an internal LOC can also be referred to as ‘self-agency’, ‘personal control’, ‘self-determination’, etc. Research has found the following trends: ÂÂ

Males tend to be more internal than females

ÂÂ

As people get older they tend to become more internal

ÂÂ

People higher up in organizational structures tend to be more internal (Mamlin, Harris, & Case, 2001)

In addition, some psychological and educational interventions have been found to produce long-term

CONFLICT A dictionary gives the following semantic range for the word conflict: Conflict n. (Konflikt): i) A struggle between opposing forces; battle. ii) Opposition between ideas, interests, etc. controversy. iii) Psychological opposition between two simultaneous but incompatible wishes or impulses, sometimes leading to emotional tension. iv) To come into opposition; clash. v) To fight. Struggle...battle...tension...are words the Collins English Dictionary uses to define conflict. Conflict is an important concept in modern management. Most psychology books suggest that conflicts come from two tendencies: approach and avoidance. To approach is to have a tendency to do something or to move in a direction that will be pleasurable and satisfying. To avoid is to resist doing something, perhaps because it will not be pleasurable or satisfying. These two categories produce three kinds of conflicts: ÂÂ

Approach-approach conflict: This is due to the pursuit of desirable but incompatible goals.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CLINICAL PSYCHOLOGY ÂÂ

Approach-avoidance conflict: Here is a desire both to do something and not to do it.

ÂÂ

Avoidance-avoidance conflict: Here there are two alternatives, both of which may be unpleasant.

of anxiety, guilt, frustration and hostility. Winners try to injure the feelings of the defeated. Losers feel defeated and demeaned, the distance between people increases. A climate of mistrust and suspicion develops, discussion replaces cohesion. Loser indulges in non co-operation and pay scant attention to the needs and interests of other group members.

Positive consequences of conflict: ÂÂ

Major stimulate for change: Conflict spotlights the problems that demand attention, forces clarification of their nature and channels organizational efforts finding better solutions. It initiates a search for ways to polish and refine objectives, methods and activities.

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Group think is avoided: With out strong vocal disagreement, group think could overpower a highly cohesive group, preventing it from making rational decisions based on fact. Conflict also counteracts the lethargy that often overtakes organization

ÂÂ

Conflict fosters creativity and innovation: It Prevents stagnation in an atmosphere of open confrontation people tend to put forward more imaginative solutions to problem. A climate of challenge compels individuals to think through their own ideas before airing them out. Conflict can help individuals to test their capacities to learn and develop. A scholar who exposes his theories and research to the scrutiny of those collogues may be stimulated to a deeper analysis when he is confronted with conflicting data and theoretical analysis by a colleague.

ÂÂ

Cohesion and satisfaction: Inter group conflict and competition drives group closer together. Under conditions of mild inter group conflict; group membership can be very satisfying to members. The whole purpose and internal unity of athletic group, for example, would disappear if there were no conflict. In the face of a common enemy, group members close ranks and put aside former disagreement.

ÂÂ

A minimum level of conflict is optional: Conflict is necessary to the organizational life. It is necessary for the internal stability of organizations. The occasional flare up of inter group conflict serves to balance power relationship between departments. It also helps individuals in reducing accumulated ill-feelings and tensions between them. A good fight clears the air.

Negative consequences of conflict: ÂÂ

Conflict creates stress in people: Conflict exacts its role on the physical and mental health of the combatants. An intense conflict generates feeling

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

ÂÂ

Diversion of energy: One of the most dreadful consequences of conflicts is the diversion of the group’s time and efforts towards winning the conflict rather that towards achieving organizational goals. Parties focus on their own narrow interests and tend to put their own aims above those of the organization. Long-term goals begin to suffer as short-term problems become more important: Too much energy is drained off in trying to put out the ‘fires’. In extreme cases sabotage, secrecy and even illegal activities occur.

ÂÂ

Instability and Chaos: Under intense conflicts, collaboration across individuals, group and departments decreases or vanishes. Tensions will continue to mount up and each new conflict will split organization subunits further apartment, leading to a communication break down. In the heat of such an internecine warfare, the disputants squander away energy and resources that could be devoted to better use; the normal work flow is disrupted; the moral fabric of the group is torn apart and while system is skewed out of balance.

REVIEW OF LITERATURE Hamarat et al (2000) findings indicate that perceived stress level predicts life satisfaction among American college students. Interestingly, they found that for middle aged and older adults combining a measure of perceived stress with a measure of coping resource effectiveness provided a better predictor of life satisfaction than did perceived stress alone. For younger adults perceived stress alone was the best predictor of life satisfaction. While investigations of life satisfaction among college students have been conducted in other cultures, for instance in New Zealand university studies, previous studies have not tested the ability of coping resource levels and its effectiveness and perceived stress to predict college student’s subjective well-being, or satisfaction with life as did Hamarat et al (2001). Using the same measure, Hamarat et al assessed this relationship in north Americans across three age groups, one of which was college students. The focus of their research was on coping with stress and life satisfaction among Turkish college students. Both separate and

CLINICAL PSYCHOLOGY joint affects of perceived stress and coping resource availability upon life satisfaction were examined. It was hypothesized that the combination of coping resources availability and perceived stress would be better predictors of life satisfaction than either of the two. Researches have found that women react to stress differently than men. They reviewed numerous studies and developed a broad model of how women deal with stressors in their life. When women are confronted with stressors, be it a predator or a bad day at office, they tend to respond by turning to their children and providing caring as well as seeking out contact and support from them. The support they seek was usually from other women. This ‘tend and befriend’ behavior has been tentatively linked with the hormone oxytoxin, which is released by the body during stress. It has been shown to make both rats and humans calmer, less fearful, and more social. While men do secrete oxytoxin, male hormones reduce the effect of oxytoxin in their bodies. Female hormones on the other researches have found that women react to stress differently than men. Dongyoung Sohn and John D. Leckenby (2001) examined the social-psychological factor of LOC in relation to perceived interactivity on the internet. To this point in the study of this new medium and concept of interactivity, most social science research has studied the psychological dimension of the individual’s relation to the Internet. This research focuses on the individual’s relation to group experience in relation to perceptions of the Internet through use of the LOC concept. Results of the study of 121 individuals recruited online and who completed an online questionnaire show that perceived interactivity of the Internet can be partially explained by the LOC variable. Those internal in their orientation to the world tend to view the Internet as more interactive than those external in their orientation. In addition, perceived reliability of the web and time spent using the web are direct, powerful predictors of perceived interactivity? Implications for theory and practice are provided. The current study examined the relationships between Internet usage and the social contexts to which people belong. Using a socialpsychological factor (LOC), the influences of social contexts on Internet usage behavior, the perceived interactivity of the web, the perceived reliability of commercial information from Internet advertising, and attitude toward Internet advertising in general were studied. The association between stress and disease is not a new one. In fact, this relationship has been held to be intuitively true for ages. But medical science does not take kindly to the use of intuition as a means of gaining

knowledge. However, some health professionals are convinced of an intangible link between stress and disease. The seeds of clinical understanding were first planted by observations made by Hans Selye, giving rise to general adaptation syndrome. In 1977, Kenneth Pelletier estimated in his book, Mind as Healer Mind as Slayer, that between 50 and 70% of all disease and illness is stress related. By 1992, estimations were even higher, indicating that between 70 and 80% of health related problems are either precipitated or aggravated by stress. The list of such disorders is nearly endless, ranging from common cold to cancer. Katz, Blumler and Gurevitch (1974), the ideal user shown in uses and gratifications theory is an active and self-reliant gratification seeker. This person’s attitudes, perceptions, and behaviors are not influenced or manipulated directly by any content or message from the mass media. “The media can have little or no impact on persons who have no use for them; that media fare is selected rather than imposed, and that particular media offerings are chosen because they are meaningful to those who choose them” (Johnstone, 1974). The active users are able not only to recognize their internal needs by themselves, but also to use media consciously to satisfy their needs. These people selectively perceive and respond to the messages from the mass media, as well as responding to their individual needs. From this perspective, psychological motives including needs and gratifications would be central problems of research. Another study identifies family sources of stress and conflicts are critical variables in the well-being of adolescents. This paper assesses the relationship of coping resources to negative emotions produced by parental conflict after controlling for social desirability; age; financial resources and measures of parental attachment and family functioning. Undergraduate students (n = 304) in a large Southwestern university were given four instruments: Inventory of Parental and Peer Attachment (IPPA); Family Adaptability and Cohesion Scale II (FACES II); Coping Resources Inventory for Stress (CRIS) and Parental Conflict Emotions. Four separate models were created for: (1) Male participants describing maternal conflict; (2) male participants describing parental conflict; (3) female participants describing maternal conflict and (4) female participants describing parental conflict. The results provide support for the literature that a person’s family background and coping resources are related to emotional functioning in the context of family relationships. The emergence of social desirability as a statistically significant predictor of variance at step one of each model was noted. The pattern of results with

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CLINICAL PSYCHOLOGY respect to female participants included more predictors emerging as statistically significant. METHOD Objective: The objective behind this research study was to study the impact of perceived stress on various conflict resolution styles and to study the impact of LOC on various conflict resolution styles. Sample: The present study was carried over on a sample of 300 adolescents (age range 15-18 years) consisting of 150 boys and 150 girls. The sample was taken from various schools of Hisar district.

Instruments Perceived Stress Scale: Cohen, Kamarck and Mermlstein (1983). It measures the degree to which one’s life situations and circumstances are perceived as stressful. This measure calls for the individual to self appraise the level of stress, so the perceived stress scale (PSS) accounts for individual differences in the assessment of environmental demands. The scale has three versions, with 4-items 10-items or 14-items. The 10-item version was used because of maximum reliability. This appraisal-based measure of stress was selected because current status of assessment researchers tends to favor such measures over checklist assessments. The PSS is an empirically established appraisal based index (Cohen, Kessler, Gordon, 1995) very few of which measure global stress experience. The PSS has strong psychometrics with coefficient alpha reliability ranging between 0.84-0.86. The measure correlates with physical and depressive symptomatology measures between 0.52 and 0.70 and 0.65 and 0.76, respectively. The scale assesses the amount of stress in one’s life rather than in response to a specific stressor and has been used widely in studies of both mental and physical health. Rotter’s LOC Scale (1966): It is a generalized measure of internal versus. external LOC and it continues to be widely used to assess perceived control in several organizational and health related researches. It’s a 29-item scale. All the items are forced choice items and the subject will have to choose only 1-item from the alternatives provided in each item. One choice represents an internal LOC orientation while the other represents an external LOC orientation. There are 23-items in the scale designed to measure the LOC expectancies and 6 are filler items. A total LOC score is obtained by counting the number of external alternatives chosen. Scores range from 0 to 23; with increasing score a person emerges as the one with external LOC, whereas a person with lower scores is

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

considered to have an internal LOC. Satisfactory test retest coefficients have been reported by Rotter (1966). Thomas-Kilmann Conflict Handling Mode Instrument (TKI) (1973): The TKI is designed to assess an individual’s behavior in conflict situations i.e., situations where the concerns of two people appear to be the incompatible. This instrument contains 30-items. In such situations, we can describe a person’s behavior along two basic dimensions: ÂÂ

Assertiveness: The extent to which the individual attempts to satisfy his or her own concerns.

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Cooperativeness: The extent to which the individual attempts to satisfy the other person’s concerns. These two basic dimensions can be used to define specific methods of dealing with conflicts. These five basic “conflict handling modes” are shown below: zz

Competing: This is an assertive and uncooperative - a power oriented mode. When competing, an individual pursues his or her own concerns at the other person’s expense, using whatever power seems appropriate to win his position. Competing might mean standing up for your rights, defending a position you believe is correct, or simply trying to win.

Accomodating: This is assertive and cooperative, the opposite of competing. When accommodating, an individual neglects his own concerns to satisfy the concerns of the other person; there is an element of self-sacrifice in this mode. Accommodating might take the form of selfless generosity or charity, obeying another person’s order when you would prefer not to do so, or yielding to another person’s point of view.

Avoiding: This is an unassertive and uncooperative style. When avoiding, an individual does not immediately neglect his or her own concerns or those of the other person. He or she does not address the conflict. Avoiding might task the form of diplomatically sidestepping an issue, postponing it until a better time or simply withdrawing from a threatening situation.

Collaborating: It is both assertive and cooperative the opposite of avoiding. When collaborating, an individual attempts to work with the person to find an alternative that meet both sets of concern. Collaborating between two persons might take the form of exploring a disagreement to learn from each other’s

CLINICAL PSYCHOLOGY insights, resolving some condition that would otherwise have them competing for resources, or confronting and trying to find a creative solution to an interpersonal problem. zz

Compromising: This is intermediate in both assertiveness and cooperativeness. When compromising, the objective is to find an expedient, mutually acceptable solution that partially satisfies both parties. Compromising falls on a middle ground between competing and accommodating, giving up more that competing but less than accommodating. Likewise, it addresses an issue more directly than avoiding but doesn’t explore it as much as depth as collaborating.

Procedure First of all, school principals were contacted and informed about the importance and the purpose of the study to get the approval of the school administration for the data collection. When the approval was granted, days were fixed for data collection. During the actual data collection, proper information regarding filling the questionnaire were given to students and their willingness to participate in the study was obtained. They were told to give true responses and were assured that there identity would be kept confidential.

Statistical Analysis Statistical package for social sciences for windows version 11.1 was used in this study. Descriptive statistics, Pearson product moment correlation and One-way ANOVA were applied as per basic assumptions. RESULTS The total sample of 300 students, out of which 150 were boys and 150 were girls participated in the study. The mean perceived stress of the whole sample came out to be 20.84, with maximum value being 34.00 and minimum score being 9.00. The mean perceived stress score amongst girls was 21.37, with maximum 34.00 and a minimum score of 10.00 whereas for boys, the mean score was 20.30 with maximum of 30.00 and minimum score of 9.00. The results indicated that the boys had lower levels of perceived stress in their life as compared to girls. This implied that the boys viewed their life in a positive light, whereas the girls view it in a negative light. The girls showed more agitated anxious and anticipating behavior as compared to boys. On computing, Pearson product moment correlation between all of the seven

Table 1. Descriptive Statistics of the Total Sample Variables

Minimum Maximum

Mean

Perceived stress scale

9.00

34.00

20.84

Locus of control

0.00

18.00

7.37

Competing

0.00

11.00

5.66

Accomodating

0.00

11.00

5.71

Avoiding

2.00

10.00

5.60

Collaborating

0.00

11.00

6.54

Compromising

0.00

11.00

6.33

Table 2. Descriptive Statistics of Boys Variables

Minimum

Maximum

Mean

Perceived stress scale

9.00

30.00

20.30

Locus of control

1.00

18.00

6.62

Competing

0.00

11.00

5.58

Accomodating

0.00

11.00

5.68

Avoiding

2.00

10.00

5.72

Collaborating

0.00

11.00

6.63

Compromising

0.00

11.00

6.28

Table 3. Descriptive Statistics of Girls Variables

Minimum

Maximum

Mean

Perceived stress scale

10.00

34.00

21.37

Locus of control

0.00

16.00

8.12

Competing

0.00

11.00

5.75

Accomodating

0.00

9.00

5.74

Avoiding

2.00

10.00

5.48

Collaborating

2.00

11.00

6.44

Compromising

0.00

11.00

6.38

variables the results were as follows: Correlation between PSS and LOC came out to be 0.36, between Competing style and PSS, 0.08; between PSS and Accommodating style, it came out to be 0.11, between PSS and avoiding style –0.15, between PSS and Collaborating style it was, –0.03; between PSS and Compromising style it was –0.42. Out of these only the correlation between PSS and avoiding style was significant at 0.01 level. The correlation between LOC and competing style is 0.04, with accommodating style it was –0.10; with avoiding style it was –0.00 with collaborating style it was 0.22 and with compromising style it was –0.013. This implies that if the person tends to adopt an avoiding coping style, he is likely to have higher levels

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CLINICAL PSYCHOLOGY Table 4. Intercorrelational Matrix of Variables Variables

PSS

LOC

COM

ACO

AVOID

COLL

COMP

Perceived stress scale

1.00

0.036

0.008

0.110

–0.15**

–0.033

–0.042

Locus of control

1.00

0.004

–102

–.002

0.22

–.013

Competing

1.00

0.12

–.104

–.182

–.231

Accomodating

1.00

–.162

–.098

–.238

Avoiding

1.00

–.165

–.037

Collaborating

1.00

0.55

Compromising

1.00

of stress, as it has been held since ages that the best way to solve a problem is to confront it directly. So, in a way avoiding the stressful situation or the conflict causes stress in the individual. LOC and perceived stress go hand in hand. If the person tends to have a highly external LOC, he is likely to get stressed and internal LOC leads to lower levels of stress but not if it is in extreme. On computing ANOVA there was 100% significant difference between the LOC of boys and that of girls; whereas, there was 96% significant difference between the perceived stress score of boys and girls. This shows that the girls have higher levels of perceived stress in their lives as compared to their male counterparts. This is also evident from the table of means of both these scales. In case of boys, their mean score on PSS was 20.30 and on LOC it was 6.62 and in case of girls the mean score on PSS was 21.37 and on LOC it was 8.12. This indicates that the girls have more external LOC as compared to that of boys. As it had been expected in the beginning of the research that lowers the scores on LOC lower will be the level of perceived stress. DISCUSSION Prof. Ahmed Rushali (1990) conducted a research on the stress events and coping strategies of Turkish adolescents and young adults. Gender and type of school (secular and nonsecular) were also considered. Subjects were 1032 students taken from two high schools and a university in Ankara. Ages of subject varied between 10 and 25. Subjects described the most stressful event of the last 6 months and responded to the items of the ways of coping inventory (Folkman and Lazarus, 1980) results indicated that the most frequently reported stress events were related to interpersonal problems, followed by academic problems, loss of a significant other hand finally health-related problems. Age, sex and school variations occurred in the reported frequencies

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

for these event categories. Factor analysis of responses to the item of The ways of coping inventory yielded an 8-factor structure for the instrument. Results of analysis on the factor scores in dictated that seeking refuge in fate, optimistic approach, withdrawal, self-blame and seeking refuge in supernatural forces were more frequent among male and helpless approach and social support were more frequent among females. High school student’s having secular education employed active coping and optimistic approach more frequently than students having semi-secular education. The latter sub sample has a significantly higher usage frequency than the first for seeking refuge in fate strategy. Significant event by strategy interactions were also obtained; seeking refuge in fate, social support, optimistic approach, and withdrawal strategies were more frequent with the event category of loss whereas self-blame was most frequent with academic problems. Every day individuals are forced to be aware of their appearance. Media images seen on television, in magazines and even advertisements portray the nation that beautiful is good and are a constant reminder that society judges its members based on their body size (which emphasizes thinness). This ideal can cause a decrease in self-esteem because individuals, especially women, constantly compare themselves with the cultural ideal of beauty and may feel that they do not measure up and lose confidence in their abilities. This concept is detrimental because a loss of self-esteem may affect adjustment to new situations, especially for the college freshman. Going to college for the first time is exciting but can also cause anxiety. The college freshman needs to adapt to a new place with new people and new sets of academic rules. They must deal with room-mates and being away from their parents for the first time. They must have confidence in their abilities to make new friends and learn new time management skills because there is no one to tell them when to eat or when to study. This current study attempts to find if

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

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

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

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

Who is Eligible?

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

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

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

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

To promote and train hands-only CPR.

Activities of the Fund Financial Assistance

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

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

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

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

Drug Subsidy

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

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

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

BPL Card (If Card holder)

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

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

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

Free Diagnostic Facility

Free Education and Employment Facility

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

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

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

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

About Heart Care Foundation of India

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

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

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

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

Committee Members

Chief Patron

President

Raghu Kataria

Dr KK Aggarwal

Entrepreneur

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

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

Advisors Mukul Rohtagi Ashok Chakradhar

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

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

Rishab Soni

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

http://heartcarefoundationfund.heartcarefoundation.org

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IIC SUMMIT 2014

For More Information call: 9582363695, E-mail naina.a@talkingpointcommunications.com Website: http://talkingpointcommunications.com

CLINICAL PSYCHOLOGY a relationship exists among the variables adaptation to college, body satisfaction and self-esteem. Adaptation to college refers to the student’s ability to cope with the stress that college brings in terms of academics roommates and social situations. Wintre and Yaffe (2000) studied adaptation to college in relation to parental relationships, and psychological well-being variables in both male and female freshmen. It was hypothesized that the current relationship between parent and student and psychological well being (depression, perceived stress and self-esteem) would affect student adaptation and achievement. Results indicated an increase in depressive symptomatology predicted poorer adaptation for both male and female students. It also indicated that selfesteem in winter was a positive indicator of female adjustment because after six-months of being at college high self-esteem females experienced higher adaptation even if their initial reaction was not positive. SUGGESTED READING 1. Cohen, Sheldon; Kamarck, Tom; Mermelstein, Robin (1983). A global measure of perceived stress. Journal of Health and Social Behavior. Vol 24(4), 385-396. 2. Dongyoung Sohn, John D. Leckenby. (2001). Locus of control and interactive advertising. In: Proceedings of the American Academy of Advertising: 265-271. 3. Dongyoung Sohn, John D. Leckenby. (2002). Social dimensions of interactive advertising. In: Proceedings of the American Academy of Advertising: 89-96. 4. Aysan,F.,Herrington,A.,Gfroerer,C.A.,Thomson,D. (2000). Coping resources, perceived stress and life satisfaction among Turkish and American university students. International Journal of Stress Management, 9(2), 81-97. 5. Hamarat, E., Thompson, D., Zabrucky, K., Steele, D, Matheny, K., & Aysan, F. (2001). Perceived stress and coping resource availability as predictors of life satisfaction in young, middle aged, and older adults. Experimental Aging Research. 27, 181-196. 6. Hans, T. (2000). A meta-analysis of the effects of adventure programming on locus of control. Journal of Contemporary Psychotherapy, 30(1), 33-60. 7. Hattie, J. A., Marsh, H. W., Neill, J. T. & Richards, G. E. (1997). Adventure Education and Outward Bound: Outof-class experiences that have a lasting effect. Review of Educational Research, 67, 43-87. 8. Johnstone, J.W.C. (1974). Social Integration and Mass Media Use Among Adolescents: A Case Study, in Blumler & Katz, eds., The Uses of Mass Communications, Beverly Hills, California:

10.

11. 12.

13. 14.

15. 16.

perspectives on gratifications research (pp. 19-34). Beverly Hills, CA: Sage. Kilmann, R. H., & Thomas, K. W.(19773). A forcedchoice measure of conflict-handling behavior: the MODE Instrument. Working Paper No. 54, Graduate School of Business, University of Pittsburgh, Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle aged community sample. Journal of Health & Social Behavior, 21, 219-239. Lange, C., & Byrd, M. (1998). The relationship between perceptions of financial distress and feelings of psychological well-being in New Zealand university students. International Journal of Adolescence and Youth, 7, 193-209. Lazarus, R. S. (1966). Psychological stress and coping processes. New York: McGraw-Hill. Mamlin, N., Harris, K. R., Case, L. P. (2001). A Methodological Analysis of Research on Locus of Control and Learning Disabilities: Rethinking a Common Assumption. Journal of Special Education, Winter. Neufeld, R. W. J. (1990), Coping with stress, coping without stress, and stress with coping: On inter-construct redundancies. Stress Medicine, 6: 117–125. Pelletier, K. R. (1977). Mind as Healer, Mind as Slayer. Dell Publishing. New York, NY.

17. Rotter, J. (1973). Internal-External Locus of Control Scale. In Robinson and Shaver (2nd Ed.), Measures of Personality and Social Psychological Attitudes, pp 227-234. 18. Rotter, J. B.(1966).Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 30, 1-26. 19. Rotter, J.B. (1966).Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 33(1), 300-303. 20. Rotter, J. (1966). Generalized expectancies for internal versus external control of reinforcements, Psychological Monographs, 80, Whole No. 609. 21. Rotter, J. B. (1970).Some implications of a social learning theory for the practice of psychotherapy. In D. J. Levis (Ed.), Learning approaches to therapeutic behavior change. Chicago: Aldine. 22. Rotter, J. B., Liverant, S. and Crowne, D. (1961).The growth and extinction of expectancies in chance controlled and skilled tasks. Journal of Psychology, 52, 161-177. 23. Thomas, K. W., & Kilmann, R. H.( 1973.). Some properties of existing conflict behavior instruments. Working Paper No. 73-11, Human Systems Development Center, Graduate School of Management, UCLA 24. Wintre MG, & Yaffe, M. (2000). First-year students’ adjustment to university life as a function of relationships with parents. Journal of Adolescent Research, 15, 9–37.

25. te WL, Aysan F, Herrington A, Gfroerer CA,Thomson D (2000). Coping resources, perceived stress and life 9. Katz,E., Blumler,J., & Gurevitch,M.(1974). Utilization of satisfaction among Turkish and American university mass communication by the individual. In J.Blumler & students. International Journal of Stress Management, E. Katz (Eds.), The uses of mass communication: Current 9(2),81-97. ■■■■

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

COMMUNITY MEDICINE

Global Pathway, Current Condition and Challenges in the Management of Dengue SATHISH AMIRTHALINGAM

ABSTRACT Dengue is still a danger to communities around the world. Number of deaths resulting from dengue fever are rising sharply every year. As yet, there has been no confirmed medical cure or vaccine for dengue fever. So, prevention is still a question mark from the medical point of view. But, proper awareness and certain preventive methods are very effective as opposed to vaccination and other medications. This article mainly outlines the background of dengue and its implications in Malaysia. The fight against the spread of dengue is a constant one, especially in all the tropical countries.

Keywords: Dengue fever, vaccination, global impact, challenges in dengue

It is believed that the increase in number of cases of dengue fever is caused by a few factors, which are urbanization, population growth and increase in international travel and global warming. The increase in dengue fever is affecting countries around the globe (Fig. 1). Currently, the experts are working to eradicate the dengue fever. A few articles are published regarding the vaccines of dengue, which are under research and development now. However, there are still a lot of

1,20,0000 1,00,0000

9,68,564

8,00,000

6,00,000

4,00,000

2,95,554

2,00,000

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

10 7 00 -2

20 00

98 9 90 -1 99 9 19

-1

97 9

19 7

60 -

1,5,497

1,22,174

908

55 -1 95

Lecturer III Dept. of Pharmacy Practice International Medical University, Kuala Lumpur, Malaysia Address for correspondence Dr Sathish Amirthalingam 126, Jalan Jalil Perkasa 19, Bukit Jalil - 57000, Kuala Lumpur, Malaysia E-mail: asathish1981@gmail.com, SathishAmirthalingam@imu.edu.my

Number of countries

19 80

In Asian countries and the pacific region, >70% (approximately 1.8 billion) of the populations are at risk of having dengue, which accounts for approximately 75% of the current global disease burden due to dengue. Dengue is spreading to new geographical areas and causing high mortality. According to WHO, since 2000, dengue has spread into countries like Bangladesh, India, Maldives, Myanmar, Sri Lanka and Thailand. Bhutan also reported the first dengue outbreak during

2004.1 This implicates that dengue is epidemic. WHO plans to aid the countries to reverse the rising trend of dengue outbreak by enhancing their preparedness to detect, characterize and stop the spread of dengue to other new areas.

Number of cases

engue is a type of mosquito-borne disease that occurs mainly in tropical countries. It is also known as breakbone-fever and is transmitted by a few species of mosquito with genus Aedes. Its classical symptoms include fever, headache, joint pain and its typical skin rashes. In 2009, the World Health Organization (WHO) classified dengue fever into two groups.1 They are uncomplicated and severe type. Severe dengue can lead to serious bleeding due to plasma leakage in the body and causes severe organ dysfunction. All other cases besides severe dengue are classified as uncomplicated ones. Between 1960 and 2010, the number of dengue fever cases increased 30-fold.2

Year

Figure 1. Average annual number of DF/DHF cases reported to WHO and average annual number of countries reporting dengue.4

COMMUNITY MEDICINE challenges in different aspects in eradicating dengue fever. GLOBAL IMPACT OF DENGUE Dengue has spread throughout the world following a pandemic in South-East Asia that occurred after World War II, and has since developed most dramatically as a significant issue in terms of morbidity and economic impact.3 A pandemic in 1998, in which 1.2 million cases of dengue fever (DF) and dengue hemorrhagic fever (DHF) were reported from 56 countries worldwide, was unprecedented. In 2001, the Americas alone reported over 6,52,212 cases of dengue of which 15,500 were DHF, nearly double the cases reported for the same region in 1995.4 Dengue has highly impacted the economic growth of South-East Asian countries.5 Also, the mortality and the morbidity associated with dengue is a major economic burden to those it affects and a significant demand on healthcare resources.6 The occurrence of conditions that favor endemicity and epidemicity, namely the presence of large territories with Aedes mosquito infestation, sizeable susceptible human groups and the continuous introduction and/or circulation of one or more serotypes are factors responsible for endemic and epidemic spread of dengue.7 As a result, most of the South-East Asian countries are spending millions of dollars every year to spread awareness and create infrastructure to support the treatment of dengue.5 For an example, Singapore has set up a separate wing and ministry to control the epidemic diseases, especially dengue.8 In addition to direct medical costs, indirect costs incurred due to lost work days and earnings, and caregiver costs, may substantially increase the overall economic burden of the disease.3 At the individual family level, the economic impact of dengue may be particularly severe, incurring significant and extended debt.4 As dengue is epidemic and can easily spread within a region, government spends more money in educating the people by public address, television advertisement, distributing pamphlet and conducting group activities.9 Besides, there is a major social impact in those countries where large epidemics occur, often disrupting primary care for hospitalized patients.10 CHALLENGES IN DENGUE ERADICATION

Environment and Poverty The main challenge in dengue eradication is unplannedurbanization with the overcrowded population, which is characterized by lack of basic infrastructures,

substandard housing conditions, deficiencies in water supply and sewage management.11,12 Improper water supply which has resulted from rapid urbanization contributes to the habitat expansion of the vector, Aedes aegypti as the residents have to reserve water in vessels, which promotes mosquitoes breeding.11-13 Evidence from research stated that low-income groups with no air-conditioning and poor street drainage are most likely to be infected.12 Furthermore, inappropriate disposal of nonbiodegradable materials like plastic containers and old tyres are potential breeding sites for mosquitoes due to the ability to serve as water reservoirs.14 Vector control method has been proven to be difficult to maintain over time.15 The main effective measure to control vector is source reduction and it is crucial to be able to distinguish the disposable sources and those are indoor versus outdoor as a study reported that 79% of the total breeding sites was indoor in Singapore.14

Transportation and Migration Rapid global migration with the aid of modern transport system creates an extensive urban network which increases the potential for vector and virus dissemination to new a territory.11-13 Global transmission and spread of virus leads to genetic expansion of virus which makes it more difficult to eradicate.11 Hence, tourism and immigration are risk factors of dengue transmission.14

Usage of Insecticides The extensive and indiscriminate use of insecticides worldwide is one of the main challenges in eradication of vector due to global pandemic of insecticide resistance.11 The ability of larvicides to control vectors also limited as it has low coverage in term of the large pool of breeding sites present in any urban environment. Insecticides are short lived in relation to the mortality of female adult A. aegypti and also short in reach when it comes to the issue of the effectiveness of insecticide penetration into vectorâ&#x20AC;&#x2122;s resting places. In Asia and America, studies show that after application of the ultra-low volume (ULV), the population of adult mosquitoes returned to the pre-treatment level within 2 weeks and even with multiple applications, the impact resulted was minimal.14

Public Perception and Other Challenges Although community participation in eradication is crucial to success, public often perceives that dengue control is solely a responsibility of governmental agencies.13,14 Several studies revealed that people from

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

COMMUNITY MEDICINE dengue endemic countries understand the disease and its transmission, but the control practices are not equivalent to the knowledge about the disease. There is no sense of urgency within the population even though the incidence of dengue has increased at an alarming rate. Education is important, but solely dependent on the interventions that rely on education strategies shown to have less impact on behavioral and entomologic indices.14 Most of the national programs regarding the eradication of dengue is under- funded, poorly managed with isolated operation from other healthcare delivery systems. Another negative issue is the field workers involved are less motivated and poorly supervised, they are under paid and they lack communication skills. Most participants involved lose interest in vector control during the low transmission period; thus, resulting in subsequent increase in vectorâ&#x20AC;&#x2122;s population.14 Despite the current efforts made, there are many other challenges for dengue eradication, which include limited infrastructure and resources in control and surveillance, limited quality of diagnosis and clinical care and the need of more advance entomological tools to standardize and classify the vectors.11 DENGUE VACCINE DEVELOPMENT The development of dengue vaccines has been initiated since the 40s. However, the low appreciation of global disease burden and potential markets for the vaccine have brought the industryâ&#x20AC;&#x2122;s interests down until recent years, when the number of dengue infections and the prevalence of four, and the newly discovered fifth dengue serotypes have mounted drastically. These serotypes are DENV-1, DENV-2, DENV-3, DENV-4 and DENV-5.16,17 Development of dengue vaccines have become a great concern now-a-days. However, there are many issues that have to be addressed in order to successfully construct and introduce a safe and effective dengue vaccine to the public.16 These issues include enhancing adequate knowledge of the pathogenesis of dengue, obtaining sustainable financing, designing a vaccine, which is safe and effective against all dengue serotypes to maintain or decrease the level of DHF, deciding on vaccine delivery systems, integrating the vaccine into existing expanded immunization programs, conducting catch-up campaigns, establishing effective surveillance systems, integrating vector control programs and training immunization staff.18

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

Challenges of Dengue Vaccine Development The ideal dengue vaccine must be safe to be used without causing intolerable adverse effects caused by cross-reactive antibodies or T cells, should provide long-term protection to all serotypes and at the same time affordable to the populations at risk. The ultimate challenge of developing dengue vaccines would be in designing the ideal vaccine in the presence of obstacles such as insufficient knowledge of the complicated pathogenesis of the disease and a lack of suitable animal models. Although, DENV can affect non-human primates, it does not replicate as well in them as it does in humans. Mouse models were used to test the vaccine candidates before testing them in non-human primates. Immune-competent mice were found to be more suitable models to test the vaccine. The drawback of using these animals; however, is that the replications of DENV in them are poor. Another significant challenge in developing a dengue vaccine is in determining a reasonable cost for it as it is important that those who need the vaccines the most are not hindered from accessing them due to excessively highpriced vaccines.19

Progress of Dengue Vaccine Development A number of vaccine options are under development even though there is no available licensed dengue vaccine present to date. Among these options are live attenuated virus vaccines, live chimeric vaccines, live recombinant, DNA and subunit vaccines, as well as inactivated virus vaccines. As of now, only the former two virus vaccines are undergoing clinical evaluations. There are also nonviral vaccines, which include subunit vaccines that are centred on a protein, known as E protein or its derivatives. NS1 is yet another subunit vaccine option, which is not associated to any virus and possesses no adverse effects.19 The most clinically advanced contender among all the vaccines undergoing development is a live-attenuated tetravalent vaccine, which is based on chimeric yellow fever-dengue virus (CYD-TDV).20 It has, thus far, proceeded to phase III efficacy studies of clinical development. It was tested on a group of school children in Thailand, where dengue is particularly endemic and was found to possess a satisfactory safety profile in its phase IIb safety profile for up to 25 months after the first vaccination dose. It was also estimated to be effective against DENV 1, 3 and 4 strains of the dengue virus, after between 1 and 3 doses.21 The worldwide expansion of DF is a growing health problem. The dengue vaccine is an urgent challenge

COMMUNITY MEDICINE that needs to be overcome. It may be commercially available within a few years, when a vaccine that could provide protection against all five dengue viruses, is discovered. Until such a vaccine is fully developed, continuous efforts must be made to improve progress that has been made and to overcome challenges in the development of a dengue vaccination. CONCLUSION Dengue is now a global threat and is endemic or epidemic in many countries and especially those located in the tropics including Malaysia is rapidly spreading. Existing vector control efforts have not prevented its rapid emergence and global spread. Compare with 2013 scenario, 2014 dengue registered patients in hospital have increased triple fold. There are currently no licensed vaccines or specific treatment for dengue. However, the ever-expanding knowledge of the pathogenesis of dengue is providing more insights into the vaccine design. While waiting for new vaccines and antiviral drugs to be introduced to the market, challenges in dengue eradication should be overcome and better use should be made of the existing vector control interventions. REFERENCES 1. World Health Organization. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control. 2009. [Cited 2014 Mar 15]. Available from: http://www.who. int/tdr/publications/documents/dengue-diagnosis.pdf 2. Whitehorn J, Farrar J. Dengue. Br Med Bull 2010;95: 161-73.

8. Carrasco LR, Lee LK, Lee VJ, Ooi EE, Shepard DS, Thein TL, et al. Economic impact of dengue illness and the cost-effectiveness of future vaccination programs in Singapore. PLoS Negl Trop Dis 2011;5(12):e1426. 9. Gubler DJ. The economic burden of dengue. Am J Trop Med Hyg 2012;86(5):743-4. 10. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature 2013;496(7446):504-7. 11. Ng LC. Challenges in dengue surveillance and control. APSAR 2011;2(2):1-3. 12. Phillips ML. Dengue reborn: widespread resurgence of a resilient vector. Environ Health Perspect 2008;116(9):A382-8. 13. Morrison AC, Zielinski-Gutierrez E, Scott TW, Rosenberg R. Defining challenges and proposing solutions for control of the virus vector Aedes aegypti. PLoS Med 2008;5(3):e68. 14. Gómez-Dantés H, Willoquet JR. Dengue in the Americas: challenges for prevention and control. Cad Saude Publica 2009;25 Suppl 1:S19-31. 15. Brathwaite Dick O, San Martín JL, Montoya RH, del Diego J, Zambrano B, Dayan GH. The history of dengue outbreaks in the Americas. Am J Trop Med Hyg 2012;87(4):584-93. 16. Rodrigues HS, Monteiro MT, Torres DF. Vaccination models and optimal control strategies to dengue. Math Biosci 2014;247:1-12. 17. Tomasulo A. Fifth Dengue Serotype Discovered. Health Map. 2013. [Cited 2014 Mar 15]. Available from: http:// healthmap.org/site/diseasedaily/article/fifth-dengueserotype-discovered-102513

3. Singh P, Jacobson J. Dengue disease dynamics. J Clin Virol 2009;46:S1-S2.

18. Planning for the Introduction of Dengue Vaccines. Americas Dengue Prevention Board, Dengue Vaccine Initiative (DVI), Brasília: Brazil 2011:p.1.

4. World Health Organization. Impact of Dengue. 2014. [Cited 2014 Mar 20]. Available from: http://www.who.int/ csr/disease/dengue/impact/en/

19. Wan SW, Lin CF, Wang S, Chen YH, Yeh TM, Liu HS, et al. Current progress in dengue vaccines. J Biomed Sci 2013;20:37.

5. Global Impact of Dengue Fever and the Fight Against The Disease. 2010. [Cited 2014 Mar 20]. Available from: http:// www.contraeldengue.com/global-impact-of-dengue fever- and-the-fight-against-the-disease. Php

20. World Health Organization. Dengue Vaccine Research. 2014. [Cited 2014 Mar 15]. Available from: http://www. who.int/immunization/research/development/dengue_ vaccines/en/

6. Guzman MG, Halstead SB, Artsob H, Buchy P, Farrar J, Gubler DJ, et al. Dengue: a continuing global threat. Nat Rev Microbiol 2010;8(12 Suppl):S7-16.

21. Roehrig JT. Current status of dengue vaccine development. Centres for Disease Control and Prevention. 2013 April. [Cited 2014 Mar 21]. Available from: http://www.who. int/immunization/sage/meetings/2013/april/2_Roehrig_ 7. Guzman A, Istúriz RE. Update on the global spread of dengue. Int J Antimicrob Agents 2010;36 Suppl 1:S40-2. Dengue_SAGE_April2013.pdf ■■■■

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CRITICAL MEDICINE

Incidence, Susceptibility Profiles and Risk Factors of Multidrug-resistant Nonfermenting Gram-negative Bacilli Causing Ventilator-associated Pneumonia in a Tertiary Care Hospital KALIDAS RIT*, BIPASA CHAKRABORTY†, UDAYAN MAJUMDER‡, PARTHASARATHI CHAKRABARTY#, SASWATI CHATTOPADHYAY# HIRAK JYOTI RAJ*

ABSTRACT Background: Nonfermenting Gram-negative bacilli (NFGB) including Pseudomonas aeruginosa and Acinetobacter spp. have been implicated in a variety of nosocomial infections. Ventilator-associated pneumonia (VAP) associated with NFGB increases morbidity, mortality as well as cost of healthcare. Aims: This study was done to determine the incidence, susceptibility profile, and risk factors of VAP caused by NFGB. Material and methods: A prospective study was carried out in ICU for a period of 10 months, which included patients on mechanical ventilation for ≥48 hours and subsequently developed VAP. Endotracheal tube (ET) aspirate collected aseptically were put on culture for bacterial isolation and identification were carried out using standard microbiological methods. The antibiotic susceptibility tests were done using Kirby-Bauer disc diffusion method following Clinical Laboratory and Standards Institute (CLSI) guidelines. Results were statistically analyzed using Graph Pad Prism software. Results: Out of 175 patients included in this study, 52 (29.71%) developed VAP. Culture of ET aspirate from these 52 patients yielded 94 isolates. Our results revealed that NFGB that is P. aeruginosa, Acinetobacter spp. and Stenotrophomonas maltophilia represented 37.77% of VAP isolates. These were high-to-moderately sensitive to amikacin, gentamicin, tobramycin, piperacillin-tazobactam, meropenem, imipenem, colistin and polymyxin B, but showed increased resistance to cefepime and ceftazidime. Risk factors significantly associated with VAP caused by NFGB in ICU were concurrent surgical procedures, prior use of antibiotics, impaired consciousness, hospitalization for 5 days or more, mechanical ventilation for 5 days or more and age more than 50 years (p < 0.0001). Conclusion: NFGB bacilli including P. aeruginosa, Acinetobacter spp. and S. maltophilia were important causes of multidrug-resistant VAP in ICU.

Keywords: Nonfermenting Gram-negative bacilli, ventilator-associated pneumonia, P. aeruginosa, Acinetobacter spp., multidrug resistance

onfermenting Gram-negative bacilli (NFGB) including Pseudomonas aeruginosa, Acinetobacter spp. and Stenotrophomonas maltophilia, have

*Assistant Professor †Postgraduate Trainee (3rd Year) Dept. of Microbiology Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal ‡Assistant Professor Dept. of Anesthesiology North Bengal Medical College, Sushrutanagar, Siliguri, West Bengal #Demonstrator Dept. of Microbiology Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal Address for correspondence Dr Kalidas Rit 70B, TC Mukherjee Street, Rishra, Hooghly - 712 248, West Bengal E-mail: kalidasrit77@gmail.com

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

been implicated in a variety of nosocomial infections like ventilator-associated pneumonia (VAP), bacteremia, urinary tract infection and secondary meningitis.1 VAP is one of the most frequent infection acquired by the patients during a stay in hospital. By definition, VAP is pneumonia with onset no less than 48-72 hours after hospital admission.2 VAP is a common and severe complication of critical illness that is associated with an increased length of stay in the ICU with a high case mortality rate. P. aeruginosa and Acinetobacter spp. are the predominant cause of nosocomial infection particularly in ventilated patients. These are intrinsically resistant to a number of antibiotics as well as they develop acquired resistance by mutation in chromosomally encoded gene transfers by antibiotic-resistant determinant.3

CRITICAL MEDICINE The resistance mechanisms of P. aeruginosa and A. baumannii include the production of b-lactamases, efflux pumps and target-site or outer membrane modifications. Resistance to multiple drugs is usually the result of the combination of different mechanisms in a single isolate or the action of a single potent resistance mechanism. S. maltophilia is emerging as an important nosocomial pathogens and the respiratory tract is the most common site of S. maltophilia infection particularly in patients with inefficient lung function.4 Thereby the purpose of this study was to know the incidence, risk factors, susceptibility profiles of Pseudomonas, Acinetobacter spp. and S. maltophilia associated VAP in our tertiary care hospital. MATERIAL AND METHODS This prospective study was carried out from May 2013 to February 2014 in our tertiary care hospital. Necessary clearance from Institutional Ethical committee was obtained prior to the study. A total of 175 patients on mechanical ventilation more than 48 hours were included in this study and prospectively reviewed. All these patients were monitored at 2-day interval for development of VAP using clinical and microbiological criteria. Details of antibiotic therapy, exposure to invasive devices, urinary catheter, central venous catheter, parenteral nutrition, concurrent surgical procedures,

other comorbid conditions (like diabetes mellitus, malignancy, corticosteroid intake, transplantation), duration of hospital stay, position of patient and other important parameters studied were summarized in Table 1. Patients with modified Clinical Pulmonary Infection Score (CPIS) >6 (CPIS is a clinical score of 0-12 based on six variables like body temperature, leukocyte count, volume and character of tracheal secretion, arterial oxygenation, chest X-ray findings, Gram stain result and results of culture of tracheal aspirate specimen) and quantitative culture of the endotracheal aspirate with growth thresholds ≥106 CFU/mL was taken as a case of VAP.3,5 From each 175 patients on ventilator for ≥48 hours, samples of endotracheal aspirate (EA) were collected aseptically at every 2-day intervals till patient was on ventilator or expired. EA samples were Gramstained and examined microscopically and also cultured quantitatively by preparing serial dilutions. All samples were homogenized by placing glass beads and vortexing for 1 minute. They were serially diluted using sterile normal saline at 1:1 ratio. Each dilution were further inoculated in blood agar, chocolate agar and MacConkey agar medium and incubated at 37°C for 24-48 hours under aerobic conditions. Bacterial isolates were further morphologically and biochemically identified by standard microbiological techniques. Antibiotic susceptibility of the bacterial

Table 1. Analysis of Risk Factors of VAP by Chi-square and Fisher’s Exact Test Risk factors

VAP (n = 52)

Non-VAP (n = 123)

P value

Prior antibiotic therapy

<0.0001

Exposure to invasive devices

0.0916

Concurrent surgical procedures

<0.0001

Diabetes mellitus

0.0651

Patients with malignancy

0.1279

Corticosteroid intake

1.0000

Transplantation

0.0714

Hospitalization for 5 days or more

<0.0001

Supine position

0.6807

Impaired consciousness

<0.0001

Neurological disorders

0.0145

Tracheostomy

0.0551

Emergency intubation

0.0716

Mechanical ventilation 5 days or more

<0.0001

Age more than 50 years

<0.0001

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CRITICAL MEDICINE isolates was tested using Kirby-Bauer disc diffusion method following Clinical Laboratory Standards Institute (CLSI) guidelines.6,7 Antibiotic discs manufactured by HiMedia were used. Piperacillin, aztreonam, ceftazidime, cefepime, amikacin, gentamicin, tobramycin, ciprofloxacin, levofloxacin, piperacillin-tazobactam, imipenem, meropenem, colistin and polymyxin B were tested against P. aeruginosa and Acinetobacter spp. as per CLSI guidelines, but for S. maltophilia levofloxacin, trimethoprim-sulfamethoxazole and chloramphenicol antibiotic discs were used as per CLSI guidelines given in Table 2.

28.88% P. aeruginosa (26/90), followed by Klebsiella pneumoniae (12/90), Acinetobacter spp. (7/90), Escherichia coli (5/90), Proteus spp. (4/90) and others as shown in (Fig. 1). NFGB constituted 37.22% (34/90) of bacterial isolates, majority contributed by P. aeruginosa (28.88%), then Acinetobacter spp. (7.77%) and single isolate of S. maltophilia (1.11%). All the important associated parameters studied and the most important risk factors significantly associated with VAP (p < 0.05) are summarized in Table 1. The antibiotic sensitivity profiles for various etiological agents of VAP are summarized in Table 2.

RESULTS Based on CPIS criteria 52 out of 175 patients were diagnosed as VAP. The incidence of VAP was observed to be 29.71%. Out of them, 71.15% (37/52) patients were male with mean age of 65 years. Early-onset VAP occurs within the first 4 days of ventilation and late-onset VAP occurs thereafter. Out of 52 VAP patients, 36 (69.23%) developed late onset VAP, whereas 16 (30.76%) had early-onset VAP. In the present study, a total of 94 isolates were obtained from 52 patients diagnosed as VAP of which four isolates were Candida spp. (4.25%). The most common isolated pathogens were Staphylococcus aureus, which constitutes 33.33% (30/90) followed by

3.3% 4.5%

2.2%

1.1%

S. aureus P. aeruginosa

5.6%

K. pneumoniae 30.33%

7.8%

Acinetobacter spp. E. coli Proteus spp.

12.13%

CONS 26.29%

S. pneumoniae S. maltophilia

Figure 1. Microbiological profile of aerobic bacterial isolates from VAP patients.

Table 2. Antibiotic Susceptibility Tests Result of Isolated NFGB Detected by Disc Diffusion Method Antibiotic discs

P. aeruginosa (%)

Acinetobacter spp. (%)

S. maltophilia (%)

Amikacin (30 μg)

17 (65.38)

4 (57.14)

Aztreonam (30 μg)

9 (34.62)

2 (28.57)

Cefepime (30 μg)

5 (19.23)

2 (28.57)

Ceftazidime (30 μg)

8 (30.76)

3 (42.85)

Ciprofloxacin (5 μg)

12 (46.15)

3 (42.85)

Levofloxacin (5 μg)

17 (65.38)

5 (71.42)

1 (100)

Gentamicin (10 μg)

15 (57.69)

4 (57.14)

Imipenem (10 μg)

20 (76.92)

5 (71.42)

Meropenem (10 μg)

21 (80.76)

6 (85.71)

Piperacillin (100 μg)

16 (61.53)

5 (71.42)

Piperacillin/tazobactam (100/10 μg)

21 (80.76)

7 (100)

Tobramycin (10 μg)

20 (76.92)

6 (85.71)

Colistin (10 μg)

25 (96.15)

7 (100)

Polymyxin B (300 units)

25 (96.15)

7 (100)

Trimethoprim-sulfamethoxazole (1.25/23.75)

1 (100)

Chloramphenicol (30 μg)

1 (100)

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CRITICAL MEDICINE DISCUSSION P. aeruginosa, Acinetobacter spp. and S. maltophilia have increasingly emerged as serious nosocomial pathogens causing infection in compromised ICU patients. The present study on VAP reported maximum bacterial isolation of S. aureus followed by P. aeruginosa and other bacteria, whereas only 4.25% of Candida species were isolated which is also similar to results reported by Stephan et al.8 In this study, 80% VAP cases showed polymicrobial infections. But, contrary to the overall incidence of 45% of VAP as reported by Dey et al,9 our study showed the incidence of 29.71% of VAP, which may be due to lower incidence of comorbid conditions and associated risk factors. Prevalence of Pseudomonas in VAP patients was 28.88%, which is corroborative with other study by Chastre et al, where they have reported 24.4% P. aeruginosa from 1,689 VAP patients.5 Predominant role of NFGB for causing VAP were also established in other studies.10 In this study, NFGB were isolated more from late-onset VAP, as they colonize more in immunocompromised state, hence prolonged hospitalization and mechanical ventilation acts as significant risk factors. Enterobacteriaceae were isolated more from early-onset VAP. Among the different parameters studied, significant risk factors associated with VAP were concurrent surgical procedures, prior use of antibiotics, impaired consciousness, hospitalization for more than 5 days, mechanical ventilation for more than 5 days and age more than 50 years (p < 0.0001). Similar parameters were studied and reported by Joseph et al,11 Giamarellou et al12 and Celis et al.13 Management of nosocomial VAP caused by NFGB is a therapeutic challenge due to increasing resistance seen among these organisms for most commonly used antimicrobial agents. Overall sensitivity pattern for NFGB as per this study showed maximum sensitivity for colistin and polymyxin B (both 97%), followed by piperacillintazobactam (85%), meropenem (81%), tobramycin (78%) and imipenem (75%). Among the fluoroquinolones, ciprofloxacin showed lower sensitivity (45%) than levofloxacin (66%). But, high resistance was seen among cefepime, ceftazidime and aztreonam. For S. maltophilia as per CLSI guidelines only levofloxacin, cotrimoxazole and chloramphenicol discs were tested and all were 100% sensitive. Therefore, a clear knowledge about the pathogens causing VAP and their susceptibility

pattern is very important. The NFGB are gradually becoming more resistant and the bacteriological as well as susceptibility pattern is changing from time to time requiring continuous surveillance of AST for effective management of VAP. REFERENCES 1. Morehead RS, Pinto SJ. Ventilator-associated pneumonia. Arch Intern Med 2000;160(13):1926-36. 2. Johanson WG Jr, Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med 1972;77(5):701-6. 3. Koenig SM, Truwit JD. Ventilator-associated pneumonia: diagnosis, treatment, and prevention. Clin Microbiol Rev 2006;19(4):637-57. 4. Nseir S, Di Pompeo C, Brisson H, Dewavrin F, Tissier S, Diarra M, et al. Intensive care unit-acquired Stenotrophomonas maltophilia: incidence, risk factors, and outcome. Crit Care 2006;10(5):R143. 5. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165(7):867-903. 6. Bauer AW, Kirby WM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Pathol 1966;45(4):493-6. 7. CLSI. Performance standards for antimicrobial disk susceptibility tests. Approved standard, 9th edition, CLSI document M2-A9. Clinical and Laboratory Standards Institute: Wayne, PA; 2006. 8. Stéphan F, Cheffi A, Bonnet F. Nosocomial infections and outcome of critically ill elderly patients after surgery. Anesthesiology 2001;94(3):407-14. 9. Dey A, Bairy I. Incidence of multidrug-resistant organisms causing ventilator-associated pneumonia in a tertiary care hospital: a nine months’ prospective study. Ann Thorac Med 2007;2(2):52-7. 10. F errara AM. Potentially multidrug-resistant nonfermentative Gram-negative pathogens causing nosocomial pneumonia. Int J Antimicrob Agents 2006;27(3):183-95. 11. J oseph NM, Sistla S, Dutta TK, Badhe AS, Parija SC. Ventilator-associated pneumonia in a tertiary care hospital in India: incidence and risk factors. J Infect Dev Ctries 2009;3(10):771-7. 12. Giamarellou H, Antoniadou A, Kanellakopoulou K. Acinetobacter baumannii: a universal threat to public health? J Hosp Infect 2007;67:245-52.

13. Celis R, Torres A, Gatell JM, Almela M, Rodríguez-Roisin R, Agustí-Vidal A. Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest 1988;93(2):318-24. ■■■■

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DENTISTRY

Multidisciplinary Management of a Patient with Idiopathic Gingival Enlargement and Congenitally Missing Mandibular Lateral Incisors RAGHU DEVANNA*, CHANDRASHEKAR SAJJAN†, SHIVANAND ASPALLI‡, SIDDANTH JAJOO#

ABSTRACT Agenesis of one or more teeth is one of the most common of human developmental anomalies. Dentists frequently encounter patients with congenitally missing teeth. The most common are maxillary lateral incisors and mandibular second premolars. Congenitally missing mandibular lateral incisors is a rare condition. This case report details the successful periodontal, orthodontic and prosthodontic management of a patient with such a rare condition.

Keywords: Idiopathic gingival enlargement, congenitally missing teeth, maxillary lateral incisors, mandibular second premolars, congenitally missing mandibular lateral incisors

entists often encounter patients with missing or malformed teeth. The maxillary lateral incisor is the second most common congenitally absent tooth.1 The term oligodontia refers to congenital absence of many but not all teeth whereas the term hypodontia implies the absence of only a few teeth. In the permanent dentition, hypodontia has a prevalence of 1.6-9.6%, excluding agenesis of the third molars. Oligodontia has a population prevalence of 0.3% in the permanent dentition.

It occurs more frequently in girls at a ratio of 3:2. Agenesis of only the third molars has prevalence between 9% and 37%. In the deciduous dentition, hypodontia occurs less often (0.1-0.9%) and has no significant sex distribution.2 The mandibular second premolar is the most frequently absent tooth after the third molar, followed by the maxillary lateral incisor and the maxillary second premolar. Agenesis of mandibular lateral incisors is

*Assistant Professor, Dept. of Orthodontics and Dentofacial Orthopedics †Assistant Professor, Dept. of Prosthodontics ‡Professor #Postgraduate Student Dept. of Periodontics AME’s Dental College, Hospital and Research Center, Raichur, Andhra Pradesh Address for correspondence Dr Raghu Devanna Assistant Professor, Dept. of Orthodontics and Dentofacial Orthopedics AME’s Dental College and Hospital, Raichur, Andhra Pradesh E-mail: drraghu_devanna@yahoo.co.in

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

rather exceptional.1 Gingival hyperplasia is greater in those with high plaque scores but there is also a genetic link. Gingivectomy is recommended to remove any hyperplastic tissue that interferes with appearance or function.3 This case report describes a case in which a 20- year-old female patient presented with significant idiopathic gingival overgrowth in the maxillary anterior region and congenitally missing mandibular lateral incisors. The case was successfully managed with gingivectomy, orthodontic treatment, and a tooth supported restoration. CASE REPORT A 20-year-old female patient reported for seeking treatment for unpleasant smile and replacement of missing teeth. Medical history was noncontributory. Queries revealed that missing teeth were not extracted, were absent since childhood (Figs. 1a and 1b). Diagnostic records included orthopantmogram (OPG), lateral cephalogram, and study models. OPG and IOPA showed missing mandibular lateral incisors (Figs. 2a and 2b). Lateral cephalogram showed orthognathic maxilla and mandible and skeletal Class I pattern with normal growth pattern (Fig. 3). Problem list consisted of missing mandibular lateral incisors, deep bite, and idiopathic gingival hyperplasia. The case was discussed in association with periodontist and prosthodontist. Treatment plan consisted of two phases. Phase I consisted of gingivectomy and gingivoplasty with

Major Conference Attended 2014-15

DENTISTRY

Figure 1 (a). Pre-treatment Figure 1 (b). Pre-treatment intraoral. extraoral.

Figure 2 (a). Pre-treatment OPG.

Figure 2 (b). Pre-treatment IOPA.

Figure 3. Pre-treatment lateral cephalogram.

Figure 4 (a). Gingivectomy and gingivoplasty.

Figure 4 (b). After gingivectomy and gingivoplasty.

done and normal contour of the gingival margins was restored thus achieving the objectives of anterior pink aesthetics (Figs. 4a and 4c). The pre-treatment intraoral photographs for orthodontic treatment were taken (Figs. 5a and 5c). After 1 month preadjusted edgewise appliance (0.022” MBT Prescription) was placed. Initial alignment was done with 0.016” HANT arch wire which also corrected the deep bite. Space consolidated on 0.017 × 0.025” SS arch wire with the help of figure of eight lace backs between the two mandibular central incisors (Fig. 6). Then rigid 0.019 × 0.025” SS arch wire was used for retaining the orthodontically achieved results. Mid-treatment photograph was taken to ascertain the parallelism of the roots (Fig. 7). After retaining the achieved results for 3 months, Phase II treatment plan was initiated. Phase II therapy consisted of replacement of missing mandibular incisors with FPD to improve aesthetics and function. Mandibular central incisors and canines were prepared as abutments for the same (Figs. 8a and 8b). A six

Figure 4 (c). After gingivectomy and gingivoplasty.

Figure 5 (a). Pre-treatment frontal.

Figure 5 (b). Pre-treatment Figure 5 (c). Pre-treatment anterior. right lateral.

the objective of improving the unpleasant smile and correcting the deep bite by orthodontic treatment in an attempt to provide ideal overjet and overbite for the phase II treatment. Phase II consisted of prosthetic rehabilitation for improving aesthetics and function. A 6 unit porcelain in the mandibular anterior segment was planned. Phase I therapy was initiated after initial oral prophylaxis. Gingivectomy and gingivoplasty was

Figure 6. Orthodontic treatment.

Figure 7. Root parallelism.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DENTISTRY

Figure 8 (a). Occlusal view before crown preparation.

Figure 8 (b). Occlusal view after crown preparation.

Figure 9 (a). Frontal view Figure 9 (b). Occlusal view of FPD. FPD.

Figure 9 (c). Frontal Figure 10 (a). Pre- Figure 10 (b). smile after FPD. treatment frontal. Frontal smile after FPD.

Figure 10 (c). Pre-treatment Figure 10 (d). Post-treatment smile. smile.

unit porcelain FPD extending from canine to canine in the mandibular arch was made and was cemented (Figs. 9a-9c). Figure 10 a-d show the excellent results achieved through this multidisciplinary treatment approach. DISCUSSION Majority of oligodontia patients, seek orthodontic care because of unesthetic malocclusion. Tooth agenesis occurs more frequently amongst a few specific teeth and clinically this is often considered a normal variant. A disturbance in the fusion of the embryonic facial processes may result in the incomplete expression of a primary cleft, which is manifested as the absence of the mandibular lateral incisors. The biologic basis

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

for the congenital absence of permanent teeth is partially explained by the failure of the lingual or distal proliferation of the tooth bud cells from the dental lamina. The causes of hypodontia are attributed to environmental factors such as irradiation, tumors, trauma, hormonal influences, rubella, and thalidomide or to hereditary genetic dominant factors or to both. Familial tooth agenesis is transmitted as an autosomal dominant, recessive, or X-linked condition.4 Affected members within a family often exhibit significant variability with regard to the location, symmetry and number of teeth involved. Residual teeth can vary in their size, shape or rate of development and the permanent dentition is more affected than the primary dentition.4 Several studies have shown that MSX1 and PAX9 play a role in early tooth development. PAX9 is a paired domain transcription factor that plays a critical role in odontogenesis. All mutations of PAX9 identified to date have been associated with nonsyndromic form of tooth agenesis.5-7 The homeobox gene MSX1 has previously been associated with agenesis of the second premolars and third molars in a single family. The involvement of MSX1 has however been excluded in other forms of hypodontia involving both second premolars and lateral incisors or lateral incisors and canines. The orthodontic treatment of patients with congenitally missing laterals is controversial as to whether to close the spaces left by the missing lateral incisors orthodontically or to open or maintain spaces for prosthodontic fixed partial denture (FPD) replacement or implants. Concern for periodontal health has resulted in recommendation for orthodontic space closure. Poor esthetic appearance of canine eminence and color incompatibility between mandibular canine and central incisors also needs to be considered while closing spaces. Reasonably stable and well-accepted results not impairing temporomandibular joint (TMJ) function or periodontal health with orthodontic space closure have been reported.8 Advocates of opening or maintaining the space for prosthodontic (FPD) replacement or implant suggest that a better occlusion and less flattening of the facial profile will result if the canines are in a Class I relationship. If the large diastema between the centrals is closed by moving them mesially, they leave papilla behind. Overtime the tissue will be keratinized but the location of the papilla will not change. This can be an esthetic dilemma for the periodontist and restorative dentist.9 The success of implants has rapidly made them a preferred way to replace missing teeth.

DENTISTRY Before placement of the implant sufficient space must be gained by uprighting and paralleling the adjacent teeth. The orthodontic treatment has to be completed with good stability followed by retention of orthodontically moved teeth. Even small movement after implant placement may cause complications e.g. tipping of the central incisor may result in tooth implant contact with marginal bone loss. Shorter the distance between the implant and the adjacent teeth, the larger the reduction of marginal bone level. Buccal bone plate in the lateral incisor area is often thin resulting in discolored soft tissue, buccally to the implant-supported crown.10 Major concerns when implants are to be placed, are adequate bone in the edentulous area to support the implant and for single tooth implants adequate space between the roots as well as the crowns of the adjacent teeth. If there is no tooth to erupt into an area of the dental arch, little or no alveolar bone ever forms. Positioning adjacent teeth for a single tooth implant can be tricky especially in replacement of missing mandibular lateral incisors because of the small area for replacement. Prosthetic replacements, whether implants or bridges, are an essential part of the orthodontic retention.11 Placement of permanent prosthesis is delayed due to time required for osseointegration and graft maturation in cases where bone grafting and implant is planned. Considering the quality of bone in the edentulous area, delay involved in bone grafting and implant and esthetic and functional considerations of closing spaces orthodontically, a 6 unit, FPD from canine to canine was preferred in this case. CONCLUSION A good esthetic and functional result was achieved for this patient. This was achieved by employing a multidisciplinary treatment protocol that was tailored specifically to this patient’s needs and liaison with other specialties. During the treatment, oral hygiene was continually reinforced and treatment mechanics adjusted to simplify oral hygiene. This case report highlights that even though patients with unusual

oligodontia and idiopathic gingival overgrowth present difficult challenges for treatment; their management can be successful if the practitioner is aware of the causes of gingival over growth, its control and its implications on treatment mechanics. A multidisciplinary approach is essential to achieve better aesthetics and function in such cases. REFERENCES 1. Bhardwaj P. Esthetic management of missing lateral incisor during orthodontic treatment- A Case Report orthocj.com/journal/uploads/2010/07/0200_en.pdf 2. Dermaut LR, Goeffers KR, De Smit AA. Tooth agenesis correlated with jaw relationship and crowding. Am J Orthod Dentofac Orthop 1986;90:204-10. 3. Hassel TM, Burtner AP, McNeal D, Smith RG. Oral problems and genetic aspects of individuals with epilepsy. Periodontal 2000 1994;6:68-78. 4. Mostowska A, Kobielak A, Trzeciak WH. Molecular basis of non-syndromic tooth agenesis: Mutations of MSX1 and PAX9 reflect their role in patterning human dentition. Eur J Oral Sci 2003;111:365. 5. Mostowska A, Biedziak B, Trzeciak WH. A novel mutation in PAX9 causes familial form of molar oligodontia. European Journal of Human Genetics Epub 2006;14:173-9. 6. Lammi L, Halonen K, Pirinen S, Thesleff I, Arte S, Nieminen P. A missense mutation in PAX9 in a family with distinct phenotype of oligodontia. European J of Hum Genet 2003;11:866-71. 7. Lammi L, Arte S, Somer M, Järvinen H, Lahermo P, Thesleff I, Pirinen S, Nieminen P. Mutations in AXIN2 Cause Familial Tooth Agenesis and Predispose to Colorectal Cancer. Am J Hum. Genet 2004;74:1043-50. 8. Robertsson S, Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorative treatment. EJO 2000;22:697-710. 9. Vincent O, Kokich. Congenitally missing teeth: Orthodontic management in adolescent patient. Am J Orthod Dentofac Orthop 2002;121:594-5. 10. Thilander B, Odman J, Kekholm U. Orthodontic aspects of the use of oral implants in adolescents: A 10 year followup study. EJO 2001;23:715-31.

11. Proffit WR, Fields Jr HW. Contemporary Orthodontics, Third Edition 2000;658-6. ■■■■

Soda and Fruit Juice are ‘Biggest Culprits in Dental Erosion’ Soft drinks are the most significant factor in severity of dental erosion, according to a new study published in the Journal of Public Health Dentistry. Dental erosion is when enamel - the hard, protective coating of the tooth - is worn away by exposure to acid. The erosion of the enamel can result in pain - particularly when consuming hot or cold food - as it leaves the sensitive dentine area of the tooth exposed.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DERMATOLOGY

Recalcitrant Plaque Psoriasis Cleared with 308 nm Excimer Light SANJEEV J AURANGBADKAR

ABSTRACT Psoriasis is an immune-mediated inflammatory disease affecting approximately 2% of the population. Narrow-band ultraviolet B light has been used extensively in the management of psoriasis over the past few years with good success. Targeted phototherapy involves the use of xenon-chloride medium, which emits a monochromatic wavelength of 308 nm excimer light. This new modality in the treatment of plaque psoriasis has shown considerable promise in the management of this disease. Fewer sessions are required when compared to conventional phototherapy. Adverse effects are minimal and well-tolerated, including transient erythema, blistering and hyperpigmentation. Larger studies are needed to establish its role in the management of psoriasis either as stand-alone therapy or in combination with other agents.

Keywords: Psoriasis, targeted phototherapy, xenon-chloride medium, a monochromatic wavelength, 308 nm excimer light

hototherapy plays an important role in the management of moderate-to-severe chronic plaque psoriasis. Topical steroids, vitamin D3 analogs and systemic agents such as methotrexate, cyclosporine, biologics, etc. have all been used either in combination or rotational therapy. Despite these measures, some patients may have recalcitrant, stubborn plaques that do not clear adequately upon conventional treatment. Targeted phototherapy in the form of 308 nm excimer lasers and light sources has been used successfully in residual chronic plaque and palmo-plantar psoriasis. The excimer laser and light devices have xenon and chloride gases as the lasing medium and on excitation emit photos in the ultraviolet portion of the electromagnetic spectrum. High energy can be delivered in a short period of time to target the specific lesions allowing a rapid response.

since 15 years and has undergone various treatments including emollients, topical steroids and, systemic methotrexate for his disease with partial response. The patient complained of residual patches on his elbows that refused to clear with prior treatments. He was socially embarrassed and conscious of his patches and wanted clearance of the unsightly lesions. On examination, erythematous plaques, with silvery-white scales were observed bilaterally and symmetrically on the elbows of the patient. Postinflammatory hyperpigmentation was noted on his legs, trunk and arms most likely following clearance of earlier lesions.

A 52-year-old male patient with chronic plaque psoriasis presented with reddish patches on the elbows with scaling. The patient gave a history of psoriasis

Since, the patient had used topical steroids and vitamin D3 analogs in the past, and had only residual patches and since, the patient desired rapid clearance of the lesions, the patient was offered targeted phototherapy. After obtaining an informed written consent and pretreatment photographs, targeted phototherapy (308 nm excimer light) was initiated twice-weekly. Topical emollients were recommended prior to and between the treatments.

Consultant Dermatologist and Laser Surgeon Skin and Laser Clinic, Begumpet, Hyderabad, Andhra Pradesh Address for correspondence Dr Sanjeev J Aurangabadkar Consultant Dermatologist and Laser Surgeon Skin and Laser Clinic, Begumpet, Hyderabad, Andhra Pradesh

Liquid paraffin oil was applied to the lesions immediately prior to the excimer session. 308 nm Excimer light (Quantel Medical, Germany) was started with a dose of 600 mj/cm2 twice-weekly and the dose increased by 100 mj/cm2 with successive sessions till clearance of the lesions. By the 4th session (dose of 900 mj/cm2) the patient had a near complete clearance of the lesions

CASE STUDY

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DERMATOLOGY

Figure 1. Resistant plaques on the right elbow.

Figure 4. Near total clearance of the plaques after 308 nm excimer light therapy.

up for a further 3 months after the last session. No recurrence was noted after the follow-up period. DISCUSSION

Figure 2. Complete clearing of the plaques after 308 nm excimer light treatment.

The mechanism of action of targeted phototherapy (308 nm excimer light) is most probably by apoptosis of the lesional T-lymphocytes. There are several advantages of targeted phototherapy including the lesser number of sessions required to clear the psoriatic plaques (<10 sessions compared to approximately 30 sessions of narrow-band UVB [NB-UVB] phototherapy), selective treatment of plaques thus minimizing the cumulative UVB dose. Another advantage is the much shorter treatment times required with excimer systems (for example, it takes only a few seconds to deliver 600 mj/cm2) as compared to full body NB-UVB treatment. Some of the limitations of the excimer systems are-they cannot be used to treat large areas due to the small spot size, cost per sessions is higher when compared to NB-UVB therapy and the increased risk of immediate adverse effects such as erythema, blistering and hyperpigmentation.

Figure 3. Psoriasis plaques on the left elbow.

with mild post-inflammatory hyperpigmentation. The patient was maintained at the same dose for a further 5 sessions with sustained clearance of the plaques. The treatment interval was increased to once a week, thereafter for 2 months and the patient was followed

The patient in the study had a very quick response to excimer light with near complete clearing after just 4 sessions. It has been well-documented in various studies that excimer lasers clear psoriasis plaques in less than 10 sessions (as compared to nearly 30 required with NB-UVB therapy) and most likely the monochromatic 308 nm light at high energy aids in this response. The reduced number of treatments required is partly due to the fact that psoriatic lesions can be treated with supraerythemogenic doses, as demonstrated by the doseresponse study, where up to 16 multiples of minimal erythema dose (MED) were used to treat psoriatic

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DERMATOLOGY plaques. The excimer system’s ability to deliver many MED multiples to a targeted area in under a few minutes has proved to be beneficial for patients with resistant plaques on the elbows and knees, recalcitrant to topical medications or conventional phototherapy. Upon clearing, the interval between sessions was increased to once-weekly as maintenance therapy. The common adverse effects after excimer light therapy include erythema, blistering and hyperpigmentation. The patient in the study developed mild post-inflammatory hyperpigmentation that cleared in a few days spontaneously. CONCLUSION Excimer light therapy represents a novel treatment modality for the treatment of mild-to-moderate psoriasis. The number of treatments required to achieve clearance is much lower than NB-UVB therapy. With relatively good safety profile and efficient treatments, excimer light targeted phototherapy can be considered a good option in patients with mild-to-moderate plaque

posriasis that is resistant to conventional therapy. Longterm data and larger trails are needed to establish the safety of this new therapeutic modality. SUGGESTED READING 1. Weatherhead SC, Farr PM, Jamieson D, et al. Keratinocyte apoptosis in epidermal remodeling and clearance of psoriasis induced by UV radiation. J Invest Dermatol 2011;131(9):1916-26. 2. Nast A, Kopp I, Augustin M, et al. German evidence based guidelines for the treatment of psoriasis vulgaris (short version). Arch Dermatol Res 2007;299(3): 111-38. 3. Mrowietz U, Reich K. Psoriasis - new insights into pathogenesis and treatment. Dtsch Arztebl Int 2009;106(12):11-8, quiz 19. 4. Johnson-Huang LM, Suárez-Fariňas M, Sullivan- halen M, et al. Effective narrow-band ultraviolet B radiation therapy suppresses the IL-23/IL-17 axis in normalized psoriasis plaques. J Invest Dermatol 2010;130(11):2654-63.

5. Winterfield L, Menter A, Gordon K. Psoriasis treatment: current and emerging directed therapies. Ann Rheum Dis 2005;64(Suppl 2):ii87-90; discussion ii91-2. ■■■■

Infusions of Donor Bone Marrow Cells Help Children with Inherited Skin Blistering Promising results from a trial of a new stem-cell based therapy for a rare and debilitating skin condition have been published in the Journal of Investigative Dermatology. The therapy, involving infusions of stem cells, was found to provide pain relief and to reduce the severity of this skin condition for which no cure currently exists. The clinical trial, led by King’s College London in collaboration with Great Ormond Street Hospital (GOSH), recruited 10 children with recessive dystrophic epidermolysis bullosa (RDEB). RDEB is a painful skin disease in which very minor skin injury leads to blisters and poorly healing wounds. About 1,000 people in the UK live with RDEB. The fragile skin in RDEB also scars, develops contractures and is prone to life-shortening skin cancers. There is currently no cure for RDEB.

Fluorouracil Cream Boosts Actinic Keratosis Clearance Long-Term NEW YORK (Reuters Health) - A single course of fluorouracil cream 5% (5FU) reduces actinic keratosis (AK) count and patients’ need for spot treatments for up to three and a half years, a new randomized controlled trial shows. The study, in 932 patients, is the largest, longest-term to date of 5FU for AK, Dr. Martin Weinstock of the Veterans Affairs Medical Center in Providence, Rhode Island, who helped conduct the study, told Reuters Health in a telephone interview. Studies to date of 5FU for AK have followed patients after treatment for six months or less.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DIABETOLOGY

Gender-related Difference in Socioeconomic and Behavioral Factor in Relation to BP and BMI of Type 2 Diabetic Workers from Match Factories and Fireworks in Sivakasi, Tamil Nadu V PRIYA*, MAZHER SULTANA*, BABUJI†, KAMARAJ†

ABSTRACT Objective: The prevalence of diabetes has been steadily increasing in workers of Match factories and Fireworks in Sivakasi area. We investigated the difference between male and female diabetic patients on impact of socioeconomic, behavioral and other risk factors like blood pressure (BP) and body mass index (BMI). Methods: Total 112 persons (64 male and 48 female) with type 2 diabetes were selected for this study, from various hospitals situated in Sivakasi area. Socioeconomic status (SES) and other behavioral factors ascertained by physical examination and interview. Result: There was significant difference between male and female diabetics only in certain factors. SES was found significant and inversely related to physical activity, marital status, food habit, duration and systolic blood pressure (SBP) in female diabetics. In male, these association were weaker or absent, when education level was considered. But in income level significant differences found in SBP and detected age. Statistical significance was found between behavioral and other risk factors in both male and female diabetics. Conclusion: Physical inactivity leads to high BMI and increased SBP. Due to lack of knowledge, these diabetic patients did not avail any type of medical attention for treating diabetic till they got other complications due to untreated diabetes.

Keywords: Prevalence of diabetes, blood pressure, body mass index, socioeconomic status, physical inactivity, smoking, alcohol intake

iabetes prevalence is increasing in all population groups in India, but this increase seems to be greater in lower level people. The prevalence of type 2 diabetes has been reported more in fire works and match factory workers in Sivakasi area. Socioeconomic status which plays an important role in healthcare and disease prevention, is a complex indicator of health services accessibility, knowledge of health promotion, willingness to seek treatment and lifestyle behavior (Mei Tang 2003). Educational attainments and income adequacy are important indicators of socioeconomic status (SES). Low SES tends to be associated with a high prevalence of diabetes in developed countries (Evans et al 2000, Robbins et al 2001, Connolly et al 2000). Obesity, physical inactivity, smoking and alcohol intake are

*Presidency College, Chennai, Tamil Nadu †Kani Lakshmi Clinic, Sivakasi, Tamil Nadu

implicated in the development of type 2 diabetes and are also associated with low socioeconomic position (Emilie et al 2004). Research suggests an association between low SES and high blood pressure (BP), although this association is not consistent. A study on smoking, alcohol consumption and body mass index (BMI) reveals that the lifestyle increases the risk of high BP. And it is more common among people with low SES. (Mathews et al 1997, Lynch et al 1997, Porton et al 1999, Dyer et al 1999). Diagnostic and treatment services for high BP may be more accessible to people with high SES (Bunker et al 1995, Hoddard et al 1997). The health impact of SES and behavioral factors may not be the same in male and female. Only a few studies have assessed sex difference in the relationship between SES and diabetes. The pathway by which SES may differently affect the development of type 2 diabetes in male and female are unclear. The impact of behavioral factors like BMI, physically inactive, smoking, alcohol consumption and family history of diabetes are closely linked with insulin resistance. But the variation of BP in SES and behavioral factors has rarely been studied.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DIABETOLOGY So, the aim of the study was to assess the sex specific association of SES, behavioral factor and the difference in BP and BMI with diagnosed type 2 diabetic workers from match factories and fireworks in Sivakasi area.

Table 1. Socioeconomic, Behavioral and Other Risk Factors Among Males and Females Factor

Male

Female

P value

Age (years) Mean SD

51.13 10.17

48.77 10.10

0.23

Diabetes detected age (years) Mean SD

47.48 9.62

44.88 9.91

0.17

Duration (years) Mean SD

3.67 2.37

3.92 2.67

0.62

SBP (mmHg) Mean SD

132.53 12.70

131.29 10.82

0.58

DBP (mmHg) Mean SD

80.03 8.09

79.23 6.84

0.57

For this present study 112 samples (64 male and 48 female) were collected from various hospitals situated in Sivakasi area. The participants were interviewed and completed questionnaires on SES and behavioral characters were collected.

Plasma glucose (mg/dL) Mean SD

170.02 39.78

172.83 42.61

0.72

BMI ( kg/m²) Mean SD

26.59 1.99

25.38 2.60

0.0086

Socioeconomic Variables

Marital status Married (%) Single/widow (%)

89.06 10.94

81.25 18.75

0.24

Food habit NV (%) Veg (%)

81.25 18.75

70.83 29.17

0.196

Physically Inactive (%) Active (%)

31.25 68.75

43.75 56.25

0.174

Smoking habit Smoker (%) Nonsmoker (%)

43.75 56.25

0 100

0.000

Alcohol intake Alcoholic (%) Nonalcoholic (%)

45.31 54.69

0 100

0.000

Family history of diabetes FH+ (%) FH - (%)

76.56 23.44

70.83 29.17

0.49

Education Primary (%) Secondary (%) Higher (%)

25.00 56.25 18.75

60.42 29.17 10.42

0.0008

Income Low (%) Medium (%) High (%)

28.13 37.50 34.37

54.17 25.00 20.83

0.02

METHOD

Area This study was carried out on workers working in match factories and fire works in Sivakasi area. Sivakasi is situated in Virudhunagar district, Tamil Nadu state, India. This place is very dry and is ideally suited for the manufacturing of fireworks, printed materials, paper and the match factories. About 3,500 match factories are situated in and around Sivakasi area. Around 30,000 persons are directly employed in these factories.

Participants

Information on educational attainment was divided into primary (Class 1-5), secondary (Class 6-10) and higher (>10th class) education and income was divided in low (< ` 3,000), medium (` 3,000 to ` 5,000) and higher level (> ` 5,000).

Behavioral Variables Body weight was measured in light clothing in kg and height was measured in centimeters. BMI was calculated by weight in kg divided by square of height in meters. BP was measured in a sitting position for 2 times at the right arm after 15 minutes rest using sphygmomanometer by a well trained nurse. All subjects were interviewed and asked about their physical activity. It was divided into ‘active’ and ‘inactive’. Alcohol drinking habit was categorized as ‘alcoholic’ and ‘nonalcoholic’. Cigarette smoking was divided into ‘smokers’ and ‘nonsmokers’. Their family history about diabetes was analyzed and grouped into FH+ and FH-. Their age, diabetes detected age and duration also asked during interview.

Laboratory Measurement Plasma glucose was measured using an enzymatic method by using ready made kits manufactured by Prison Diagnostic Pvt. Ltd. Mumbai.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

FH+: Family history of diabetes present; FH- : Family history of diabetes absent; NV: Nonvegetarian; SBP: Systolic blood pressure; DBP: Diastolic blood pressure.

DIABETOLOGY Statistical Analysis

or proportions for categorical variables were calculated among the SES groups.

Analysis was carried out separately for males and females using Systat 12 (2007) statistical software. Descriptive analyses were obtained for all variables and differences between males and females were assessed using ‘t’ test, X2 tests and ANOVA. Sex differences in SES indicators were evaluated using linear or logistic regression models including original SES variables. Means [standard deviation (SD)] for normal distribution and means for log normal distributed continuous variables

RESULT Socioeconomical, behavioral and other risk factors among male and female participants are shown in Table 1. Systolic BP (SBP), diastolic BP (DBP) and BMI were higher and blood sugar was lower among males than females. Physical inactivity was more in female compared to males. Smoking and alcohol intake was

Table 2a. The Distribution of Risk Factor of Type 2 Diabetes by SES in Men Factor

Education

Income

P value

Primary

Secondary

Higher

P value

Low

Medium

High

Marital status Married (%) Single (%)

75.00 25.00

94.44 5.55

91.67 8.33

0.11

83.33 16.67

100 --

0.127

Food habit NV (%) Veg (%)

93.75 6.25

75.00 25.00

83.33 16.67

0.27

72.22 27.78

83.33 16.67

86.36 13.64

0.49

Physically Active (%) Inactive (%)

62.50 37.50

66.67 33.33

83.33 16.67

0.46

16.67 83.33

79.17 20.83

100 --

0.000

Smoking habit Smoker (%) Nonsmoker (%)

43.75 56.25

44.44 55.56

41.67 58.33

0.98

38.89 61.11

45.83 54.17

45.45 54.55

0.88

Alcohol intake Alcoholic (%) Nonalcoholic (%)

37.50 62.50

47.22 52.78

50.00 50.00

0.76

38.89 61.11

45.83 54.17

50.00 50.00

0.77

Family history of diabetes FH+ (%) FH - (%)

6.25 93.75

30.56 69.44

25.00 75.00

0.16

27.78 72.22

16.67 83.33

27.27 72.73

0.61

SBP (mmHg) Mean SD

137.00 13.06

130.39 13.19

133.00 9.67

139.67 11.19

133.58 11.72

125.55 11.66

DBP (mmHg) Mean SD

81.75 9.18

78.94 7.61

81.00 8.16

83.11 7.36

81.00 8.89

76.45 6.59

Plasma glucose (mg/dL) Mean SD

166.94 48.99

174.97 35.79

159.25 38.66

167.61 33.39

173.33 42.59

168.36 42.88

BMI (kg/m²) Mean SD

26.94 1.59

26.43 2.06

26.61 2.34

27.70 2.24

26.73 1.73

25.23 1.52

Detected age (years) Mean SD

48.94 9.46

46.44 9.67

48.67 10.11

54.11 9.37

46.00 8.80

43.68 8.15

Duration (years) Mean SD

3.56 2.34

3.67 2.53

3.83 2.08

4.39 2.64

3.63 2.64

3.14 1.69

NS: No significance; **Significance p < 0.01

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DIABETOLOGY found only in males. Nonvegetarians were more in males (81.25%) compared to females (70.81%). Family history of diabetes was seen more in males than females. Significant difference was found in income (p = 0.02) and educational status (p = 0.0008) between male and female subjects. The age at which the diabetes detected was high in males (47 years) and low in females (44 years). The distributions of various risk factors by SES are shown in Table 2a and 2b. In patients with secondary education level, more male (94.44%) members were

found married than female (92.86%). In male diabetics with primary education level number of singles or widows was high. But for female diabetics number of single or widows was high in higher education level. There was significant difference in education level and marital status among female diabetics (p = 0.03). Most of the male nonvegetarians were found in primary education group. But female nonvegetarians were more in secondary education group. While comparing income level, there was no significant difference noticed in male food habits. But in females there was a

Table 2b. The Distribution of Risk Factor of Type 2 Diabetes by SES in Women Primary

Secondary

Higher

P value

Low

Medium

High

P value

Marital status Married (%) Single (%)

Factor

82.76 17.24

92.86 7.14

40.00 60.00

0.03

76.92 23.08

83.33 16.67

90.00 10.00

0.65

Food habit NV (%) Veg (%)

68.97 31.03

78.57 21.43

60.00 40.00

0.69

84.62 15.38

58.33 41.67

50.00 50.00

0.067

Physically Active (%) Inactive (%)

37.93 62.07

78.57 21.43

100.00 --

0.004

30.46 61.54

75.00 25.00

80.00 20.00

0.025

Smoking habit Smoker (%) Nonsmoker (%)

0 100

0.0001

0 100

0.008

Alcohol intake Alcoholic (%) Nonalcoholic (%)

0 100

0.0001

0 100

0.008

Family history FH+ (%) FH - (%)

20.69 79.31

42.86 57.14

40.00 60.00

0.28

26.92 73.08

33.33 66.67

30.00 70.00

0.92

SBP (mmHg) Mean SD

134.41 9.01

128.29 12.19

121.60 10.14

133.92 11.01

129.33 8.06

126.80 12.15

DBP (mmHg) Mean SD

80.45 7.16

78.29 6.27

74.80 5.02

80.27 7.41

76.33 6.14

80.00 5.58

Plasma glucose (mg/dL) Mean SD

170.79 40.89

177.36 51.08

172.00 32.33

178.00 38.22

161.08 49.62

173.50 46.38

BMI (kg/mÂ˛) Mean SD

26.00 2.78

24.71 2.05

23.64 1.92

25.68 2.99

25.39 2.26

24.58 1.84

Detected age (years) Mean SD

45.97 10.38

43.86 8.58

41.40 11.46

46.31 11.61

42.92 9.13

43.5 7.15

Duration (years) Mean SD

4.28 3.17

3.79 1.58

2.20 0.84

***

3.96 3.21

3.83 1.69

3.90 2.28

NS: No significance; ** Significance p < 0.01; *** p < 0.001

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DIABETOLOGY Table 3a. The Relationship Between Behavioral and Other Risk Factors in Male Factor

Food habit

Smoker Yes

Alcohol

P value Yes

Physically

P value Inactive

P value

Nonveg

Veg

P value

Active

Family history FH + (%) FH - (%)

21.15 78.85

33.33 66.67

0.37

25.00 22.22 75.00 77.78

0.79

31.03 17.14 68.97 82.86

0.19

70.00 30.00

79.55 20.45

0.40

Marital status Married (%) Single (%)

90.38 9.62

83.33 16.67

0.48

96.43 83.33 3.57 16.67

0.09

100.0 80.00 20.00

0.01

85.00 15.00

90.91 9.09

0.48

SBP (mmHg) Mean SD

131.8 13.22

135.5 10.06

0.29

135.0 130.6 8.83 14.88

0.15

134.0 131.2 110.1 13.98

0.37

138.9 10.53

129.6 12.64

0.004

DBP (mmHg) Mean SD

80.08 7.74

79.83 9.85

0.94

81.07 79.22 8.70 7.61

0.38

81.59 78.74 8.20 7.88

0.16

81.30 8.81

79.45 7.78

0.43

Plasma glucose mg/dL Mean SD

168.7 40.36

175.5 38.36

0.59

171.8 168.5 35.02 43.57

0.74

176.7 164.4 30.08 40.83

0.21

164.3 38.19

172.6 40.65

0.43

BMI (kg/m²) Mean SD

26.43 1.93

27.29 2.18

0.22

27.23 26.09 1.36 2.26

0.01

26.72 26.48 1.80 2.15

0.63

27.79 1.87

26.05 1.81

0.001

Detected age (years) Mean SD

46.50 9.69

51.75 8.38

0.07

47.36 47.58 8.17 10.73

0.92

47.24 47.69 8.83 10.35

0.85

55.05 5.19

44.05 9.22

0.000

Table 3b. The Relationship Between Behavioral and Other Risk Factors in Female Factor

Smoker

Alcoholic

Nonveg

Food habit Veg

P value

Inactive

Physically Active

P value

Family history FH+ (%) FH - (%)

29.41 70.59

28.57 71.43

0.95

29.17 70.83

19.05 80.95

37.04 62.96

0.17

Marital status Married (%) Single (%)

76.47 23.53

92.86 7.14

0.19

81.25 18.75

76.19 23.81

85.19 14.82

0.43

SBP (mmHg) Mean SD

132.8 10.72

127.5 10.50

0.13

131.2 10.82

136.5 8.42

127.1 10.82

0.001

DBP (mmHg) Mean SD

79.38 6.77

78.86 7.26

0.82

79.23 6.84

79.86 7.21

78.74 6.64

0.58

Plasma glucose (mg/dL) Mean SD

170.2 41.56

179.2 46.01

0.53

172.8 42.61

168.48 38.72

176.2 45.83

0.53

BMI (kg/m²) Mean SD

25.49 2.80

25.12 1.93

0.61

25.38 2.60

26.46 2.86

24.54 2.07

0.01

Detected age (years) Mean SD

44.44 11.33

45.93 5.21

0.54

44.88 9.91

51.33 5.33

39.85 9.78

0.000

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

DIABETOLOGY significant difference (p = 0.06). Physical inactivity was high in primary education level and low income group in both males and females. But, there was significant difference in education level (p = 0.004) and income level (p = 0.02) in females. In males, smoking habit was high in secondary education level with medium income. And there was no smoking habit among female of any education and income level. Alcohol intake was high in higher education level and high income level male. Family history of diabetes reported high among both male (30.56%) and female (42.86%) with secondary education and no significant association found in income groups. SBP was more in primary educated (137 mmHg) and lower income level (139 mmHg) males. Also similar trend found in female diabetics. There was statistical significance found in diastolic pressure in males at income level and female at education levels. Plasma glucose level was high in both male (174.9 mg/dL) and female (177.3 mg/dL) subjects with secondary education level. Male (173.3 mg/dL) diabetics with medium income and female (178 mg/dL) diabetics in lower income level had high glucose level. Male diabetics in lower income level had high BMI 27.7 kg/m². But female diabetics with primary education level had high BMI 26.9 kg/m². Diabetes detected age was high among male diabetics (54 years) and low among female diabetics (46 years) who were in low income level. And diabetes was detected very early in both the males and females in high income level. Table 3a and 3b shows the relation between behavioral factors and other risk factors. Among male diabetics, significant association found between marital status and smoking habit (p = 0.09). Systolic pressure in male diabetics was more in vegetarians (135.5 mmHg), smokers (135 mmHg), alcoholic (134 mmHg) and physically inactive (138.9 mmHg). But, there was statistical significance found only in physical activity and SBP (p = 0.003). In male diabetics, plasma glucose was more in vegetarians (175.58 mg/dL), smokers (171.86 mg/dL) and alcoholic (176 mg/dL). BMI was also more in vegetarians (27.2 kg/m²), smokers (27.23 kg/m²) and physically inactive (27.79 kg/m²) males. But, BMI showed statistical significance between smokers and nonsmokers (p = 0.015) and physically active and inactive (p = 0.01) males. In female diabetics, SBP was high in nonvegetarians (132.8 mmHg) and physically inactive (136.57 mmHg). Statistical significance (p = 0.01) was found between

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

physical activity and SBP in females. Plasma glucose was found more in vegetarians (179.21 mg/dL) and physically active (176.22 mg/dL) females. In female diabetics, BMI showed significance (p = 0.01) with physical activity, it was more (26.46 kg/m²) in case of physically inactive females. Duration of diabetes shows significant difference between physical active and inactive females (p = 0.02). DISCUSSION This study shows that there is significant difference between male and female diabetics only in certain factors. In the third National Health and Nutrition Examination Survey (2001), SES was significantly associated with type 2 diabetes in both African American and white women. But, no relationship was found for men. Rathmann et al (2005) found that patients with long- standing diabetes along with severe disabling diabetic complication and poor health may result in low SES. According Tang et al (2003) in the National Population Health Survey in Canada, low income and education remained significantly associated with self-reported diabetes after controlling for BMI and physical activity in women. In men, the association was weaker and did not persist after controlling for risk factors. In the present study, there was significant difference in male only in few factors and SES. But, female showed significant inverse association with SES. This study reveals BMI was more among low income level male diabetics. Poor diet, lack of physical activity and smoking habit had lead to increase in BMI of these diabetic cases. Female diabetics in primary education level have more BMI. Lack of knowledge, consumption of junk food and sedentary lifestyle has increased the BMI of female diabetics. The association between SES and obesity was found in several studies, obesity being stronger in women than in men. Rathman et al (2005) analyzed that an inverse association of BMI and SES was found only in women. Ramachandran et al (2002) found that obesity is common in Indians and the adverse effect of central obesity is manifested in increasing tertiles of BMI both in men and women. BMI was found more in Indian women. Physical inactivity is another major behavioral risk factor of type 2 diabetes. Lantz et al (1998) found in US adult that physical activity was less in low SES groups. Ford et al found women with higher SES were more physically active than women with low SES; whereas this social gradient may be less pronounced in men. Rathman et al (2005) in KORA survey proved that physical inactivity was reported more in men

DIABETOLOGY and women in low SES. In the present study, physical inactivity is high among both male and female diabetics who were in low income level. Physically inactive female were more in low education level. Normally welleducated and those who earn more are more likely to engage in high physical activity. Mathews et al (1997) identified people with high occupational status and in particular high education attainments were less likely to smoke and drink excess alcohol. Study conducted in Canada showed that lower income was inversely associated with smoking and diet intake. But in this present study there was no difference in smoking habit between education level and income level in males. Alcohol intake was more in higher income group. Because of more work, stress, body pain and work tension they may resort to take alcohol. Kivimaki et al (2004) identified that there was a weak inverse relationship between SES and BP. Higher education attainment was associated with lower SBP. But association involving occupational status and DBP did not reach statistical significance. Stronger links with lifestyle and risk factor may partially explain the greater BP differences between educational levels and occupational status. Marmot et al (2001) in the Whitehall study found difference in SBP was no more than 3-5 mmHg between the highest and lowest employment grade. INTER-SALT study, Stamler (1992) proved an inverse association between years of education and BP. He found that, for men 28 out of 47 populations and for women 38 of 47 populations, this inverse association was seen. The US Hanes III study showed no association between SES and BP. In this present study SBP was more in primary education and low income level in both males and females. Tension, worry about the uncertainty in life, work pressure and poor diet regulation may increase the BMI. Previous researches consistently showed a positive relationship between body weight and BP. Increased BMI was the predictor of higher BP. Hoskins et al found that a family history of diabetes was a risk factor for diabetes in Melanesians and Indians living in Fiji. Ramachandran et al (1988) reported a high prevalence of diabetes among Indian children who had one or two diabetic parents. But in the present study, there was no significant difference in family history of diabetes and SES between males and females. This study shows low income male diabetics had longer duration of diabetes and diabetes detected age was also higher. Even in female diabetics, primary

education group had diabetes over long duration and the diabetes detected age was high. Due to poverty and lack of knowledge these diabetic patients were not aware of the free healthcare facilities and never tried to avail any type of medical attention for treating diabetes, till they got complication due to prolonged untreated diabetes. In conclusion, in female diabetics SES was found to be significantly and inversely related to physical activity, marital status, food habit, duration and SBP. In males these associations were weaker or absent when education level, was considered. But in income level significant differences, were found in SBP and diabetes detected age. Significant differences found in both male and female behavioral characters and other risk factors like SBP and BMI. Physical inactivity leads to high BMI and it increases SBP. But, the differences between male and female diabetic patients needs to be further investigated.

Acknowledgment We thank Mr. Ramadas, Mr Navaneethan and Mrs. Asha for the help they extended while collecting the samples. Also we thank Mr Ponmurugan for the statistical and secretarial help.

SUGGESTED READING 1. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health. No easy solution. JAMA 1993;269(24):3140-5. 2. 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. 3. Brown AF, Ettner SL, Piette J, Weinberger M, Gregg E, Shapiro MF, et al. Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiol Rev 2004;26:63-77. 4. Connolly V, Unwin N, Sherriff P, Bilous R, Kelly W. Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas. J Epidemiol Community Health 2000;54(3):173-7. 5. Choi BC, Shi F. Risk factors for diabetes mellitus by age and sex: results of the National Population Health Survey. Diabetologia 2001;44(10):1221-31. 6. Dyer AR, Liu K, Walsh M, Kiefe C, Jacobs DR Jr, Bild DE. Ten-year incidence of elevated blood pressure and its predictors: the CARDIA study. Coronary Artery Risk Development in (Young) Adults. J Hum Hypertens 1999;13(1):13-21. 7. Agardh EE, Ahlbom A, Andersson T, Efendic S, Grill V, Hallqvist J, et al. Explanations of socioeconomic differences in excess risk of type 2 diabetes in Swedish men and women. Diabetes Care 2004;27(3):716-21.

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DIABETOLOGY 8. Evans JM, Newton RW, Ruta DA, MacDonald TM, Morris AD. Socio-economic status, obesity and prevalence of Type 1 and Type 2 diabetes mellitus. Diabet Med 2000;17(6):478-80. 9. Brancati FL, Kao WH, Folsom AR, Watson RL, Szklo M. Incident type 2 diabetes mellitus in African American and white adults: the Atherosclerosis Risk in Communities Study. JAMA 2000;283(17):2253-9. 10. House JS, Lepkowski JM, Kinney AM, Mero RP, Kessler RC, Herzog AR. The social stratification of aging and health. J Health Soc Behav 1994;35(3):213-34. 11. House JS, Kessler RC, Herzog AR. Age, socioeconomic status, and health. Milbank Q 1990;68(3):383-411. 12. Ismail AA, Beeching NJ, Gill GV, Bellis MA. Capturerecapture-adjusted prevalence rates of type 2 diabetes are related to social deprivation. QJM 1999;92(12):707-10. 13. Lynch JW, Kaplan GA, Salonen JT. Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic life course. Soc Sci Med 1997;44(6):809-19. 14. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA 1998 ;279(21):1703-8. 15. Tang M, Chen Y, Krewski D. Gender-related differences in the association between socioeconomic status and selfreported diabetes. Int J Epidemiol 2003;32(3):381-5. 16. Kivimäki M, Kinnunen ML, Pitkänen T, Vahtera J, Elovainio M, Pulkkinen L. Contribution of early and adult factors to socioeconomic variation in blood pressure: thirty-four-year follow-up study of school children. Psychosom Med 2004;66(2):184-9.

18. Poston WS 2nd, Foreyt JP. Obesity is an environmental issue. Atherosclerosis 1999;146(2):201-9. 19. Robbins JM, Vaccarino V, Zhang H, Kasl SV. Socioeconomic status and type 2 diabetes in African American and nonHispanic white women and men: evidence from the Third National Health and Nutrition Examination Survey. Am J Public Health 2001;91(1):76-83. 20. Stamler R, Shipley M, Elliott P, Dyer A, Sans S, Stamler J. Higher blood pressure in adults with less education. Some explanations from INTERSALT. Hypertension 1992;19(3):237-41. 21. Shah SK, Saikia M, Burman NN, Snehalatha C, Ramachandran A. High prevalence of type 2 diabetes in urban population in north eastern India. Int J Diabetes Dev Countries 1999;19:144-7. 22. Maty SC, Everson-Rose SA, Haan MN, Raghunathan TE, Kaplan GA. Education, income, occupation, and the 34year incidence (1965-99) of Type 2 diabetes in the Alameda County Study. Int J Epidemiol 2005;34(6):1274-81. 23. Gary TL, Brancati FL. Commentary: socioeconomic position and the risk of type 2 diabetes. Int J Epidemiol 2005;34(6):1282-3. 24. Rathmann W, Haastert B, Icks A, Giani G, Holle R, Meisinger C et al; KORA Study Group. Sex differences in the associations of socioeconomic status with undiagnosed diabetes mellitus and impaired glucose tolerance in the elderly population: the KORA Survey 2000. Eur J Public Health 2005;15(6):627-33.

25. Williams DR. Socioeconomic differentials in health: a 17. Power C, Matthews S. Origins of health inequalities in a review and redirection. Soc Psychol Q 1990;53(2):81-99. national population sample. Lancet 1997;350(9091):1584-9. ■■■■

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ENT

Facial Necrotizing Fasciitis: A Rare Complication of Maxillary Sinusitis N GUPTA*, S VARSHNEY†, P GUPTA‡

ABSTRACT Necrotizing fasciitis is an uncommon infection of the fascia and subcutaneous tissue, which is extremely rare in head and neck region because of high vascularity. Necrotizing fasciitis arising as a complication of maxillary sinusitis is exceptionally rare. We present the case of a 50-year-old female patient who was immunocompetent and developed facial necrotizing fasciitis as a sequel of maxillary sinusitis. She was effectively managed by surgical debridement and antibiotics. To the best of our knowledge, this is the second case report in English literature presenting as necrotizing fasciitis secondary to maxillary sinus infection.

Keywords: Maxillary, sinusitis, facial, necrotizing, fasciitis

axillary sinus lies close to the orbit superiorly, nasal cavity medially, teeth inferiorly, pterygopalatine fossa posteriorly, and facial skin anteriorly. Complications occurring as a sequelae of maxillary sinusitis can involve all these structures but with the advent of highly effective antibiotics, it is rare to see them in the modern era.1 Necrotizing fasciitis of facial region is even a rarer occurrence, especially in an immunocompetent patient. The most common causes of cervicofacial necrotizing fasciitis are of odontogenic origin.2 Maxillary sinusitis is an uncommon cause of necrotizing fasciitis. The onset is often insidious in the form of nonspecific regional facial swelling, erythema, and fever. Thus, clinical distinction from more benign inflammatory conditions of the neck, such as cellulitis, may be impossible at an early stage. Without immediate surgical treatment, however, necrotizing fasciitis of the head and neck invariably

*Assistant Professor Dept. of ENT Government Medical College and Hospital, Chandigarh, Punjab †Professor and Head Dept. of ENT All India Institute of Medical Sciences, Rishikesh, Uttarakhand ‡Lecturer Dept. of Orthodontics Subharti Dental College, Meerut, Uttar Pradesh Address for correspondence Dr Nitin Gupta Dept. of ENT Government Medical College and Hospital, Sec 32, Chandigarh, Punjab E-mail: nitinent123@gmail.com

leads to mediastinitis and fatal sepsis.3 Therefore, it is important to establish the correct diagnosis at an early stage. Contrast-enhanced computed tomography (CECT) scan is the investigation of choice to evaluate the extent of the disease. The diagnosis of necrotizing fasciitis should be suspected if the inflammatory signs on CT scan are not limited to cellulitis, but include widespread fasciitis of the superficial and deep fascia.4 Antibiotic treatment alone is insufficient; prompt and aggressive surgical exploration and debridement are imperative to prevent a fatal outcome. CASE REPORT A 50-year-old female presented in the ENT OPD with swelling over right cheek and upper lip for the last 3 days. Swelling was sudden in onset, rapidly progressive in size, associated with severe pain and fever for 2 days and black discoloration of the skin. Patient also complained of obstruction and purulent discharge in right nasal cavity. There was no history of diabetes, any drug reaction, or insect bite. There was swelling and pain over right eyelid. Examination of the patient revealed temperature of 100.3°F, tachycardia (pulse rate 104/min). On local examination, there was a swelling on right cheek, upper lip, and partly extending to lower lip with patchy black discoloration. Swelling was tender, 4 × 6 cm in size and temperature over surface raised, diffused with ill-defined margins, soft in consistency, and nonfluctuant (Fig. 1). There was edema over the right eyelid while the left eyelid was normal in texture and function. Anterior rhinoscopy

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ENT

Figure 2. CECT scan of the nose and PNS showing features of acute right-side sinusitis and soft tissue swelling of right cheek with marked thickening of fascia. Figure 1. Patient showing diffuse swelling over right cheek and lips.

and diagnostic nasal endoscopy were suggestive of purulent discharge in middle meatus of right nasal cavity. Vision and examination of cranial nerves was normal except for hypoesthesia over right cheek. The patient was hospitalized and started on broad-spectrum intravenous antibiotics (Ceftriaxone, Gentamycin, and Metronidazole) along with analgesics, antipyretics, and nasal decongestants. Pus was sent for culture and sensitivity. Routine blood examination was suggestive of leukocytosis while other tests (urine, random blood sugar, and serum creatinine) were within normal range. Enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV) was negative. CECT scan of the nose and paranasal sinus (PNS) was done, which revealed air–fluid level in right maxillary sinus along with mucosal thickening in bilateral maxillary, ethmoid, and frontal sinuses, and a soft tissue swelling of right cheek extending to temporal region. There was marked thickening of superficial and deep fascia of this region (Fig. 2). Considering the clinical and CT scan findings, a diagnosis of necrotizing fasciitis was made. The patient was posted for emergency surgery where debridement of the wound and followup wound care was done. Pus culture revealed growth of b-hemolytic streptococci Group A, Pseudomonas spp., and Staphylococcus aureus that were sensitive to the prescribed antibiotics. Surgery and postoperative period was uneventful. Pain and swelling subsided considerably after 48 h. Histopathological examination

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of the tissue was suggestive of acute abscess. A postoperative CT scan done 5 days after surgery was normal and had no inflammatory signs (Fig. 3). The patient was discharged on the sixth postoperative day. Patient has been on a regular follow-up for the last 4 months with no recurrence of disease. DISCUSSION The term “necrotizing fasciitis” is used to describe a severe, acute and potentially life-threatening inflammatory condition caused by streptococcal or mixed bacterial infection and propagating continuously within soft tissues.5 Necrotizing fasciitis is a rare infection of the fascial planes, which is less common in head and neck because of higher vascularity in the region. The most common causes of necrotizing fasciitis are dental infections (dental abscess, gingivitis, and pulpits), blunt trauma, radiotherapy and tonsillitis.6 Maxillary sinusitis is an uncommon cause of necrotizing fasciitis. The predisposing factors for the development of necrotizing fasciitis are diabetes, hypertension, obesity, malnutrition, peripheral vascular diseases, severe liver disease, alcoholism and acquired immunodeficiency syndrome (AIDS).7 Although necrotizing fasciitis has been described mainly in elderly and immunocompromised patients, it recently has been observed increasingly in young, otherwise healthy, individuals. Normally, infection progresses rapidly and can involve the vascular structures causing small vessel thromboses. The most common clinical

ENT useful by some authors.9 The morbidity and mortality seems to be related to the promptness of medical and surgical intervention. The mortality rate reported in the literature ranges from 19% to 40%.5 The higher mortality rate is related to pre-existing systemic illness, late surgical intervention, septicemia within 24 h, old age and mediastinal and thoracic extension of the infection. REFERENCES 1. Stamenkovic I, Lew D. Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy N Engl J Med 1984;310(26):1689-93. 2. Raboso E, Llavero MT, Rosell A, Martinez-Vidal A. Craniofacial necrotizing fasciitis secondary to sinusitis. J Laryngol Otol 1998;112(4):371-2. Figure 3. Postoperative CT scan showing normal nose and PNS.

presentations are painful edema, erythema, warmth, tenderness and crepitation. Patients can develop mediastinitis and consequent septic shock.8 CT scan has been advocated for detecting gas, identifying the spread of infection in vascular sheaths, and detecting the extension of infection to remote areas (mediastinitis and pleural or pericardial effusions). Necrotizing fasciitis is a polymicrobial infection; the most common pathogens are Streptococcus spp., but S. aureus and anaerobes are also present in large proportion of cases. Effective treatment and management of necrotizing fasciitis is based on early recognition aggressive surgical intervention, use of broad-spectrum antibiotics, and supportive therapy. It is important to explore and drain all involved fascial planes. Hyperbaric oxygen was found to be

3. Banerjee AR, Murty GE, Moir AA. Cervical necrotizing fasciitis: a distinct clinicopathological entity? J Laryngol Otol 1996;110(1):81-6. 4. Becker M, Zbären P, Hermans R, Becker CD, Marchal F, Kurt AM, et al. Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. Radiology 1997;202(2):471-6. 5. Bahu SJ, Shibuya TY, Meleca RJ, Mathog RH, Yoo GH, Stachler RJ, et al. Craniocervical necrotizing fasciitis: an 11-year experience. Otolaryngol Head Neck Surg 2001;125(3):245-52. 6. Krespi YP, Lawson W, Blaugund SM, Biller HF. Massive necrotizing fasciitis infections of the neck. Head Neck Surg 1981;3(6):475-81. 7. Zbaren P, Rothen HU, Läng H, Becker M. Necrotizing fasciitis of soft tissues of the face and neck. HNO 1995; 43(10):619-23. 8. Vaid N, Kothadiya A, Patki S, Kanhere H. Necrotizing fasciitis of the neck. Indian J Otolaryngol Head Neck Surg 2002;54(2):143-5.

9. Kantu S, Har-El G. Cervical necrotizing fasciitis. Ann Otol Rhinol Laryngol 1997;106(11):965-70. ■■■■

An Overlooked Antiseptic Reduces Surgical Infections ORLANDO, Florida — When patients undergoing spinal surgery swabbed the inside of their noses with a topical antiseptic before the procedure, there was a dramatic reduction in surgical-site infections, researchers report. “I don’t know why use of this antiseptic has not been more widely taken up. Certainly our results are very compelling,” said Nicholas Flynn, MD, from the University of Tennessee in Nashville. “This may be because there have been no randomized trials.” Dr Flynn presented the results here at the Society for Healthcare Epidemiology of America Spring 2015 Conference.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

INTERNAL MEDICINE

Multisystem Involvement in Melioidosis: A Case Report PRIYADARSHINI GUNASEELAN*, SWAMIKANNU M†, VAIDEHI R‡, SARVESWARI KN#

ABSTRACT Melioidosis is an infection caused by facultative intracellular, aerobic, Gram-negative soil and water living bacterium Burkholderia pseudomallei, which was previously classified under Pseudomonas. Melioidosis is an uncommon yet fatal infection dreaded as a potential bio threat. The infection spreads by inoculation, inhalation or ingestion. Diabetes, alcohol abuse, chronic renal failure, pulmonary diseases are identified risk factors. We report a case of a 39-year-old male diagnosed as melioidosis who presented with splenic abscess, pulmonary consolidation, skin nodules and later developed cellulitis of the foot, which required incision and drainage.

Keywords: Melioidosis, Burkholderia pseudomallei, consolidation, splenic abscess, cellulitis

CASE REPORT A 39-year-old man with no known comorbid illnesses came to our emergency room (ER) with a long history for fever for 5 weeks. He was treated elsewhere with multiple antibiotics and a course of antimalarial. On examination, he was febrile, temperature of 103˚F, tachycardic and also had a palpable spleen. On further interrogation, he revealed a history of pilgrimage by barefoot for about 90 km, 3 weeks prior to the onset of initial symptom (around early August, which is monsoon in this part of India). Preliminary investigations showed a normal blood count with few neutrophilic band forms and raised erythrocyte sedimentation rate (ESR), normal renal and liver functions. Probable causes of fever like typhoid, malaria, scrub typhus were negative. Human immunodeficiency virus (HIV) enzymelinked immunosorbent assay (ELISA) was negative. Diabetes mellitus was detected after admission with

*Postgraduate Dept. of Family Medicine †Consultant Physician ‡Consultant Microbiologist #Consultant Dermatologist Sundaram Medical Foundation, Chennai, Tamil Nadu Address for correspondence Dr Priyadarshini Gunaseelan Postgraduate Dept. of Family Medicine Sundaram Medical Foundation, Chennai, Tamil Nadu

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

glycosylated hemoglobin (HbA1C) of 13.9%. Ultrasound of the abdomen was unremarkable except for an enlarged spleen of 13 cm. He was empirically started on ceftriaxone. Blood culture of the patient grew Gram-negative bacilli identified by Vitek system as Burkholderia cepacia (Fig. 1). Since, the patient’s immune system was not severely debilitated for B. cepacia infection the cultures were repeated. In the meantime, he continued to have fever spikes, developed pustules over the face and arm and lost significant weight (lost 6 kg since admission) (Fig. 2). Computed tomography (CT) showed consolidation of the lower zone of left lung and splenic

Figure 1. Blood culture plate showing wrinkled pink colonies.

INTERNAL MEDICINE drainage was done and 30 mL of pus was drained, which also showed heavy growth of B. pseudomallei. We planned to continue ceftazidime for a total period of 6 weeks. Glycemic control was achieved with insulin. Blood cultures done at the end of 3, 4 and 6 weeks were sterile. Ultrasound showed resolution of the splenic abscess. Patient was discharged with oral eradication therapy with doxycycline 100 mg twice-daily and co-trimoxazole thrice-daily for 6 months and is under regular follow-up. DISCUSSION Melioidosis is an illness endemic to South-East Asia regions, Indian subcontinent and Northern Australia. Though, there were few monographs from Malaysia and Rangoon describing features similar to the disease in the early 20th century, the first case report came from Burma in 1911 described by Whitmore and Krishnaswami.1-3

Figure 2. Skin nodules.

The bacteria causing melioidosis was named as Pseudomonas pseudomallei. It was further classified under the new genus Burkholderia in 1992 by Yabuuchi et al. It is a soil and water pathogen. Stagnation of water in places like paddy fields and rainfall causes clustering of cases. The bacterium is found in the soil of almost all states of India.2,3 Bruce Short from Australia in his monograph states that melioidosis is a military problem - because deployments, where personnel on patrol through paddy fields are at particular risk.4

Figure 3. CT of abdomen demonstrates splenic abscesses that were not easily visualized on a sonogram. Thoracic imaging shows consolidation of the left lower zone.

abscesses of size 5 Ă&#x2014; 6 cm (Fig. 3). The repeat blood culture and swab culture from the pustules grew Burkholderia pseudomallei sensitive to most groups of antibiotics. Antibiotic therapy with ceftazidime was started at 2 g IV 8th hourly. Fever spikes gradually subsided, but patient developed pain and swelling of the dorsum of the right foot on the 9th day of specific antibiotic therapy. Deep-vein thrombosis (DVT) was ruled out; uric acid was 1.6 mg/dL. The swelling progressively increased in size and was warm and tender. The cellulitis failed to subside, with continuing antibiotic therapy, hence incision and

Apart from the environmental risk factors, 80% of cases of melioidosis are documented to occur in individuals with some identified comorbidity.5 A prospective study done on 540 patients in Northern Australia for 20 years has identified diabetes and hazardous alcohol use as high-risk factors.6 In about 60% of cases, diabetes has been detected after presentation with melioidosis like in our patient.2 However, mortality is not determined by these conditions. An underlying malignancy, cardiac failure, chronic kidney disease and biofilm formation as in in-dwelling catheters are associated with higher mortality.7 The overall mortality rate of melioidosis is 14%.6 Melioidosis is transmitted through inoculation or inhalation or ingestion. A case of vertical transmission through breast milk from a mother suffering from mastitis has also been reported. The incubation period varies from 1 to 21 days. The shortest incubation period is reported in a case of near drowning leading to aspiration pneumonia. Melioidosis has a spectrum

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INTERNAL MEDICINE of clinical presentation ranging from indolent asymptomatic disease to acute respiratory distress syndrome and septicemia. Various case reports include pneumonia, abscesses of skin, subcutaneous tissue, deep-seated visceral abscesses and lymphadenitis.7-11 Even rare cases of mycotic aneurysm, osteomyelitis and mastitis have been described in literature. Pneumonia carries the risk of rapidly progressing to respiratory failure.9 Significant weight loss is an important observation as in our patient. Because of the intracellular activity of the bacterium and its ability to form multinucleated giant cells, melioidosis mimicks tuberculosis.8,10 Whitmore described the autopsy lesions on the first ever reported case of melioidosis as ‘peculiar cheesy consolidation that was neither lobar pneumonia nor tubercular’. Challenges in diagnosis of melioidosis require a clinical suspicion and a strong laboratory support. There are no specific guidelines currently for the treatment of melioidosis. Various centres follow different antibiotic protocol depending on the organ involved. Ceftazidime remains the drug of choice in most centers. Use of ciprofloxacin, amoxicillin-clavulanic acid, etc. have also been reported. The duration of treatment varies from 2 to 8 weeks depending on the site of infection; deep-seated abscesses require longer duration of antibiotics followed by oral eradication therapy with co-trimoxazole and doxycycline. The organism exhibits characteristic resistance to aminoglycosides. A study in Malaysia on 146 isolates of B. pseudomallei revealed that all isolates were susceptible to ceftazidime and carbapenems, 88% sensitive to co-trimoxazole and 82% sensitive to ciprofloxacin.

REFERENCES 1. Whitmore A. An account of a Glanders-like disease occurring in Rangoon. J Hyg (Lond) 1913;13(1):1-34.1. 2. Puthucheary SD. Melioidosis in Malaysia. Med J Malaysia 2009;64(4):266-74. 3. Pandey V, Rao SP, Rao S, Acharya KK, Chhabra SS. Burkholderia pseudomallei musculoskeletal infections (melioidosis) in India. Indian J Orthop 2010;44(2):216-20. 4. Short BH. Melioidosis: an important emerging infectious disease - a military problem? ADF Health 2002;3:13-21. 5. Wiersinga WJ, Currie BJ, Peacock SJ. Melioidosis. N Engl J Med 2012;367(11):1035-44. 6. Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis 2010;4(11):e900. 7. Jin JL, Ning YX. Septicemic melioidosis: a case report and literature review. J Thorac Dis 2014;6(2):E1-4. 8. Sugi Subramaniam RV, Karthikeyan VS, Sistla SC, Ali SM, Sistla S, Vijayaraghavan N, et al. Intra-abdominal melioidosis masquerading as a tubercular abdomen: report of a rare case and literature review. Surg Infect (Larchmt) 2013;14(3):319-21. 9. Redondo MC, Gómez M, Landaeta ME, Ríos H, Khalil R, Guevara RN, et al. Melioidosis presenting as sepsis syndrome: a case report. Int J Infect Dis 2011;15(3):e217-8. 10. Saravu K, Mukhopadhyay C, Eshwara VK, Shastry BA, Ramamoorthy K, Krishna S, et al. Melioidosis presenting with mediastinal lymphadenopathy masquerading as malignancy: a case report. J Med Case Rep 2012;6:28.

11. Wijekoon S, Prasath T, Corea EM, Elwitigala JP. Melioidosis presenting as lymphadenitis: a case report. BMC Res Notes 2014;7:364. ■■■■

Daptomycin Safe for Children with Skin Infections Daptomycin (Cubicin, Cubist Pharmaceuticals) is safe and effective for the treatment of complicated skin infections in children, according to the results of a trial presented here at the 33rd Annual Meeting of the European Society for Paediatric Infectious Diseases (ESPID). The drug is already approved by the US Food and Drug Administration for complicated skin infections in adults, as well as for Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) bloodstream infections, but it is not currently available for use in children.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

NEUROSURGERY

Pneumocephalus after Ventriculoperitoneal Shunt: Diagnostic Dilemma and its Endoscopic Management HANISH BANSAL*, RAKESH KAUSHAL†, MANISH MUNJAL‡

ABSTRACT Pneumocephalus, a common entity in neurosurgical practice is a very rare phenomenon after ventriculoperitoneal shunt insertion and generally is result of long-standing hydrocephalus causing bony erosion. Defect may remain completely plugged by gliotic brain tissue and meningeal scarring but lowering of intracranial pressure following shunt placement causes opening up of fistula and pneumocephalus. We report a case of a 55-years-old male with pineal region tumor with hydrocephalus who presented to us with severe headache after ventriculoperitoneal shunt insertion for hydrocephalus. Computed tomography (CT) head revealed tension pneumocephalus and pneumoventricle. Thin cut coronal CT images localized the air leak to left basifrontal region and patient underwent successful endoscopic transnasal skull base repair using fat and fascia lata graft. Pneumocephalus, a well-known condition in neurosurgery practice is extremely rare after shunt operations. Air can gain access to the intracranial cavity only when there is a break in basal structures in connection with the paranasal sinus, and when the nasal air pressure exceeds the intracranial pressure. Most cases resolve spontaneously but recurrent cases require definite repair. Thin axial CT cuts are used to localize the defect in the skull base. We add a new dimension to the treatment of this rare complication via endoscopic transnasal skull base repair technique.

Keywords: Pneumocephalus, ventriculoperitoneal shunt, hydrocephalus

neumocephalus, a common entity in neurosurgical practice is a very rare phenomenon after ventriculoperitoneal shunt (VP) insertion and less than 50 cases have been described in the literature. Pneumocephalus after ventriculoperitoneal shunt generally is result of long-standing hydrocephalus causing bony erosion. Defect may remain completely plugged by gliotic brain tissue and meningeal scarring but lowering of intracranial pressure following shunt placement causes opening up of fistula and pneumocephalus. Management involves prompt diagnosis and closure of the defect if conservative

*Resident †Professor and Head ‡Professor Dept. of Neurosurgery Dept. of ENT Dayanand Medical College and Hospital, Ludhiana, Punjab Address for correspondence Dr Hanish Bansal Dept. of Neurosurgery 10-B, Udham Singh Nagar, Civil Lines Ludhiana -141 001 Punjab E-mail: y2khanish@rediffmail.com

treatment fails. We report this case so as to add to the existing scanty literature and also add a new dimension to the treatment of this rare complication via endoscopic transnasal skull base repair technique. CASE REPORT We report a case of a 55-year-old male who presented to us with gait ataxia and who after complete diagnostic work-up was later diagnosed as a case of pineal region tumor, ?? pineocytoma with obstructive hydrocephalus. Patient underwent ventriculoperitoneal shunt and was discharged in satisfactory condition. The patient was readmitted 2 days later with complaint of severe headache. Computed tomography (CT) head revealed extensive pneumocephalus with pneumoventricle (Fig. 1). Patient was initially managed conservatively with supplementary O2 and was kept on strict bed rest in supine position. CT head done after 1 week revealed resolution of air. Patient symptoms reappeared once patient was ambulated. Repeat CT head revealed increase in pneumocephalus. The shunt tube was ligated and the repeat CT head revealed hydrocephalus with resolution of

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NEUROSURGERY

Figure 1. CT head showing extensive pneumocephalus and pneumoventricle.

Figure 2. CT head showing hydrocephalus with focal air collection in left basifrontal region.

pneumocephalus with focal air collection in left basifrontal region. Thin axial cuts of CT head localized left basifrontal region as suspected site of air leak (Fig. 2). The patient was then taken up for endoscopic transnasal skull base exploration, which revealed

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

yellowish smooth tissue prolapsing from the roof of posterior ethmoidal sinus. The mass was fulgrated and an endoscopic transnasal skull base repair was done using fat and fascia lata graft. Postoperative course was uneventful and the shunt was restored few days

NEUROSURGERY later. Repeat CT head showed complete resolution of pneumocephalus and patient was discharged in satisfactory condition. In our case, the mechanism of development of pneumocephalus was mainly based on two factors: A reduction in the intracranial pressure and the presence of a defect in the dura and skull that was caused by long-standing elevation in intracranial pressure, due to hydrocephalus secondary to pineal region tumor. Probably, because of the ball-valve action of a dural leaflet, there was no cerebrospinal fluid (CSF) leakage. His neurosurgical history could indicate neoplastic fistula, but the primary site of the tumor was far from the identified pneumocephalus. DISCUSSION Pneumocephalus, also known as intracerebral aerocele or pneumatocele is defined as the presence of gas within any of the intracranial compartments (intraventricular, intraparenchymal, subarachnoid, subdural and epidural) of the cranial vault.1 Pneumocephalus is a well-known condition in neurosurgery practice and the common causes of pneumocephalus are trauma, surgery, tumors and infections.2 Pneumocephalus is a common finding after intracranial surgery and generally resolves spontaneously. It is extremely rare after shunt operations and less than 50 cases have been described in the literature. CSF shunting has been associated with a significant number of complications. Infections, shunt malfunction, slit ventricle, subdural hematomas are among the most common. Although, pneumoventricle is common immediately after the shunting procedure, tension pneumocephalus or pneumoventricle following CSF diversion is an extremely rare complication.3 Air can gain access to the intracranial cavity only when there is a break in basal structures in connection with the paranasal sinus, and when the nasal air pressure exceeds the intracranial pressure.4 The bone defect may be congenital but more often occurs as a result of bony erosion due to long-standing raised intracranial pressure by hydrocephalus. The common sites of congenital skull base defects are anterior fossa, followed by the middle fossa and tegmen tympani in temporal bone.5 Osteomas, epidermoid and pituitary tumors are examples of neoplasms that can cause erosion through the skull base or skull. Infection with gasproducing organisms or a ventriculoperitoneal shunt catheter perforating the colon remain unlikely

possibilities of post-shunt pneumocephalus.6 The possible mechanism of pneumocephalus development is based mainly on two factors: 1) The presence of a defect in the dura and skull causing air inflow with a 'one-way ball valve mechanism'; and 2) a decrease in intracranial pressure causing a pressure imbalance. The pressure gradient between the outside and inside of the skull, which increases in the sitting or standing position, causes inflow of air into the subdural and subarachnoid spaces, although no defect could be found radiologically. Probably because of the ballvalve action of a dural leaflet, there may be no CSF leakage. Gliotic brain tissue and cicatrized meninx may possibly invaginate into this defect and the defect may then not allow entry of air to the intracranial cavity during the long-lasting intracranial hypertension. Significant lowering of intracranial pressure, following shunt placement, causes unplugging of the defect that results in the opening up of the fistula.7 Clinical presentation includes headaches, nausea and vomiting, seizures, dizziness and depressed neurological status. Management of pneumocephalus is based on the treatment of elevated intracranial pressure, treatment of meningitis, shunt management and finally closure of the main source of air inflow. The etiology of pneumocephalus has to be verified clearly in most cases with careful clinical evaluation and the air entrance site may be searched by thin slice CT, which is sensitive for detecting intracerebral/ intracranial air as small as 0.5 cc. Furthermore, 3D CT may show the defect of basis cranii as a possible site of air entry. Smaller and multiple fistulous tracts at the skull base are difficult to diagnose and are frequently associated with recurrent pneumocephalus or meningitis. When a porencephalic cyst is present, the identification of fistulous defect is relatively easier because of its close proximity with the cyst.8 Most cases of small pneumocephalus do not require any surgical management. Intracranial air also often resolves spontaneously. Supplemental oxygen increases the rate of absorption of pneumocephalus. The treatment must be focused on direct surgical closure of the main site of air entry. If the site of fistula cannot be established, dural repair in the most likely site of the fistula is recommended. Temporary closure of the shunt may stop the vicious circle established between displaced volume of CSF, intracranial negative pressure and pneumocephalus.9 Cont'd on page 85...

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OBSTETRICS AND GYNECOLOGY

A Comparative Study to Assess the Interference of Calcium Lysinate with Iron Absorption When it is Co-administered with Iron Supplements N VIJAYALAKSHMI, SB JOSHI, PN KASTURE*, KH NAGABHUSHANâ&#x20AC;

ABSTRACT Poor maternal and newborn health and nutrition remain significant contributors to the burden of diseases in these populations. It is estimated that 41.8% of pregnant women worldwide are anemic. Iron deficiency anemia may affect growth and development both in utero and in the long-term. Similarly, inadequate consumption of calcium by pregnant women can lead to adverse effects in both the mother and the fetus, including osteopenia, tremor, paresthesia, muscle cramping, tetanus, delayed fetal growth, low birth weight and poor fetal mineralization. Clinical observations suggest that iron absorption is adversely affected by minerals such as calcium. To address this issue of interference and inhibition of iron by calcium, a novel form of calcium chelated with amino acid has been introduced, which does not interfere with iron absorption. The objective of this study was to prove that the chelated calcium, when administered simultaneously with iron preparation does not interfere with iron absorption.

Keywords: Calcium lysinate, iron absorption, iron supplements, pregnant women, iron deficiency anemia

oor maternal and newborn health and nutrition remain significant contributors to the burden of diseases in these populations. In 2010, 3.1 million babies died in the first 28 days of life, mostly due to low birth weight, severe infections, asphyxia and preterm birth. Every year, 15 million babies are born prematurely, of whom 1.1 million die in the neonatal period or in infancy. In addition, many of those who survive have a lifetime disability such as learning disabilities and/or visual and hearing problems.1

gestation is lower than 11 g/dL.4 Low Hb concentrations, indicative of moderate or severe anemia during pregnancy, have been associated with an increased risk of premature delivery, maternal and child mortality and infectious diseases.5 Iron deficiency anemia may affect growth and development both in utero3 and in the long-term.6 It contributes to low birth weight, lowered resistance to infection, poor cognitive development and reduced work capacity.7 Iron helps both the mother and babyâ&#x20AC;&#x2122;s blood carry oxygen.

Iron deficiency anemia is the most common micronutrient deficiency in the world affecting more than 2 billion people globally. It is estimated that 41.8% of pregnant women worldwide are anemic.2 As many as two-thirds of women and young children may be affected in many developing countries. At least half of this burden is assumed to be due to iron deficiency,3 with the rest due to conditions such as folate, vitamin B12 or vitamin A deficiency, chronic inflammation, parasitic infections and inherited disorders. A pregnant woman is considered to be anemic if her hemoglobin (Hb) concentration during the first and third trimester of

Similarly, calcium is essential for many diverse processes, including bone formation, muscle contraction and enzyme and hormone functioning.8 Inadequate consumption of this nutrient by pregnant women can lead to adverse effects in both the mother and the fetus, including osteopenia, tremor, paresthesia, muscle cramping, tetanus, delayed fetal growth, low birth weight and poor fetal mineralization.9 Calcium supplementation has the potential to reduce adverse gestational outcomes, in particular, by decreasing the risk of developing hypertensive disorders during pregnancy, which are associated with a significant number of maternal deaths and considerable risk of preterm birth, the leading cause of early neonatal and infant mortality.10 Calcium supplementation during pregnancy can prevent a new mother from losing her own bone density, as the fetus uses the mineral for bone growth. Approximately 2,87,000 women died

*Senior Medical Advisor-Medical Services â&#x20AC; Vice President-Medical Services Micro Labs Limited, 27, Race Course Road, Bangalore

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OBSTETRICS AND GYNECOLOGY during pregnancy and childbirth in 2010, mostly due to maternal health complications.11 Dietary iron intake exceeds the bodyâ&#x20AC;&#x2122;s requirements by a significant margin. Iron deficiency occurs because the human diet contains compounds that limit the absorption of the food iron when physiological requirements are increased by growth, pregnancy or blood loss. Calcium salts and dairy products have been shown, in various experimental studies, to have this property. The importance of an adequate calcium intake for bone formation and the strong advocacy of calcium supplementation (National Institutes of Health [NIH] Consensus Development Panel on Optimal Calcium Intake, 1994) have raised concern in the nutritional community about possible deleterious effects on iron nutrition.12 Consumption of calcium supplements with meals is recommended to enhance the bioavailability of calcium in the supplement. Iron status may, therefore, be compromised by long-term use of calcium supplements or intake of foods high in calcium, particularly in women of reproductive age in whom iron deficiency is common.13 Clinical observations suggest that iron absorption is adversely affected by minerals such as

Fe2+

Fe3+

Fe2+

Fe3+

DCYTB

Ca2+ Ca2+

Chyme flow

Fe2+

Fe3+

DMT1

DCYTB

Fe2+

Ca2+

DMT1

Fe2+

Ferritin Fe2+ Ferroportin

Gastrointestinal distress is a common observation in women consuming large amounts of supplemental iron, particularly on an empty stomach. Use of highdose iron supplements is commonly associated with constipation and other gastrointestinal effects, including nausea, vomiting and diarrhea, with the frequency and severity depending on the amount of elemental iron released in the stomach. In supplements, calcium is present in the form of carbonate, citrate, citrate malate, lactate or gluconate, and in all these forms, has varied elemental content (between 10% and 40%) with varied bioavailability (9-90%). These inorganic salts of calcium get ionized in the gut and seem to interfere with the absorption of other ions. Fe(II) is transported across the cellular membrane in the gut by a 12-transmembrane-segment protein, divalent metal transporter 1 (DMT1), also known as SLC11A2, NRAMP2 and DCT1. Besides iron, DMT1 also transports other divalent metals including zinc, magnesium, cobalt, copper, cadmium, nickel and lead by a proton-coupled mechanism.

Fe2+

Chyme flow

Fe3+

calcium. Calcium supplements reduce absorption of dietary iron.14 Calcium, when given as a supplement or in the form of dairy products, may reduce both heme and nonheme iron absorption by 40-60%.15-19

Ferritin Fe2+ Hephaestin

Ferroportin

Hephaestin

Transferrin Fe2+

Fe3+

Blood flow

Transferrin Fe2+

Fe3+

Blood flow

Figure 1. Calcium reduces DMT1 expression at the apical cell membrane, thereby downregulating iron transport into the cell and inhibiting iron absorption.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

OBSTETRICS AND GYNECOLOGY The role of calcium ions in causing iron deficiency may be explained by their ability to reduce DMT1 expression at the apical cell membrane, thereby downregulating iron transport into the cell and inhibiting iron absorption (Fig. 1).20 Both iron and calcium supplements are imperative during pregnancy and lactation stages and thereby are indicated to all the pregnant and lactating women. Compliance is improved when these supplements are taken together. To address this issue of interference and inhibition of iron by calcium, a novel form of calcium, chelated with amino acid has been introduced, which does not interfere with iron absorption; this chelated form of calcium gets absorbed in toto without any ionization, thereby not interacting with the absorption of iron. The objective of this study was to prove that the chelated calcium when administered simultaneously with iron preparation does not interfere with iron absorption. CHELATES The word ‘chelate’ is derived from a Greek word which means ‘claw’. A chelate represents an organic chemical complex in which the metal part of the molecule is held so tightly that it cannot be broken by contact with other substances, which could convert it to an insoluble form. Chelates form as a result of reaction between amino acids and metals including calcium. A chelate can be formed between the amino acid lysine (the chelator) and calcium (the mineral). These organic molecules trap or encapsulate certain metal ions like calcium, magnesium, iron, cobalt, zinc and manganese and then release these metal ions slowly. The agents that bound to metals and form chelates are termed as chelating agents. Amino acid chelation bypasses the competitive interactions that can occur between different minerals when they are absorbed as salts. Use of chelated minerals avoids this problem, since they get absorbed in ‘toto’ in non-ionized form. The organic chelating agent amino acid ‘AA’ is added to the solution of inorganic calcium salts. AA

AA Calcium

The organic chelating agents have a natural affinity to the calcium and form a strong bond. AA AA Calcium AA AA

Calcium Lysinate The inorganic calcium salt is chelated with lysine (amino acid) to form calcium lysinate. Studies have indicated that taking nonchelate calcium supplements with meals makes it more difficult for women to meet their daily iron requirement. This negative effect has been seen with all ionizable forms of calcium - carbonates, citrates, phosphates, etc. Unlike these sources of calcium, calcium-amino acid chelates do not ionize in the gut, thus eliminating the potential to interfere with iron absorption. Thus, both calcium and iron which are imperative for pregnant and lactating women can be consumed simultaneously without any interference and less adverse effects, thereby increasing the compliance. MATERIAL AND METHODS

Study Objective The aim of CAlcium Lysinate does not interfere with iRon absorptiON (CALRON) study, was to assess the effect of calcium lysinate on iron absorption when coadministered. The study intended to prove that the chelate form of calcium with lysine does not interfere with iron absorption, thereby not adversely affecting the increase in the Hb levels, even when consumed simultaneously.

Study Design and Methodology This study was an open-labeled, randomized, comparative, multicentric, prospective trial conducted to evaluate the change in the Hb levels in pregnant women taking iron and calcium supplements simultaneously as against the conventional method of taking them at different times of the day. Three centers from Bangalore and one from Mumbai participated in the study. The protocol was approved by the Ethics Committee. Pregnant women attending the antenatal care clinic with no obvious obstetric complications were examined for study eligibility.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

OBSTETRICS AND GYNECOLOGY All the women were informed and written consent was obtained for participation in the study. A total 180 subjects were recruited and randomized to both the groups. The study arm was given calcium lysinate and iron preparation simultaneously and the control arm was given iron preparation in the morning and calcium citrate malate in the evening. The duration of the study was 8 weeks; at completion of 4th week first follow-up visit was done and the 2nd at the end of 8 weeks. Follow-up visits were planned after every 4 weeks. Every subject would visit 3 times including the enrollment visit. In each follow-up, physical and clinical examinations with Hb measurements were repeated. They were interviewed for side-effects (heart burn, nausea, vomiting, diarrhea and constipation) at each follow-up visit. The Hb levels measured at each followup visits were compared between the two groups. Hb was determined by using autoanalyzer and the sample drawn was intravenous for all the subjects.

Inclusion and Exclusion Criteria Inclusion Criteria ÂÂ

Pregnant women in second trimester or third trimester.

ÂÂ

Breastfeeding mother (postnatal care <4 months should be considered).

ÂÂ

Subjects with Hb concentration of >7 and <11 g/dL.

ÂÂ

Subject should be able to provide informed consent before participation.

Exclusion Criteria ÂÂ

Subjects taking laxatives, diuretics or antacids.

ÂÂ

Subjects donating blood during the study.

ÂÂ

Subjects with any gastrointestinal disorders known to influence iron absorption according to the investigator.

ÂÂ

Postnatal mother of >4 months duration.

RESULTS Initially, 199 pregnant women were screened. Out of these, total 180 eligible subjects were recruited in the study, 90 women each were randomized in the interventional and control groups (Fig. 2). Overall, 163 completed 8 weeks of the study and remaining 17 (9.4%) dropped out in between which was below the acceptable level of 10%. More women (n = 83) in study group completed the study as compared to control group (n = 80). Data reveal that 84.3% of cases among study group were in the age group of 19-35 years, which was

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

Pregnant women initially examined (n = 199)

Eligible women included in the study (n = 180)

90 women randomized to intervention group (n = 90)

90 women randomized to control group (n = 90)

Women completed the study (n = 83)

Women completed the study (n = 80)

Women dropped out (7)

Women dropped out (10)

Figure 2. Flow chart showing allocation of the women in the study.

Table 1. Age Distribution of the Subjects in Both the Groups Age distribution

Study Group

Control Group

No.

19-25

37.3

26-35

47.0

36-45

15.7

Total

100

By Chi-square test p > 0.05. Not significant.

comparable to 85.0% of cases among control group and the difference was not significant (Table 1). It also correlated with the active reproductive age group where maximum women are expected to be pregnant during the same age group. The average baseline Hb value was 8.24 g/dL and 8.64 g/dL in the study and control groups, respectively (Table 2). The mean Hb rise at end of 4 weeks was 0.80 g/dL and 0.68 g/dL and at the end of 8 weeks was 1.48 g/dL and 1.34 g/dL in study and control groups, respectively (Table 2 and Fig. 3). The increase in the mean Hb levels from baseline levels to the end of the study was significant in both the groups (p < 0.01). Comparing the mean Hb rise at the end of the study (i.e. 8 weeks), comparable rise in both the groups was found to be statistically significant (p < 0.01); however, the same mean difference of Hb values may not be clinically significant. This similarity pointed towards the absence of interference of iron absorption

OBSTETRICS AND GYNECOLOGY Table 2. Mean Hb Values of Both the Groups

the nutrients i.e., iron and calcium supplements at the same time thereby increasing the compliance.

Baseline

4 Weeks

8 Weeks

Study group (n = 83)

8.24 ± 0.69

9.04 ± 0.64

9.72 ± 0.68

CONCLUSION

Control group (n = 80)

8.64 ± 0.83

9.32 ± 0.73

9.98 ± 0.71

There was a significant change in the mean Hb levels from baseline to the end of the study in both the groups, whereas the difference in the mean change in Hb levels within the groups was not significant. This similar rise in Hb levels indicates that the chelated formulation of calcium did not interfere with the iron absorption which was administered simultaneously.

10 9

Hb (g/dL)

9.04

9.72

8.24

8.64

9.32

9.98

Baseline

Week 4

Week 8

5 4 3 2 1 0

Study group

Control group

Figure 3. Mean rise of Hb levels in study and control group.

by calcium supplementation when given in the form of chelates. Eight subjects in study group and 12 subjects in control group reported mild adverse effects of gastrointestinal disturbances like nausea, vomiting, dyspepsia, but none of them discontinued the study and required any concomitant medications. DISCUSSION India has a very high prevalence of anemia in pregnant women, which is further complicated by malnutrition, repeated pregnancies separated by short intervals, thus having adverse implications on the birth outcomes. Iron and calcium are important nutrients required during pregnancy and lactation for the woman and child health. Conventional practice is to administer iron and calcium supplements at different times of the day as iron absorption gets hampered in the presence of calcium. The results of this study showed that in the intervention group, where iron and calcium preparations were given simultaneously, there was a significant rise in the Hb levels from the baseline levels and when compared to the control group, the rise in Hb levels was noninferior indicating that the chelated form of calcium did not interfere with the iron absorption even when given simultaneously. This gives an option for the treating doctors to convince the pregnant women to take both

LIMITATIONS Other parameters of iron deficiency anemia were not considered as the primary objective of this study was to assess the mean rise in the Hb levels indicating noninterference of calcium with iron absorption even if given simultaneously. However, other parameters should have been considered which was beyond the purview of this study.

Acknowledgment We sincerely thank Dr Anjali Radkar and Mr Ajay Gupta for their statistical inputs for this article. REFERENCES 1. Dean S, Bhutta ZA, Mason EM, Howson CP, ChandraMouli V, Lassi Z, et al. Chapter 3: Care before and between pregnancy. In: Howson CP, Kinney MV, Lawn JE (Eds.). Born Too Soon: The Global Action Report on Preterm Birth. World Health Organization, Geneva; 2012 (March of Dimes, PMNCH, Save the Children, World Health Organization). 2. WHO Global Database on Anaemia, WHO/CDC. (2008). Worldwide prevalence of anaemia 1993-2005. Geneva, World Health Organization. [online] Available from: http:// whqlibdoc.who.int/publications/2008/9789241596657_ eng.pdf [Accessed 29 April, 2015]. 3. WHO/UNICEF/UNU. (2001). Iron deficiency anaemia assessment, prevention, and control: a guide for programme managers. [online] Available from: http:// www.who.int/nutrition/publications/en/ida_assessment_ prevention_control.pdf [Accessed 29 April, 2015]. 4. WHO/NMH/NHD/MNM. (2011). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. [online] Available from: http://www. who.int/vmnis/indicators/haemoglobin.pdf [Accessed 29 April, 2015]. 5. International Anemia Consultative Group. Why is iron important and what to do about it: a new perspective. Washington, DC, INACG Secretariat; 2002. pp. 1-50.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

OBSTETRICS AND GYNECOLOGY 6. Lozoff B, Jimenez E, Smith JB. Double burden of iron deficiency in infancy and low socioeconomic status: a longitudinal analysis of cognitive test scores to age 19 years. Arch Pediatr Adolesc Med. 2006;160(11):1108-13. 7. Stolzfus RJ, Dreyfuss ML. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. Washington, DC, ILSI Press, 1998 [online] Available from: http://inacg.isli.org/file/b2_VUHUQ8AK pdf [Accessed 29 April, 2015]. 8. World Health Organization, Food and Agricultural Organization of the United Nations. Vitamin and mineral requirements in human nutrition, 2nd Edition. Geneva, World Health Organization, 2004 [online] Available from http://www.who.int/nutrition/publications/ micronutrients/9241546123/en /index.html [Accessed 29 April, 2015]. 9. Villar J, Say L, Shennan A, Lindheimer M, Duley L, Conde-Agudelo A, et al. Methodological and technical issues related to the diagnosis, screening, prevention and treatment of pre-eclampsia and eclampsia. Int J Gynaecol Obstet. 2004;85(Suppl 1):S28-41. 10. WHO Guideline (2013). Calcium supplementation during pregnancy. [online] Avaialable from: http://www.who.int/ about/licensing/copyright_form/en/index.html [Accessed 29 April, 2015]. 11. World Health Statistics 2013. [online] Available from:http://apps.who.int/iris/bitstream/10665/81965/ 1/9789241564588_eng.pdf [Accessed 29 April, 2015].

13. Kalkwarf HJ, Harrast SD. Effects of calcium supplementation and lactation on iron status. Am J Clin Nutr. 1998;67:1244-9. 14. Cook JD, Dassenko SA, Whittaker P. Calcium supplementation: effect on iron absorption. Am J Clin Nutr. 1991;53:106-11. 15. Seligman PA, Caskey JH, Frazier JL, Zucker RM, Podell ER, Allen RH. Measurements of iron absorption from prenatal multivitamin-mineral supplements. Obstet Gynecol. 1983;61:356-62. 16. Dawson-Hughes B, Seligson FH, Hughes VA. Effects of calcium carbonate and hydroxyapatite on zinc and iron retention in post-menopausal women. Am J Clin Nutr. 1986;44:83-8. 17. Deehr MS, Dallal GE, Smith KT, Taulbee JD, DawsonHughes B. Effects of different calcium sources on iron absorption in post-menopausal women. Am J Clin Nutr. 1990;51:95-9. 18. Hallberg L, Brune M, Erlandsson M, Sandberg AS, Rossander-Hulten L. Calcium: effect of different amounts on nonheme- and heme-iron absorption in humans. Am J Clin Nutr. 1991;53:112-9. 19. Hallberg L, Rossander-Hulthen L, Brune M, Gleerup A. Inhibition of haem-iron absorption in man by calcium. Br J Nutr. 1992;69:533-40.

20. Thompson BA, Sharp PA, Elliott R, Fairweather-Tait SJ. Inhibitory effect of calcium on non-heme iron absorption may be related to translocation of DMT-1 at 12. Lynch SR. The effect of calcium on iron absorption. Nutr the apical membrane of enterocytes. J Agric Food Chem. Res Rev. 2000;13(2):141-58. 2010;58(14):8414-7. ■■■■

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

OPHTHALMOLOGY

Adult Unilateral Chorioretinal Atrophy Secondary to Acquired Rubella MEENAKSHI PATIL*, NEELAM REDKAR†, MARUTI KARALE‡, MANISH DODMANI#

ABSTRACT Rubella retinopathy in adults is uncommon. Here we report a case of 25-year-old healthy female who presented with blurring of vision of right eye, and was detected to have chorioretinal atrophy on fundus examination. Detailed investigations of the patient to evaluate the cause of chorioretinal atrophy were done in which her serology against rubella was found strongly positive. This is an uncommon case of acquired adult unilateral rubella retinopathy, which is a rare presentation of rubella infection in adults.

Keywords: Acquired rubella, viral retinopathy

ubella virus is a member of the family Togaviridiae and is only found in humans; there is no known animal reservoir. Rubella is usually a mild acute viral infection of short duration, which characteristically includes fever, rash and lymphadenopathy. Congenital chronic fetal rubella infection may cause various systemic and ocular malformations. Adults are more likely to experience a prodromal phase with malaise, low-grade fever, headache and conjunctivitis. Rubella has a broadspectrum of other possible manifestations and atypical presentations can be seen in adults.1,2

CASE REPORT A 25-year-old female, married since 5 years and having two children, presented to our hospital with history of right hemicranial headache and blurred vision of right eye since 3 months. There was history of fever and upper respiratory tract infection 15 days prior to appearance of her symptoms. There was no history of rash, joint pains and no other significant history.

*Assistant Professor †Professor ‡Senior Resident #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) - 400 072, Mumbai, Maharashtra E-mail: meenakshi.patil90@gmail.com

Her general and systemic clinical examination was unremarkable. On ophthalmic examination for blurred right eye vision, her right eye visual acuity was 6/9 and her right eye fundus showed large chorioretinal atrophic patch in the inferotemporal region (Fig. 1). Her left eye visual acuity was normal at 6/6 and left eye fundus was normal. Patient’s investigations were initiated to evaluate the cause for chorioretinal atrophy. Her enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was negative, venereal disease research laboratory (VDRL) for syphilis was negative, antibodies against tuberculosis and tuberculin test were negative. Antibodies to hepatitis C and hepatitis B antigen test were negative. Her erythrocyte sedimentation rate (ESR),

Figure 1. Right eye fundus showing large chorioretinal atrophic patch in the inferotemporal region.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

OPHTHALMOLOGY antinuclear antibody test (ANA), double-stranded deoxyribonucleic acid (dsDNA), rheumatoid factor, complete blood counts, urine and stool examination, chest X-ray and ultrasonography were normal. Her TORCH test (ELISA for Toxoplasmosis, Rubella, Cytomegalovirus (CMV) and Herpes simplex virus [HSV]-1&2) revealed both immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies positive for rubella; IgM antibody titers - 20 IU/mL (positive >10 IU/mL) and IgG antibody titers were 160 IU/mL (positive >10 IU/mL). IgG antibodies were positive for toxoplasma, CMV and HSV-1 but IgM was negative suggestive of past infection. Her magnetic resonance imaging (MRI) brain was normal. Patient was treated symptomatically with analgesics for headache and dark goggles were advised. Repeat TORCH test after one and half months showed negative rubella IgM and decrease in IgG titers to 110 IU/mL. Patient’s symptoms of headache improved over 1 month with some improvement in visual acuity, though mild blurring of vision persisted. Thus, after detailed work-up of patient to rule out other causes of chorioretinitis and chorioretinal atrophy and with the evidence of positive serology for rubella, diagnosis of chorioretinal atrophy secondary to acquired rubella chorioretinitis was made. DISCUSSION Rubella (which means ‘little red’ and is also known as German measles) was originally thought to be a variant of measles. It is a mild disease in children and adults, but can cause devastating problems if it infects the fetus, especially if infection is in the first few weeks of pregnancy. The sequelae of congenital rubella syndrome are congenital heart defects, neurologic problems, ophthalmic problems (cataract, glaucoma, retinopathy), hepatosplenomegaly and intrauterine growth retardation. Man is the only host. Rubella virus is spread via an aerosol route and occurs throughout the world. The initial site of infection is the upper respiratory tract. The virus replicates locally (in the epithelium, lymph nodes) leading to viremia and spreads to other tissues. As a result the disease symptoms develop. There is usually no prodrome in young children but in older children and adults, disease results in low-grade fever, rash, sore throat and some individuals get arthralgia and arthritis (especially adult women). The patient is infectious from about 1 week before onset of rash to about 1 week after that. Complications of rubella in adults are extremely rare (1 in 6,000 cases). Rubella

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

encephalopathy, panencephalitis, orchitis and neuritis are some of the rare complications.1,2 Rubella retinitis can be associated with significant secondary chorioretinal atrophy. Rubella retinopathy is believed to be an ongoing disease capable of developing subretinal neovascularization, greater pigment epithelial mottling, and progressive retinal changes, including choroidal atrophy.3,4 Salt and pepper pigmentary disturbance is the most common ocular complication in congenital rubella but it is not common in adult acquired rubella.5 A clinical diagnosis of rubella may be difficult to make because many exanthematic diseases may mimic rubella infection. Typical rubilliform rashes may also be induced by other viruses like Enteroviruses, Chikungunya virus, Ross virus and Parvovirus B19. In addition, as many as 50% rubella infections may be subclinical; therefore, laboratory studies are important to confirm the diagnosis of acute rubella infection. The ocular complications of rubella must be differentiated from other causes of vasculitis and retinitis. In our patient, diagnostic tests to rule out other causes of vasculitis and retinitis were solicited: VDRL, serology for CMV, toxoplasmosis antibodies, HIV, herpes, ESR, chest radiographs, rheumatologic tests and white blood cell count, which were within normal limits.6 The laboratory diagnosis of rubella can be made either through serologic testing or by viral culture. But the process of culture is difficult and the facilities for culture are lacking in most of the laboratories. Hence, serodiagnosis is considered the most useful and reliable method for detection of infection. Acute rubella infection is usually established by demonstration of seroconversion in paired sera or by demonstration of rubella-specific IgM antibodies in a single specimen. IgM antibodies usually attain their maximum concentration within 10-14 days after the onset of illness but the duration of response is variable. In general, following primary infection, they persist for 6-12 weeks, although some patients may exhibit a more prolonged response, which may extend for as long as a year. ELISA is a rapid, reliable and sensitive method of measuring rubella-specific IgM antibodies in the serum sample of patients with acute rubella infection.7 Natural rubella infection normally confers lifelong immunity. In India, about 50% of children acquire rubella antibodies by the age of 5 years and 80-90% become immune by the age of 15. A study among unvaccinated girls, 10-16 years of age, found that 86.5% had

OPHTHALMOLOGY antibodies against rubella. Another study funded by the Serum Institute of India Pvt. Ltd. manufacturers of the MMR (mumps, measles, rubella) vaccine in India, conducted among unvaccinated girls with a mean age of 10.7 years reported that 90% were protected despite not being vaccinated.8,9 In India, the measles vaccine is already given in the Government Universal Immunization Program (UIP) at the age of 9-12 months and the combined MMR vaccine is given at the age of 15 months as an optional vaccine in the private sector.10 Our patient was not vaccinated for rubella. Because the antibody levels to rubella in our patient were high during the subacute stage and decreased within 2 months, we believe this patient had unilateral rubella retinitis with chorioretinal atrophy, a condition rarely described in adult rubella infection. There are very few case reports of adult rubella chorioretinitis described in literature.11 REFERENCES 1. Best JM. Rubella. Semin Fetal Neonatal Med 2007;12(3): 182-92.

3. Deutman AF, Grizzard WS. Rubella retinopathy and subretinal neovascularization. Am J Ophthalmol 1978;85(1):82-7. 4. Menne K. Congenital rubella retinopathy - a progressive disease. Klin Monbl Augenheilkd 1986;189(4):326-9. 5. Khurana RN, Sadda SR. Images in clinical medicine. Salt-and-pepper retinopathy of rubella. N Engl J Med 2006;355(5):499. 6. Schuil J, van de Putte EM, Zwaan CM, Koole FD, Meire FM. Retinopathy following measles, mumps, and rubella vaccination in an immuno-incompetent girl. Int Ophthalmol 1998;22(6):345-7. 7. Morgan-Capner P. 1989;299(6695):338-9.

Diagnosing

rubella.

BMJ

8. Ramamurty N, Murugan S, Raja D, Elango V, Mohana, Dhanagaran D. Serosurvey of rubella in five blocks of Tamil Nadu. Indian J Med Res 2006;123(1):51-4. 9. Yadav S, Wadhwa V, Chakarvarti A. Prevalence of rubella antibody in school going girls. Indian Pediatr 2001;38(3):280-3. 10. Sunderlal, Adersh, Pankaj. Textbook of community medicine. 1st edition, CBS Publishers and Distributers: New Delhi and Bangalore 2007. ISBN:81-239-1441-5.

2. Heggie AD, Robbins FC. Natural rubella acquired after 11. Damasceno N, Damasceno E, Souza E. Acquired unilateral birth. Clinical features and complications. Am J Dis Child rubella retinopathy in adult. Clin Ophthalmol 2010;5:3-4. 1969;118(1):12-7. ■■■■

...Cont'd from page 75

CONCLUSION We report a very rare case of pneumocephalus secondary to ventriculoperitoneal shunt insertion and its endoscopic transnasal skull base repair. Due to rarity of the condition there is scanty data related to its diagnosis and management. We also bring about a new dimension to the treatment of this rare complication via endoscopic transnasal skull base repair technique. REFERENCES 1. Schirmer CM, Heilman CB, Bhardwaj A. Pneumocephalus: case illustrations and review. Neurocrit Care 2010;13(1):152-8. 2. Sunada S, Yamaura A, Hosaka Y, Uozumi A, Makino H. Tension pneumocephalus as a complication of a ventriculoperitoneal shunt. Case report. Neurol Med Chir (Tokyo) 1984;24(1):42-5. 3. Tuğcu B, Tanriverdi O, Günaldi O, Baydin S, Postalci LS, Akdemir H. Delayed intraventricular tension pneumocephalus due to scalp-ventricle fistula: a very

rare complication of shunt surgery. Turk Neurosurg 2009;19(3):276-80. 4. Ikeda K, Nakano M, Tani E. Tension pneumocephalus complicating ventriculoperitoneal shunt for cerebrospinal fluid rhinorrhoea: case report. J Neurol Neurosurg Psychiatry 1978;41(4):319-22. 5. Kim YH, Lee WI, Park MN, Choi HS, Kim NH, Han SJ. Otogenic pneumocephalus associated with a ventriculoperitoneal shunt. Clin Exp Otorhinolaryngol 2009;2(4):203-6. 6. Shetty PG, Fatterpekar GM, Sahani DV, Shroff MM. Pneumocephalus secondary to colonic perforation by ventriculoperitoneal shunt catheter. Br J Radiol 1999;72(859):704-5. 7. Lee WY, Kim SH, Kim OL, Choi BY. Delayed tension pneumocephalus caused by ventriculoperitoneal shunt. J Korean Neurosurg Soc 2007;41:47-9. 8. Sankhla S, Khan GM, Khan MA. Delayed tension pneumocephalus: a rare complication of shunt surgery. Neurol India 2004;52(3):401-2. 9. Pieri F, Anania CD, Perrini P, Puglioli M, Parenti GF. Delayed otogenic pneumocephalus complicating ventriculoperitoneal shunt. Neurol India 2011;59(4):616-9.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

EXPERTS’ VIEW

What are the Risks of Myocardial Infarction and/ or Death in a Patient with Unstable Angina During Hospital Admission? TS KLER, KK AGGARWAL*

he natural history of atheromatous coronary artery disease (CAD) is complex. Patients presenting with acute coronary syndrome without ST-segment elevation are classified as having unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI); however, this classification depends on the absence or presence of biochemical markers of myocardial necrosis, respectively. While increased creatine kinase and isoenzyme creatine kinase-MB (CK-MB) are characteristic of myocardial injury, elevation of the more sensitive and myocardial specific cardiac troponins signifies NSTEMI.1 Risk stratification is an integral part of the management of patients with unstable angina. ST-segment alterations predict higher cardiac event rates. However, patients without ECG changes or T-wave inversions have been noted to have a considerable risk of ≈4% mortality in 42 days. Therefore, better prognostic markers are required. Cardiac-specific troponins appear to be powerful independent predictors of future cardiac events in patients with unstable angina.2 Unstable angina with rest pain within 48 hours without a recent MI (Class IIIB) is a very frequent condition. Within Class IIIB, cardiac-specific troponins T and I, C-reactive protein and fibrinogen allow differentiation between high-risk and low-risk patients.2 It has been noted that Class IIIB troponin-negative (Tneg) patients have a far better prognosis, with cardiac death or MI within 1 month of <2%.2 The Thrombolysis in Myocardial Infraction (TIMI) risk score is a simple prognostication scheme that classifies a patient’s risk of death and ischemic events. The seven TIMI risk score predictor variables include:3 ÂÂ

Age ≥65 years

ÂÂ

At least 3 risk factors for CAD

ÂÂ

Prior coronary stenosis of 50% or more

ÂÂ

ST-segment deviation on ECG at presentation

ÂÂ

At least 2 anginal events in prior 24 hours

ÂÂ

Use of aspirin in prior 7 days

ÂÂ

Elevated serum cardiac markers.

The Timing of Intervention in Acute Coronary Syndrome (TIMACS) trial included patients with unstable angina or NSTEMI who presented to a hospital within 24 hours of the onset of symptoms. All received standard medical therapy, and 3,031 were randomly assigned to undergo angiography either within 24 hours after randomization or 36 or more hours after randomization. At 6 months, the primary outcome of death, new MI or stroke had occurred in 9.6% of the patients in the early-intervention group and in 11.3% of those in the delayed-intervention group, but the difference was not statistically significant. The difference in the rate of a secondary endpoint, death, MI or refractory ischemia, was statistically significant: 9.5% vs 12.9%.4 A recent study by Shaikh et al5 evaluated the Global Registry of Acute Coronary Event (GRACE) risk score and noted that during the in-hospital stay, 3.6% patients died and out of those 8.4% patients belonged to highrisk group. In a study by Maddox et al,6 unstable angina patients had a greater prevalence of angina at 1 year than STEMI patients and similar rates as NSTEMI patients. Additionally, unstable angina patients had similar rehospitalization rates as MI patients, despite better 2-year survival. Therefore, several factors appear to affect mortality, MI or recurrent ischemia in unstable angina and NSTEMI. REFERENCES

*Senior Physician and Cardiologist, Moolchand Medcity, New Delhi Group Editor-in-Chief, IJCP Group and eMedinewS

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

1. Sheridan PJ, Crossman DC. Critical review of unstable angina and non-ST elevation myocardial infarction. Postgrad Med J 2002;78(926):717-26.

EXPERTS’ VIEW 2. Hamm CW, Braunwald E. A classification of unstable angina revisited. Circulation 2000;102:118-22. 3. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non–st elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;284(7):835-42.

5. Shaikh MK, Hanif B, Shaikh K, et al. Validation of Grace Risk Score in predicting in-hospital mortality in patients with non ST-elevation myocardial infarction and unstable angina. J Pak Med Assoc 2014;64: 807.

6. 4. Mehta SR, Granger CB, Boden WE, et al; TIMACS Investigators. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med 2009;360(21):2165-75. ■■■■

ÂÂ ÂÂ

ÂÂ

Maddox TM, Reid KJ, Rumsfeld JS, et al. One-year health status outcomes of unstable angina versus myocardial infarction: a prospective, observational cohort study of ACS survivors. BMC Cardiovasc Disord 2007;7: 28.

5 Foods that Fight High Cholesterol Oats give you soluble fiber. Add a banana or some strawberries to get more soluble fibers. Beans are especially rich in soluble fiber. They also take a while for the body to digest, meaning you feel full for longer after a meal. Nuts: Eating almonds, walnuts, peanuts and other nuts is good for the heart. Eating 2 ounces of nuts a day can slightly lower LDL by about 5%. Nuts have additional nutrients that protect the heart in other ways. Foods fortified with sterols and stanols. Companies are adding them to foods ranging from margarine and granola bars to orange juice and chocolate. They’re also available as supplements. Getting 2 grams of plant sterols or stanols a day can lower LDL cholesterol by about 10%. Fatty fish. Eating fish 2 to 3 times a week can lower LDL in two ways: by replacing meat, which has LDL– boosting saturated fats and by delivering LDL-lowering ω-3 fats.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

ALGORITHM

Fever in the ICU Patient Patient with body temperature >101°F

Physical examination

Look for obvious focus of infection*

Present

Absent

Exclude noninfectious causes of fever**

Focused diagnostic work-up

⊕

Central line >48 hours old? Re-evaluate patient after 48 hours

⊕

Nasal tubes? Fever persistent or progressive signs of sepsis

Yes

⊕

Diarrhea?

⊕

Abdominal signs and symptoms?

⊕

Urinary tract manipulation?

Remove and culture

Remove and CT scan sinuses Stool R/E and C. difficile toxin assay CT scan abdomen

Urine culture

Empiric broad-spectrum antibiotic

Re-evaluate patient after 48 hours

Fever persistent or progressive signs of infection

No Stop antibiotics

Yes

yy yy

Empiric antifungals Additional diagnostic tests - Venography - Differential white cell count - Abdominal imaging

*• Purulent nasal discharge

• Abdominal tenderness • Profuse green diarrhea

** Noninfectious causes of fever

• • • • • •

Pancreatitis GI bleed Phlebitis Hematoma Post-transfusion Acalculous cholecystitis

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

Adapted from Chest 2000;117(3):855-69.

DR BAD AND DR GOOD

Dr. Good and Dr. Bad

SITUATION: A patient with generalized anxiety disorder (GAD) on medication showed no improvement.

CONTINUE IT

LESSON: Numerous behavioral therapies have been investigated in

©IJCP Academy

IT IS NOT A GOOD CHOICE

ADDING CBT WILL HELP TO RELIEVE SYMPTOMS

©IJCP Academy

CONTINUE WITH THE PRESCRIBED TREATMENT

SITUATION: A patient with agoraphobia with panic disorder was put on Alprazolam.

LESSON: In a multicenter trial, Alprazolam was found to be effective

the management of anxiety and stress-related disorders. There is strong evidence to support cognitive behavioral therapy (CBT) in the management of GAD, post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder and social phobias. Adjunctive behavioral sleep intervention may enhance results for GAD and initiation of a selective serotonin reuptake inhibitor for GAD before CBT also may enhance response.

and well-tolerated in patients with panic disorder and agoraphobia. There were significant Alprazolam-placebo differences in improvement for (1) Spontaneous and situational panic attacks (2) Phobic fears (3) Avoidance behavior (4) Anxiety (5) Secondary disability, all significant by the end of Week 1. At the primary comparison point (Week 4), 82% of the patients receiving Alprazolam were rated moderately improved or better versus 43% of the placebo group. At that point, 50% of the Alprazolam recipients versus 28% of placebo recipients were free of panic attacks.

FP Essent 2014;418:28-40.

Arch Gen Psychiatry 1988;45(5):413-22.

Dr. Good and Dr. Bad

SITUATION: A diabetic female was found to have twin pregnancy.

IT CARRIES EXTRA RISK

YES

LESSON: Twin pregnancy in women with either type of DM dramatically increased the risk of perinatal morbidity. In mothers with T1DM, twin pregnancy was more often associated with hypertensive complications than singleton pregnancy. Transfer of more than one embryo should be avoided, if ART is needed in a woman with DM.

Int J Gynaecol Obstet 2014;126(1):83-7.

©IJCP Academy

IT CARRIES NO EXTRA RISK

SITUATION: A diabetic patient wanted to know the likelihood of her developing osteoporosis.

LESSON: Diabetes-specific parameters do not predict BMD.

Fracture occurrence is similar in both diabetes groups and related to lower BMD, but seems unrelated to the threshold T-score, <−2.5 SD. The results suggest that osteoporosis, and related fractures, is a clinically significant and commonly underestimated problem in diabetes patients. BMC Endocr Disord 2014;14(1):33.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

CPA

Medical Negligence and Consumer Protection Act JUSTICE NV RAMANA

t is a great pleasure for me to be in the midst of distinguished and eminent doctors, engaged in the practice of medicine. I am also honored to share the dais along with Hon’ble Justice DK Jain, President, National Consumer Disputes Redressal Commission and Hon’ble Smt M Sreesha, Member, National Consumer Disputes Redressal Commission and Padma Shri Awardees Dr A Marthanda Pillai, Dr KK Aggarwal and Dr K Shyam Sundar, President IMA Telangana. Hon’ble Justice DK Jain is a humble and simple person with a human touch. He is respected by one and all in judicial circles. When I went to Delhi as Chief Justice of Delhi High Court, he was the first person to welcome me. He made me feel at home and comfortable to work in Delhi High Court as the Chief Justice. I have utmost respect and regard towards him. His judgments give an erudite, scholarly reading and reflect a balance approach to the issues involved. He has molded the law to benefit the deserving sections of the society. Smt M Sreesha is a committed individual and a good human being. She worked as a Member of the District Forum and State Commission before her appointment as Member of the National Commission. She has rendered several orders in consumer-related cases and I can say that she is an authority on the law relating to medical negligence. As there are eminent speakers on the dais, who are masters on the subject, I do not want to delve on the issues relating to medical negligence. Good health is very important for a nation’s future. It makes an important contribution to economic growth. Unless the health of the masses is good, no country can prosper. Doctors play an important and significant role in keeping the health of the country. Medicine is a science of art and healing. Indian doctors are known for their charitable attitude, dedication, hard work and personal touch. That is the reason why they are in demand all over the world. A doctor meets a man at birth and also sees him at the

Judge Supreme Court of India

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

end of his life. The reputation of a doctor is determined by his professionalism, attitude towards patients, commitment, competency and his theoretical and practical skills in his profession. Trust is fundamental to the relationship of doctor and patient. The vulnerability of patients and their need for care force them to trust a doctor. Rapid development in medicine in the last century as revolutionized the field of medical practice. With this, the medical profession in India is at cross roads facing many ethical and legal challenges. The fact which cannot be ignored is increasing dissatisfaction on part of the patient who are expecting more and more from the doctors leading to increasing litigation, The patients are expecting that the service provided by the doctors should be free from any fault, imperfection, shortcoming or inadequacy in quality. Doctors, who are dealing with the precious life of human being, should be vigilant and should take utmost care in treating them. The glory of the medical profession has come down to an extent where people are claiming damages against it equating it to any other profession. Man is the only animal who believed in keeping order in his work. This is one of the reasons why he invented the concept of law since no man is perfect in his work and a person who is skilled can also commit mistakes during his practice, which lead¬ to minor or major injury to the patient. The Supreme Court, in Indian Medical Association vs VP Shantha, bought the service rendered by the doctor to his patient within the definition of service as defined in section 2(1)(o) of the Consumer Protection Act. The test to be applied for considering a case of medical negligence is a principal laid down in Bolam’s case. The said principle states that “a man need not possess the highest expert skill but it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising the particular act”. In Jacob Mathew’s case, the Supreme Court explained the meaning of negligence in medical profession and discussed the difference between the concept of negligence in civil and criminal law and held at that the negligence in civil law may not be necessarily be

CPA negligence in criminal law and the element of mens rea must be shown to establish the criminal liability. In Martin F D’Souza’s case, the Supreme Court sought to protect the doctors from unnecessary harassment and laid down the guidelines to be followed by the consumer forum as well as police officials when they receive complaints of medical negligence.

medicolegal issues. Ignorance of law in its implications will be detrimental to the doctor even though he treats the patient in good faith. All the actions that are done in good faith may not stand the legal scrutiny. I hope this conference will proactively deliberate on several issues which are helpful in discharging your professional skills with utmost caution and satisfaction.

The law does not aim to punish all acts of a doctor that causes injury to a patient. It is only concerned with negligent acts. Negligence is a branch of law of torts. Then what is negligence? Negligence is the breach of a legal duty to take care. A doctor vows certain duties to the patient who consults him for his illness. A deficiency in his service results in negligence, which is termed as medical negligence. It is important to punish a guilty doctor but it is equally important to protect a doctor who acted in a good faith from harassment. It is essential to note that protection of patients’ rights shall not be at the cost of professional integrity and autonomy. There is definitely a need for striking a delicate balance. From the times of Lord Denning till today it has been the consistent view of the courts that a charge of professional negligence against a medical professional stood on a different footing from a charge of negligence against the driver of a motor car. The burden of proof is correspondingly greater on a person who alleges negligence against a doctor.

I believe that doctors are role models for the general public not only in the matters of health but also on the moral issues. It is the constitutional right of every person to receive proper and timely health care and it is also the responsibility of doctors and hospital management to provide proper service with utmost care. I hope this noble profession will be instrumental in giving the constitutional right to the citizen with cost-effective treatment, with state-of-the art technologies and with higher medical expertise and skill, which make the people of this country healthy.

It is imperative that the present day medical practitioners need to have some awareness on the

Before I conclude, I would like to thank the IMA President, Secretary, office bearers and all members, in particular, Dr N Apparao National leader, IMA who has organized this meeting and for giving me an opportunity to be part of this conference. I would like to conclude by quoting the words of Douglas Adams. I quote, “To give real service you must add something which cannot be bought or measured with money and that is sincerity and integrity.” I unquote. Jai Hind

■■■■

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

Do at least 30 minutes of moderate-intensity aerobic activity on at least 5 days of the week

Eat high fiber foods

Eat foods that lower your cholesterol levels

Maintain a healthy body weight

Eat foods that contain monounsaturated and/or polyunsaturated fats

Choose healthy cooking methods

Check your blood sugar levels regularly if you are diabetic

Keep your blood pressure <120/80 mmHg

Reduce stress

Do not smoke

Avoid alcohol

Avoid excess of sweets or sugar-sweetened beverages

Avoid foods that contain trans fats

AROUND THE GLOBE

News and Views ÂÂ According to a new study presented at the American

Roentgen Ray Society 2015 Annual Meeting, the correlation between radiographic evidence of a displaced enthesophyte and underlying tendon rupture can serve as a “red flag” for potential tendon injury that requires further assessment.

ÂÂ For people with type 2 diabetes, quitting smoking

may lead to a worsening of glycemic control unrelated to weight gain, suggests a new study published online in Lancet Diabetes & Endocrinology.

ÂÂ Patients receiving frequent nocturnal hemodialysis

have a higher mortality rate than patients receiving conventional dialysis, suggest data from the Frequent Hemodialysis Network (FHN) Nocturnal Trial published online in the American Journal of Kidney Diseases.

ÂÂ When labor is induced with a Foley catheter

balloon, women deliver, on average, 10 hours sooner than when it is induced with a Cook Cervical Ripening Balloon, suggests a new retrospective study presented at the American Congress of Obstetricians and Gynecologists Annual Clinical Meeting 2015.

ÂÂ Professionals whose jobs involve a variety of

challenging work tasks may be better protected from memory and cognitive decline in old age than others, suggests a new study published in Neurology.

ÂÂ Recent studies in animal models and on human

cells have shown an effect of sodium chloride (NaCl) on Th17 cells promoting inflammation.

ÂÂ Delays in the recognition and treatment of strokes

occurring during hospitalization are common, and in-hospital strokes tend to be more severe and have worse outcomes than strokes occurring among those who are not hospitalized, researchers have reported in JAMA Neurology, published online May 4.

ÂÂ According

to a study in Gastroenterology. 2014;147(4):784-792, monotherapy with nonselective (ns) NSAIDs increased the risk of diagnosis of upper GI bleeding (UGIB) (IRR, 4.3) to a greater extent than monotherapy with COX-2 inhibitors (IRR, 2.9) or low-dose aspirin (IRR, 3.1). Combination therapy generally increased the risk

of UGIB; concomitant nsNSAID and corticosteroid therapies increased the IRR to the greatest extent (12.8) and also produced the greatest excess risk (RERI, 5.5). Concomitant use of nsNSAIDs and aldosterone antagonists produced an IRR for UGIB of 11.0 (RERI, 4.5). Excess risk from concomitant use of nsNSAIDs with selective serotonin reuptake inhibitors (SSRIs) was 1.6, whereas that from use of COX-2 inhibitors with SSRIs was 1.9 and that for use of low-dose aspirin with SSRIs was 0.5. Excess risk of concomitant use of nsNSAIDs with anticoagulants was 2.4, of COX-2 inhibitors with anticoagulants was 0.1, and of low-dose aspirin with anticoagulants was 1.9 (Source: Medscape). ÂÂ An influential US panel of experts says there’s

just not enough data to decide whether or not e-cigarettes can help smokers quit.

ÂÂ Five months after 14 women died in sterilization

camps in Chhattisgarh, there is no sign of justice being delivered to those who lost their kin.

ÂÂ Research has shown that environmental exposures,

such as parental smoking, can play an important role in the initiation and severity of asthma, particularly in children. Recent work at NIEHS suggests that maternal smoking during pregnancy may have trans-generational effects on asthma development. Studying indoor and outdoor exposures, as well as genetics, helps researchers develop cost-effective interventions and novel treatments for asthma.

ÂÂ Omega-3 fatty acid supplements appear to be

effective for controlling joint pains and stiffness from aromatase inhibitors in women with earlystage breast cancer, but placebos made of soybean and corn oil are every bit as good, suggests a randomized controlled trial. The findings are published online in the Journal of Clinical Oncology.

ÂÂ New interferon (IFN)-free treatment regimens

demonstrated a high rate of sustained virologic response among patients with chronic hepatitis C virus (HCV) infection, including those who had been previously treated or have compensated cirrhosis, suggest new data published online May 5 in JAMA.

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

AROUND THE GLOBE ÂÂ Twice-daily application of sodium nitrite and

citric acid creams cleared anogenital warts more effectively than placebo, suggests new research published in JAMA Dermatology.

ÂÂ People with type 2 diabetes who are obese and have

on the surrogate markers but did not slow down atherosclerosis any better in the Japanese MILLION trial. ÂÂ For people with type 2 diabetes, quitting smoking

may lead to a worsening of glycemic control unrelated to weight gain, a new study suggests. The findings, from a large UK primary-care database, were published online April 29 in Lancet Diabetes & Endocrinology by Deborah Lycett, PhD, RD, clinical dietitian and principal lecturer in nutrition and dietetics at Coventry University, United Kingdom, and colleagues.

dyslipidemia should be considered for screening for nonalcoholic fatty liver disease (NAFLD), suggests new research published online in Gut.

ÂÂ Corneal collagen crosslinking reduces the risk for

ectasia in LASIK patients, suggests a new study presented at the American Society of Cataract and Refractive Surgery 2015 Symposium.

ÂÂ Patients with rheumatoid arthritis are at increased

risk of a surprise heart attack, suggests new research presented at ICNC 12. Risk was increased even when patients had no symptoms and was independent of traditional cardiovascular risk factors such as smoking and diabetes.

ÂÂ Hemoglobin

A1C (HbA1C) identifies three times more undiagnosed individuals as having prediabetes or diabetes than does fasting plasma glucose (FPG), researchers from Canada report.

ÂÂ A woman in central Kashmir’s Ganderbal district

ÂÂ A distinct set of bone metabolism biomarkers appears

to be associated with more severe periodontal disease, suggests new research published online in The Journal of Clinical Endocrinology & Metabolism. Researchers noted that older men with more severe periodontitis had significantly higher levels of parathyroid hormone and lower vitamin D levels.

ÂÂ The American Society for Radiation Oncology

(ASTRO) has released new evidence-based guidelines on external-beam radiotherapy for patients with locally advanced nonsmall cell lung cancer (NSCLC). The guideline is published in the May-June issue of Practical Radiation Oncology.

ÂÂ Two new antibiotics, the first broad-spectrum

fluoroketolide antibiotic and a novel fluorocycline, could provide alternatives for the treatment of drug-resistant bacteria, suggest studies presented at the 25th European Congress of Clinical Microbiology and Infectious Diseases Hemoglobin A1c identifies three times more undiagnosed individuals as having prediabetes or diabetes than does fasting plasma glucose (FPG), suggests new research published online in Diabetes Care.

ÂÂ Aggressive blood pressure and lipid-lowering

treatment after stenting had the expected effect ■■■■

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

died Friday hours after giving birth to a baby due to alleged medical negligence by authorities. Kadija Begum, 35, wife of Ghulam Muhammad Lone, resident of Wusan in Kangan was admitted at the hospital under MRD number 117 after she developed labor pains yesterday morning. She was operated upon by the doctors and gave birth to a girl child, the family of the deceased said. “However, the woman was continuously in state of unconsciousness and her situation worsened following which a team of doctors shifted her to SKIMS Soura”, her family said. They said that instead of sending a doctor with her, the medical authorities deputed a nurse in an ambulance along with the patient. “In the ambulance, Khadija was put on ventilator but the oxygen exhausted after 15 minutes leading to her death at Wayul Bridge”, the family alleged, adding, “it is a sheer negligence on the part of hospital authorities. She was declared ‘brought dead’ by doctors at SKIMS”. Meanwhile, the Chief Medical Officer RD Kasana told GNS that a four-member team has been constituted to probe the cause of death. He said the Medical Superintendent Dr Javaid has been attached with CMO Office until further orders [greaterkashmir.com].

LIGHTER READING

“In the back of your truck there’s a shotgun. Shoot the pig in the head and when it stops wriggling you can pull it out and throw it in a bush.” The farm worker says okay and signs off. About 10 minutes later he radios back. “Boss I did what you said, I shot the pig and dragged it out and threw it in a bush.”

THAT DARNED CAT A man absolutely hated his wife’s cat and decided to get rid of him 1-2 day by driving him 20 blocks from his home and leaving him at the park. As he was getting home, the cat was walking up the driveway. The next day he decided to drive the cat 40 blocks away. He put the beast out and headed home.

“So what’s the problem now?” his Boss snapped. “The blue light on his motorcycle is still flashing!”

Driving back up his driveway, there was the cat! He kept taking the cat further and further and the cat would always beat him home. At last he decided to drive a few miles away, turn right, then left, past the bridge, then right again and another right until he reached what he thought was a safe distance from his home and left the cat there. Hours later the man calls home to his wife: “Jen, is the cat there?” “Yes”, the wife answers, “why do you ask?” Frustrated, the man answered, “Put that darned cat on the phone. I’m lost and need directions!”

HUMOR The world’s thinnest book has only one word written in it: “Everything”; and the book is titled: “What Women Want!”There was this man driving along in his car when he suddenly got a flat tire. When he pulled over he was at the fence of a mental hospital. When he got out of the car one of the patients came to the fence and asked “Can I help you?” And the man said “No, I need to figure out how to make it home with only 2 lugs on this wheel.”

TOMATOES

The patient asked again “Are you sure you do not need any help?” And the man said “No.” The man tried to figure it out when all of a sudden the patient said “If I were you I would take one lug off the other 3 wheels and put them on that wheel and you should be able to get home.” The man asked “How did you think of that?” The patient replied “I am in here because I’m crazy not because I’m stupid.”

A small boy was looking at the red ripe tomatoes growing in the farmer’s garden. “I’ll give you my two pennies for that tomato,” said the boy pointing to a beautiful, large, ripe fruit hanging on the vine. “No,” said the farmer, “I get a dime for a tomato like that one.” The small boy pointed to a smaller green one, “Will you take two pennies for that one?”

DAUGHTER IN COLLEGE

“Yes,” replied the farmer, “I’ll give you that one for two cents.”

Did you hear about the banker who was recently arrested for embezzling $100,000 to pay for his daughter’s college education? As the policeman, who also had a daughter in college, was leading him away in handcuffs, he said to the banker, “I have just one question for you. Where were you going to get the rest of the money?”

“OK,” said the lad, sealing the deal by putting the coins in the farmer’s hand, “I’ll pick it up in about a week.” Getting Rid of the Problem A farmhand is driving around the farm, checking the fences. After a few minutes he radios his boss and says, “Boss, I’ve got a problem. I hit a pig on the road and he’s stuck in the bull-bars of my truck. He’s still wriggling. What should I do?”

QUOTE

LAUGH-A-WHILE

Lighter Side of Medicine

“Inventing is the mixing of brains and materials. The more brains you use, the less materials you need.” –Charles F Kettering

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

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,

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

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.

Discussion –

This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g., practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111.

Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat. – All photomicrographs should indicate the magnification of the print. – Special features should be indicated by arrows or letters which contrast with the background. – The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen. – Color illustrations will be accepted if they make a contribution to the understanding of the article. –

Do not use clips/staples on photographs and artwork.

–

Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”.

Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________ 2. Total number of pages ________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________

Books

5. Special requests _____________________________

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

6. Suggestions for reviewers (name and postal address)

Articles in Books

2.____________ 2.________________

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

3.____________ 3.________________

4.____________ 4.________________

Tables –

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends – These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text. –

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

Indian 1.____________Foreign 1.________________

7. All authors’ signatures________________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Online Submission Also e-Issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Indian Journal of Clinical Practice E-219, Greater Kailash, Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com

Indian Journal of Clinical Practice, Vol. 26, No. 1, June 2015

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