IJCP June 2018 by IJCP

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A Multispecialty Journal Volume 29, Number 1

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yy American Family Physician yy Cardiology yy Community Health yy Community Medicine yy ENT yy Infertility yy Neurology yy Obstetrics and Gynecology yy Pediatrics

an i c i ys ians

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Phly Physic y l mi ami

yy Conference Proceedings

Fademy of F n ica Aca

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yy Spiritual Update

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IJCP Group of Publications A Multispecialty Journal

Dr Sanjiv Chopra Group Consultant Editor

Volume 29, Number 1, June 2018

Dr Deepak Chopra Chief Editorial Advisor

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

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

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

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

From the desk of THE group editor-in-chief

Nipah Virus Encephalitis: A Newly Emerging Disease KK Aggarwal

American Family Physician

Aortic Stenosis: Diagnosis and Treatment Brian H. Grimard, Robert E. Safford, Elizabeth L. Burns

Practice Guidelines

Photo Quiz CARDIOLOGY

To Study the Clinical Outcome of Cardiorenal Syndrome in a Tertiary Care Hospital of Bihar Jyoti Prakash, Kk Singh

Community health

Effect of Pollution on Health of People Living Near Landfill Sites in Delhi-NCR Kk Aggarwal, Aniruddha Sharma, Rahul Manav

Community medicine

Medication Reconciliation

Kasthuri P, N Chidambaranathan, Latha Venkatesan

Challenges Facing Medical Education

Amit Agrawal

ENT

Perspectives in the Management of Vertigo and Dizziness: A Review Shrinivas Chavan

Infertility

Indications, Patient Selection and Work-up Before Intrauterine Insemination Rutvij Dalal, Hrishikesh D Pai, Nandita P Palshetkar

NEUROLOGY

Isolated Central Sulcus Hemorrhage in a Case of Cerebral Amyloid Angiopathy Bhawna Sharma, Divya Goel

OBSTETRICS AND GYNECOLOGY

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

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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.

Periodontal Disease and Pregnancy Outcome Sneha Mayuri, Swati Sharan, Abhishek Verma, Anindita Banerjee, Manju Geeta Mishra

Scope and Limitations of Medical Management of Ectopic Pregnancy: Comparison of Single versus Multiple Dose of Methotrexate Rita Sinha, Rupam Sinha, Manju Gita Mishra, Subhashree Sethi

Uterine Didelphys with Pregnancy and Obstructed Labor: Intrapartum Course Complicated by a Rare Uterine Anomaly Shashidhar B, Hemalatha M Shetti

Torsion of the Postmenopausal Uterus: A Surgical Emergency Anupama Hari, Adithya H, Swetha G, Jijiya A

PEDIATRICS

Editorial Policies

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

A Rare Case of Disseminated Tuberculosis with Severe Reactive Thrombocytosis Shrikrishna Sad, Priyasha Tripathi, Gunjan Kela, Devendra Barua, Harsha Kumawat

MEDICOLEGAL

Right to Avail Health Insurance is an Integral Part of the Right to Healthcare and the Right to Health, as Recognised in Article 21 of the Constitution of India, 1950 Ira Gupta

CONFERENCE PROCEEDINGS

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

News and Views Spiritual Update

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

The Right Action

KK Aggarwal

Lighter reading

Lighter Side of Medicine

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From the desk of THE group editor-in-chief

Dr KK Aggarwal

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

Nipah Virus Encephalitis: A Newly Emerging Disease

he cause of death of three people, who were suffering from acute viral encephalitis, in Kozhikode has been confirmed to be due to the Nipah virus by the National Virology Institute in Pune.

intermediate hosts. The virus derives its name from Sungai Nipah, a village in the Malaysian Peninsula where the pig farmers became ill with encephalitis. Since then, several outbreaks of acute Nipah encephalitis have been reported from Bangladesh, West Bengal (Siliguri), India with reports of personto-person transmission in hospital settings and in the Southern Philippines. Raw date palm sap that had been contaminated by infected fruit bats was identified as the source of infection in an outbreak that occurred in Bangladesh in 2004.

Nipah and Hendra viruses are two related zoonotic pathogens that have emerged in the Asia-Pacific region. Both are RNA viruses that belong to the Paramyxoviridae family. The viruses jump the species barrier and infect a secondary animal host (e.g., pigs or horses), and transmit infections to humans. Here are some key facts about Nipah virus infection. ÂÂ

Nipah virus infection is a newly emerging zoonosis, which causes severe disease in both humans and animals. The associated mortality is high.

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The natural hosts for the Nipah virus are the fruit bats of the Pteropus genus, which are symptomless carriers. Mainly four species have been demonstrated to have serologic evidence of infection with this virus. The virus is shed in the saliva, urine, semen and excreta of the infected bats.

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Nipah virus spreads to humans through direct contact with infected bats, infected pigs or other people who are infected with the virus. People have been also cautioned to avoid eating fruits that have fallen to the ground. Nipah virus was first identified in 1998 as the cause of an outbreak of viral encephalitis among pig farmers in Malaysia, where pigs were the

IJCP Sutra 1: Maintain a healthy weight. Check your waistline.

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The incubation period is 5-14 days.

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Clinically, the main presentation of Nipah virus infection is as an encephalitic syndrome characterized by onset of nonspecific symptoms sudden onset of fever, headache, myalgia, nausea and vomiting followed by drowsiness, disorientation and mental confusion. The infected person can become comatose within 24-48 hours.

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The case fatality rate of Nipah encephalitis ranges from 9% to 75%.

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Meningismus is seen in approximately one-third of patients although marked nuchal rigidity and photophobia are uncommon.

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Patients infected with Hendra virus have presented with fever and influenza like illnesses, or with meningoencephalitis.

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Nipah virus infection can be diagnosed by enzymelinked immunosorbent assay (ELISA) test.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

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On magnetic resonance imaging (MRI), typically multiple, small (<5 mm), asymmetric focal lesions in the subcortical and deep white matter without surrounding edema are seen.

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There is no effective treatment for Nipah virus infection. The mainstay of treatment is supportive care focusing on managing fever and the neurological symptoms. Infection control practices and barrier nursing are important as personto-person transmission may occur. Severely ill patients need intensive care.

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Ribavirin, a nucleoside analog, can be given empirically as it has a broad-spectrum of antiviral activity against both RNA and DNA viruses. In the Malaysian outbreak, 140 treated patients were compared to 54 control patients who did not receive ribavirin. Fewer treated patients died (32% vs. 54%). However, treated patients were

identified later in the outbreak, so it is possible that they were given better general medical care compared to untreated patients seen earlier. Subsequent animal models found that ribavirin, as well as chloroquine, were ineffective. ÂÂ

Antithrombotic agents, aspirin and pentoxyfylline, were administered in some patients based upon the recognition that arterial thrombosis may play an important role in the central nervous system (CNS) disease.

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Nipah virus is classified internationally as a biosecurity level (BSL) 4 agent. Biosafety Level 4 is required for work with dangerous and exotic agents that pose a high individual risk of aerosoltransmitted laboratory infections and life-threatening disease that is frequently fatal, for which there are no vaccines or treatments, or a related agent with unknown risk of transmission (CDC).

■■■■

Chat with Dr KK Heat it, Boil it, Cook it, Peel it or Forget it

IJCP Sutra 2: Eat mindfully. Emphasize colorful, vitamin-packed vegetables and fruits; whole grains; fish, lean poultry, tofu and beans and other legumes as protein sources plus healthy fats.

American Family physician

Aortic Stenosis: Diagnosis and Treatment BRIAN H. GRIMARD, ROBERT E. SAFFORD, ELIZABETH L. BURNS

Abstract Aortic stenosis affects 3% of persons older than 65 years. Although survival in asymptomatic patients is comparable to that in age- and sex-matched control patients, it decreases rapidly after symptoms appear. During the asymptomatic latent period, left ventricular hypertrophy and atrial augmentation of preload compensate for the increase in after-load caused by aortic stenosis. As the disease worsens, these compensatory mechanisms become inadequate, leading to symptoms of heart failure, angina, or syncope. Aortic valve replacement is recommended for most symptomatic patients with evidence of significant aortic stenosis on echocardiography. Watchful waiting is recommended for most asymptomatic patients. However, select patients may also benefit from aortic valve replacement before the onset of symptoms. Surgical valve replacement is the standard of care for patients at low to moderate surgical risk. Transcatheter aortic valve replacement may be considered in patients at high or prohibitive surgical risk. Patients should be educated about the importance of promptly reporting symptoms to their physicians. In asymptomatic patients, serial Doppler echocardiography is recommended every six to 12 months for severe aortic stenosis, every one to two years for moderate disease, and every three to five years for mild disease. Cardiology referral is recommended for all patients with symptomatic moderate and severe aortic stenosis, those with severe aortic stenosis without apparent symptoms, and those with left ventricular systolic dysfunction. Medical management of concurrent hypertension, atrial fibrillation, and coronary artery disease will lead to optimal outcomes.

Keywords: Aortic stenosis, left ventricular hypertrophy, surgical valve replacement, Doppler echocardiography, atrial fibrillation, coronary artery disease

ortic valve stenosis affects 3% of persons older than 65 years and is the most significant cardiac valve disease in developed countries.1 Its pathology includes processes similar to those in atherosclerosis, including lipid accumulation, inflammation, and calcification.2 The development of significant aortic stenosis tends to occur earlier in persons with congenital bicuspid aortic valves and in those with disorders of calcium metabolism, such as in renal failure.3 Although the survival rate in asymptomatic patients is comparable to that in ageand sex-matched control patients, it decreases rapidly after symptoms appear. Pathophysiology and Natural History Aortic stenosis has a prolonged latent period, during which progressive worsening of left ventricular (LV) outflow obstruction leads to compensatory hypertrophic

BRIAN H. GRIMARD, MD, is an instructor at the Mayo Medical School in Jacksonville, Fla. ROBERT E. SAFFORD, MD, PhD, is a professor of medicine at the Mayo Medical School in Jacksonville. ELIZABETH L. BURNS, MD, is an instructor at the Mayo Medical School in Jacksonville. Source: Adapted from Am Fam Physician. 2016;93(5):371-378.

changes in the LV myocardium.4,5 The resultant increase in LV systolic function helps maintain adequate systemic pressures.6 However, LV hypertrophy may also lead to diastolic dysfunction and increased resistance to LV filling.7,8 Thus, a strong left atrial contraction may be needed to provide sufficient LV diastolic filling and to support adequate stroke volume.9 As aortic stenosis worsens, these adaptations become inadequate to overcome the outflow obstruction and maintain systolic function.10 Impaired systolic function, alone or combined with diastolic dysfunction, may lead to clinical heart failure. Similar symptoms may occur if the atrial kick is lost and diastolic filling time shortens, such as in atrial fibrillation with a rapid ventricular response. Progressive LV hypertrophy from aortic stenosis may also result in increased myocardial oxygen needs11; concurrently, myocardial hypertrophy may compress the intramural coronary arteries as they carry blood toward the myocardium. These changes, along with reduced diastolic filling of the coronary arteries, may cause angina, even in the absence of coronary artery disease.12 In addition, as aortic stenosis becomes severe, cardiac output no longer increases with exercise.13 InÂ this setting, a drop in systemic vascular resistance with exertion may lead to hypotension and syncope.14-16

IJCP Sutra 3: Cut down on unnecessary calories from sweets, sodas, refined grains like white bread or white rice, unhealthy fats, fried and fast foods and mindless snacking. Keep a close eye on portion sizes, too.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Figure 1 shows a normal aortic valve, and Figure 2 depicts echocardiographic changes that occur in severe aortic stenosis.17 Diagnosis

Signs and Symptoms The cardinal symptoms of aortic stenosis include dyspnea and other symptoms of heart failure, angina, and syncope. Symptom onset identifies clinically significant stenosis and the need for urgent intervention. However, some patients with severe aortic stenosisâ&#x20AC;&#x201D; especially older patientsâ&#x20AC;&#x201D;may not develop classic symptoms initially and instead only experience a decrease in exercise tolerance. Others may have a more acute presentation, sometimes with symptoms precipitated by concurrent medical conditions or treatments. For example, new-onset atrial fibrillation with a resultant decrease in atrial filling may lead to symptoms of heart failure, and initiation of vasodilator medications may cause syncope.

The classic physical finding of aortic stenosis is a harsh, late-peaking systolic murmur that is loudest over the second right intercostal space and radiates to the carotid arteries. This may be accompanied by a slow and delayed carotid upstroke, a sustained point of maximal impulse, and an absent or diminished aortic second sound. However, in older persons, the murmur may be less intense and often radiates to the apex instead of to the carotid arteries. Also, the classic carotid pulse changes may be masked in persons with atherosclerosis or hypertension. A recording of systolic murmurs of aortic stenosis is available at http://youtube/Gbk2465HO98. Primary care physicians should consider aortic stenosis in adults who present with any of the cardinal symptoms accompanied by a systolic murmur. In addition, asymptomatic patients who have holosystolic and late systolic murmurs, grade 3 or louder mid-peaking systolic murmurs, or murmurs that radiate to the neck should be evaluated for aortic stenosis. A low-intensity murmur alone does not exclude aortic stenosis, especially as LV systolic function deteriorates.

Aortic valve

Aorta

Left atrium

Mitral valve

Aortic valve

Right ventricle

Left ventricle

Figure 1. Transesophageal echocardiograms of a normal aortic valve. (A) Axial view. (B) Horizontal four-chamber view. Reprinted with permission from Grimard BH, Larson JM. Aortic stenosis: diagnosis and treatment. Am Fam Physician. 2008;78(6):718.

IJCP Sutra 4: Exercise regularly. Aim for 2Â˝ to 5 hours weekly of brisk walking (at 4 mph). Or try a vigorous exercise like jogging (at 6 mph) for half that time.

American Family Physician

Calcific diseased aortic valve

Diseased aortic valve

Left ventricular hypertrophy

Left atrium

Right ventricle

Figure 2. Transesophageal echocardiograms of severe aortic stenosis. (A) The axial view shows diffusely thickened leaflets with a restricted opening motion. (B) The horizontal four-chamber view shows the resultant severe left ventricular hypertrophy and left atrial enlargement. Reprinted with permission from Grimard BH, Larson JM. Aortic stenosis: diagnosis and treatment. Am Fam Physician. 2008;78(6):719.

The only physical examination finding that can exclude severe aortic stenosis is a normally split second heart sound.

Diagnostic Testing Echocardiography is indicated in patients with a loud unexplained systolic murmur, a single second heart sound, a history of a bicuspid aortic valve, or symptoms that may be caused by aortic stenosis.18-20 Transthoracic echocardiography, the recommended initial test for patients with suspected aortic stenosis, allows reliable identification of the number of valve leaflets and assessment of valve motion, leaflet calcification, and LV function.20 The primary indices of stenosis severity are maximum transaortic velocity and the Doppler-derived mean pressure gradient (Table 1).20 Patients typically remain asymptomatic until maximum transvalvular velocity is more than four times the

Table 1. Classification of Aortic Stenosis Severity Classification

Normal

Transaortic Mean pressure Aortic valve velocity (m per gradient area (cm2) second) (mm Hg) < 2.0

< 10

3.0 to 4.0

Mild

2.0 to 2.9

10 to 19

1.5 to 2.9

Moderate

3.0 to 3.9

20 to 39

1.0 to 1.4

≥ 4.0

≥ 40

< 1.0

Severe

Information from references 4 through 6.

normal velocity or at least 4.0 m per second.21-23 However, stenosis severity may be more difficult to assess in some patients who have only a moderately elevated transaortic velocity (3.0 to 4.0 m per second) but an aortic valve area less than 1.0 cm2. If concurrent LV dysfunction is detected (ejection fraction [EF] less than 50%), these patients may have clinically significant “low-flow” aortic stenosis.

IJCP Sutra 5: Keep an eye on important health numbers. In addition to watching your weight and waistline, keep a watch on your cholesterol, triglycerides, blood pressure, and blood sugar numbers.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Referral and Treatment The presence or absence of symptoms, severity of aortic valve obstruction, and LV response to pressure overload are the primary drivers for clinical decision making in patients with aortic stenosis (Figure 3).20

Aortic Valve Replacement Classic symptoms of aortic stenosis accompanied by echocardiographic findings consistent with severe stenosis should prompt cardiology consultation.20,22,24,25 Although outcomes in asymptomatic patients with aortic stenosis are similar to those in age-matched control patients, survival is extremely poor once even subtle symptoms are present. Two-year mortality rates of 50% to 68%—most often secondary to congestive heart failure—have been reported in symptomatic older patients who did not undergo surgical treatment.26-28 Aortic valve replacement is the only effective treatment for symptomatic, hemodynamically severe aortic stenosis. Surgical replacement leads to significant improvement in survival, usually accompanied by symptom improvement.28-32 The 10-year survival rate in Medicare-aged patients after aortic valve replacement is almost identical to that in age- and sex-matched persons who do not have aortic stenosis.33 Although no randomized trials have compared aortic valve replacement with medical management in persons at low surgical risk, observational studies showing a more than fourfold difference in survival between surgically and medically treated patients support the well-accepted recommendation that valve replacement be performed promptly in symptomatic patients with severe aortic stenosis. Cardiology referral is also appropriate when a symptomatic patient is found to have moderate stenosis because it may lead to the identification of low-flow, low-gradient severe aortic stenosis despite a normal EF (due to a small stroke volume in a patient with a small ventricular cavity). This scenario is more common in older women with hypertension. Alternatively, if the EF is less than 50%, dobutamine stress echocardiography may reveal severe aortic stenosis or prompt evaluation for other causes of LV dysfunction. Aortic valve replacement is also recommended for asymptomatic patients with severe stenosis accompanied by LV systolic dysfunction (EF less than 50%). When severe stenosis is found to be the primary

pathology in this setting, aortic valve replacement is a lifesaving therapy and improves LV function.34,35 Aortic valve replacement is also indicated in asymptomatic patients with severe or even moderate stenosis who are undergoing cardiac surgery for other indications; this avoids the need for repeat surgery once the valve disease inevitably progresses.

Watchful Waiting Watchful waiting is recommended for most asymptomatic patients with aortic stenosis, including those with severe disease.20,25,34,36 Survival rates are comparable to those in patients without aortic stenosis, and the mortality risk in patients undergoing valve replacement outweighs the risk of sudden death in asymptomatic patients with aortic stenosis. Attempts have been made to identify patients who are more likely to have poor outcomes without early aortic valve replacement. Patients with severe stenosis (transaortic velocity of at least 5.0 m per second) or a rapid increase in transaortic velocity over time (0.3 m per second or more per year) have a high likelihood of becoming symptomatic and of needing aortic valve replacement within the next one to two years. Valve replacement may be considered in these patients if they have a low surgical risk. High-risk patients, including those who do not live near a medical care facility, may need closer monitoring or consideration of potential benefits vs. risks of early valve replacement.25,34,36 It is important to distinguish patients who are truly asymptomatic from those whose routine activity level has subtly decreased to below their symptom threshold. This is especially important in older patients, who may attribute their symptoms to normal aging or concurrent illness. In patients whose symptom status is unclear, cautious exercise stress testing can objectively assess exercise tolerance or detect an abnormal blood pressure response (hypotension with exertion), possibly leading to a recommendation for aortic valve replacement.37,38

Surgical vs. Transcatheter Aortic Valve Replacement Surgical aortic valve replacement is the standard of care in patients with low or intermediate surgical risk.20 Overall 30-day surgical mortality for isolated valve replacement is 3% and approximately 4.5% for valve replacement with coronary artery bypass grafting.39 Transcatheter aortic valve replacement is recommended for patients who have an indication for valve replacement but are at prohibitive surgical risk. Transcatheter valve replacement is also a reasonable alternative to surgical valve replacement

IJCP Sutra 6: An observational trial in patients awaiting surgery found that patients’ subjective reports of decreased anxiety were consistent with heart rate variability, an objective marker of anxiety.

American Family Physician in high-risk patients. Surgical risk should be assessed by a multidisciplinary team composed at minimum of a clinical cardiologist and a cardiac surgeon, and usually including subspecialists in interventional cardiology, cardiovascular imaging, anesthesiology, and heart failure management. Medical Management In asymptomatic patients, serial Doppler echocardiography should be performed every six to 12 months in those with severe aortic stenosis, every one to two years in those with moderate stenosis, and every three to five years in those with mild stenosis.20 Transthoracic echocardiography should also be performed when any changes are detected on physical examination. Most importantly, patients should be educated about symptoms and the importance of promptly reporting them to their physician. No medical treatments delay the progression of aortic valve disease or improve survival. However, many patients with asymptomatic stenosis have concurrent cardiac conditions, including coronary artery disease, hypertension, and atrial fibrillation; these conditions should be controlled while keeping in mind their potential effects on progressive aortic stenosis.20,34

Cardiovascular Risk Reduction In addition to discussing the benefits and risks of statin therapy and aspirin prophylaxis, the physician should determine a patient’s 10-year cardiovascular risk according to current guidelines. The overall risk of cardiovascular events increases 1.5- to twofold in the presence of aortic valve calcification, even in the absence of valvular stenosis.40,41 Other risk-reduction measures should include discontinuation of tobacco use and participation in regular exercise if exertional symptoms are not present. Patients with mild stenosis should not be restricted from physical activity. Asymptomatic patients with moderate to severe stenosis should avoid competitive or vigorous activities that involve high dynamic and static muscular demands, although other forms of exercise are safe.20,42

Hypertension Approximately 40% of patients with aortic stenosis also have hypertension,34,43 which results in elevated LV afterload due to the “double load” created by stenosis plus increased vascular resistance. Treatment of hypertension is recommended in patients with asymptomatic aortic

stenosis.44-46 However, these patients can be particularly sensitive to the manipulation of preload, contractility, or systemic vasomotor tone.47 Antihypertensive agents should be initiated at low doses and gradually titrated. In addition to being well tolerated, angiotensin-converting enzyme inhibitors improve hemodynamic parameters, augment effort tolerance, and reduce dyspnea in symptomatic patients with severe aortic stenosis.46,48 Second-generation dihydropyridine calcium channel blockers (e.g., amlodipine, felodipine) do not seem to depress LV function as older calcium channel blockers do, and are safe to use in patients with aortic stenosis. Diuretics should be started at low doses because of the potential for reducing LV diastolic filling, which may reduce cardiac output. Use of peripheral alpha blockers may lead to hypotension or syncope and should be avoided.

Atrial Fibrillation Atrial fibrillation occurs in 5% of patients with aortic stenosis. New-onset atrial fibrillation may precipitate heart failure in a previously asymptomatic patient with significant aortic stenosis. Heart rate control is important to allow time for optimal diastolic filling. However, physicians should be aware that beta blockers and rate-slowing calcium channel blockers may depress LV systolic function in patients with aortic stenosis.

Endocarditis Prophylaxis Antimicrobial prophylaxis for bacterial endocarditis is recommended in patients with a history of endocarditis and in those with prosthetic heart valves (mechanical valves, bioprostheses, and homografts), but not in those with aortic stenosis or other acquired valve diseases.49 Note: For complete article visit: www.aafp.org/afp. REFERENCES 1. Lindroos M, Kupari M, Heikkilä J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993;21(5):1220-1225. 2. Otto CM, Kuusisto J, Reichenbach DD, Gown AM, O’Brien KD. Characterization of the early lesion of ‘degenerative’ valvular aortic stenosis. Histological and immunohistochemical studies. Circulation. 1994;90(2): 844-853. 3. Lewin MB, Otto CM. The bicuspid aortic valve: adverse outcomes from infancy to old age. Circulation. 2005;111(7):832-834.

IJCP Sutra 7: Music did not show a benefit during endoscopy in a trial of patients under conscious sedation.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018 4. Tobin JR Jr, Rahimtoola SH, Blundell PE, Swan HJ. Percentage of left ventricular stroke work loss. A simple hemodynamic concept for estimation of severity in valvular aortic stenosis. Circulation. 1967;35(5):868-879. 5. Pantely G, Morton M, Rahimtoola SH. Effects of successful, uncomplicated valve replacement on ventricular hypertrophy, volume, and performance in aortic stenosis and in aortic incompetence. J Thorac Cardiovasc Surg. 1978;75(3):383-391. 6. Grossman W, Jones D, McLaurin LP. Wall stress and patterns of hypertrophy in the human left ventricle. J Clin Invest. 1975;56(1):56-64.

20. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol. 2014;63(22):2489]. J Am Coll Cardiol. 2014;63(22):2438-2488. 21. Oh JK, Taliercio CP, Holmes DR Jr, et al. Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients. J Am Coll Cardiol. 1988;11(6):1227-1234.

7. Hess OM, Ritter M, Schneider J, Grimm J, Turina M, Krayenbuehl HP. Diastolic stiffness and myocardial structure in aortic valve disease before and after valve replacement. Circulation. 1984;69(5):855-865.

22. Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation. 1997;95(9):2262-2270.

8. Hess OM, Villari B, Krayenbuehl HP. Diastolic dysfunction in aortic stenosis. Circulation. 1993;87(5 suppl): IV73-IV76.

23. Galan A, Zoghbi WA, Quiñones MA. Determination of severity of valvular aortic stenosis by Doppler echocardiography and relation of findings to clinical outcome and agreement with hemodynamic measurements determined at cardiac catheterization. Am J Cardiol. 1991;67(11):1007-1012.

9. Stott DK, Marpole DG, Bristow JD, Kloster FE, Griswold HE. The role of left atrial transport in aortic and mitral stenosis. Circulation. 1970;41(6):1031-1041. 10. Ross J Jr. Afterload mismatch and preload reserve: a conceptual framework for the analysis of ventricular function. Prog Cardiovasc Dis. 1976;18(4):255-264. 11. Johnson LL, Sciacca RR, Ellis K, Weiss MB, Cannon PJ. Reduced left ventricular myocardial blood flow per unit mass in aortic stenosis. Circulation. 1978;57(3):582-590. 12. Marcus ML, Doty DB, Hiratzka LF, Wright CB, Eastham CL. Decreased coronary reserve: a mechanism for angina pectoris in patients with aortic stenosis and normal coronary arteries. N Engl J Med. 1982;307(22):1362-1366. 13. Bache RJ, Wang Y, Jorgensen CR. Hemodynamic effects of exercise in isolated valvular aortic stenosis. Circulation. 1971;44(6):1003-1013. 14. Grech ED, Ramsdale DR. Exertional syncope in aortic stenosis: evidence to support inappropriate left ventricular baroreceptor response. Am Heart J. 1991;121(2 pt 1): 603-606. 15. Schwartz LS, Goldfischer J, Sprague GJ, Schwartz SP. Syncope and sudden death in aortic stenosis. Am J Cardiol. 1969;23(5):647-658. 16. Kulbertus HE. Ventricular arrhythmias, syncope and sudden death in aortic stenosis. Eur Heart J. 1988;9 (suppl E):51-52. 17. Grimard BH, Larson JM. Aortic stenosis: diagnosis and treatment. Am Fam Physician. 2008;78(6):717-724. 18. Munt B, Legget ME, Kraft CD, MiyakeHull CY, Fujioka M, Otto CM. Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome. Am Heart J. 1999;137(2):298-306. 19. Etchells E, Glenns V, Shadowitz S, Bell C, Siu S. A bedside clinical prediction rule for detecting moderate or severe aortic stenosis. J Gen Intern Med. 1998;13(10):699-704.

24. Stewart RA, Kerr AJ, Whalley GA, et al.; New Zealand Heart Valve Study Investigators. Left ventricular systolic and diastolic function assessed by tissue Doppler imaging and outcome in asymptomatic aortic stenosis. Eur Heart J. 2010;31(18):2216-2222. 25. Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med. 2000;343(9):611-617. 26. Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation. 2005;111(24):3290-3295. 27. BenDor I, Pichard AD, Gonzalez MA, et al. Correlates and causes of death in patients with severe symptomatic aortic stenosis who are not eligible to participate in a clinical trial of transcatheter aortic valve implantation. Circulation. 2010;122(11 suppl):S37-S42. 28. Makkar RR, Fontana GP, Jilaihawi H, et al.; PARTNER Trial Investigators. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis [published correction appears in N Engl J Med. 2012;367(9):881]. N Engl J Med. 2012;366(18):1696-1704. 29. Kodali SK, Williams MR, Smith CR, et al.; PARTNER Trial Investigators. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012;366(18):1686-1695. 30. Vasques F, Messori A, Lucenteforte E, Biancari F. Immediate and late outcome of patients aged 80 years and older undergoing isolated aortic valve replacement: a systematic review and meta-analysis of 48 studies. Am Heart J. 2012;163(3):477-485. 31. Reynolds MR, Magnuson EA, Lei Y, et al. Costeffectiveness of transcatheter aortic valve replacement

IJCP Sutra 8: Ensure that the food you eat is not contaminated by bats or their feces. Avoid consuming fruits bitten by bats.

American Family Physician compared with surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results of the PARTNER (Placement of Aortic Transcatheter Valves) trial (Cohort A). J Am Coll Cardiol. 2012;60(25): 2683-2692. 32. Schwarz F, Baumann P, Manthey J, et al. The effect of aortic valve replacement on survival. Circulation. 1982; 66(5):1105-1110. 33. Lindblom D, Lindblom U, Qvist J, Lundström H. Long term relative survival rates after heart valve replacement. J Am Coll Cardiol. 1990;15(3):566-573. 34. Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol. 2006;47(11):2141-2151. 35. Pellikka PA, Nishimura RA, Bailey KR, Tajik AJ. The natural history of adults with asymptomatic, hemodynamically significant aortic stenosis. J Am Coll Cardiol. 1990;15(5):1012-1017. 36. Vaquette B, Corbineau H, Laurent M, et al. Valve replacement in patients with critical aortic stenosis and depressed left ventricular function: predictors of operative risk, left ventricular function recovery, and long term outcome. Heart. 2005;91(10):1324-1329. 37. Rajani R, Rimington H, Chambers JB. Treadmill exercise in apparently asymptomatic patients with moderate or severe aortic stenosis: relationship between cardiac index and revealed symptoms. Heart. 2010;96(9):689-695. 38. Maréchaux S, Hachicha Z, Bellouin A, et al. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. Eur Heart J. 2010;31(11):1390-1397. 39. Society of Thoracic Surgeons. Executive summary: STS spring 2015 report. http://www.sts.org/nationaldatabase/database managers/executivesummaries. Accessed November 16, 2015. 40. Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS. Association of aorticvalve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med. 1999;341(3):142-147. 41. Olsen MH, Wachtell K, Bella JN, et al. Aortic valve sclerosis relates to cardiovascular events in patients with hypertension (a LIFE substudy). Am J Cardiol. 2005;95(1):132-136.

42. Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol. 2005;45(8):1334-1340. 43. Antonini-Canterin F, Huang G, Cervesato E, et al. Symptomatic aortic stenosis: does systemic hypertension play an additional role? Hypertension. 2003;41(6): 1268-1272. 44. O’Brien KD, Zhao XQ, Shavelle DM, et al. Hemodynamic effects of the angiotensin-converting enzyme inhibitor, ramipril, in patients with mild to moderate aortic stenosis and preserved left ventricular function. J Investig Med. 2004;52(3):185-191. 45. Jiménez-Candil J, Bermejo J, Yotti R, et al. Effects of angiotensin converting enzyme inhibitors in hypertensive patients with aortic valve stenosis: a drug withdrawal study. Heart. 2005;91(10):1311-1318. 46. Chockalingam A, Venkatesan S, Subramaniam T, et al. Safety and efficacy of angiotensin-converting enzyme inhibitors in symptomatic severe aortic stenosis: Symptomatic Cardiac Obstruction Pilot Study of Enalapril in Aortic Stenosis (SCOPEAS). Am Heart J. 2004; 147(4):E19. 47. Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 7th ed. Philadelphia, Pa.: Saunders; 2005: 1582-1592. 48. Dalsgaard M, Iversen K, Kjaergaard J, et al. Short-term hemodynamic effect of angiotensin-converting enzyme inhibition in patients with severe aortic stenosis: a placebo-controlled, randomized study. Am Heart J. 2014;167(2):226-234. 49. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group [published correction appears in Circulation. 2007;116(15):e376377]. Circulation. 2007;116(15):1736-1754.

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Rule of 25 of Diabetes Mean blood sugar (mg/dL) = A1c (1) × 25

Rule of 18 Diabetes Sugar (mg/dL) = Sugar (mmol/L) × 18

IJCP Sutra 9: Avoid drinking toddy that is brewed in open containers near palm trees.

American Family Physician

Practice Guidelines ACCP Provides Updated Recommendations on the Management of Somatic Cough Syndrome and Tic Cough A cough that has no medical diagnosis and does not respond to treatment is sometimes labeled as psychogenic cough, habit cough, or tic cough. These disorders should be distinguished from other forms of chronic cough, but there is little consistency or evidence on how to best diagnose a chronic cough as a psychogenic, habit, or tic cough. The American College of Chest Physicians (ACCP) has updated the 2006 guidelines to assist physicians in the management of a patient with suspected somatic cough syndrome or tic cough.

Recommendations To be consistent with the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), it is recommended that the terms somatic cough syndrome and tic cough replace the terms psychogenic and habit cough, respectively. When disseminating research findings on somatic cough syndrome and tic cough, adding the parenthetical terms (psychogenic) and (habit) for three years will help with the adoption of the new terms. Somatization refers to the transfer of psychological distress into a physical symptom. An extensive evaluation should be performed to rule out uncommon causes and tic disorders. The patient must meet the DSM-5 criteria for a diagnosis of somatic cough disorder. Diagnostic criteria include: one or more

Source: Adapted from Am Fam Physician. 2016;93(5):416.

somatic symptoms resulting in the disruption of daily life; excessive thoughts about the seriousness of the symptoms, persistent anxiety about health or symptoms, or excessive time and energy devoted to symptoms or health concerns; and persistence of symptoms (typically more than six months). The severity of the disorder depends on how many criteria are present. In children with diagnosed somatic cough disorder, nonpharmacologic trials of hypnosis or suggestion therapy, or combinations of reassurance, counseling, or referral to a psychologist or psychiatrist are recommended. A tic cough is defined as a chronic cough that shares core clinical features of tics (distinct from Tourette syndrome), including suppressibility, distractibility, suggestibility, variability, and the presence of a premonitory sensation. If after a comprehensive evaluation a chronic cough remains medically unexplained, it is recommended that a diagnosis of tic cough be made if the patient manifests the core clinical features. A simple tic cough in children may improve with suggestion therapy alone. The presence or absence of night-time cough, or a cough with a barking or honking quality, should not be used to diagnose or exclude somatic or tic cough. These cough characteristics lack specificity for a diagnosis and could be caused by a variety of diseases. Adults who have a persistent, chronic cough can develop depression or anxiety when the cough remains untreatable. It is recommended that the presence of these psychologic symptoms not be used as diagnostic criteria for somatic cough. Studies show that adverse physical and psychological effects from chronic cough can be improved with successful treatment.

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Rule of 10/20/30 BP Measurement ÂÂ

There may be a difference of 10 mmHg in BP in the two arms.

ÂÂ

Lower limb BP is usually 20 mmHg higher than upper arm BP.

ÂÂ

If the BP rises by up to 30 mmHg, after seeing a doctor, it is called white coat hypertension.

IJCP Sutra 10: Prevent contact with anyone who has contracted the disease. Sanitize and wash your hands thoroughly of you happen to visit someone with NiV.

American Family Physician

Foot Deformity at Time of Delivery in a Premature Infant

female infant was born at 35 weeks’ gestation by spontaneous vaginal delivery, following induction of labor for premature rupture of membranes. The pregnancy was otherwise uncomplicated. The newborn required three minutes of positive pressure ventilation, but transitioned well on room air over the next hour and did not require further treatment in the neonatal intensive care unit. At the time of birth, physical examination showed that the newborn’s right foot was grossly externally rotated (Figure 1). There was no crepitus on palpation of the foot, ankle, or leg, and a bilateral hip examination was unremarkable. The newborn spontaneously dorsiflexed and plantar-flexed the foot. The foot could be easily moved into normal alignment with gentle traction but returned when released. Her legs were equal in length. There were no dysmorphic features, no evidence of sacral dimple, and no signs of spina bifida. The remainder of the physical examination, including musculoskeletal and neurologic findings, was normal.

Question Based on the patient’s history and physical examination findings, which one of the following is the most likely diagnosis? A. Congenital vertical talus. B. Paralytic calcaneus foot deformity. C. Posteromedial bowing of the tibia. D. Talipes calcaneovalgus. E. Talipes equinovarus.

Discussion The answer is D: talipes calcaneovalgus. Talipes calcaneovalgus, also known as positional calcaneovalgus foot deformity, is relatively common and associated with intrauterine positioning. Although studies are limited, one study estimated an incidence of seven or eight per 1,000 births.1 On physical examination, the affected foot will be in a slightly abducted and valgus position. There may be tibial torsion. The infant is able

Source: Adapted from Am Fam Physician. 2016;94(4):314-316.

Figure 1.

to spontaneously move the affected limb, the foot is easily reduced into a normal or near-normal position, and the legs are of equal length. Typically, the abnormality resolves spontaneously over a few months; however, stretching or splinting is sometimes needed for full resolution.2 Because talipes calcaneovalgus is associated with congenital hip dislocation, particularly from breech delivery, hip instability should be ruled out.3 Many other conditions in the differential diagnosis do not resolve spontaneously and should be ruled out. Congenital vertical talus, or rocker-bottom foot, has a similar presentation. However, unlike talipes calcaneovalgus, the foot is rigidly fixed in valgus rotation because of structural deformity. The deformity includes a dorsal dislocation of the medial column of the foot at the talonavicular joint or dislocation of the entire midfoot on the hindfoot.2 It cannot be passively reduced by the examiner and will not resolve spontaneously, requiring prompt orthopedic referral for surgery or serial casting. This condition is often associated with neuromuscular disease or genetic syndromes, such as trisomies 13 and 18.3 A paralytic calcaneus foot deformity presents as valgus rotation and dorsiflexion. There is partial to full paralysis of plantar flexion, and the patient is unable to move it back into alignment spontaneously; it can be reduced by the examiner. It may occur with a number of disorders, including meningocele,4 trisomies, and polio.2,3

IJCP Sutra 11: Clothes, utensils and items typically used in the toilet or bathroom, like buckets and mugs, should be cleaned separately and maintained hygienically.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Summary Table Condition

Characteristics

Congenital vertical talus

Foot rigidly fixed in valgus rotation because of structural deformity (dorsal dislocation at the medial column of the foot at the talonavicular joint or dislocation of the entire midfoot at the hindfoot); cannot be passively reduced; associated with genetic syndromes, such as trisomies 13 and 18

Paralytic calcaneus foot deformity

Valgus rotation and dorsiflexion; the infant cannot spontaneously move the foot, but it can be reduced by the examiner; may occur with meningocele, trisomies, and polio

Posteromedial bowing of the tibia Tibial deformity causing leg-length discrepancy; the foot can be abducted with valgus rotation Talipes calcaneovalgus

Foot abducted, valgus rotation, occasional tibial torsion; can be easily reduced by the examiner, and the infant is able to spontaneously move it; equal leg length

Talipes equinovarus

Foot is excessively plantar-flexed, and the forefoot is medially rotated in the varus position; does not resolve spontaneously

Posteromedial bowing of the tibia is a more proximal deformity that can cause the foot to be abducted with valgus rotation. It is most commonly associated with leg-length discrepancy. The length discrepancy and the foot deformity often improve during skeletal growth, but nearly all patients need some treatment ranging from orthotics (e.g., shoe lift) to surgical management, including epiphysiodesis or osteotomy.2 Talipes equinovarus, commonly known as club foot, is a relatively common diagnosis occurring in approximately one per 1,000 births, and affects boys twice as often as girls.5,6 The foot is excessively plantarflexed, and the fore-foot is medially rotated in the varus position so that the sole of the foot points medially and sometimes superiorly. This deformity does not resolve spontaneously. Treatment includes stretching and splinting, with minor surgical procedures to more extensive reconstructive surgery.6

REFERENCES 1. Widhe T, Aaro S, Elmstedt E. Foot deformities in the newborn—incidence and prognosis. Acta Orthop Scand. 1988;59(2):176-179. 2. Sarwark JF. Essentials of Musculoskeletal Care. 4th ed. Rosemount, Ill.: American Academy of Orthopaedic Surgeons; 2010:1042-1044. 3. Graham JM, Sanchez-Lara PA. Smith’s Recognizable Patterns of Human Deformation. 4th ed. Philadelphia, Pa.: Elsevier; 2016:30-33. 4. Westcott MA, Dynes MC, Remer EM, Donaldson JS, Dias LS. Congenital and acquired orthopedic abnormalities in patients with myelomeningocele. Radiographics. 1998;12(6):1155-1173. 5. Keret D, Ezra E, Lokiec F, Hayek S, Segev E, Wientroub S. Efficacy of prenatal ultrasonography in confirmed club foot. J Bone Joint Surg Br. 2002;84(7):1015-1019. 6. Bridgens J, Kiely N. Current management of clubfoot (congenital talipes equinovarus). BMJ. 2010;340:c355.

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Cardiac Fitness Formula of 6 If you cannot cover more than 600 feet in 6 minutes’ walk test, you are not fit for Amarnath Yatra. Formula of 4 If your SpO2 (arterial oxygen saturation) falls by more than 4% after walking six min, you are not fit for Amarnath or Kailash Mansarovar Yatra. Formula of 2 If you can climb two flights of stairs or walk 2 km at a stretch, you are cardiac fit.

Eye Exercises for Heart Patients ÂÂ

After every 20 min of working on your computer, look at any object placed 20 feet away, blink the eyes 2 times to moisten them.

ÂÂ

Relax the body by walking 20 steps after 20 min of sitting in a particular posture.

IJCP Sutra 12: It is important to cover the face while transporting the dead body of anyone who dies after contracting Nipah fever.

CARDIOLOGY

To Study the Clinical Outcome of Cardiorenal Syndrome in a Tertiary Care Hospital of Bihar JYOTI PRAKASH*, KK SINGH†

Abstract Background: Cardiorenal syndrome (CRS) is defined as disorders of heart and kidney whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. The exact mechanism of CRS is complex and multifactorial. Objective of the study: To identify and categorize various patients admitted with CRS into different subtypes and assess the clinical outcome at discharge and 3 months. Material and methods: We took 50 patients of CRS admitted in ICU of Medicine Department, Darbhanga Medical College and Hospital (DMCH), Laheriasarai, Darbhanga, Bihar. Outcome was addressed as favorable for stable patients at discharge and 3 month follow-up, whereas unfavorable for patients who expired or were put on hemodialysis. Results: Out of 50 patients, 30 patients (60%) were males, with mean ages of males and females being 65.15 and 66.48 years, respectively. Majority of patients had type 1 CRS (44%), followed by type 4 (28%), type 2 (24%) and type 5 (4%). There were no patients with type 3 CRS. At the end of the study, 25 (50%) patients were stable, 12 (24%) required dialysis and 13 (26%) patients expired. Conclusion: CRS occurs in all age groups, more commonly in elderly subjects, with male preponderance. CRS 1 is more prevalent than CRS 4. Prognosis was unfavorable in CRS 1, CRS 4 and CRS 5, bad prognostic factors being pre-existing renal impairment, anemia, decreased glomerular filtration rate (GFR) and decreased ejection fraction. Sepsis was the predominant cause of death in patients with CRS 5.

Keywords: Cardiorenal syndrome, sepsis, low GFR, low ejection fraction

ardiorenal syndrome (CRS) is defined as disorders of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. The mechanism of CRS is quite complex and multifactorial, the factors being renin-angiotensinaldosterone system (RAAS) activation, imbalance between nitric oxide (NO) and reactive oxygen species (ROS), sympathetic activation and chronic inflammation. CRS has been divided into 5 subtypes by Ronco et al in 2008. Type 1 CRS (acute CRS) is characterized by rapid worsening of cardiac function leading to acute kidney injury (AKI). Type 2 CRS (chronic CRS) is characterized by chronic heart failure leading to progressive decline in glomerular filtration rate (GFR) leading to chronic kidney disease (CKD).

*Assistant Professor †Professor and Head Dept. of Medicine Darbhanga Medical College and Hospital, Laheriasarai, Darbhanga, Bihar Address for correspondence: Dr Jyoti Prakash Jawahar Tola, Bypass Road, Ara - 802 301, Bhojpur, Bihar E-mail: drjyoti1997@gmail.com

Type 3 CRS (acute renocardiac syndrome) manifests as AKI, which can occur as a primary event (e.g., acute glomerulonephritis) or a secondary event (e.g., radiocontrast dye, exogenous or endogenous nephrotoxins, post-surgical, etc.) followed by cardiac dysfunction. Type 4 CRS (chronic renocardiac syndrome) is a condition characterized by increased cardiovascular (CV) risk in CKD patients. Type 5 CRS (secondary CRS) is associated with multiple systemic conditions, either acute or chronic, such as sepsis, systemic lupus erythematosus (SLE), amyloidosis and diabetes mellitus. The co-existence of renal and cardiac involvement leads to increased morbidity and mortality, and also increased cost of the care. Material and Methods A total of 50 patients, above 18 years of age having both cardiac and renal involvement, were admitted in our hospital. Detailed history taking, examination and investigations were carried out, with special focus on comorbidities such as hypertension (HTN), diabetes mellitus (DM), coronary artery disease (CAD), dyslipidemia, hypothyroidism, chronic obstructive pulmonary disease (COPD) and nephrotoxic drug ingestion. Outcome was addressed as favorable

IJCP Sutra 13: It is important to get enough vitamin D as it helps in the absorption of calcium.

CARDIOLOGY (for stable patients at discharge and 3 months) and unfavorable (for patients who died or were put on hemodialysis). Investigations included complete blood count (CBC), kidney function tests (KFT), cardiac enzymes, pro–B-type natriuretic peptide (pro-BNP), lipid profile, thyroid profile, urine routine examination (R/E) and culture, electrocardiography (ECG), chest X-ray (CXR)-posteroanterior (PA) view, ultrasonography (USG)-whole abdomen. Heart failure was classified by New York Heart Association (NYHA) classification, whereas CKD as per Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines. Estimated GFR (eGFR) was calculated using the Modification of Diet in Renal Disease Study (MDRD) equation. All patients were classified into various subtypes of CRS as per Ronco guidelines (2008).

In all, 40 patients were hypertensive, 34 were diabetic, 28 were known cases of CKD, 22 were having CAD and 20 had dyslipidemia.

Prevalence of CRS Majority of patients had type 1 CRS (44%), followed by type 4 (28%), type 2 (24%) and type 5 (4%) (Table 3). At the time of discharge, 27 patients were stable, 16 required dialysis and 7 patients expired (Table 4). At the end of the study, 25 (50%) were stable, 12 (24%) required dialysis and 13 (26%) patients expired (Table 5). No patients were having CRS type 3. Table 2. Laboratory Parameters Lab parameters

Statistical Analysis All statistical analyses were performed using Chi-square test and student t-test. Differences with a probability of type 1 error <5% were considered statistically significant. Results

No. of patients

Mean ± SD

Creatinine (mg/dL)

2.5 ± 1.32

eGFR (mL/min)

28.05 ± 10.52

EF (%)

46 ± 11.50

Baseline

At admission

Demographic Profile Out of 50 patients, 30 patients (60%) were males, with mean ages of males and females being 65.15 and 66.48 years, respectively. Majority of patients had type 1 CRS (44%), followed by type 4 (28%), type 2 (24%) and type 5 (4%).

Symptomatology All patients presented with dyspnea, while pedal edema was noted in 38 patients, as shown in Table 1.

Laboratory Parameters Out of 50 patients, 28 patients were known cases of CKD, whereas 30 patients had heart failure with reduced ejection fraction. Table 2 summarizes the findings for laboratory parameters at different study time points.

Hemoglobin (>10)

Hemoglobin (<10)

Creatinine (mg/dL)

3.42 ± 1.9

eGFR (mL/min)

27.02 ± 15.50

EF (%)

32.8 ± 11.6

Creatinine (mg/dL)

3.26 ± 1.58

eGFR (mL/min)

25.12 ± 11/34

Creatinine (mg/dL)

3.18 ± 1.68

eGFR (mL/min)

30.06 ± 14.45

EF (%)

36.45 ± 10.07

At discharge

At 2 months

EF = Ejection fraction.

Table 1. Clinical Parameters Parameters

Comorbidities

No. of patients

Table 3. Distribution of CRS Subtype

Dyspnea

CRS subtypes

Dependent edema

CRS type 1

Chest pain

CRS type 2

Syncope

CRS type 4

Decreased urine output

CRS type 5

IJCP Sutra 14: Some sources of vitamin D include milk, fortified orange juice, mushrooms and egg yolk.

No. of patients

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Table 4. Outcome at Discharge Outcome

No. of patients

Stable

Dialysis

Death

Table 5. Outcome at 3 Months Outcome

No. of patients

Stable

Dialysis

Death

Discussion CRS has emerged as a significant problem over a few decades as a result of increased prevalence of HTN, diabetes, dyslipidemia, etc. Western studies have shown a complex relationship between heart and kidneys, but in the Indian scenario, it remains an uncharted territory. Our study aimed at identifying and classifying patients with CRS into various subtypes and assessing outcomes at discharge and at 3 months follow-up. There was a male preponderance in our study (M:F = 3:2), which might be due to increased number of risk factors in male population such as acute coronary syndrome (ACS), HTN, diabetes, dyslipidemia, etc. Nearly half of the patients had unfavorable outcomes (as shown in Tables 4 and 5), which were significantly higher in CRS 1 and CRS 4, probably due to devastating presentation of CRS 1 with ACS, acute left ventricular failure (LVF) or AKI, resulting in further progression to end-stage renal disease (ESRD) and increased CV mortality. Co-existing renal insufficiency is one of the strongest independent risk factors and predictors of mortality. Our study revealed more than half of the population had hemoglobin <10 g/dL (cardiorenal anemia syndrome). Anemia causes increase in oxidative stress and hypoxia to myocardium, leading to compensatory increase in heart rate and stroke volume, which activates RAAS and sympathetic nervous system (SNS), causing renal vasoconstriction and fluid retention. In a previous study, it was established that prevalence of anemia was high amongst patients with CRS; however, anemia was not the single contributory

mortality factor as uremia and low ejection fraction were also contributing to adverse outcomes. Three-fourth of the population had significant left ventricular dysfunction. All these people had unfavorable outcome at follow-up. This is possibly due to a complex interplay of various factors such as imbalance of failing heart, neurohormonal system activation, sympathetic overactivity, NO, renin-angiotensin system (RAS) and inflammatory cascade. Risk factors contributing towards worsening renal function during heart failure include old age, comorbidities, drugs like diuretics, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), prior myocardial infarction and previous renal insufficiency. In past also, it was determined that in patients with chronic heart failure, renal dysfunction is common, deteriorates over a relatively short period of time, is unlikely to recover substantially and augurs a poor prognosis. Our study has limitations in terms of small sample size. Cystatin C could not be estimated at our center due to its nonavailability. Longer follow-up at 6 months or 1 year could derive better understanding and more accurate analysis of various CRS subtypes. Conclusion CRS is a common entity nowadays. There are five subtypes of CRS. The exact mechanism is multifactorial. CRS can occur in all age groups but is more common in elderly population with a male preponderance. CRS 1 was more prevalent followed by CRS 4. Unfavorable outcomes were noted with CRS 1, CRS 4 and CRS 5. Sepsis was the predominant cause of death in patients having CRS 5 with 100% mortality during hospital stay. Risk factors like pre-existing renal impairment, anemia, reduced ejection fraction and reduced eGFR were significantly associated with poorer outcome across all CRS subtypes. Therefore, large populationbased studies are warranted to chart the prevalence of CRS subtypes and prognosticate each individually. Longer follow-up studies should be undertaken in order to understand the natural history of CRS. Suggested reading 1. Ronco C, Haapio M, House AA, Anavekar N, Bellomo R. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52(19): 1527-39. 2. Silva RP, Barbosa PH, Kimura OS, Sobrinho CR, Sousa Neto JD, Silva FA, et al. Prevalence of anemia and its

IJCP Sutra 15: Get enough physical activity for about 30 minutes each day.

CARDIOLOGY association with cardiorenal syndrome. Int J Cardiol. 2007;120(2):232-6. 3. Santoro A. Heart failure and cardiorenal syndrome in the elderly. J Nephrol. 2012;25 Suppl 19:S67-72. 4. Forman DE, Butler J, Wang Y, Abraham WT, O’Connor CM, Gottlieb SS, et al. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol. 2004;43(1):61-7. 5. Silverberg DS, Wexler D, Blum M, Tchebiner J, Sheps D, Keren G, et al. The correction of anemia in severe resistant heart failure with erythropoietin and intravenous iron prevents the progression of both the heart and the renal failure and markedly reduces hospitalization. Clin Nephrol. 2002;58 Suppl 1:S37-45. 6. Smith GL, Lichtman JH, Bracken MB, Shlipak MG, Phillips CO, DiCapua P, et al. Renal impairment and outcomes in heart failure: systematic review and meta-analysis. J Am Coll Cardiol. 2006;47(10):1987-96.

7. Eren Z, Ozveren O, Buvukoner E, Kaspar E, Degertekin M, Kantarci G. A single-centre study of acute cardiorenal syndrome: incidence, risk factors and consequences. Cardiorenal Med. 2012;2(3):168-76. 8. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351(13):1296-305. 9. Dries DL, Exner DV, Domanski MJ, Greenberg B, Stevenson LW. The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with left ventricular systolic dysfunction. J Am Coll Cardiol. 2000;35(3):681-9. 10. de Silva R, Nikitin NP, Witte KK, Rigby AS, Goode K, Bhandari S, et al. Incidence of renal dysfunction over 6 months in patients with chronic heart failure due to left ventricular systolic dysfunction: contributing factors and relationship to prognosis. Eur Heart J. 2006;27(5):569-81.

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Make sure During Medical Practice

Situation:

A hypertensive patient with long-standing type 2 diabetes on a calcium channel blocker was found to have moderately increased albuminuria (between 30 and 300 mg/day).

Add losartan.

Lesson:

In the RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan) study in patients with type 2 diabetes already receiving conventional antihypertensive therapy, the use of the ARB losartan significantly decreased the risk of end-stage renal disease. Losartan also significantly decreased the degree of proteinuria. N Engl J Med. 2001;345(12):861-9.

IJCP Sutra 16: Limit the intake of caffeine as this can decrease the absorption of calcium.

community health

Effect of Pollution on Health of People Living Near Landfill Sites in Delhi-NCR KK AGGARWAL*, ANIRUDDHA SHARMA†, RAHUL MANAV‡

Abstract Introduction: Pollution has become a major public health problem because of its impact on human health. Landfills are the most commonly used methods for disposing municipal solid waste. But, solid waste as a source of environmental pollution has been relatively under-discussed. To the best of our knowledge, there is no study available in India, which has analyzed the implications of pollution on a large number of health parameters. Aims: The study was conducted to compare the health of people living in close proximity to landfill sites (within 2 km) to those living in non-landfill areas (beyond 7 km) and also to find out any association between the living conditions on various health parameters in the study population. Materials and methods: An observational study was conducted jointly by Heart Care Foundation of India (HCFI) and Dainik Bhaskar Group in association with Urja, a non-governmental organization (NGO). Three landfill sites in Delhi-National Capital Region (NCR) were selected for the study. People residing within 2 km of the three selected landfill sites formed the study group (n = 276). The control group (n = 252) included people residing beyond 7 km of the three landfill sites. An 8-member team visited all the six sites on different days and carried out the study. Height, weight, peak expiratory flow rate (PEFR), abdominal circumference, pulse rate, blood pressure (BP), heart rate, blood (peripheral capillary) oxygen saturation (SpO2), the 6-minute walk test (6MWT), particular matter (PM)2.5 and PM10 were measured. Water samples were collected for analysis. Results: The levels of PM2.5 and PM10 were quite high in the landfill areas compared to the control group; 264 µg/m3 vs. 155 µg/m3; 320 µg/m3 vs. 172 µg/m3, respectively. Height was lower in the study group (159 cm vs. 164 cm) as also weight (63 kg vs. 71 kg). Participants in the study group had lower PEFR (315 L/min) in comparison to the control group (398 L/min). The study group also had reduced effort tolerance on 6MWT and lower SpO2. Water samples tested from the landfill sites also showed increased total dissolved solids (TDS), hardness and bicarbonate levels indicating ground water contamination. Conclusion: Compared to the control group, systolic and diastolic BP were found to be significantly higher, while height, weight, body mass index (BMI), PEFR, SpO2 (before and after 6MWT) were lower in the study group. Our study has only focused on observing the changes in health parameters due to exposure to pollution and does not attempt to identify a cause and effect association. Our observations are significant enough to consider a trial in a larger sample size. An extended study is being undertaken.

Keywords: Solid waste, PM2.5, PM10, PEFR, effort tolerance, total hardness, total dissolved solids

ollution is a burning issue today and has become a major public health problem because of its impact on human health. The adverse health effects of air pollution can be due to either short- or long-term exposure. The latest World Health Organization (WHO) data show that many countries in the world have dangerously high

*President, Heart Care Foundation of India †City Chief Delhi Dainik Bhaskar ‡Senior Correspondent Dainik Bhaskar Address for correspondence Dr KK Aggarwal Padma Shri Awardee E-219, GK - I, New Delhi - 110 048 E-mail: editorial@ijcp.com

levels of air pollution. Nine out of 10 people breathe air containing high levels of pollutants and around 7 million people die every year from exposure to fine particles in polluted air.1 Air pollution has been linked to many diseases such as stroke, heart disease, lung cancer, chronic obstructive pulmonary disease (COPD) and respiratory infections. As per WHO estimates, 24% of all adult deaths from heart disease, 25% from stroke, 43% from COPD and 29% from lung cancer are attributed to air pollution. More than 90% of air pollution-related deaths occur in low- and middleincome countries. Ambient (outdoor) air pollution alone accounted for around 4.2 million deaths in 2016.1 Amongst the various pollutants, particulate matter (PM), ozone (O3), nitrogen dioxide (NO2) and sulfur dioxide (SO2) have the strongest body of evidence for their effects on human health.2

IJCP Sutra 17: If you smoke or drink, it is a good idea to quit both these habits.

community health Pollution-related diseases increase healthcare costs, particularly in middle-income countries that have high levels of pollution.3 Pollution also affects worker productivity by reducing how much is produced “on the job.”4 Ozone and PM2.5 have also been shown to be associated with worker productivity. Ozone reduces lung function, increases lung sensitivity to allergens and irritants and causes chronic damage to the lung structure.5 PM2.5 can penetrate deep into the lung, where they irritate and it damages the alveolar wall resulting in impaired lung function.6 PM2.5 is also known to affect blood pressure (BP), cognitive function and immune function.4,7 Ozone breaks down rapidly and disappears indoors; hence, its effects are more evident outdoors. PM2.5, on the other hand can affect workers both outdoors and indoors as indoor levels can be 70-100% of outdoor levels.4 Vehicular exhaust emissions, industrial emissions, crop stubble burning, construction activities, garbage burning, dust on roads are major sources of air pollution. While, traffic emissions, crop stubble burning, construction activities, industrial waste have been established as major contributors to air pollution, particularly in Delhi-National Capital Region (NCR), solid waste as a source of environmental pollution has been relatively under-discussed.8 Solid waste includes municipal waste, industrial waste and hazardous wastes.9 Municipal solid waste, also called urban solid waste, includes mainly household waste (domestic waste) with sometimes the addition of commercial wastes, construction and demolition debris, sanitation residue and waste from streets collected by a municipality within a given area.10 There are generally five categories of municipal solid waste in India:11 ÂÂ

Biodegradable waste: Food and kitchen waste, green waste (vegetables, flowers, leaves, fruits) and paper.

ÂÂ

Recyclable material: Paper, glass, bottles, cans, metals, certain plastics, etc.

ÂÂ

Inert waste: Construction and demolition, dirt, debris, rocks.

ÂÂ

Composite waste: Waste clothing, Tetra packs, waste plastics such as toys.

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Domestic hazardous waste (also called “household hazardous waste”) and toxic waste: Waste medicine, e-waste, paints, chemicals, light bulbs, fluorescent tubes, spray cans, fertilizer and pesticide containers, batteries and shoe polish.

Untreated solid waste can pollute air, water and soil, due to improper handling and transportation and cause health hazard. Hence, solid waste management is very essential.9 Landfills are the most commonly used method for disposing municipal solid waste.12 Living near landfills is a known health hazard.13 Delhi-NCR has three main landfill sites, all of which have exhausted their capacity. Also, their present height has crossed the permitted height of 5-20 m as recommended by Central Pollution Control Board (CPCB), Ministry of Environment and Forests,14 posing a threat to the health of the people living in their vicinity and also endangering their safety. Last year in September, a part of the Ghazipur landfill collapsed due to heavy rains killing two people and injuring few others. While a Graded Response Action Plan has been notified by the Govt. When air quality index (AQI) has ranged between severe and hazardous levels in Delhi-NCR, not much is being done about the landfills and not quickly enough. With this background, we decided to conduct a study with the aim to compare the health of people living in close proximity to landfill sites (within 2 km) to those living in non-landfill areas (beyond 7 km). The study also attempted to find out any association between the living conditions on various health parameters in the study population. To the best of our knowledge, there is no study available in India, which has analyzed the implications of pollution on a large number of health parameters. MATERIALS AND METHODS This is an observational study conducted jointly by Heart Care Foundation of India (HCFI) and Dainik Bhaskar Group in association with Urja, a non-governmental organization (NGO). Ethical clearance for the study was taken by the HCFI Internal Ethics Committee.

Study Sites Three landfill sites in Delhi were selected for the study namely: ÂÂ

Bhalswa landfill site in Northwest Delhi

ÂÂ

Ghazipur landfill site in East Delhi

ÂÂ

Okhla landfill site in South Delhi.

IJCP Sutra 18: Eat foods high in folic acid, such as dried beans, dark green leafy vegetables, wheat germ and orange juice.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Bhalswa landfill site in Northwest Delhi is spread over 40 acres. It started overflowing in 2003 and was declared exhausted in 2006. It is 50 meters high.

Body mass index (BMI) was calculated using the formula weight (in kg) divided by height in meters squared.

Okhla landfill site located in South Delhi is spread over 56 acres and is 50 m high. It was declared as exhausted way back in 2010.

PEFR (in L/min) was measured using peak flow meter. PM2.5 and PM10 levels were measured using Particulate Pollution meter. Effort tolerance of all the participants was measured using the 6MWT with rounds of 50 feet each. SpO2 was measured before and after the 6MWT with a finger pulse oximeter. Ground water samples were collected for analysis.

Study Population

RESULTS

The study group included people residing within 2 km of the three selected landfill sites in Delhi.

Sample Size

Ghazipur landfill site in East Delhi is the oldest landfill site. Spread over 70 acres, it is around 60 meters in height. The landfill site exceeded its capacity in 2002.

The control group included people residing beyond 7 km of the three landfill sites. The three non-landfill locations selected for the study were: ÂÂ

Ashok Vihar in Northwest Delhi, located at a distance of around 8 km from Bhalswa landfill site

ÂÂ

GTB Enclave in East Delhi, located at a distance of 8 km from Ghazipur landfill site

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Kotla Mubarakpur in South Delhi, located at a distance of around 10-11 km from Okhla landfill site.

Data Collection The study was conducted in the month of December 2017. An 8-member team comprising of 1 doctor, 2 technicians, 1 representative of Dainik Bhaskar Group and 4 members of HCFI visited all the six sites on different days and carried out the study. ÂÂ

The team visited Bhalswa landfill site on 13.12.2017, Ghazipur landfill site on 16.12.2017 and Okhla (Lal Kuan village) landfill site on 21.12.2017 between 10 am to 5 pm.

ÂÂ

The team also visited the three non-landfill areas on the following dates: Ashok Vihar on 17.12.2017 and GTB Enclave on 23.12.2017 between 10 am to 5 pm. The visit at Kotla Mubarakpur was on 22.12.2017 between 9:30 am to 5:00 pm.

The variables included in the study were: Height, weight, peak expiratory flow rate (PEFR), abdominal circumference, pulse rate, BP, heart rate, blood (peripheral capillary) oxygen saturation (SpO2), the 6-minute walk test (6MWT), PM2.5 and PM10. Data was collected by means of physical examination and check-up. Height (in cm), weight (in kg), BP, both systolic and diastolic (in mmHg), abdominal circumference (in cm) were measured.

We had planned to enroll 100 subjects in each of the three landfill sites (study group; n = 300) and three nonlandfill areas (control group; n = 300). But, we could enroll 276 participants in the study group and 252 participants in the control group. There were 134 males and 142 females in the study group, while the control groups had 186 males and 66 females. The mean age (in years) was 49.20 years (standard deviation [SD] 17.05) in the study group. In the control group, the mean age was 46.33 years (SD 17.16). Table 1 shows the overall comparison of the health parameters between the landfill and non-landfill areas. Compared to the control group, the systolic BP, diastolic BP, PM2.5 and PM10 levels were higher while height, weight, BMI, PEFR, SpO2 (before and after 6MWT) were lower in the study group. These findings were statistically significant. There was no change in heart rate after 6MWT. The observations in males were same as in males and females combined in both the study group and the control group (Table 2). Changes in diastolic BP, abdominal circumference and SpO2 after 6MWT were not statistically significant in females, though the trends were similar to those observed in males (Table 3). Table 4 shows overall comparison between the three landfill areas. Table 5 shows overall comparison between the three non-landfill areas. The various health parameters were also compared between each landfill site and non-landfill areas as shown in Tables 6-8. Bhalswa landfill site, when compared to non-landfill area, showed similar findings except for no significant difference in weight and BMI (Table 6). Ghazipur area when compared to non-landfill areas showed similar findings except for diastolic BP, which

IJCP Sutra 19: Eat foods high in vitamin C, such as citrus fruits and fresh, raw vegetables.

community health Table 1. Overall Comparison between Landfill and Non-landfill Areas Parameters

Non-landfill areas (Control group) (n = 252)

Landfill areas (Study group) (n = 276)

P value

Mean

SEM

Mean

SEM

Age (years)

49.20

17.05

1.07

46.33

17.16

1.03

0.055

Systolic BP (mmHg)

122.10

7.57

0.48

128.95

17.66

1.10

0.000

Diastolic BP (mmHg)

76.31

6.40

0.40

80.57

12.60

0.78

0.000

Height (cm)

164.45

10.40

0.66

159.18

11.86

0.72

0.000

Weight (kg)

71.98

15.70

0.99

63.02

15.14

0.99

0.000

(kg/m2)

26.35

4.77

0.30

24.56

5.00

0.33

0.000

PEFR (L/min)

398.80

105.98

6.69

315.35

105.72

6.47

0.000

PM10 (µg/m3)

172.55

76.76

4.88

320.12

161.86

10.10

0.000

PM2.5 (µg/m3)

155.60

64.18

4.08

264.74

125.22

7.83

0.000

6MWT (rounds of 50 feet each)

23.10

6.38

0.40

20.40

6.43

0.40

0.000

SpO2 before 6MWT (%)

98.24

0.67

0.00

97.57

2.00

0.00

0.000

SpO2 after 6MWT (%)

96.88

1.00

0.00

96.23

2.23

0.00

0.000

Pulse rate after 6MWT (beats per minute)

112.57

9.41

0.60

112.37

9.86

0.62

0.814

BMI

SD = Standard deviation; SEM = Standard error of the mean.

Table 2. Overall Male-wise Comparison between Landfill and Non-landfill Areas Parameters

Non-landfill areas (Control group) (n = 186)

Landfill areas (Study group) (n = 134)

P value

Mean

SEM

Mean

SEM

Age (years)

49.18

17.56

1.29

45.58

19.33

1.67

0.084

Systolic BP (mmHg)

121.88

7.66

0.56

129.89

18.07

1.64

0.000

Diastolic BP (mmHg)

75.81

6.12

0.45

81.25

10.97

0.99

0.000

Height (cm)

167.27

9.72

0.72

163.73

12.50

1.09

0.005

Weight (kg)

73.00

16.70

1.23

64.37

16.54

1.54

0.000

BMI (kg/m2)

25.65

4.46

0.33

23.48

4.32

0.40

0.000

PEFR (L/min)

417.54

108.61

7.98

364.18

109.36

9.55

0.000

PM10 (µg/m3)

177.69

75.60

5.62

308.98

164.32

14.88

0.000

(µg/m3)

161.75

63.68

4.73

253.67

127.02

11.50

0.000

6MWT (rounds of 50 feet each)

22.88

6.34

0.47

20.89

6.70

0.61

0.009

SpO2 before 6MWT (%)

98.21

0.73

0.05

97.44

2.64

0.24

0.000

SpO2 after 6MWT (%)

96.96

1.01

0.07

95.87

2.66

0.23

0.000

Pulse rate after 6MWT (beats per minute)

112.44

9.32

0.69

111.80

10.28

0.94

0.578

PM2.5

IJCP Sutra 20: Cook in cast iron pots as this can add up to 80% more iron to your food.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Table 3. Overall Female-wise Comparison between Landfill and Non-landfill Areas Parameters

Non-landfill areas (Control group) (n = 66)

Landfill areas (Study group) (n = 142)

P value

Mean

SEM

Mean

SEM

Age (years)

49.24

15.65

1.93

47.04

14.87

1.25

0.328

Systolic BP (mmHg)

122.73

7.35

0.90

128.13

17.31

1.47

0.016

Diastolic BP (mmHg)

77.73

6.97

0.86

79.97

13.90

1.18

0.217

Height (cm)

156.62

7.98

0.98

154.88

9.43

0.80

0.200

Weight (kg)

69.15

12.17

1.50

61.73

13.61

1.24

0.000

BMI (kg/m2)

28.26

5.09

0.63

25.59

5.40

0.49

0.001

PEFR (L/min)

346.29

77.52

9.54

268.31

77.22

6.62

0.000

PM10 (µg/m3)

158.47

78.73

9.69

330.18

159.55

13.73

0.000

PM2.5 (µg/m3)

138.74

62.98

7.75

274.82

123.16

10.64

0.000

6MWT (rounds of 50 feet each)

23.70

6.50

0.80

19.95

6.16

0.53

0.000

SpO2 before 6MWT (%)

98.32

0.47

0.00

97.71

1.04

0.00

0.000

SpO2 after 6MWT (%)

96.65

0.95

0.00

96.56

1.68

0.00

0.694

Pulse rate after 6MWT (beats per minute)

112.94

9.74

1.20

112.87

9.47

0.82

0.964

Table 4. Overall Comparison between Different Locations of Landfill Areas Parameters

Bhalswa (n = 92)

Ghazipur (n = 96)

Okhla (Lal Kuan village) (n = 88)

Mean

SEM

Mean

SEM

Mean

SEM

Age (years)

46.41

15.91

1.66

54.36

14.30

1.46

37.48

17.11

1.82

Systolic BP (mmHg)

137.48

22.75

2.54

131.04

13.80

1.41

118.45

8.71

0.95

Diastolic BP (mmHg)

90.30

16.67

1.86

77.65

6.93

0.71

74.64

6.30

0.69

Height (cm)

159.16

9.86

1.06

159.30

9.16

0.94

159.06

15.76

1.68

Weight (kg)

68.67

15.83

2.22

64.22

12.73

1.30

58.45

15.95

1.70

BMI (kg/m2)

26.67

5.78

0.81

25.07

4.97

0.51

22.79

3.88

0.41

PEFR (L/min)

344.37

108.07

11.39

296.40

105.26

10.92

305.24

97.95

10.69

PM10 (µg/m3)

336.55

35.39

4.14

139.39

34.71

3.54

503.65

66.34

7.07

PM2.5 (µg/m3)

278.90

29.88

3.50

123.29

27.48

2.82

405.69

47.87

5.10

6MWT (rounds of 50 feet each)

17.58

2.66

0.31

19.24

5.63

0.59

24.02

7.76

0.83

SpO2 before 6MWT (%)

96.65

3.35

0.40

0.97

0.10

98.30

0.51

0.05

SpO2 after 6MWT (%)

96.30

3.00

0.32

1.78

0.19

97.24

0.84

0.09

Pulse rate after 6MWT (beats per minute)

108.80

12.14

1.28

116.53

6.94

0.79

112.38

7.89

0.84

IJCP Sutra 21: Take your prenatal multivitamin and mineral pill, which contains extra folate.

community health Between Bhalswa and Ghazipur

Between Bhalswa and Okhla (Lal Kuan Village)

Between Ghazipur and Okhla (Lal Kuan Village)

Parameters

P value

Parameters

P value

Age (years)

0.000

Age (years)

0.000

Systolic BP (mmHg)

0.000

Systolic BP (mmHg)

0.000

Diastolic BP (mmHg)

0.000

Diastolic BP (mmHg)

0.003

Height (cm)

0.958

Height (cm)

0.896

Weight (kg)

0.000

Weight (kg)

0.007

0.000

BMI

(kg/m2)

0.001

PEFR (L/min)

0.013

PEFR (L/min)

0.565

PM10 (µg/m3)

0.000

PM10 (µg/m3)

0.000

PM2.5

(µg/m3)

0.000

6MWT (rounds of 50 feet each)

0.000

6MWT (rounds of 50 feet each)

0.000

Parameters

P value

Age (years)

0.000

Systolic BP (mmHg)

0.022

Diastolic BP (mmHg)

0.000

Height (cm)

0.921

Weight (kg)

0.066

BMI (kg/m2)

0.083

PEFR (L/min)

0.003

PM10 (µg/m3)

0.000

PM2.5 (µg/m3)

0.000

6MWT (rounds of 50 feet each)

0.019

SpO2 before 6MWT (%)

0.011

SpO2 before 6MWT (%)

0.000

SpO2 before 6MWT (%)

0.000

SpO2 after 6MWT (%)

0.003

SpO2 after 6MWT (%)

0.005

SpO2 after 6MWT (%)

0.000

Pulse rate after 6MWT (beats per minute)

0.000

Pulse rate after 6MWT (beats per minute)

0.021

Pulse rate after 6MWT (beats per minute)

0.000

BMI

(kg/m2)

PM2.5

(µg/m3)

Table 5. Overall Comparison between Different Locations of Non-landfill Areas Parameters

Ashok Vihar (n = 75)

GTB Enclave (n = 91)

Kotla Mubarakpur (n = 86)

Mean

SEM

Mean

SEM

Mean

SEM

Age (years)

56.23

15.82

1.83

52.67

16.70

1.75

39.40

13.85

1.49

Systolic BP (mmHg)

123.33

8.90

1.03

122.75

6.16

0.65

120.35

7.43

0.80

Diastolic BP (mmHg)

76.53

6.88

0.79

77.36

5.93

0.62

75.00

6.28

0.68

Height (cm)

168.43

12.87

1.52

161.86

9.86

1.03

163.85

7.33

0.79

Weight (kg)

79.41

19.10

2.25

71.01

12.37

1.30

66.79

13.30

1.43

BMI (kg/m2)

27.14

4.72

0.56

27.21

4.92

0.52

24.79

4.29

0.46

PEFR (L/min)

390.20

98.00

11.39

426.92

106.21

11.13

376.45

106.89

11.53

PM10 (µg/m3)

137.61

26.97

3.22

130.30

28.26

2.96

245.70

85.37

9.21

PM2.5 (µg/m3)

138.93

50.57

6.04

118.20

24.90

2.61

208.76

67.85

7.32

6MWT (rounds of 50 feet each)

23.25

6.12

0.72

23.78

6.60

0.69

22.24

6.32

0.68

SpO2 before 6MWT (%)

98.07

0.84

0.10

98.42

0.54

0.06

98.19

0.59

0.00

SpO2 after 6MWT (%)

96.19

1.05

0.12

97.14

0.81

0.08

97.19

0.86

0.00

Pulse rate after 6MWT (beats per minute)

114.52

7.77

0.92

109.51

8.93

0.94

114.16

10.37

1.12

IJCP Sutra 22: Adequate physical activity can help maintain body weight and improve muscle and bone strength.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Between Ashok Vihar and GTB Enclave

Between Ashok Vihar and Kotla Mubarakpur

Between GTB Enclave and Kotla Mubarakpur

Parameter

P value

Parameter

P value

Parameter

P value

Age (years)

0.164

Age (years)

0.000

Age (years)

0.000

Systolic BP (mmHg)

0.618

Systolic BP (mmHg)

0.022

Systolic BP (mmHg)

0.020

Diastolic BP (mmHg)

0.405

Diastolic BP (mmHg)

0.141

Diastolic BP (mmHg)

0.011

Height (cm)

0.000

Height (cm)

0.006

Height (cm)

0.130

Weight (kg)

0.001

Weight (kg)

0.000

Weight (kg)

0.030

BMI (kg/m2)

0.919

BMI (kg/m2)

0.001

BMI (kg/m2)

0.001

PEFR (L/min)

0.024

PEFR (L/min)

0.401

PEFR (L/min)

0.002

PM10 (µg/m3)

0.099

PM10 (µg/m3)

0.000

PM10 (µg/m3)

0.000

PM2.5 (µg/m3)

0.001

PM2.5 (µg/m3)

0.000

PM2.5 (µg/m3)

0.000

6MWT (rounds of 50 feet each)

0.596

6MWT (rounds of 50 feet each)

0.314

6MWT (rounds of 50 feet each)

0.116

SpO2 before 6MWT (%)

0.002

SpO2 before 6MWT (%)

0.295

SpO2 before 6MWT (%)

0.008

SpO2 after 6MWT (%)

0.000

SpO2

after 6MWT (%)

0.000

SpO2

after 6MWT (%)

0.731

Pulse rate after 6MWT (beats per minute)

0.000

Pulse rate after 6MWT (beats per minute)

0.810

Pulse rate after 6MWT (beats per minute)

0.002

Table 6. Comparison between Non-landfill Areas and Bhalswa Parameters

Non-landfill areas (n = 252)

Bhalswa (n = 92)

P value

Mean

SEM

Mean

SEM

Age (years)

49.20

17.05

1.07

46.41

15.91

1.66

0.173

Systolic BP (mmHg)

122.10

7.57

0.48

137.48

22.75

2.54

0.000

Diastolic BP (mmHg)

76.31

6.40

0.40

90.30

16.67

1.86

0.000

Height (cm)

164.45

10.40

0.66

159.16

9.86

1.06

0.000

Weight (kg)

71.98

15.70

0.99

68.67

15.83

2.22

0.171

BMI (kg/m2)

26.35

4.77

0.30

26.67

5.78

0.81

0.671

PEFR (L/min)

398.80

105.98

6.69

344.37

108.07

11.39

0.000

PM10 (µg/m3)

172.55

76.76

4.88

336.55

35.39

4.14

0.000

PM2.5 (µg/m3)

155.60

64.18

4.08

278.90

29.88

3.50

0.000

6MWT (rounds of 50 feet each)

23.10

6.38

0.40

17.58

2.66

0.31

0.000

SpO2 before 6MWT (%)

98.24

0.67

0.04

96.65

3.35

0.40

0.000

SpO2 after 6MWT (%)

96.88

1.00

0.06

96.30

3.00

0.32

0.008

Pulse rate after 6MWT (beats per minute)

112.57

9.41

0.60

108.80

12.14

1.28

0.003

IJCP Sutra 23: Those with hemophilia should avoid physical activity that can cause injury and resultant bleeding.

community health Table 7. Comparison between Non-landfill Areas and Ghazipur Parameters

Non-landfill areas (n = 252)

Ghazipur (n = 96)

P value

Mean

SEM

Mean

SEM

Age (years)

49.20

17.05

1.07

54.36

14.30

1.46

0.009

Systolic BP (mmHg)

122.10

7.57

0.48

131.04

13.80

1.41

0.000

Diastolic BP (mmHg)

76.31

6.40

0.40

77.65

6.93

0.71

0.090

Height (cm)

164.45

10.40

0.66

159.30

9.16

0.94

0.000

Weight (kg)

71.98

15.70

0.99

64.22

12.73

1.30

0.000

BMI (kg/m2)

26.35

4.77

0.30

25.07

4.97

0.51

0.030

PEFR (L/min)

398.80

105.98

6.69

296.40

105.26

10.92

0.000

PM10 (µg/m3)

172.55

76.76

4.88

139.39

34.71

3.54

0.000

PM2.5 (µg/m3)

155.60

64.18

4.08

123.29

27.48

2.82

0.000

6MWT (rounds of 50 feet each)

23.10

6.38

0.40

19.24

5.63

0.59

0.000

SpO2 before 6MWT (%)

98.24

0.67

0.04

97.59

1.00

0.10

0.000

SpO2 after 6MWT (%)

96.88

1.00

0.06

95.20

1.78

0.19

0.000

Pulse rate after 6MWT (beats per minute)

112.57

9.41

0.60

116.53

6.94

0.79

0.001

Table 8. Comparison between Non-landfill Areas and Okhla (Lal Kuan Village) Parameters

Non-landfill areas (n = 252)

Okhla (Lal Kuan village) (n = 88)

P value

Mean

SEM

Mean

SEM

Age (years)

49.20

17.05

1.07

37.48

17.11

1.82

0.000

Systolic BP (mmHg)

122.10

7.57

0.48

118.45

8.71

0.95

0.000

Diastolic BP (mmHg)

76.31

6.40

0.40

74.64

6.30

0.69

0.039

Height (cm)

164.45

10.40

0.66

159.06

15.76

1.68

0.00

Weight (kg)

71.98

15.70

0.99

58.45

15.95

1.70

0.00

BMI (kg/m2)

26.35

4.77

0.30

22.79

3.88

0.41

0.00

PEFR (L/min)

398.80

105.98

6.69

305.24

97.95

10.69

0.00

PM10 (µg/m3)

172.55

76.76

4.88

503.65

66.34

7.07

0.00

PM2.5 (µg/m3)

155.60

64.18

4.08

405.69

47.87

5.10

0.00

6MWT (rounds of 50 feet each)

23.10

6.38

0.40

24.02

7.76

0.83

0.270

SpO2 before 6MWT (%)

98.24

0.67

0.04

98.30

0.51

0.05

0.455

SpO2 after 6MWT (%)

96.88

1.00

0.06

97.24

0.84

0.09

0.003

Pulse rate after 6MWT (beats per minute)

112.57

9.41

0.60

112.38

7.89

0.84

0.862

IJCP Sutra 24: Clean your teeth and gums thoroughly.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Table 9. Comparison of Water Quality between Non-landfill Areas and Bhalswa Parameters

Non-land fill areas

Bhalswa

Mean

SEM

Value

P value

Alkalinity (as CaCO3) (mg/L)

302.07

60.18

34.75

1211.60

0.006

Acidity (as CaCO3) (mg/L)

36.40

29.53

17.05

222.30

0.032

Chloride (as Cl) (mg/L)

66.20

30.34

17.52

1191.00

0.001

Conductivity (µS/cm)

1016.67

251.66

145.30

6000.00

0.003

Total hardness (as CaCO3) (mg/L)

278.40

82.02

47.36

960.00

0.019

Bicarbonate alkalinity (as CaCO3) (mg/L)

302.07

60.18

34.75

1211.60

0.006

7.85

0.32

0.19

7.47

0.417

Total solids (mg/L)

664.00

180.13

104.00

3980.00

0.004

Total suspended solids (mg/L)

15.67

3.21

1.86

80.00

0.003

Total dissolved solids (mg/L)

648.33

179.78

103.80

3900.00

0.004

Total volatile solids (mg/L)

67.67

14.57

8.41

488.00

0.002

Total Kjeldahl nitrogen (as N) (mg/L)

2.49

1.57

1.11

10.80

0.145

Nitrate (as N) (mg/L)

1.40

0.28

0.20

3.70

0.095

Calcium (as Ca) (mg/L)

52.53

17.33

10.01

184.50

0.022

Magnesium (as Mg) (mg/L)

35.77

9.39

5.42

121.30

0.016

Potassium (as K) (mg/L)

1.40

0.78

0.45

14.20

0.005

Sodium (as Na) (mg/L)

87.73

19.14

11.05

614.00

0.002

Iron (as Fe) (mg/L)

0.01

0.00

0.03

0.104

Manganese (as Mn) (mg/L)

0.03

0.04

0.03

0.06

0.667

showed comparable findings between the two groups (Table 7). Okhla (Lal Kuan village) landfill site when compared to non-landfill areas showed similar findings except for no difference in 6MWT and baseline SpO2 (Table 8). Quality of water was compared between the non-landfill areas and each landfill site individually (Tables 9-11). The water in Bhalswa area was more alkaline and had more hardness and total dissolved solids (Table 9). The water in Ghazipur area had only high potassium levels (Table 10). The water in Okhla (Lal Kuan village) was more alkaline and had more hardness and total dissolved solids (Table 11).

for waste disposal, landfill sites in metro cities have exhausted their capacity11 as is also the case with the three landfill sites (Bhalswa, Ghazipur and Okhla [Lal Kuan village]) selected for our study. With rising population and urbanization, the garbage quantity generated increases, which, in turn, exhausts the landfill sites.15 These three landfill sites are also nearing or have crossed their life span, which has been defined as at least 20-25 years as per the latest Solid Waste Management Rules, 2016 notified in April 2016. Ghazipur is the oldest landfill site in Delhi having been commissioned in the year 1984; Bhalswa landfill site became functional in 1994 and Okhla in 1996.16

DISCUSSION

Hence, these landfills are potential sources of exposure to hazardous chemicals.

Landfilling is a common method for disposal of solid waste in India. But, because of the scarcity of land

Studies have shown that living near municipal solid waste landfill is harmful to health as people are exposed

IJCP Sutra 25: Get tested regularly for blood infections and get your doctor’s advice on hepatitis A and B vaccinations.

community health Table 10. Comparison of Water Quality between Non-landfill Areas and Ghazipur Parameters

Non-landfill areas

Ghazipur

Mean

SEM

Value

P value

Alkalinity (as CaCO3) (mg/L)

302.07

60.18

34.75

453.00

0.162

Acidity (as CaCO3) (mg/L)

36.40

29.53

17.05

74.10

0.384

Chloride (as Cl) (mg/L)

66.20

30.34

17.52

35.70

0.476

Conductivity (µS/cm)

1016.67

251.66

145.30

1200.00

0.593

Total hardness (as CaCO3) (mg/L)

278.40

82.02

47.36

240.00

0.724

Bicarbonate alkalinity (as CaCO3) (mg/L)

302.07

60.18

34.75

453.00

0.162

7.85

0.32

0.19

7.60

0.575

Total solids (mg/L)

664.00

180.13

104.00

779.00

0.636

Total suspended solids (mg/L)

15.67

3.21

1.86

22.00

0.230

Total dissolved solids (mg/L)

648.33

179.78

103.80

757.00

0.653

Total volatile solids (mg/L)

67.67

14.57

8.41

60.00

0.693

Total Kjeldahl nitrogen (as N) (mg/L)

2.49

1.57

1.11

1.10

0.601

Nitrate (as N) (mg/L)

1.40

0.28

0.20

0.80

0.333

Calcium (as Ca) (mg/L)

52.53

17.33

10.01

46.10

0.778

Magnesium (as Mg) (mg/L)

35.77

9.39

5.42

30.30

0.664

Potassium (as K) (mg/L)

1.40

0.78

0.45

7.00

0.025

Sodium (as Na) (mg/L)

87.73

19.14

11.05

66.60

0.440

Iron (as Fe) (mg/L)

0.01

0.00

0.01

0.732

Manganese (as Mn) (mg/L)

0.03

0.04

0.03

0.02

0.808

to the emitted air pollutants (landfill gas containing methane, carbon dioxide, hydrogen sulfide and other contaminants including volatile organic compounds [VOCs], PM and bioaerosols) or to contaminated soil and water.17 Exposure may occur through dispersion in the ground and in contaminated air, and through percolation and seepage of leachates. Leaching occurs not only in landfill sites that are functional, but also after they have been deactivated, as the organic substances continue to decompose.18 The Solid Waste Management Rules, 2016 now stipulate that the landfill site shall be 100 m away from river, 200 m from a pond, 200 m from Highways, Habitations, Public Parks and water supply wells and 20 km away from Airports or Airbase. A study from Italy, which examined the potential health effects of living near (within 5 km) nine landfills, found respiratory symptoms among residents, both

in adults and in children, living close to waste sites. Exposure to hydrogen sulfide, a tracer of air-borne contamination from landfills, was positively associated with lung cancer mortality as well as with mortality and morbidity from respiratory diseases including hospitalizations, especially acute respiratory infections among children (0-14 years).17 Our study too found reduced PEFR in residents living within 2 km of landfill sites compared to those residing beyond 7 km of landfill sites; 315 L/min vs. 398 L/min, respectively. Occurrence of respiratory symptoms in workers engaged in waste collection and sorting has been linked to inhalation exposure to endotoxin and microorganisms during work, which increases the risk of respiratory problems including other health-related complaints.19 CONCLUSION A large number of data is required to perform an observational study. With this in mind, we conducted

IJCP Sutra 26: High blood pressure, blood sugar and blood cholesterol can remain silent for up to a decade.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Table 11. Comparison of Water Quality Between Non-landfill Areas and Okhla (Lal Kuan Village) Parameters

Non-landfill areas

Okhla (Lal Kuan village)

Mean

SEM

Mean

P value

Alkalinity (as CaCO3) (mg/L)

302.07

60.18

34.75

591.00

0.053

Acidity (as CaCO3) (mg/L)

36.40

29.53

17.05

136.50

0.099

Chloride (as Cl) (mg/L)

66.20

30.34

17.52

6452.00

0.000

Conductivity (ÂľS/cm)

1016.67

251.66

145.30

4200.00

0.008

Total hardness (as CaCO3) (mg/L)

278.40

82.02

47.36

768.00

0.035

Bicarbonate alkalinity (as CaCO3) (mg/L)

302.07

60.18

34.75

591.00

0.053

7.85

0.32

0.19

7.33

0.299

Total solids (mg/L)

664.00

180.13

104.00

2730.00

0.010

Total suspended solids (mg/L)

15.67

3.21

1.86

12.00

0.427

Total dissolved solids (mg/L)

648.33

179.78

103.80

2718.00

0.010

Total volatile solids (mg/L)

67.67

14.57

8.41

191.00

0.018

Total Kjeldahl nitrogen (as N) (mg/L)

2.49

1.57

1.11

4.14

0.548

Nitrate (as N) (mg/L)

1.40

0.28

0.20

2.27

0.241

Calcium (as Ca) (mg/L)

52.53

17.33

10.01

153.80

0.037

Magnesium (as Mg) (mg/L)

35.77

9.39

5.42

95.30

0.032

Potassium (as K) (mg/L)

1.40

0.78

0.45

2.83

0.254

Sodium (as Na) (mg/L)

87.73

19.14

11.05

383.00

0.006

Iron (as Fe) (mg/L)

0.01

0.00

0.01

0.448

Manganese (as Mn) (mg/L)

0.03

0.04

0.03

0.01

0.677

an observational study at six locations in Delhi-NCR; three in the vicinity of the landfill sites and three away from the landfills. Our study is more focused on observing the changes in health parameters in different population and does not attempt to identify a cause and effect association. Systolic and diastolic BP were found to be significantly higher in the study group, while height, weight, BMI, PEFR, SpO2 before and after 6MWT were lower in the study group compared to the control group. Water samples tested from the landfill sites also showed increased total dissolved solids, hardness and bicarbonate levels indicating ground water contamination. These findings re-emphasize the urgent need to manage solid waste in Delhi-NCR. All stakeholders including concerned authorities and environmental agencies should join hands to formulate and implement policies

that uphold modern and sustainable practices for solid waste management. There are some methodological limitations of our study. We did not check for VOCs, benzene, SO2 and NO2. Also, we have not identified the possible route of exposure among the study population. We cannot rule out the effect of bias and confounding factors on these observations. This is preliminary data indicative of the risks, which people residing in the vicinity of landfill sites are exposed to. Nevertheless, our observations are significant enough to consider a trial in a larger sample size as the culprit environmental factor needs to be investigated further. An extended study is being undertaken. Conflict of Interest: None.

Acknowledgment We are grateful to Urja for their help in organizing camps to collect data for the study.

IJCP Sutra 27: A pulse rate of less than 60 or more than 100 is abnormal.

community health Environmental Engineering Organization (CPHEEO), October 2013.

REFERENCES 1. WHO News Release. May 2, 2018. Available at: http:// www.who.int/news-room/detail/02-05-2018-9-out-of10-people-worldwide-breathe-polluted-air-but-morecountries-are-taking-action 2. World Health Organization. Ambient air pollution: Pollutants. Available at: http://www.who.int/airpollution/ ambient/pollutants/en/ 3. Landrigan PJ, Fuller R, Acosta NJR, Adeyi O, Arnold R, Basu N, et al. The Lancet Commission on pollution and health. Lancet. 2018;391(10119):462-512. 4. Neidell M (2017): Air pollution and worker productivity. IZA World of Labor, ISSN 2054-9571, Institute for the Study of Labor (IZA), Bonn, Iss. 363, http://dx.doi.org/10.15185/ izawol.363. 5. O'Neill MS, Ramirez-Aguilar M, Meneses-Gonzalez F, Hernández-Avila M, Geyh AS, Sienra-Monge JJ, et al. Ozone exposure among Mexico City outdoor workers. J Air Waste Manag Assoc. 2003;53(3):339-46. 6. Xing YF, Xu YH, Shi MH, Lian YX. The impact of PM2.5 on the human respiratory system. J Thorac Dis. 2016;8(1):E69-74. 7. Song P, Wanga L, Hui Y, Li R. PM2.5 concentrations indoors and outdoors in heavy air pollution days in winter. Procedia Engineering. 2015;121:1902-6. 8. Ali AOG. Solid waste pollution and the importance of environmental planning in managing and preserving the public environment in Benghazi city and its surrounding areas. Int Scholar Sci Res Innovat. 2013;7(12):924-9. 9. Chadar SN, Chadar K. Solid waste pollution: a hazard to environment. Recent Adv Petrochem Sci. 2017;2(3):555586. 10. Ministry of Urban Development Government of India, Advisory on improving municipal solid waste management services. Central Public Health and

11. Joshi R, Ahmed S. Status and challenges of municipal solid waste management in India: A review. Cogent Environ Sci. 2016;2:1139434. 12. Aderemi AO, Falade TC. Environmental and health concerns associated with the open dumping of municipal solid waste: A Lagos, Nigeria experience. Am J Environ Eng. 2012;2(6):160-5. 13. Delaimy WK, Larsen CW, Pezzoli K. Differences in health symptoms among residents living near illegal dump sites in Los Laureles Canyon, Tijuana, Mexico: a cross sectional survey. Int J Environ Res Public Health. 2014;11(9):953252. 14. Criteria for hazardous waste landfills. Central Pollution Control Board, Ministry of Environment & Forests, February 2001. 15. Narayana T. Municipal solid waste management in India: From waste disposal to recovery of resources? Waste Manag. 2009;29(3):1163-6. 16. Waste management. Delhi Govt. Available at: http://www. delhi.gov.in/wps/wcm/connect/environment/Environment/ Home/ Environmental+Issues/Waste+ Management 17. Mataloni F, Badaloni C, Golini MN, Bolignano A, Bucci S, Sozzi R, et al. Morbidity and mortality of people who live close to municipal waste landfills: a multisite cohort study. Int J Epidemiol. 2016;45(3):806-15. 18. Gouveia N, Prado RR. Health risks in areas close to urban solid waste landfill sites. Rev Saude Publica. 2010;44(5):859-66. 19. Park DU, Ryu SH, Kim SB, Yoon CS. An assessment of dust, endotoxin, and microorganism exposure during waste collection and sorting. J Air Waste Manag Assoc. 2011;61(4):461-8.

■■■■

Snoring Formula of 5/10/15 ÂÂ

Men with more than 5 attacks of apnea or hypopnea per hour during sleep are 5 times more prone to automobile accident.

ÂÂ

Patients with more than 10 attacks of apnea or hypopnea per hour during sleep need continuous positive airway pressure (CPAP) treatment.

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Man and woman with more than 15 attacks of apnea or hypopnea per hour during sleep are 7 times are more likely to have an accident.

IJCP Sutra 28: Weight loss of 10 kg can reduce upper blood pressure by 5-20 mmHg.

Community Medicine

Medication Reconciliation KASTHURI P*, N CHIDAMBARANATHAN†, LATHA VENKATESAN‡

Abstract The Institute of Medicine (IOM) stated that preventable medication errors are the most common type of errors in healthcare. It is of fundamental significance when building a safer care continuum, as it highlights the reason for continuous and more vigilant medication reconciliation and required effort at all interfaces of care, including community. Without a robust medication reconciliation process, the potential for catastrophic outcomes remains a constant concern. Prevention of medication errors is essential through strategies that are based in evidence of medication reconciliation strategies on medication errors in community.

Keywords: Medication errors, healthcare delivery system, medication reconciliation, adverse drug reaction, quality improvement

edication safety is a significant issue in hospitals and throughout healthcare. Great improvements are needed, and hospitals are engaged in many efforts to reduce errors and increase this aspect of patient safety. Nurses are the most involved at the medication administration phase, although they provide a vital function in detecting and preventing errors in the prescribing, transcribing and dispensing stages too. Administration errors constitute a significant proportion of all errors, yet, there isn’t much known about the causes or about the effectiveness of proposed solutions.

Medication Errors

Research addressing the complex process of medication use in hospitals is the need of the hour and requires a new approach to produce valid knowledge from studies done in the field with few controls of confounding factors. There is a large and growing body of research addressing medication safety in healthcare.

Some of the factors associated with medication errors include the following:

*PhD Research Scholar Apollo College of Nursing, Chennai, Tamil Nadu †Head Dept. of Radiology and Imaging Sciences, Radio Diagnosis Apollo Hospitals, Chennai, Tamil Nadu ‡Principal Apollo College of Nursing, Chennai, Tamil Nadu Address for correspondence Kasthuri P PhD Research Scholar Apollo College of Nursing, The Tamil Nadu Dr MGR Medical University, Chennai, Tamil Nadu E-mail: kasthurisenthil77@gmail.com

Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the healthcare professional, patient or consumer is termed a medication error. These events may be associated with professional practice, healthcare products, procedures and systems, including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring and use.

ÂÂ

Medications packaging

with

similar

names

similar

ÂÂ

Medications that are not commonly used or prescribed

ÂÂ

Commonly used medications to which many patients are allergic (e.g., antibiotics, opiates and nonsteroidal anti-inflammatory drugs).

Error-Prone Processes There are five stages of the medication process: (a) ordering/prescribing, (b) transcribing and verifying, (c) dispensing and delivering, (d) administering and (e) monitoring and reporting. Monitoring and reporting is a newly identified stage about which there is little research. Some of the most noted hospitalized patients suffer preventable injury or even death as a result of adverse drug events (ADEs) associated with

IJCP Sutra 29: Restricting salt intake to less than 6 g/day can reduce upper blood pressure by 2.8 mmHg.

Community Medicine errors made during the prescribing, dispensing and administering of medications to patients. Nurses are primarily involved in the administration of medications across settings. Nurses can also be involved in both the dispensing and preparation of medications (similar to pharmacists), such as crushing pills and drawing up a measured amount for injections. Preliminary research on medication administration errors (MAEs) reported an error rate of 60%. Medication errors have been reported mainly in the form of wrong time, wrong rate or wrong dose. In other studies, approximately one out of every three ADEs were attributable to nurses administering medications to patients. Medication Error-Prevention Strategies Medication errors are common in hospital settings. To limit and mitigate these errors, it is necessary to have a thorough knowledge of the medicationuse process in the emergency department and develop strategies targeted at each individual step. Some of these strategies include medication-error analysis, computerized provider-order entry systems, automated dispensing cabinets, barcoding systems, medication reconciliation, standardizing medicationuse processes, education and emergency-medicine clinical pharmacists. Nurses’ Education and Training Lack of medication knowledge is a constant problem, and there is a need to continually gain more knowledge about current and new medications. Nurses with more education and experience may have greater knowledge of medications.

Educational Strategies Aimed to Improve Medication Safety and Avert Unnecessary Medication Errors Educational and training programs on drug therapy are required for medical/paramedical students, drug prescribers (doctors) and nurses (administering drugs) to reduce drug errors and to improve patient safety. A systematic approach is urgently needed to decrease organizational susceptibility to error, through providing required resources to monitor, analyze cause of errors and implement preventive strategies to reduce them. A proper functioning national standardized system for medication errors detection and reporting using a unified terminology all over the country is necessary to allow for better knowledge sharing and practice change.

Medication Reconciliation Medication reconciliation is a process that matches a patient’s current hospital medication regimen against a patient’s long-term medication regimen. Or Medication reconciliation is the process of comparing an individual’s medication orders to all of the medications that the individual has been taking. It is a process that is an integral part of safety for older adults living in their homes in community settings. Medication reconciliation is flexible enough to enhance hospital specific workflows and keep current on new information (Medication Reconciliation) relating to prescription medications and their reactions while supporting and exceeding the Patient Safety Goals, i.e., From admission, transfer and discharge to post visit patient care, including community. Medication reconciliation simplifies the process of reconciling a patient’s medication therapy across the continuum of care. Healthcare system (HCS) works with hundreds of hospitals across the nation to simplify and streamline medication reconciliation. While every hospital has a goal of improving patient safety and saving time, every hospital is unique with its policies, protocols and guidelines. Solutions of Medication Reconciliation ÂÂ

Obtain a patient’s prior medication history including medication fill and refill information and previous visit information.

ÂÂ

Analyze prior medication history.

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Provide medication transfer and discharge reports electronically or through printed media.

ÂÂ

Provide discharge prescriptions including patient medication education.

ÂÂ

Communicate and link directly to existing hospital clinical information systems.

ÂÂ

Identify high risk patients for medication nonadherence and obtain fill/refill information for clinicians use in follow-up visit.

HCS medication reconciliation has been proven to save time and increase accuracy during medication reconciliation: ÂÂ

2.4 more critical medications identified during admission

ÂÂ

50% increase in computerized physician order entry

ÂÂ

51-minute reduction in time to reconcile

ÂÂ

23% increase in ordered critical medications.

IJCP Sutra 30: A 1% increase in cholesterol increases chances of heart attack by 2%.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Components of medication reconciliation include: ÂÂ

Medication procurement

ÂÂ

Medication knowledge.

Medication procurement ÂÂ

How and where the patient obtains and refills prescriptions?

ÂÂ

How the patient pays for the medications?

ÂÂ

Whether or not medication doses are ever missed due to lack of funds?

Current Medication Proforma (For Medication Reconciliation) Current Dose medications

Route

Steps for self-medication management ÂÂ

Assessing the patient’s knowledge of dose and frequency of medications

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Special instructions related to medications

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Medication mode of action

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Side effects to monitor and report

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Monitoring with each change in medication regimen. Provide educational materials including medication instructions written in large letters and in bullet or list format, use of medication schedules and tailored instructions on how medications should be taken.

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Patients also need to understand the importance of communicating any changes in their medications to their healthcare providers.

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Patients should be encouraged to bring the medication list with them to physician visits to encourage medication reconciliation, and the list should be updated when medications are added or discontinued.

ÂÂ

Pharmacists can help empower patients by teaching them what it means to be an alert consumer and involved in their healthcare.

Medication reconciliation is centred on the safety principle of independent redundancy. Independent redundancy is a process whereby more than one care provider checks to make sure procedural steps are completed correctly. The specific issues most in need of research (QI-Quality Improvement activities) are as follows: ÂÂ

Barcoding and other medication safety technology—widely recommended, but little or no valid research using before-and-after designs.

Yes/No

ÂÂ

Independent RN double-checks—logical and widely recommended, but no research has been done describing, let alone testing, the effects of this policy.

ÂÂ

Relationship between nurse staffing and medication errors—a few descriptive studies and studies asking RN perceptions of the problem suggest that staffing and workload are major factors, but there are no research studies using valid and reliable data.

ÂÂ

Techniques to reduce distractions, interruptions, other risk factors for medication error need to be tested.

ÂÂ

Methods of effective education in medication safety for nurses and all care providers.

ÂÂ

Effectiveness of implementing new checklists, policies and procedures.

ÂÂ

Understanding work-arounds.

ÂÂ

Methods and techniques for successful implementation of system and process change.

Medication Knowledge ÂÂ

FreTo be Patient/ quency continued Family during teaching hospital stay

Conclusion Medication safety for patients is dependent upon systems, process and human factors, which can vary significantly across healthcare settings. Hence, corrective actions should target priority areas and root causes to prevent recurrence. There is a need of qualityimprovement programs that focus on educating the staff about medication errors and the importance of reporting. Suggested reading 1. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

IJCP Sutra 31: A 1% increase in good HDL cholesterol decreases chances of heart attack by 3%.

Community Medicine 2. Hughes RG (Ed.). Patient Safety and Quality: An EvidenceBased Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. 3. National Coordinating Council for Medication Error Reporting and Prevention. What is a medication error? Available at: www.nccmerp.org/aboutMedErrors.html. Accessed October 1, 2007. 4. Available at: www.jointcommission.org/NR/rdonlyres/ C92AAB3F-A9BD-431C-8628-1DD2D1D53CC/0/lasa.pdf. 5. Institute of Medicine. Preventing medication errors. Washington, DC: National Academy Press; 2007. 6. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29-34. 7. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43. 8. Pepper GA. Errors in drug administration by nurses. Am J Health Syst Pharm. 1995;52(4):390-5.

11. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995; 10(4):199-205. 12. Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med. 2014;6:45-55. 13. O’Shea E. Factors contributing to medication errors: a literature review. J Clin Nurs. 1999;8(5):496-504. 14. Armitage G, Knapman H. Adverse events in drug administration: a literature review. J Nurs Manag. 2003;11(2):130-40. 15. Joint Commission National patient safety goals. 2014. Available at: http://www.jointcommission.org/standards_ information/npsgs.aspx. Accessed February 17, 2014. 16. Pronovost P, Weast B, Schwarz M, Wyskiel RM, Prow D, Milanovich SN, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care. 2003;18(4):201-5. 17. Joint Commission on Accreditation of Healthcare Organizations, USA. Using medication reconciliation to prevent errors. Sentinel Event Alert. 2006;(35):1-4.

9. Kaushal R, Bates D. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs). In: Shojania K, Duncan B, McDonald K, et al. (Eds.). Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001. pp. 59-69.

18. Sourdet S, Rougé-Bugat ME, Vellas B, Forette F. Frailty and aging. J Nutr Health Aging. 2012;16(4):283-4.

10. Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensivecare units. Lancet. 1989;2(8659):374-6.

19. Elden NM, Ismail A. The importance of medication errors reporting in improving the quality of clinical care services. Glob J Health Sci. 2016;8(8):243-51.

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IJCP Sutra 32: Any chest pain, which lasts for less than 30 minutes duration is not a heart pain.

Community Medicine

Challenges Facing Medical Education AMIT AGRAWAL

edical education not only helps to provide health services direct to the patients, but also helps in training and assessing future doctors, leading research and developing new treatments strategies. Worldwide, an estimated 1.3 billion people lack access to effective and affordable healthcare, while annually an additional 150 million persons in 44 million households face financial catastrophe as a direct result of having to pay for healthcare. More than 100 million individuals are pushed into poverty by the need to pay for health services.1 Approximately 27,000 doctors graduate each year in our country, but most want to work in major cities and millions of patients must walk miles to see a physician.2

Total costs attributable to any medical education program are composed of hospital costs (physician visits, outpatient care, inpatient/emergency care and diagnostic tests) and indirect costs (cost of running the medical college, including the training of the graduates and postgraduates). With the advancement in both treatment and teaching facilities, it is anticipated that the costs will continue to escalate for healthcare institutions involved in providing medical education, both in government and private sector. In a study by British Medical Association, it was not possible to speculate which universities and courses opted for top up fees in England, but it seemed fairly clear that medical degrees were very costly indeed.3 With all these factors, the outcomes can be one of low cost/low quality or high cost/high quality education; both not a viable option.

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

There are many other difficult questions particularly in the mind of the younger generation who opt for training in medical education where they may feel that they have invested a huge amount of time and efforts. All of us know that in spite of a huge investment of time in medical science, it may take many years to get personal, professional and financial achievements. To find an answer to this, we need to find out the expectations at entry level rather than at the completion of the education to avoid the frustration. It also becomes more relevant where every completed level of medical education is followed by more and more expectations and advanced set up to work that may make the people more reluctant to work in remote and rural areas, where the facilities may be nonexisting. Despite the visibility of education-financial relationships, data on the extent and predictors of such relationships are sparse, and there are no systematic data on education-financial relationships in medical field and it is difficult to find out the exact incidence and magnitude with huge disparities in the cost of medical education provided by the government funded institutions versus private funded institutions. The major issue is whether with high cost/high quality medical education would we be able to convince the people to provide low cost/high quality healthcare in rural and remote areas of the country? There is a need for a systematic review to investigate these issues further and their impact on education, healthcare and on the health professionals. References 1. Xu K, Evans D, Carrin G, Aguilar-Rivera AM. Designing Health Financing Systems to Reduce Catastrophic Health Expenditure. Technical Briefs for Policy-Makers. WHO/ EIP/HSF/ PB/05.02. Geneva: WHO; 2005. 2. Bagchi S. Growth generates health care challenges in booming India. CMAJ. 2008;178(8):981-3. 3. Kennedy B. Impact of England’s university fees on medical education in Scotland, Scottish Parliamentary briefing. January 2004 BMA. Available at: http:// www.bma.org.uk/ap.nsf/Content/impactengland universityfeesonscotland. Accessed on 10th July, 2008.

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IJCP Sutra 33: Keep air pollution (particulate matter PM2.5 and PM10 levels) below 80 µg per cubic meter.

ENT

Perspectives in the Management of Vertigo and Dizziness: A Review Shrinivas Chavan

Abstract Dizziness is a term which includes a wide range of medical disorders, which makes a stepwise approach towards its differential diagnosis as well as management very important. The condition is not only seen frequently in the general population, but also in a wide range of pathologies. This makes its accurate diagnosis a challenge for the physician. The different treatment approaches include drugs, physical therapy and psychotherapeutic measures based on the diagnosis. A review was conducted to study the prevalence of vertigo and dizziness, its impact on the quality-of-life of the patients, the challenges faced by a primary physician and the current management strategies for vertigo and dizziness.

Keywords: Dizziness, vertigo, management, diagnosis

izziness is a common and challenging condition seen in the primary care setting. Estimates show that more than one-third of Americans see a healthcare provider for dizziness during their lifetime. Dizziness is a vague term which may incorporate a wide array of medical disorders, hence, a stepwise approach to differentially diagnose the cause becomes important.1

The etiology of vertigo and dizziness is often multifactorial. The most common causes of vertigo and dizziness are cited to be peripheral and central vestibular diseases; however, they can also be provoked by cardiovascular diseases, polyneuropathy, medication or they can have a psychosomatic origin.2 There are four common types of dizziness: (1) Presyncope, (2) disequilibrium, (3) psychogenic dizziness and (4) vertigo. While assessing the patient, the doctor should specifically ask the patient to explain their symptoms. Vertigo is a false sense of motion of either the environment or self. Patients describe vertigo as either ‘the room is spinning’ or ‘tilting’. There are four common causes of vertigo in ambulatory settings, including benign paroxysmal peripheral vertigo (BPPV), vestibular neuritis, vestibular migraine and Meniere’s disease.1

Professor and Head Dept. of ENT Grant Government Medical College and Sir JJ Hospital, Mumbai, Maharashtra E-mail: shrinivasc77@hotmail.com

The present article discusses the prevalence of vertigo and dizziness, challenges faced in their diagnosis and treatment, and the therapy available for the management. Methodology PubMed, Cochrane database and Google Scholar were the databases used for the literature search. The search strategy included a combination of ‘key word search’ and ‘backward chronological search’. The search terms included dizziness, vertigo, epidemiology, prevalence, incidence, treatment, management, diagnosis, guidelines. Boolean operators were used for the search. Forty original research articles, systematic reviews and meta-analyses were included for the development of this review (Table 1). Prevalence of vertigo and dizziness Vertigo and dizziness as symptoms are seen in a wide range of pathologies and occur frequently in the population. One of the challenges associated with them is the difficulty in making an accurate diagnosis.3 It has been reported in a study that the prevalence of dizziness in the world population is 5-10% and the prevalence rate in individuals older than 65 years is 65%.4 It has been reported in large populationbased studies that annually, dizziness (including vertigo) affects about 15% to over 20% of adults. Vestibular vertigo accounts for about a quarter of dizziness complaints and has a 12-month prevalence of 5% and an annual incidence of 1.4%. Its prevalence

ENT Table 1. Literature Search Strategy Databases

Search terms

Result

PubMed, Cochrane, Google Scholar

Dizziness, vertigo, epidemiology, 40 Original research articles + Published literature corresponding prevalence, incidence, treatment, systematic reviews + meta-analyses only to human subjects and in management, diagnosis, guidelines English language were selected

rises with age and is about 2-3 times higher in women than in men.5 Global data has shown that about 1 out of 3 elderly people suffers from dizziness.5 The 1-year prevalence of dizziness was reported to be 18.2% in a community of elderly population.6 Vertigo and dizziness occur with considerable frequency in childhood and adolescence. Most causes are benign and can be treated.7 There is a dearth of prevalence data from India. A study conducted in rural population in India reported an overall prevalence of 0.71%.8 The most commonly reported vertigo was psychogenic form in this population. However, another study conducted across many centers in India reported that BPPV accounted for a considerable percentage of the overall burden of vertigo. It was reported in this study that peripheral causes were predominant in majority (74%), with BPPV being the most frequent (68%). Other causes, like migraine, were second in occurrence which was mainly associated with lifestyle issues.9 Another study conducted in a teaching tertiary care hospital in Central India reported the magnitude of vertigo in geriatric patients attending outpatient clinic to be 3%, inflicting a considerable healthcare burden. In this study, it was found that BPPV was prevalent in 22% of the study population, while 78% constituted the non-BPPV group.10 Impact on the Quality-of-life With vertigo becoming a growing public health problem, patients with vertigo often experience intense emotional distress, with symptoms of anxiety, fear and depression. Moreover, patients with new onset of vertigo, imbalance, nausea and vomiting pose significant challenge. The various physical, emotional and functional disturbances associated with vertigo may impact the professional, social and overall day-to-day activities of these patients. Available evidence suggests that the impact of vertigo on the health-related qualityof-life (QoL) may be significantly underestimated.11-13 Several studies have been conducted showing the impact of vertigo on overall QoL,14-17 emphasizing on the fear of new vertigo attacks, increase in distress and

Comments

phobias because of labyrinthopathies.17-19 There are a limited number of studies assessing the QoL of Indian patients with vertigo. A recent study has suggested that 50% of patients with vertigo present with the symptoms such as nausea and vomiting, which are known to have significantly negative impact on overall QoL.9 The patients presenting with vertigo often experience falls and suffer from postural instability, disturbances and risk of falling. Patients suffering with central syndromes are at risk of recurrent and injurious falls.20,21 In this regard, it is important to adopt an individualized approach for the management of vertigo. Challenges in the management of dizziness and vertigo in the primary care physician’s clinic Dizziness and vertigo are some of the most common reasons for seeking medical help but are often inaccurately diagnosed. The management of acute dizziness and vertigo require interdisciplinary cooperation.22 Various balance disorders which present with symptoms of dizziness and vertigo are due to various diseases. The appropriate clinical approach provides an opportunity to timely identify emergency situations and most common causes.23 The choice of therapy (liberatory maneuvers of misplaced otoliths, physiotherapy, prescription of medications, adjustment of medication regimes or cognitive behavioral therapy) is dependent on an accurate diagnosis of the underlying cause of the symptoms.24 Despite the fact that once accurately diagnosed, the treatment follows a simple straightforward path, a cloud of uncertainty still hovers over the management of vertigo in primary physician’s care.24,25 Evidences suggest that there are almost 86% of cases which could have been correctly diagnosed by the primary and secondary care physicians who otherwise received a diagnosis of ‘unspecific dizziness’ and hence incorrect treatment.2 The responsibility of deciding on the diagnostic approach for the patient lies with the primary care physician who will decide on initiating

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

diagnostic procedures and treatment or to refer the patient to the appropriate specialist.26 If the assessment at the primary care physician level is not correct, the patient may have to bear the brunt of redundant or unnecessary procedures and medication intake.2 Evidence suggests that there is an unmet need with respect to the diagnostic and therapeutic requirements of patients with vestibular disease.24 This leads to chronification and the development of secondary, functional symptoms.27 Data shows that almost 45% vertigo and dizziness patient’s first contact with healthcare is with the primary care physician and hence the expertise of a primary care physician is of utmost importance.28 Management approach in the treatment of vertigo and dizziness It is clear now that the difficulty associated with the treatment of vertigo is due to the fact that it is not a definite disease but a symptom. It usually occurs due to a disturbance in the vestibular system. There are various modes of treatment of the vestibular diseases, dependent on the etiology. These include drugs, physical therapy, psychotherapeutic measures and rarely, surgery. Physical therapy has also emerged as an effective modality in the management of balance disorders.29 The specific regimen of drug therapy can be tailored for the treatment of vertigo based on the four broad causes of vertigo. Otological vertigo includes disorders of the inner ear including Meniere’s disease, vestibular neuritis, BPPV and bilateral vestibular paresis. In both Meniere’s disease and vestibular neuritis, vestibular suppressants such as anticholinergics and benzodiazepines are used. In Meniere’s disease, salt restriction and diuretics are recommended to prevent flare-ups. In vestibular neuritis, only brief use of vestibular suppressants is now recommended. In the case of BPPV and bilateral vestibular paresis, drug treatment is not recommended. However, physical therapy can be very useful in both these conditions.30 In cases of central vertigo, such as vertigo associated with migraine, prophylactic agents (calcium channel antagonists, tricyclic antidepressants, b-blockers) are the mainstay of treatment. In individuals with stroke or other structural lesions of the brainstem or cerebellum, an eclectic approach incorporating trials of vestibular suppressants and physical therapy is recommended. Undetermined and ill-defined causes of vertigo make up a large proportion of diagnoses and an empirical approach to these patients, incorporating trials of medications of general utility, such as benzodiazepines,

as well as trials of medication withdrawal when appropriate, physical therapy and psychiatric consultation, is recommended.30 Pharmacotherapy plays a crucial role in the management of vertigo. There is no ideal drug for the treatment of vertigo, and most of the existing drugs have essentially been found during clinical use rather than developed specifically for the treatment of vertigo.31 Pharmacotherapy in the management of vertigo and dizziness Till date, the information available on the drug treatment of vertigo is scarce owing to the absence of multicentric, well-controlled clinical studies to show the advantage of treatment over no treatment.32 Medications are most useful in treating acute vertigo, which lasts a few hours to several days. However, vertigo lasting more than a few days is suggestive of a permanent vestibular injury and medications should be stopped in this case to allow the brain to adapt to a new vestibular input.31 The various drugs used in the pharmacotherapy of vertigo and dizziness may either modify the intensity of symptoms (e.g., vestibular suppressants) or they may affect the underlying disease process (e.g., calcium channel antagonists in the case of vestibular migraine). Most of these agents, especially those that are sedating, also have a potential to modulate the rate of compensation for vestibular damage.

Vestibular Suppressants Vestibular suppressants are the mainstay of treatment in patients suffering from vertigo today. They work by reducing the asymmetry in the vestibular tone between the ears and hence reducing the vertigo.33 The drugs included in this category comprise of anticholinergics, antihistaminics, antidopaminergic drugs and benzodiazepines. Acute vertigo is usually managed with vestibular suppressants and antiemetic medications. It is recommended that vestibular suppressants should be used for a few days at most because they delay the brain’s natural compensatory mechanism for peripheral vertigo.31 It has been seen that among the various vestibular suppressants, cinnarizine and prochlorperazine are the most frequently prescribed drugs by the general physician. However, the expert opinion suggests that precaution should be exercised while prescribing prochlorperazine in patients at extremes of age.20 A study was conducted to comparatively assess prochlorperazine versus cinnarizine in cases of vertigo.

ENT An equal number of cases, selected randomly, underwent treatment with prochlorperazine ± head balance exercises and cinnarizine ± head balance exercises. At the end of 5 weeks treatment, it was seen that there was 100% subjective improvement with prochlorperazine as compared to 97.14% in cinnarizine group. Fewer side effects were seen in the case of prochlorperazine with drowsiness being the most common side effect, and was statistically more significant with cinnarizine group. The response to the treatment was significantly more in cases with vertigo of peripheral origin as compared with vertigo of central origin.34 Anticholinergics These act on muscarinic receptors and increase motion tolerance. Only centrally acting anticholinergics are useful in treating vertigo. The most effective agent in this category to prevent vertigo is scopolamine.35 These are associated with prominent side effects such as dry mouth, dilated pupils, sedation, decreased alertness and impaired attention. If scopolamine transdermal patch is used for a long duration, it may lead to chemical addiction.36 Antihistamines The most commonly prescribed drugs for vertigo include H1 blockers which include diphenhydramine, cyclizine, dimenhydrinate, meclizine and promethazine.37,38 This is the only class of drug which has been cited to possess antivertigo properties.39 They have lesser side effects as compared to anticholinergics. Histaminergic medications This class of drugs is represented by betahistine whose antivertigo effects are attributable to vasodilatory effect, improving blood flow in the microcirculation of the internal auditory and vestibular systems. There is low quality evidence to suggest that in patients suffering from different causes there may be a positive effect of betahistine in terms of reduction of vertigo symptoms.40 A double-blind crossover trial was conducted to compare the therapeutic effects of prochlorperazine and betahistine on patients with confirmed Meniere’s disease (range of duration 1-11 years). In spite of the superior therapeutic efficacy of betahistine, it was observed in the study that the number of vertigo attacks were reduced to an equal value by both the drugs. In addition, side effects were not seen with both betahistine and prochlorperazine.41 Dopaminergic antagonists These drugs are commonly used to control nausea in vertiginous patients.42 Dopaminergic antagonists

such as prochlorperazine and chlorperazine act at the chemoreceptor trigger zone, reducing the neural impulses to the vomiting center.31 Various antipsychotics namely phenothiazine derivatives and butyrophenones are popularly used in this condition. They reduce the neurovegetative symptoms that commonly parallel vertigo and may improve the psychoaffective symptoms accompanying vertigo. The specific dopaminergic vestibular effects along with anticholinergic and antihistaminic (H1) properties of these drugs lead to their vestibular suppressant activity.42 Prochlorperazine improves vestibular as well as associated vegetative symptoms of vertigo. In addition to its anticholinergic and antidopaminergic activity, prochlorperazine acts on serotonergic neurotransmitter system and hence could be the reason for being the drug of choice for short-term symptomatic management of vertigo associated with anxiety as a psychiatric comorbidity. Further, prochlorperazine is less sedative than cinnarizine and cinnarizine combinations and other fixed-dose combinations of vestibular suppressants. It has also been recommended that if prochlorperazine is prescribed for short-term (up to 7 days), symptomatic management of vertigo, there are no concerns regarding the extrapyramidal symptoms.20 Benzodiazepines These cause vestibular suppression through the gamma-aminobutyric acid (GABA)ergic system. Benzodiazepines enhance the role of GABA in the central nervous system and hence are effective in relieving vertigo and associated anxiety and panic disorders. The commonly prescribed benzodiazepines are diazepam, lorazepam, clonazepam, alprazolam and cause muscle relaxation, anterograde amnesia and muscle relaxation.42 Calcium antagonists Drugs such as cinnarizine and flunarizine have been used as antivertigo drugs and prevent motion sickness and are used as vestibular depressants. These drugs also possess anticholinergic, antihistaminergic and antidopaminergic action.42 Sympathomimetics These drugs are used to enhance vigilance and counterbalance the sedative effects of other antivertigo drugs such as antihistaminics. These drugs are rare in use because they have addictive potential.42

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Table 2. Medications Commonly used in the Treatment of Acute Vertigo and Associated Nausea and Emesis (Treatment of Vertigo) Medication

Class

Dosage

Sedation

Antiemesis

Meclizine

Antihistamine

12.5-50 mg oral every 4-8 hours

Moderate

Mild

Dimenhydrinate

Antihistamine

25-100 mg orally, IM or IV every 4-8 hours

Mild

Moderate

Diazepam

Benzodiazepine

2-10 mg orally or IV every 4-8 hours

Moderate

Mild

Lorazepam

Benzodiazepine

0.5-2 mg orally, IM or IV every 4-8 hours

Moderate

Mild

Metoclopramide

Dopaminergic antagonist

5-10 mg orally or IM every 6 hours

Mild

Prominent

Prochlorperazine

Dopaminergic antagonist 5-10 mg orally or IM every 6-8 hours (phenothiazine) 25 mg rectally every 12 hours 5-10 mg by slow IV over 2 minutes

Mild

Prominent

Promethazine

Antihistamine

Prominent

Moderate

12.5-25 mg orally, IM, or rectally every 4-12 hours

IM = Intramuscular; IV = Intravenous. Source: Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician. 2005;71(6):1115-22.

A list of medications commonly used in treatment of acute vertigo and associated nausea and emesis is given in Table 2.43 Conclusion Vertigo is a type of dizziness, best described as the, ‘illusion of motion, usually rotational motion’. Associated symptoms include nausea, emesis and diaphoresis. Vertigo can have multiple causes, especially in older patients and hence a specific diagnosis can sometimes be elusive. Medications are most useful for treating acute vertigo that lasts a few hours to several days. However, they have limited benefits in patients with BPPV, because the vertiginous episodes usually last less than 1 minute, while vertigo lasting more than a few days is suggestive of permanent vestibular injury and warrants cessation of medications. It has been seen that there is a need for alternative approaches for the management of vertigo, emphasizing timing and triggers over type, as the investigating factor. Vestibular suppressants are found to be crucial in the management of acute phase vertigo. Given the heterogeneity of treatment effect, a link between patient presentation and the type of molecule is quintessential. Prochlorperazine acts on serotonergic neurotransmitter system and this could be the reason for it being the drug of choice for shortterm symptomatic management of dizziness or vertigo associated with anxiety and vomiting. Cinnarizine is more efficacious in peripheral vertigo, without nausea and vomiting. Vestibular rehabilitation therapy has also emerged as a highly effective modality for most of the disorders of the vestibular or central balance system.

References 1. Wipperman J. Dizziness and vertigo. Prim Care. 2014;41(1):115-31. 2. Geser R, Straumann D. Referral and final diagnoses of patients assessed in an academic vertigo center. Front Neurol. 2012;3:169. 3. Bécares Martínez C, Arroyo Domingo MM, López Llames A, Marco Algarra J, Morales Suárez-Varela MM. Vertigo and dizziness in hospital: Attendance, flow and characteristics of patients. Acta Otorrinolaringol Esp. 2017. pii: S0001-6519(17)30173-5. [Epub ahead of print] 4. Santana GG, Doná F, Ganança MM, Kasse CA. Vestibulopathy in the elderly. Collective Health. 2011;8(48):52-6. 5. Neuhauser HK. The epidemiology of dizziness and vertigo. Handb Clin Neurol. 2016;137:67-82. 6. Sloane P, Blazer D, George LK. Dizziness in a community elderly population. J Am Geriatr Soc. 1989;37(2):101-8. 7. Jahn K, Langhagen T, Heinen F. Vertigo and dizziness in children. Curr Opin Neurol. 2015;28(1):78-82. 8. Abrol R, Nehru VI, Venkatramana Y. Prevalence and etiology of vertigo in adult rural population. Indian J Otolaryngol Head Neck Surg. 2001;53(1):32-6. 9. Kameswaran M, Pujari S, Singh J, Basumatary LJ, Sarda K, Pore R. Clinicoetiological pattern and pharamcotherapy practices in patients with new onset vertigo: findings from a prospective multicentre registry in India. Int J Otorhinolaryngol Head Neck Surg. 2017;3(2):404-13. 10. Saxena A, Prabhakar MC. Performance of DHI score as a predictor of benign paroxysmal positional vertigo in geriatric patients with dizziness/vertigo: a cross-sectional study. PLoS One. 2013;8(3):e58106. 11. Ten Voorde M, van der Zaag-Loonen HJ, van Leeuwen RB. Dizziness impairs health-related quality of life. Qual Life Res. 2012;21(6):961-6.

ENT 12. Grauvogel J, Kaminsky J, Rosahl SK. The impact of tinnitus and vertigo on patient-perceived quality of life after cerebellopontine angle surgery. Neurosurgery. 2010;67(3):601-9; discussion 609-10. 13. Weidt S, Bruehl AB, Straumann D, Hegemann SC, Krautstrunk G, Rufer M. Health-related quality of life and emotional distress in patients with dizziness: a crosssectional approach to disentangle their relationship. BMC Health Serv Res. 2014;14:317.

symptom dizziness 2014;76(6):e32-8.

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Gesundheitswesen.

27. Dieterich M, Staab JP. Functional dizziness: from phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness. Curr Opin Neurol. 2017;30(1):107-13. 28. Grill E, Penger M, Kentala E. Health care utilization, prognosis and outcomes of vestibular disease in primary care settings: systematic review. J Neurol. 2016;263 Suppl 1:S36-44.

14. Handa PR, Kuhn AM, Cunha F, Schaffleln R, Ganança FF. Quality of life in patients with benign paroxysmal positional vertigo and/or Ménière’s disease. Braz J Otorhinolaryngol. 2005;71(6):776-82.

29. Biswas A, Barui B. Specific organ targeted vestibular physiotherapy: the pivot in the contemporary management of vertigo and imbalance. Indian J Otolaryngol Head Neck Surg. 2017;69(4):431-42.

15. Grimby A, Rosenhall U. Health-related quality of life and dizziness in old age. Gerontology. 1995;41(5):286-98.

30. Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs. 2003;17(2):85-100.

16. Hsu LC, Hu HH, Wong WJ, Wang SJ, Luk YO, Chern CM. Quality of life in elderly patients with dizziness: analysis of the Short-Form Health Survey in 197 patients. Acta Otolaryngol. 2005;125(1):55-9.

31. Trkanjec Z, Aleksic-Shibabi A, Demarin V. Pharmacotherapy of vertigo. Rad Za Medicinska Znanosti, Zagreb. 2007:69-76.

17. Santos EM, Gazzola JM, Ganança CF, Caovilla HH, GanançaFF. Impact of dizziness on the life quality of elderly with chronic vestibulopathy. Pro Fono. 2010;22(4):427-32. 18. Savastano M, Maron MB, Mangialaio M, Longhi P, Rizzardo R. Illness behaviour, personality traits, anxiety, and depression in patients with Menière’s disease. J Otolaryngol. 1996;25(5):329-33. 19. Kuhn AMB, Bocchi EA, Bulbarelli K, Casagrande MC. Vertigo and its psychological implications. In: Ganança MM, Vieira RM, Caovilla HH (Eds.). Principles of Otoneurology. São Paulo: Atheneu; 1998. pp. 101-5. 20. Prabhat D, Kulkarni GB, Kelkar P. Management approach to vertigo at primary care level in India: an expert opinion. Indian J Clin Pract. 2018;28(10):923-30. 21. Hanley K, O'Dowd T. Symptoms of vertigo in general practice: a prospective study of diagnosis. Br J Gen Pract. 2002;52(483):809-12. 22. Löhler J, Eßer D, Wollenberg B, Walther LE. Management of acute vertigo and dizziness: Patients in emergency departments in Germany. HNO. 2018 Mar 2. [Epub ahead of print] 23. Bouccara D, Rubin F, Bonfils P, Lisan Q. Management of vertigo and dizziness. Rev Med Interne. 2018. pii: S02488663(18)30040-7. [Epub ahead of print] 24. Grill E, Strupp M, Müller M, Jahn K. Health services utilization of patients with vertigo in primary care: a retrospective cohort study. J Neurol. 2014;261(8):1492-8. 25. Kruschinski C, Kersting M, Breull A, Kochen MM, Koschack J, Hummers-Pradier E. Frequency of dizzinessrelated diagnoses and prescriptions in a general practice database. Z Evid Fortbild Qual Gesundhwes. 2008;102(5):313-9. 26. Rieger A, Mansmann U, Maier W, Seitz L, Brandt T, Strupp M, et al. Management of patients with the cardinal

32. Ruckenstein MJ, Rutka JA, Hawke M. The treatment of Menière's disease: Torok revisited. Laryngoscope. 1991;101(2):211-8. 33. Daroff, R. Dizziness, vertigo. In: Fauci, AS, et al (Eds.). Principles of Internal Medicine. Vol. 298, New York: McGraw-Hill, n.d. 144. 34. Singh AK, Chaturvedi VN. Prochlorperazine versus cinnarizine in cases of vertigo. Indian J Otolaryngol Head Neck Surg. 1998;50(4):392-7. 35. Takeda N, Morita M, Hasegawa S, Kubo T, Matsunaga T. Neurochemical mechanisms of motion sickness. Am J Otolaryngol. 1989;10(5):351-9. 36. Luetje CM, Wooten J. Clinical manifestations of transdermal scopolamine addiction. Ear Nose Throat J. 1996;75(4):210-4. 37. Cohen B, DeJong JM. Meclizine and placebo in treating vertigo of vestibular origin. Relative efficacy in a doubleblind study. Arch Neurol. 1972;27(2):129-35. 38. Bickerman, H. Drugs for disturbances in equilibrium. In: Modell W (Ed.). Drugs of Choice 1978-79. St Louis (MO): CV Mosby Co; 1978. pp. 502-11. 39. Gilman, A, Rall T, Nies A, et al (Eds.). Goodman and Gilman's Pharmacological Basis of Therapeutics. New York: Pergamon Press; 1990. p. 585. 40. Murdin L, Hussain K, Schilder AG. Betahistine for symptoms of vertigo. Cochrane Database Syst Rev. 2016;(6):CD010696. 41. Aantaa E, Skinhoj A. Controlled clinical trial comparing the effect of betahistine hydrochloride and prochlorperazine maleate on patients with Meniére's disease. Ann Clin Res. 1976;8(4):284-7. 42. Singh KR, Singh M. Current perspectives in the pharmacotherapy of vertigo. Otorhinolaryngology Clinics: An International Journal. 2012;4(2):81-5. 43. Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician. 2005;71(6):1115-22.

Infertility

Indications, Patient Selection and Work-up Before Intrauterine Insemination RUTVIJ DALAL*, HRISHIKESH D PAI†, NANDITA P PALSHETKAR†

Abstract Intrauterine insemination (IUI) is a common treatment for infertility. It involves the deposition of a good number of highly motile and morphologically normal sperms in the uterus near the fundus at the anticipated time of ovulation, bypassing factors which depend upon deposition of sperms in vagina and transport through the cervical mucus to the upper genital tract. This procedure is used for couples with unexplained infertility, minimal male factor infertility and women with cervical mucus problems. Despite its popularity, the effectiveness of IUI treatment is not consistent. Therefore, in spite of the fact that many a times the treatment is empirical, appropriate patient selection is very important and a complete work-up is required before taking up the patient for IUI. Patients should be counseled about the procedure involved, success rates, other options and risks associated.

Keywords: Intrauterine insemination, unexplained infertility, patient selection, work-up

ppropriate patient selection is the most important factor which determines success of any treatment. With intrauterine insemination (IUI), many a times the treatment is empirical, still it is possible to deduce a group of couples where the treatment will be actually beneficial. The rationale behind the treatment is to deposit a good number of highly motile and morphologically normal sperms in the uterus near the fundus at the anticipated time of ovulation, bypassing factors which depend upon deposition of sperms in vagina and transport through the cervical mucus to the upper genital tract. There are several indications of IUI which may be due to male factor, female factor or combined factors.

Indications of IUI

Male Factors Impotence/Ejaculatory dysfunction This can be due to number of causes. ÂÂ

ÂÂ

A complete work-up is required before taking up the patient for IUI. Any contraindications to the procedure must be ruled out. Patients should be counseled about the procedure involved, success rates, other options and risks associated.

*Fellow in Reproductive Medicine †Senior Consultant Dept. of IVF Lilavati Hospital and Research Centre, Mumbai, Maharashtra Address for correspondence Dr Rutvij Dalal 20, Shreerang Society, Near Football Ground, Kankaria Ahmedabad - 380 022, Gujarat

Anatomical - Hypospadias: Here deposition of semen occurs outside vagina or much away from the os. In such patients semen is collected by masturbation for IUI. Neurological: This can be due to: zz

Spinal cord injury

Diabetes mellitus

Multiple sclerosis

Atherosclerosis

Damaged hypogastric nerves during surgeries like abdominoperineal resection of rectum, retroperitoneal lymph node dissection and aortoiliac surgery.

In these conditions, the sperm quality, especially its motility, is hampered despite high sperm density. Furthermore debris, inflammatory cells and quite often bacteria abound in these samples. The success of treatment depends upon sperm quality. Good results are obtained with samples where the progressive motility is more than 20-30%. ÂÂ

Retrograde ejaculation: In this condition, there is reflux of semen backwards from the

IJCP Sutra 34: Make exercise an important part of your daily routine. Start slow and increase the duration as you go along.

Infertility posterior urethral valve and into the bladder at the time of ejaculation. The sperms lose their viability due to toxic effects and acidity of urine. It can be due to diabetes mellitus, multiple sclerosis, drugs like α-adrenergic blockers and phenothiazines and damage to innervation of bladder neck during surgeries like transurethral resection of the prostate (TURP) and retropubic prostatectomy. In retrograde ejaculation, urine is centrifuged and then washed to isolate sperms and IUI is then performed.1 The treatment for various causes of male infertility is summarized in Table 1. ÂÂ

ÂÂ

Psychological conditions: Such patients need sex-psychotherapy. Drugs such as sildenafil or papaverine may be given to bring about a good erection. Some patients benefit with the use of mechanical vibrators. Very occasionally, the patients may have to be subjected to general anesthesia and electroejaculation. Drug-induced: Drugs like sedatives, antidepressants, antihypertensive agents, cimetidine, etc. can cause ejaculatory dysfunction.

Subnormal semen parameters This includes: ÂÂ

Oligozoospermia

ÂÂ

Asthenozoospermia

ÂÂ

Teratozoospermia

ÂÂ

Hypospermia

ÂÂ

Highly viscous semen.

The cause of infertility in such conditions is decreased availability of normal motile sperms for fertilization. As defined by the World Health Organization (WHO), a normal semen sample has a sperm count of more than 20 million/mL, with 50% or more of them showing forward progression and 30% or more having normal morphology.2 Table 1. Treatment for Various Causes of Male Infertility Treatment yy Treat the cause yy Intracavernosal injection: Papaverine, phenoxybenzamine, phentolamine yy Surgical methods: Epididymal sperm aspiration, percutaneous vasal sperm aspiration yy Penile vibrator yy Electroejaculation

Mild male factor is defined as follows: ÂÂ

Patient with only one abnormal male parameter

ÂÂ

Total motile sperm concentration of more than 5 million.

Ideally, a total motile pre-wash count of more than 10 million or a post-wash motile sperm count of 5 million is necessary to achieve a good pregnancy rate. Additionally, percentage motility of more than 40% in the final semen preparation correlates well with favorable outcome. Patients with severe male factor infertility should go directly for in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) or the use of donor sperms for insemination (artificial insemination with donor sperm - AID). Other factors The main treatment for obstructive azoospermia is percutaneous epididymal sperm aspiration (PESA) with ICSI. There is a recent report of achieving pregnancy after extracting sperm with PESA and performing IUI. Other conditions such as allergy to semen, vaginismus and other sexual dysfunctions may be treated with IUI. Human immunodeficiency virus (HIV) infection: Sperm washing can significantly reduce the viral load.3 Recently, insemination of HIV negative women with processed semen sample of HIV positive partners has been carried out to reduce the risk of transfer. However, prepared semen sample should be tested by polymerase chain reaction (PCR) before insemination.

Female Factors Ovulatory dysfunction It contributes to 30-40% of the female factors. In these cases, the first choice would be ovulation induction combined with timed intercourse or IUI. Many studies have shown that IUI gives better results as compared to timed intercourse. Cervical factor The cervix plays an important role in achieving successful pregnancy. It performs the following functions: ÂÂ

Control of sperm entry into the upper genital tract

ÂÂ

Protection of sperms from vaginal acidity

ÂÂ

Nutrition of sperms

ÂÂ

Selection of sperms based on motility

ÂÂ

Sperm reservoir function

ÂÂ

Initiation of capacitation.

IJCP Sutra 35: Take precautions during high-intensity activities. Athletes should drink only as much fluid as they lose due to sweating during a race.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

The following are some common causes of cervical factor infertility: ÂÂ

Insufficient mucus production, which may be due to previous cauterization, surgery or rarely cystic fibrosis

ÂÂ

Altered quality of mucus

ÂÂ

Abnormal cervix: Stenosis, injury, malformation, infection, erosion

ÂÂ

Abnormal post-coital test (PCT) or hostile cervical mucus (the general consensus is that PCT has nonpredictive value in terms of pregnancy).

IUI helps bypass these hostile factors. It has been observed that only 0.1% of the sperms placed in vagina are present in the cervical canal 1 hour after insemination.4 Direct deposition of motile sperms in the uterine cavity can reverse this situation, and increase the chance of pregnancy. The use of IUI in patients with cervical factor of infertility yields very good pregnancy rates, in the range of 14-18%.

diagnostic protocol should include an assessment of ovulation, evaluation of tubal patency and a normal semen analysis. The average incidence of unexplained infertility is around 10-15%. Defects in folliculogenesis, gamete development, fertilization and embryo development may be the factors responsible. The rationale of empirical therapy is to bypass these causative factors. The managing principles are: ÂÂ

Increasing availability of gametes by ovulation induction

ÂÂ

Improving gamete quality

ÂÂ

Bringing the gametes together by IUI or IVF.

The efficacy of various treatments in unexplained infertility is shown in Table 2.5 Insemination with husband’s frozen semen This is required in the following conditions: ÂÂ

Absentee husband

Endometriosis

ÂÂ

Antineoplastic treatment

IUI with ovulation induction can be tried in cases of mild endometriosis. Patients with mild-to-moderate endometriosis have good pregnancy rates between 7% and 18%. However, as the pregnancy rates (3-5%) are very low with severe endometriosis, it is best to opt for IVF/ICSI.

ÂÂ

Vasectomy

ÂÂ

Poor semen parameters

ÂÂ

Drug therapy.

Common Factors Immunological Antisperm antibody can be found in both males and females. Causes in men are usually testicular trauma or obstruction to the male genital tract. In women, it can happen due to a break in the vaginal epithelium, peritoneal instillation, anal or oral intercourse. These antibodies prevent binding of sperm to zona pellucida and also impair the sperm movement. Various treatments like prolonged use of condoms, immunosuppression with steroids and laboratory procedures to wash sperm have been tried. However, all these have limited success.

Insemination with donor sperms It is now mandatory to use cryopreserved donor samples only, to minimize risk of HIV transmission. The indications for insemination with donor semen are: ÂÂ

Azoospermia

ÂÂ

Severely subnormal semen parameters

Table 2. Efficacy of Various Treatments in Unexplained Infertility Treatment

Combined pregnancy rate per initiated cycle (%)

No treatment

1.3

IUI

3.8

5.6

CC with IUI

8.3

HMG

7.7

Unexplained infertility

HMG with IUI

17.1

This diagnosis is made when a couple fails to conceive despite there being no obvious cause, even after subjecting the patient to a complete work-up. The

IVF

20.7

Both IUI and IVF have shown to have high pregnancy rates in such patients. IUI helps to bypass these antibodies in cervical mucus.

IUI = Intrauterine insemination; CC = Clomiphene citrate; HMG = Human menopausal gonadotropin; IVF = In vitro fertilization.

IJCP Sutra 36: Ask your doctor about replacing water with sports beverages that contain electrolytes when participating in endurance events such as marathons, triathlons and other demanding activities.

Infertility ÂÂ

Hereditary disease in father

Hormonal investigations:

ÂÂ

Persistent IVF/ICSI failures

ÂÂ

Rhesus isoimmunization

ÂÂ

Patient unable to afford IVF.

Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2) on Day 2/3 of cycle zz

FSH >10 mIU/mL and E2 >60 pg/mL indicates poor ovarian reserve

LH/FSH >2/1 indicates syndrome (PCOS)

Low LH, FSH, E2 indicates hypogonadotropic hypogonadism

FSH >17 mIU/mL on Day 10 after clomiphene citrate indicates poor prognosis.

Patient Selection and Work-up An appropriate patient selection is the key to success for any treatment. A complete work-up including a detailed history is required before taking a patient for IUI. Many infertile couples have more than one contributory factor, which should be identified at the earliest. A scientific approach is warranted for a complete and efficient evaluation of female and male factors. More importantly, any contraindications to the procedure should be ruled out, as these can compromise the results (Table 3). Apart from a detailed history and physical examination, and routine investigations, certain specific tests for both the partners are required.

ÂÂ

Anthropometric measurements such as body mass index (BMI) and waist-hip ratio (WHR) help identify subjects with central adiposity. These patients may require further evaluation of hyperandrogenism and hyperinsulinemia that may cause aberration in ovulation and cause luteal phase deficiency despite medication. Table 3. Contraindications of IUI

ovary

In case of patients who are suspected to be poor responders, one can do these additional tests: zz

Serum inhibin - B test which is >45 pg/mL in poor responders.

Clomiphene citrate challenge test: Clomiphene citrate 100 mg/day from Day 5 to Day 9 and FSH on Day 10. A high FSH (>10 mIU/mL) indicates poor response and poor prognosis. This also points towards direct stimulation with gonadotropins, instead of clomiphene citrate.

Serum AMH (anti-mullerian hormone).

Evaluation of the Female Partner Routine investigations: Complete blood count (CBC), erythrocyte sedimentation rate (ESR), sexually transmitted disease (VDRL, HBsAg, HIV), blood sugars, urine routine, bleeding and clotting time.

polycystic

ÂÂ

Serum prolactin and triiodothyronine/thyroxine/ thyroid-stimulating hormone (T3/T4/TSH)

ÂÂ

In case of patients with PCOS diagnosed by ultrasonography (USG), or symptomatology or having feature of androgenization, one can do the following tests: zz

Fasting serum insulin level (>10 mIU/mL is significant).

yy Bilateral tubal block

Fasting and postprandial blood sugars.

yy Very severe oligoasthenospermia

Dehydroepiandrosterone sulfate androstenedione and testosterone.

In obese patients, a follicle phase 17-OHP level (to rule out congenital adrenal hyperplasia) and dexamethasone suppression test (to rule out Cushing’s syndrome) should be carried out.

Rarely serum alanine transaminase level is done in patients who are intolerant to metformin treatment and who need to be placed on rosiglitazone.

In women with past history of renal disease on metformin treatment, serum creatinine and/or 24 hours creatinine clearance may have to be done.

Contraindications

yy Genital tract infection yy Pregnancy contraindicated in female partners yy Unexplained genital tract bleeding Relative contraindications yy Tubal pathology yy Genetic abnormality yy Pelvic mass yy Older women yy Multiple infertility etiologies yy Pelvic surgery yy Severe illness in one or both partners yy Recent chemotherapy or radiotherapy

(DHEAS),

IJCP Sutra 37: While drinking water is vital for health, don't overdo it. Thirst and the color of your urine are usually the best indications of how much water you need.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

For screening and academic purposes, a C-peptide assay may be performed to pick-up latent diabetes. ÂÂ

Tests for ovulation (ovulatory or anovulatory)

Evaluation of male partner It involves evaluation of various clinical and laboratory parameters as shown in Table 6.

Basal body temperature

Pre-requisites for IUI

Serial vaginal ultrasound follicular scan in a spontaneous cycle

ÂÂ

Age less than 40 years.

ÂÂ

Patient capable ovulation.

ÂÂ

At least 1 patent fallopian tube with good tuboovarian relationship.

ÂÂ

Sperm count of more than 10 million/mL pre-wash or a post-wash count of >3-5 million motile sperms with percentage motility of more than 40%.

ÂÂ

Easy access to the uterine cavity via a negotiable cervical canal.

Serum progesterone on Day 21 of cycle >4 ng/mL indicates ovulation and >10 ng/mL indicates adequate luteal phase.

Pelvic sonography: This helps in evaluating uterus, uterine cavity and adnexae. Ovarian volume, antral follicle count and presence or absence of PCO pattern should be noted. Hysterosalpingography (HSG): This is done on Day 8 of periods. It helps in evaluation of uterine cavity and to check the tubal patency.

yy CBC with ESR

Pre-procedural work-up for IUI is summarized in Table 4.

yy Mantoux test

Table 4. Pre-procedure Work-up for IUI

spontaneous

induced

Table 5. Tests to Rule Out Tuberculosis

Diagnostic laparoscopy and hysteroscopy may be required in certain cases to establish the exact diagnosis.

Tests to rule out tuberculosis: These are especially important in developing countries (Table 5).

yy Chest X-ray yy Endometrial biopsy yy TB ELISA IgG and IgM yy TB-PCR yy Bactec CBC = Complete blood count; ESR = Erythrocyte sedimentation rate; TB = Tuberculosis; ELISA = Enzyme-linked immunosorbent assay; Ig = Immunoglobulin; PCR = Polymerase chain reaction.

Physical parameters

Clinical

Endocrinological

Anthropometry

Transvaginal sonography

Day 2/3 hormones

Evaluation of uterus and cavity

Serum LH, FSH, E2

Clinical parameters

Laboratory parameters: Investigations

Measurement of ovarian volume

TSH, prolactin, SHBG, F. insulin

Detailed history and examination

Semen analysis and culture

No. of antral follicles, PCOS/non-PCOS

Hair distribution scoring

Normospermia: No further investigations

Body mass index

HSG (to evaluate uterine cavity and tubal status)

Examination of testis, vas, epididymis

Astheno/necrospermia: Antisperm antibody Teratospermia: Check for DM

Waist-hip ratio

Diagnostic laparoscopy and hysteroscopy (if necessary): for evaluation of cervical, tubal, uterine and ovarian factors

Volumes of testis in case of azoospermia

Weight (kg) Height

Day 21 hormones: progesterone

PCOS = Polycystic ovary syndrome; LH = Luteinizing hormone; FSH = Follicle-stimulating hormone; E2 = Estradiol; TSH = Thyroid-stimulating hormone; SHBG = Sex hormonebinding globulin; HSG = Hysterosalpingography.

Table 6. Evaluation of the Male Partner

Moderate oligospermia: Sperm function test Severe oligospermia: Vasogram, color Doppler scrotum Azoospermia: Testicular biopsy/ FNA testis Endocrine evaluation: LH, FSH, Testosterone, PRL, TSH

IJCP Sutra 38: Normal way to know is to have 30 mL/kg body water liquid intake with 500 mL extra in summers.

Infertility immunodeficiency type 1 virus-serodiscordant couples with an infected male partner to have a child. Fertil Steril. 2004;82(4):857-62.

References 1. Zhao Y, Garcia J, Jarow JP, Wallach EE. Successful management of infertility due to retrograde ejaculation using assisted reproductive technologies: a report of two cases. Arch Androl. 2004;50(6):391-4. 2. World Health Organization Laboratory Manual for Examination of Human Semen and Sperm - Cervical Mucus Interaction. 4th Edition, Cambridge University Press; 1999. 3. Bujan L, Pasquier C, Labeyrie E, Lanusse-Crousse P, Morucci M, Daudin M. Insemination with isolated and virologically tested spermatozoa is a safe way for human

4. Settlage DS, Motoshima M, Tredway DR. Sperm transport from the external cervical os to the fallopian tubes in women: a time and quantitation study. Fertil Steril. 1973;24(9):655-61. 5. Guzick DS, Carson SA, Coutifaris C, Overstreet JW, Factor-Litvak P, Steinkampf MP, et al. Efficacy of superovulation and intrauterine insemination in the treatment of infertility. National Cooperative Reproductive Medicine Network. N Engl J Med. 1999; 340(3):177-83.

■■■■

Make sure During Medical Practice

Situation:

A patient with hypertension on ACEI had nonresponding dry cough.

Why did you not stop the ACEI?

Lesson:

Make sure to remember that the commonest cause of cough in a patient with high BP is the intake of ACEIs. A dry, persistent cough is a well-described class effect of the ACEI medications. Chest. 2006;129(1 Suppl):169S-173S.

IJCP Sutra 39: Develop healthy habits including eating, sleeping and exercising right.

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

NEUROLOGY

Isolated Central Sulcus Hemorrhage in a Case of Cerebral Amyloid Angiopathy BHAWNA SHARMA*, DIVYA GOEL†

Abstract Central sulcus hemorrhage in an elderly patient may occur without an obvious etiology like hypertension or trauma. This may be attributed to cerebral amyloid angiopathy. We report a case of a patient who presented clinically with recurrent transient ischemic attacks, had isolated central sulcus hemorrhage on computed tomography head and was finally found to have numerous unforeseen hemorrhages on gradient recalled echo (GRE) sequence, both cortical and subcortical. This lead to a diagnosis of cerebral amyloid angiopathy in this patient.

Keywords: Central sulcus hemorrhage, cerebral amyloid angiopathy, GRE

ntracranial hemorrhage is a common presentation in Neurology Emergency Department encountered in day-to-day practice. Trauma and hypertension are the two most common harbingers of intracranial hemorrhages. In young patients, arteriovenous malformations are another important cause. Thus, when noncontrast computed tomography (NCCT) head reveals an intracranial hemorrhage in a normotensive patient, CT angiography brain is a norm to look for any aneurysm or arteriovenous malformation. It has been seen in elderly patients that cerebral amyloid angiopathy (CAA) is a common cause and thus should be kept in mind when no obvious cause of sulcal subarachnoid hemorrhage is apparent on angiogram of brain vessels. Thus, in these cases, magnetic resonance imaging (MRI) brain with gradient recalled echo (GRE) sequence should follow to rule out CAA.

There was no history of headache, dizziness, vomiting or visual disturbances. There was no history of trauma, hypertension, diabetes or coronary artery disease. On examination, vitals were normal. Neurological examination did not reveal any sensory or motor deficits. The laboratory investigations were normal. Unenhanced CT head scan (Fig. 1) revealed a hyperdense left central sulcus suggestive of left central sulcus hemorrhage

Case Report A 75-year-old nonhypertensive female presented with history of recurrent transient episodes of rightsided weakness and numbness of body for 3 days.

*Senior Professor †Senior Resident Dept. of Neurology SMS Medical College, Jaipur, Rajasthan Address for correspondence Dr Divya Goel 4 Ba-19, Jawahar Nagar, Jaipur, Rajasthan - 302 005 E-mail: drdivyagoel@hotmail.com

Figure 1. NCCT head showing left central sulcus hemorrhage.

IJCP Sutra 40: Do not overdo anything. From drinking to using the cell phone, everything must be in moderation.

NEUROLOGY without any mass effect. CT angiogram brain did not reveal any vascular malformations. Since the cause of hemorrhage was not apparent yet, MRI brain was carried out which revealed hyperintensity in left central sulcus area on T2-weighted image (Fig. 2) along with numerous cortical/subcortical hemorrhages in bilateral cerebral hemispheres on GRE sequence (Fig. 3).

Figure 2. MRI brain axial view T2-weighted image showing left central sulcus hemorrhage.

Thus, a diagnosis of CAA was made, applying the Boston criteria.1 Patient was discharged in a stable condition after 5 days of hospital stay. Discussion The most common causes of cortical, subcortical and sulcal subarachnoid hemorrhage are trauma, aneurysm rupture, vascular malformations, vasculitis, amyloid angiopathy, hypertension, arterial dissection, bleeding diathesis, drug abuse, malignancy, posterior reversible encephalopathy syndrome (PRES) and venous thrombosis.2 CAA occurs due to amyloid deposition in brain, producing increased fragility of blood vessels.3 Amyloid deposition in brain occurs in other diseases like Alzheimerâ&#x20AC;&#x2122;s dementia, Creutzfeldt-Jacob disease, spongiform encephalopathies and postradiation necrosis. Due to its predilection for cortical and subcortical vessels, most of the hemorrhages in CAA are peripheral with sparing of white matter and basal ganglia. Apart from intracranial hemorrhage, there are varied clinical manifestations of CAA in the form of leukoencephalopathy, atrophy and cerebral volume loss, vascular luminal narrowing and ischemia and amyloidoma.2 Nontraumatic isolated central sulcus hemorrhage in elderly, normotensives is a rare finding and can be a presentation of cerebral amyloid angiopathy. There have been few cases in literature reporting the same.2,4,5 NCCT head is the first imaging modality easily accessible for identification of hemorrhage. CT and MR angiogram brain is the next to look for aneurysms or arteriovenous malformations. Having these excluded, MRI brain with GRE or susceptibility weighted imaging (SWI) sequences should be carried out to look for cortical and subcortical hemorrhages in other locations. Combining the clinical and radiological findings and application of Boston criteria, a working diagnosis of CAA is made. Biopsy is not required in such cases to reach at a diagnosis. Management of such patients involves control of comorbidities like hypertension, supportive treatment and avoiding any antiplatelet or anticoagulant medications (which can worsen the condition in CAA).2 Conclusion

Figure 3. MRI brain GRE sequence showing multiple cortical/ subcortical hemorrhages in bilateral cerebral hemispheres.

Cerebral amyloidosis is a common presentation and cause of intracranial hemorrhage in elderly after hypertension, trauma- and drug-induced hemorrhages. It can be easily identified through MRI brain with GRE sequence. This helps to guide future management and

IJCP Sutra 41: Follow ancient wisdom. Do Yoga and Meditation for your mental and spiritual well-being and maintain equilibrium. Allow your body to heal itself.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

prognosis of the patient. As seen in this case, isolated central sulcus hemorrhage is a rare imaging finding and may represent the index finding of cerebral amyloidopathy. References 1. Knudsen KA, Rosand J, Karluk D, Greenberg SM. Clinical diagnosis of cerebral amyloid angiopathy: validation of the Boston criteria. Neurology. 2001;56(4):537-9. 2. Chamarthy MR, Kumar Y, Meszaros MD, Shah A, Rosovsky MA. Isolated central sulcus hemorrhage: A rare

presentation most frequently associated with cerebral amyloid angiopathy. Case Rep Radiol. 2012;2012:574849. 3. Biffi A, Greenberg SM. Cerebral amyloid angiopathy: a systematic review. J Clin Neurol. 2011;7(1):1-9. 4. Cuvinciuc V, Viguier A, Calviere L, Raposo N, Larrue V, Cognard C, et al. Isolated acute nontraumatic cortical subarachnoid hemorrhage. AJNR Am J Neuroradiol. 2010;31(8):1355-62. 5. Raposo N, Viguier A, Cuvinciuc V, Calviere L, Cognard C, Bonneville F, et al. Cortical subarachnoid haemorrhage in the elderly: a recurrent event probably related to cerebral amyloid angiopathy. Eur J Neurol. 2011;18(4):597-603.

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IJCP Sutra 42: Get periodic checkups done. Early detection of most health problems can help in correcting lifestyles to slow the degeneration process and lead a longer and healthier life.

OBSTETRICS AND GYNECOLOGY

Periodontal Disease and Pregnancy Outcome SNEHA MAYURI*, SWATI SHARAN†, ABHISHEK VERMA†, ANINDITA BANERJEE‡, MANJU GEETA MISHRA#

Abstract Periodontal disease is one of the most common chronic disorders of infectious origin known in humans. Infection and/or inflammation in the reproductive tract and at sites remote from the fetoplacental unit continue to be investigated as potential causative factors for adverse pregnancy outcomes. This study was conducted to examine the relationship between periodontal disease in early pregnancy and the risk of preterm birth and pre-eclampsia. A prospective study of obstetrical outcome of 262 women, examined for periodontal disease at 15-24 weeks gestation was carried out. In our study, 60.7% patients suffering from periodontal disease had preterm deliveries as compared to 20% preterm deliveries in those not having periodontal disease. Incidence of pre-eclampsia was found to be 53.57% in patients with periodontal disease as compared to 13.33% in those without periodontal disease. Thus, we conclude that there is a definite relationship between periodontal diseases and adverse pregnancy outcome.

Keywords: Pregnancy, periodontal diseases, pre-eclampsia, preterm birth

eriodontal disease is one of the most common chronic disorders of infectious origin known in humans, with a reported prevalence varying between 10% and 90% in adults, depending on diagnostic criteria.1-5

Periodontal disease presents as two main types:6 ÂÂ

Gingivitis—an inflammatory condition of the soft tissues surrounding a tooth or the gingiva

ÂÂ

Periodontitis—involving the destruction of supporting structures such as the periodontal ligament, bone, cementum or soft tissues.

Over the years, several risk factors for periodontitis have been identified. For example, stress, poor dietary habits with high sugar intake, smoking and tobacco use, obesity, age and poor dental hygiene all contribute to the development of periodontal disease.

*Postgraduate Trainee (Final Year) †Professor ‡Professor and Head Dept. of Periodontics Buddha Institute of Dental Sciences and Hospital, Patna, Bihar #Ex-Professor Dept. of Obstetrics and Gynecology Patna Medical College and Hospital, Patna, Bihar Address for correspondence Dr Sneha Mayuri Postgraduate Trainee (Final Year) Dept. of Periodontics Buddha Institute of Dental Sciences and Hospital, Patna, Bihar E-mail: snehamayuri@gmail.com

Other major risk factors include clinching or grinding teeth, genetic factors, other family factors, other medical diseases such as diabetes, cancer or acquired immunodeficiency syndrome (AIDS), defective dental restorations medication use and conditions that change estrogen levels (puberty, pregnancy, menopause).7,8 Pregnancy complications, including pre-eclampsia, preterm delivery and low birth weight (LBW), represent major public health problems because of their prevalence, associated mortality, economic burden and long-term disability. Infection and/or inflammation in the reproductive tract and at sites remote from the fetoplacental unit continue to be investigated as potential causative factors for these adverse outcomes. Periodontal infection is one of the many infections that have been associated with adverse pregnancy outcomes. Consequently, the relationship between adverse pregnancy outcomes and maternal periodontal infections has to be studied extensively, particularly since periodontal infections are most prevalent in populations at highest risk of adverse pregnancy outcomes. Aims and Objectives This study was conducted to examine the relationship between periodontal disease in early pregnancy and the risk of preterm birth and pre-eclampsia.

IJCP Sutra 43: Both active and passive smoking are harmful for the body.

OBSTETRICS AND GYNECOLOGY Material and Methods A prospective study of obstetrical outcome of 262 women, examined for periodontal disease at 15-24 weeks of gestation was carried out. Participants underwent periodontal examination along with routine antenatal examination and patients having other foci of infection were excluded from the study. Periodontal disease was defined as the presence of one or more sites with probing depths >4 mm and >10% bleeding on probing. The obstetrical outcome of all the patients was analyzed. Results Among 262 patients, 112 were suffering from periodontal disease. Of these, 68 women delivered a preterm baby (60.7%). Among the remaining 150 patients, there were 30 preterm deliveries (20%). Pre-eclampsia was seen in 60 cases (53.57%) with periodontal disease as compared to 20 cases in those not suffering from periodontal diseases (13.33%). Discussion Infection and inflammation have been associated with spontaneous preterm delivery and LBW. In addition, evidence suggests an important role for inflammation and endothelial activation in the pathophysiology of pre-eclampsia.9 Consequently, reproductive biologists and immunologists hypothesized that periodontal disease could induce adverse pregnancy outcomes mediated by systemic infectious and inflammatory processes. The first association between periodontal disease and preterm LBW was documented by Offenbacher and colleagues in 1996 using a case-control study design with 124 patients.10 Investigators from the University of Alabama conducted a prospective evaluation of over 1,300 pregnant women. Complete medical, behavioral and periodontal data were collected between 21 and 24 weeks of gestation. They concluded that the risk for preterm birth was increased among women with generalized periodontal infection; this risk was inversely related to gestational age.11 Offenbacher et al12 conducted a prospective study of obstetric outcomes of over 1,000 women who received an antepartum and postpartum periodontal examination. Periodontal disease progression was found to be an independent risk factor for preterm delivery.

Santos-Pereira et al13 studied 124 women between the ages of 15 and 40 to determine if chronic periodontitis increased the risk of experiencing preterm labor. In this cross-sectional study, they concluded that chronic periodontitis increased the risk of having preterm labor. Pitiphat et al14 conducted a prospective study to determine if self-reported periodontitis was a risk factor for poor pregnancy outcomes. The authors concluded that periodontitis is an independent risk factor for poor pregnancy outcomes. Agueda et al15 enrolled over 1,200 women to evaluate the association between periodontitis and preterm birth and/or LBW. In their study, no significant association was found between LBW and periodontitis. A study examined the relationship between multiple periodontal parameters, including mean probing depths, percent of tooth sites with probing depths >4 mm, percent of sites with bleeding on probing and percent of sites with clinical attachment loss > either 2 or 3 mm. No difference was found in the periodontal parameters between women with preterm birth and without preterm birth.16 Buduneli and colleagues17 found no differences in periodontal infection between women who delivered preterm versus full-term. However, women were at significantly increased risk for preterm birth if either Porphyromonas gingivalis or Campylobacter rectus were found in the subgingival plaque. Vettore et al18 recruited 542 postpartum women who were over 30 years old. The investigators sought to explore the relationship between periodontal disease and preterm LBW. The results of this study indicated that the extent of periodontal disease did not increase the risk of preterm LBW. Evidence suggests a role for inflammation and endothelial activation in the pathophysiology of preeclampsia;19,20 periodontal infection is one of many potential stimuli for these host responses. Contreras et al21 found that women with pre-eclampsia were twice as likely to have chronic periodontitis. Several other investigators have been unable to confirm an association between maternal periodontal infection and pre-eclampsia.22,23 The conflicting results are yet to be resolved. Conclusion In our study, 60.7% patients suffering from periodontal disease had preterm deliveries as compared to 20%

IJCP Sutra 44: Quit smoking and talk to your children about the negative health effects of this habit.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

preterm deliveries in those not having periodontal disease. Incidence of pre-eclampsia was found to be 53.57% in patients with periodontal disease as compared to 13.33% in those without periodontal disease. Thus, we conclude that there is a definite relationship between periodontal diseases and adverse pregnancy outcome, preterm birth and pre-eclampsia, and treating periodontal diseases in the antenatal period may be beneficial in improving the pregnancy outcome. References 1. Papapanou PN. Periodontal diseases: epidemiology. Ann Periodontol. 1996;1(1):1-36. 2. Albandar JM, Rams TE. Global epidemiology of periodontal diseases: an overview. Periodontol 2000. 2002;29:7-10. 3. Albandar JM. Periodontal diseases in North America. Periodontol 2000. 2002;29:31-69. 4. Offenbacher S, Lieff S, Boggess KA, Murtha AP, Madianos PN, Champagne CM, et al. Maternal periodontitis and prematurity. Part I: Obstetric outcome of prematurity and growth restriction. Ann Periodontol. 2001; 6(1):164-74. 5. Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. Lancet. 2005;366(9499):1809-20.

birth: results of a prospective study. J Am Dent Assoc. 2001;132(7):875-80. 12. Offenbacher S, Boggess KA, Murtha AP, Jared HL, Lieff S, McKaig RG, et al. Progressive periodontal disease and risk of very preterm delivery. Obstet Gynecol. 2006;107(1):29-36. 13. Santos-Pereira SA, Giraldo PC, Saba-Chujfi E, Amaral RL, Morais SS, Fachini AM, et al. Chronic periodontitis and pre-term labour in Brazilian pregnant women: an association to be analysed. J Clin Periodontol. 2007;34(3):208-13. 14. Pitiphat W, Joshipura KJ, Gillman MW, Williams PL, Douglass CW, Rich-Edwards JW. Maternal periodontitis and adverse pregnancy outcomes. Community Dent Oral Epidemiol. 2008;36(1):3-11. 15. Agueda A, Ramón JM, Manau C, Guerrero A, Echeverría JJ. Periodontal disease as a risk factor for adverse pregnancy outcomes: a prospective cohort study. J Clin Periodontol. 2008;35(1):16-22. 16. Xiong X, Buekens P, Vastardis S, Pridjian G. Periodontal disease and gestational diabetes mellitus. Am J Obstet Gynecol. 2006;195(4):1086-9. 17. Buduneli N, Baylas H, Buduneli E, Türkoğlu O, Köse T, Dahlen G. Periodontal infections and preterm low birth weight: a case-control study. J Clin Periodontol. 2005;32(2):174-81.

6. Kinane DF. Causation and pathogenesis of periodontal disease. Periodontol 2000. 2001;25:8-20.

18. Vettore MV, Leal Md, Leão AT, da Silva AM, Lamarca GA, Sheiham A. The relationship between periodontitis and preterm low birthweight. J Dent Res. 2008;87(1):73-8.

7. Periodontal Diseases. Chicago, Ill. American Academy of Periodotnology. Available at: http://www.perio.org/ consumer/2a.html.

19. Roberts JM, Taylor RN, Musci TJ, Rodgers GM, Hubel CA, McLaughlin MK. Preeclampsia: an endothelial cell disorder. Am J Obstet Gynecol. 1989;161(5):1200-4.

8. Periodontal (Gum) Disease: Causes, Symptoms, and Treatments. Bethesda, MD: National Institute of Dental and Craniofacial Research. Available at: http://www. nidcr.nih.gov/nidcr.nih.gov.

20. Dong M, He J, Wang Z, Xie X, Wang H. Placental imbalance of Th1- and Th2-type cytokines in preeclampsia. Acta Obstet Gynecol Scand. 2005;84(8):788-93.

9. Dong M, He J, Wang Z, Xie X, Wang H. Placental imbalance of Th1- and Th2-type cytokines in preeclampsia. Acta Obstet Gynecol Scand. 2005;84(8):788-93. 10. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol. 1996;67(10 Suppl):1103-13. 11. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm

21. Contreras A, Herrera JA, Soto JE, Arce RM, Jaramillo A, Botero JE. Periodontitis is associated with preeclampsia in pregnant women. J Periodontol. 2006;77(2):182-8. 22. Khader YS, Jibreal M, Al-Omiri M, Amarin Z. Lack of association between periodontal parameters and preeclampsia. J Periodontol. 2006;77(10):1681-7. 23. Meurman JH, Furuholm J, Kaaja R, Rintamäki H, Tikkanen U. Oral health in women with pregnancy and delivery complications. Clin Oral Investig. 2006; 10(2):96-101.

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IJCP Sutra 45: Avoid secondhand smoke if you happen to live in and around a smoker.

2018

OBSTETRICS AND GYNECOLOGY

Scope and Limitations of Medical Management of Ectopic Pregnancy: Comparison of Single versus Multiple Dose of Methotrexate RITA SINHA*, RUPAM SINHA†, MANJU GITA MISHRA‡, SUBHASHREE SETHI#

Abstract The present study was a pilot study conducted at Nalanda Medical College and Patna Medical College, Patna, Bihar. The study included 120 women with ectopic pregnancy who were given single dose or multiple dose of methotrexate. In our study, the success rate in single dose group was 73.33% and in multiple dose group was 83.33% (p value 0.34) and the difference was statistically insignificant. The study showed that medical management of ectopic pregnancy with single dose IM methotrexate regimen is as effective as multiple dose regimen with lesser side effects and this option should be given to the women fulfilling the inclusion criteria.

Keywords: Ectopic pregnancy, methotrexate, single dose, multiple dose regimen

ctopic pregnancy is a condition where the blastocyst implantation occurs at any site other than the usual endometrial lining of the uterine cavity. The most common ectopic implantation site is within the fallopian tube (95%). The sites of tubal implantation in descending order of frequency are ampulla (73%), isthmus (12.5%), fimbrial (11.6%) and interstitial (2.6%). The remaining 5% of non-tubal ectopic pregnancies implant in the ovary, peritoneal cavity, cervix or prior cesarean scar or abdominal cavity. An ectopic pregnancy can be an acute emergency if not timely diagnosed and treated. Timely diagnosis and appropriate treatment can reduce the risk of maternal mortality and morbidity related to ectopic pregnancy. It is an important diagnosis to exclude when a woman presents with bleeding per vagina in early pregnancy.

*Professor †Associate Professor ‡Ex-Professor #3rd Year Student Dept. of Obstetrics and Gynecology Patna Medical College, Patna, Bihar Address for correspondence Dr Rita Sinha Professor Dept. of Obstetrics and Gynecology E-mail: drritasinha2@gmail.com

Reports of incidence from elsewhere shows an increase from 0.5% to 1-2%. There has been a rise of 3-5 in ectopic pregnancies from assisted reproductive technique (ART). The clinical presentation of ectopic pregnancy has changed from a life-threatening disease to a more benign condition for which nonsurgical treatment options are available. Use of beta-human chorionic gonadotropin (β-hCG) and transvaginal ultrasound scan (TVS) has improved the accuracy of diagnosis. With early diagnosis and treatment, definite therapy for unruptured ectopic pregnancy is feasible even before the onset of symptoms. Methotrexate (MTX) has been used successfully to treat ectopic pregnancy. MTX is a folic acid antagonist that inhibits the enzyme dihydrofolate reductase and reduces the supply of tetrahydrofolate which is a cofactor in the synthesis of DNA and RNA and necessary for cell division. MTX is currently administered either in a single or as a multiple dose regimen to treat ectopic pregnancy. The purpose of this study was to compare the two regimens of medical management of ectopic pregnancy (single dose and multiple dose), their effectiveness and their side effects.

IJCP Sutra 46: Avoid areas where people smoke, such as bars and restaurants, and seek out smoke-free options.

OBSTETRICS AND GYNECOLOGY Material and Methods

Observation

This was a study conducted at Nalanda Medical College and Patna Medical College, Patna, Bihar which included 120 women from March 2012 to February 2018.

In our study, no statistically significant difference was found between single and multiple dose MTX groups in terms of clinical and laboratory characteristics. Mean age of women, period of gestation, size of ectopic mass, pre-treatment β-hCG level and mean time of resolution of ectopic pregnancy were comparable in both groups (Table 1).

An informed consent was taken from each woman after explaining all treatment modalities and side effects of the drug. These women were given either single or multiple doses of MTX for ectopic pregnancy. Sixty women were given single dose and 60 were given multiple doses of MTX for ectopic pregnancy on the basis of computer generated random number. In the single dose regimen, MTX 50 mg/m2 intramuscular (IM) was given on Day 1. Then β-hCG levels were measured on Day 7. If the difference was a fall of 15%, the test was repeated weekly until β-hCG level was ≤2 mIU/mL or undetectable. If difference was <15% between Day 1 and Day 7 levels, it was treated as a failure. In multiple dose regimen, MTX 1 mg/kg body weight IM was given on days 1, 3, 5 and 7. Leucovorin 0.1 mg/m2 was given on days 2, 4, 6 and 8. Then, weekly β-hCG levels were measured until β-hCG was ≤2 mIU/mL or undetectable. In case the fall was inadequate or the patient presented with pain in abdomen, medical management was discontinued and surgical intervention was sought. For this study, the various inclusion and exclusion criteria were as follows:

Inclusion Criteria ÂÂ

Unruptured ectopic pregnancy

ÂÂ

The woman should be hemodynamically stable

ÂÂ

Ectopic mass size ≤3.5 cm ultrasonographically

ÂÂ

No cardiac activity

ÂÂ

β-hCG level <5,000 mIU/mL.

Exclusion Criteria ÂÂ

Lactating mother

ÂÂ

Immunodeficiency

ÂÂ

Alcoholism

ÂÂ

Blood dyscrasias

ÂÂ

Chronic hepatic, renal or pulmonary diseases

ÂÂ

Peptic ulcer diseases

ÂÂ

Heterotrophic pregnancy.

Of the 60 women who received single dose MTX 44 (73.33%) were successfully treated and of the other 60 women who received multiple dose MTX, 50 (83.33%) were successfully treated. This difference was statistically insignificant (p value 0.3479) (Table 2). In our study, the most common side effect during the course of treatment was found to be gastric upset (Table 3). In the single dose group, gastrointestinal (GI) Table 1. Patient Characteristics Multi-dose

Single dose

Age (year)

30.53 ± 4.45

31.4 ± 4.41

0.52

Period of gestation

6.01 ± 7.78

5.75 ± 1.01

0.217

Sample size

Pre-treatment 1507.2 ± 1184.82 1686.14 ± 1217.33 β-hCG level Mean time of resolution (days)

5.76 ± 0.83

5.27 ± 0.88

P value

0.301 0.061

Table 2. Success and Failure Rates with the Two Regimes Group

Multi-dose

Single dose

Success

50 (83.33%)

44 (73.33%) 94 (78.33%)

Failure

10 (16.67%)

16 (26.67%) 26 (21.67%)

Total

60 (100%)

Total

P value 0.347

120 (100%)

Table 3. Side Effects of MTX in Multi-dose and Single Dose Group Multi-dose GI upset

Single dose

Total

28 (46.67%) 10 (16.67%) 38 (31.67%)

P value 0.26

LFT deranged

4 (6.67%)

0 (0.00%)

4 (3.33%)

0.491

Skin rash

2 (3.33%)

0 (0.00%)

2 (1.67%)

1.00

Statistical Methods

None

For all statistical tests, p value <0.05 was taken to indicate a significant difference.

Total

26 (43.33%) 50 (83.33%) 76 (63.33%) 60 (100%)

60 (100%)

IJCP Sutra 47: Take precautions to protect yourself from exposure to toxic chemicals at work. You can wear a mask for protection.

0.003

60 (100%)

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

upset was seen in 16.67% (10/60) patients and in multidose group in 46.67% (28/60); this was found to be statistically significant (p = 0.026). Other side effects such as liver function test (LFT) alteration was seen only in the multi-dose group among 6.674% (4/60) patients. Skin rashes were also seen only in multi-dose group in 3.33% patients (2/60); this showed no significant statistical difference. Discussion Several studies report comparable rates of success with both regimens. However, Zargar et al recommended the single dose regimen in their comparative study because of greater chance of response with single dose than multiple dose management. Single dose regimen was associated with better results, patient tolerance and no need of hospitalization. In present study, the most common side effect during the course of treatment was found to be gastric upset in single dose group (16.67%) and in multi-dose group (46.67%) and the difference was statistically significant (p = 0.026). Other side effects such as LFT alteration was noted in 0% in single dose group and in 6.67% in multi-dose group. Skin rashes were seen in 0% in single dose regimen and in 3.33% in multi-dose group, which showed no significant statistical difference. Barnhart et al, in their study, showed that single dose regimen was associated with fewer side effects. Conclusion In treatment with MTX, the patient avoids surgery and anesthesia. This study showed that medical management of ectopic pregnancy with single dose IM MTX regimen is as effective as multiple dose regimen, with lesser side effects and this option should be given to those women who fulfill the inclusion criteria.

Suggested Reading 1. Guvendag Guven ES, Dilbaz S, Dilbaz B, Aykan Yildirim B, Akdag D, Haberal A. Comparison of single and multiple dose methotrexate therapy for unruptured tubal ectopic pregnancy: a prospective randomized study. Acta Obstet Gynecol Scand. 2010;89(7):889-95. 2. Goldner TE, Lawson HW, Xia Z, Atrash HK. Surveillance for ectopic pregnancy - United States, 1970-1989. MMWR CDC Surveill Summ. 1993;42(6):73-85. 3. Eskandar M. Single dose methotrexate for treatment of ectopic pregnancy: risk factors for treatment failure. Middle East Fertile Soc J. 2007;12(1):57-62. 4. Rock JA, Jones HW. Telinde’s Operative Gynaecology.10th Edition, New Delhi: Lippincott Williams and Wilkins; 2009. pp. 789-824. 5. Lipscomb GH, Givens VM, Meyer NL, Bran D. Comparison of multidose and single-dose methotrexate protocols for the treatment of ectopic pregnancy. Am J Obstet Gynecol. 2005;192(6):1844-7; discussion 1847-8. 6. Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing “single dose” and “multidose” regimens. Obstet Gynecol. 2003;101(4):778-84. 7. Zargar M, Razi T, Bararti M. Comparison of single and multi-dose of methotrexate in medical treatment of ectopic pregnancy. Pak J Med Sci. 2008;24(4):586-9. 8. Srivichai K, Uttavichai C, Tongsong T. Medical treatment of ectopic pregnancy: a ten-year review of 106 cases at Maharaj Nakorn Chiang Mai Hospital. J Med Assoc Thai. 2006;89(10):1567-71. 9. Tabatabaii Bafghi A, Zaretezerjani F, Sekhavat L, Dehghani Firouzabadi R, Ramazankhani Z. Fertility outcome after treatment of unruptured ectopic pregnancy with two different methotrexate protocols. Int J Fertil Steril. 2012;6(3):189-94. 10. Elkilani OA, Sayyed TM, Metwalli AH. Multiple doses versus single-dose methotrexate protocols for the management of some cases of ectopic pregnancy. Menoufia Med J. 2015;28(1):250-3.

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Obesity Rule of 30 ÂÂ

Take no more than 30 mL per kg of body weight liquids per day.

ÂÂ

It takes 30 calories per kg to maintain one’s weight.

Smoking Rule of 6: Smoking one cigarette takes away 6 minutes of your life.

IJCP Sutra 48: Eat a healthy diet that is rich in fruits and vegetables. Food sources of vitamins and nutrients are best.

OBSTETRICS AND GYNECOLOGY

Uterine Didelphys with Pregnancy and Obstructed Labor: Intrapartum Course Complicated by a Rare Uterine Anomaly SHASHIDHAR B*, HEMALATHA M SHETTI†

Abstract Mullerian duct anomalies (MDAs) are congenital anatomic abnormalities of the female genital tract that arise from nondevelopment or non-fusion of the mullerian ducts or failed resorption of the uterine septum, with a reported incidence of 0.110.0%. MDAs are clinically important because they are associated with an increased incidence of impaired fertility, menstrual disorders and obstetric complications. We hereby report a case of a primigravida with full-term pregnancy with obstructed labor referred from a primary health center. During the course of examination, she was found to have congenital abnormality of uterus and vagina. She underwent an emergency cesarean section with good perinatal outcome. Women with uterus didelphys belong to a high-risk group, although pregnancy outcome is comparatively good.

Keywords: Mullerian duct anomalies, congenital anatomic abnormalities, obstructed labor, uterus didelphys

he true incidence of congenital uterine anomalies in the general population and among women with recurrent pregnancy loss is not known accurately. Although incidences of 0.1-10% have been reported, the overall data suggest an incidence of 1% in the general population and 3% in women with recurrent pregnancy loss and poor reproductive outcome. Female genital tract develops from 3 sites, ovaries from the germ cells that migrate from the yolk sac into the mesenchyme of the peritoneal cavity and develop into ova and supporting cells; lower third of vagina develops from the ascending sinovaginal bulb; and uterus, fallopian tubes and upper two-thirds of vagina develop from the fusion of two mullerian ducts. Incomplete fusion of the mullerian or paramesonephric ducts results in the most common types of uterine malformation: uterus didelphys, uterus bicornis bicollis, uterus bicornis

*Assistant Professor †Professor and Head Dept. of Obstetrics and Gynecology Sri Devraj Urs Medical College, Tamaka, Kolar, Karnataka Adddress for correspondence Dr Shashidhar B Assistant Professor Dept. of Obstetrics and Gynecology Sri Devraj Urs Medical College, Tamaka, Kolar - 563 101, Karnataka E-mail: shashi0328@gmail,com

unicollis, uterus subseptate, uterus arcuatus and uterus unicornis. Uterus bicornis bicollis is characterized by double or single vagina, double cervix and two singlehorned uterus which show partial fusing of their muscular walls with duplication running right down to the uterine orifice. Congenital anomaly of the mullerian duct system can result in various urogenital anomalies including uterus didelphys with blind hemivagina and ipsilateral renal agenesis.1 The diagnosis of this condition is usually made after menarche, but its rarity and variable clinical features may contribute to a diagnostic delay for years after menarche.2 With timely and accurate diagnosis, appropriate management is likely to provide the best possible outcome for all such patients. Case Report A 20-year-old primigravida, wife of a farmer, who was referred from a primary health care center, reported to labor room on 31st May 2009 at 09:13 pm with a history of 9 months of amenorrhea and leak per vagina since 3 days and pain abdomen since 3 days. She was married for 1 year. General examination was unremarkable. On abdominal examination, uterus was term size and cephalic presentation and there was an unusual contour of abdomen on right side. Fetal heart sound was localized

IJCP Sutra 49: Try and exercise on most days of the week. If you don't exercise regularly, start out slowly.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Figure 1. Per speculum examination showing right and left hemi vagina with complete vertical vaginal septum.

Figure 3. Posterior view of didelphic gravid hemi uterus.

section was made. She underwent an emergency cesarean section on 01/06/09 at 12:30 am; a full-term male baby of weight 3.2 kg was extracted who cried after delivery. Uterus was found to be bicornis bicollis and pregnancy was found in the right hemi uterus (Figs. 2 and 3). Postoperative stay was uneventful and sutures were removed on 7th postoperative day and the patient was discharged the same day. The patient is still on follow-up. Discussion

Figure 2. Anterior view of gravid right hemi uterus with incision on the lower segment and nongravid left hemi uterus.

in the right iliac fossa and was 146 bt/min. Per speculum examination revealed complete vertical vaginal septum (Fig. 1) and bulging of vaginal fornices in right hemivagina, active clear liquor leak demonstrated on the blade of speculum in right hemivagina. Internal examination revealed right cervix was partially effaced and 2 cm dilated and presenting part at minus three station, and in left hemivagina cervix was uneffaced and os closed. On clinical examination, the pelvis was found to be grossly contracted. A decision for emergency cesarean

Mullerian anomaly rate is reported between 0.1-1% in general population with significantly higher rates associated with infertility and reproductive wastage. Uterus didelphys is one of the least common anomalies, representing approximately 5-7% of mĂźllerian defects. The reproductive outcomes are slightly better than those of women with unicornuate uterus. AciĂŠn reported that poorest viability results were found in the bicornuate (40%), arcuate (45%) and septate uterus groups (59%) and rates of children surviving for more than 7 days were around 70% in the bicornis bicollis, didelphys, unicornuate and subseptus uterus groups.3 Maneschi et al reported live birth rate of 81% and suggested that reproductive and gestational performances of women with uterus didelphys are preserved. In patients with infertility complaints, associated causes must be ruled out before surgical correction. If these are present, their correction must be attempted as first therapeutic step, and term pregnancy with live baby is the rule.4 Interestingly, pregnancy has been observed consistently in right horn.5

IJCP Sutra 50: Sanitize and wash your hands thoroughly of you happen to visit someone with NiV.

OBSTETRICS AND GYNECOLOGY In case of single pregnancy, it is in the right uterus in uterus didelphys. Even in this present case, pregnancy has been found in the right hemi uterus. Heinonen and colleagues observed a cesarean section rate of 82% and fetal survival rate of 67.5% and premature delivery of 21%.6 All the patients also had a longitudinal vaginal septum. Three-dimensional sonography has contributed the most and has become the investigation of choice in units where available. Raga et al and Wu et al reported that three-dimensional sonography offered a 100% specificity and is reproducible and reliable noninvasive diagnostic procedure for the exclusion of uterine anomalies and was able to differentiate between the different anomalies.7,8 Magnetic resonance imaging (MRI) is the most sensitive imaging modality for congenital anomalies. Conclusion Congenital uterovaginal anomalies can have adverse effects on pregnancy outcome. Early diagnosis and an aggressive evaluation of any patient presenting with mid-trimester abortion, premature labor, malpresentation, prevent additional pregnancy wastage and maternal morbidity and are likely to provide the best possible outcome for all such patients.

References 1. Zurawin RK, Dietrich JE, Heard MJ, Edwards CL. Didelphic uterus and obstructed hemivagina with renal agenesis: case report and review of the literature. J Pediatr Adolesc Gynecol. 2004;17(2):137-41. 2. Varras M, Akrivis Ch, Karadaglis S, Tsoukalos G, Plis Ch, Ladopoulos I. Uterus didelphys with blind hemivagina and ipsilateral renal agenesis complicated by pyocolpos and presenting as acute abdomen 11 years after menarche: presentation of a rare case with review of the literature. Clin Exp Obstet Gynecol. 2008;35(2):156-60. 3. Acién P. Reproductive performance of women with uterine malformations. Hum Reprod. 1993;8(1):122-6. 4. Maneschi I, Maneschi F, Parlato M, Fucà G, Incandela S. Reproductive performance in women with uterus didelphys. Acta Eur Fertil. 1989;20(3):121-4. 5. Suhail S, Suhail MF, Khan H. Uterus didelphys - a case having pregnancy only in her right uterus. 2007. 6. Heinonen PK. Uterus didelphys: a report of 26 cases. Eur J Obstet Gynecol Reprod Biol. 1984;17(5):345-50. 7. Raga F, Bonilla-Musoles F, Blanes J, Osborne NG. Congenital Müllerian anomalies: diagnostic accuracy of three-dimensional ultrasound. Fertil Steril. 1996;65(3):523-8. 8. Wu MH, Hsu CC, Huang KE. Detection of congenital müllerian duct anomalies using three-dimensional ultrasound. J Clin Ultrasound. 1997;25(9):487-92.

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Chat with Dr KK

Swachh Bharat, Swasth Bharat

IJCP Sutra 51: It is important to cover the face while transporting the dead body of anyone who dies after contracting Nipah fever.

OBSTETRICS AND GYNECOLOGY

Torsion of the Postmenopausal Uterus: A Surgical Emergency ANUPAMA HARI*, ADITHYA H†, SWETHA G‡, JIJIYA A#

Abstract Torsion of the nongravid uterus is rare, but can present as an acute abdominal emergency. As it causes irreversible ischemic damage to uterus and its adnexae, emergency laparotomy is mandatory as a diagnostic and therapeutic procedure. We report a case of torsion of fibroid uterus in a postmenopausal woman who presented with an acute abdomen requiring laparotomy.

Keywords: Torsion of uterus, uterine fibroids, acute abdominal emergency, laparotomy, postmenopausal

he clinical presentations as an acute abdomen in patients with uterine fibroids may include red degeneration, torsion of the subserous fibroid, torsion of the uterus along with fibroid and sarcomatous degeneration.1 As uterine torsion leads to irreversible ischemic damage to uterus and its appendages, prompt diagnosis and treatment are needed. In the present case, the woman presented with severe abdominal pain due to torsion of fibroid uterus along with its adnexae. Accurate diagnosis and subsequent emergency management saved the woman from this potentially fatal complication. Case Report A 52-year-old tribal woman was admitted to our hospital on 26/10/2010 with severe pain abdomen for 2 days. She had two living children and the last child birth was 22 years ago. Both were normal vaginal deliveries. She reached menopause 3 years ago. On probing, she volunteered that there was mild abdominal heaviness of nearly 2-month duration before coming to the hospital.

*Professor †Internee ‡Postgraduate Student Dept. of Obstetrics and Gynecology #Professor and HOD Dept. of Pathology Gandhi Medical College and Hospital, Hyderabad, Telangana Address for correspondence Dr Anupama Hari C1-Vora Towers, Madura Nagar, Hyderabad - 500 038, Telangana E-mail: hradhakrishna2020@rediffmail.com

On examination, her general condition was stable; pulse was 90/min, blood pressure (BP) was 130/80 mmHg. Abdomen examination revealed 18 weeks size midline tender mass; on bimanual examination, the same mass was felt and cervical movements were also tender. Ectocervix and vagina were found to be normal on speculum examination. Clinically, torsion of an ovarian mass was diagnosed. Computerized tomographic (CT) scan of abdomen and pelvis showed a large pelvic mass of 15.7 × 12.8 cm size, which was continuous with the uterus with multiple intralesional areas of degeneration and a preoperative diagnosis of fibroid uterus was made. Doppler ultrasound revealed hypervascularity of the mass. Serological investigations: Cancer antigen 125 (CA-125) - 27 µg/dL, triiodothyronine (T3) - 1.29 ng/mL, thyroxine (T4) - 9.4 µg/mL, thyroid-stimulating hormone (TSH) - 2.16 µIU/mL, hemoglobin - 9.8 g/dL, clotting time - 3’30”, bleeding time - 2’18”, blood group - AB +ve, fasting blood glucose - 80 mg/dL, blood urea - 26 mg/dL, serum creatinine - 0.9 mg/dL, ECG - within normal limits. On 27/10/2010, laparotomy was done using subumbilical midline incision. Laparotomy findings: Multiple fundal subserous fibroids with cumulative measurement of 22 × 15 cm along with several seedling fibroids. Uterine torsion of 360° along with its adnexae was found at the level of isthmus (Fig. 1); both fallopian tubes and ovaries were highly congested and gangrenous. Posterior surface of the fibroids showed arborizing dilated vessels (Fig 2). In view of the gangrenous appendages, total abdominal hysterectomy along with fibroids and

IJCP Sutra 52: Choose whole grains instead of foods containing processed or refined grains.

OBSTETRICS AND GYNECOLOGY

Figure 1. Torsion of 360° of uterus and its adnexae with multiple fundal fibroids.

Figure 3. Areas of hemorrhagic necrosis in the H&E stained section within the myoma. Figure 2. Dilated tortuous vessels over the fibroids and congestion of adnexae.

bilateral salpingo-oophorectomy was performed. Total weight of the specimen was 1.5 kg. Her postoperative period was good. Patient was started on higher antibiotics. One unit of blood was transfused during the postoperative period. The patient was discharged on 10th postoperative day in a stable condition. Histopathology of specimen revealed subserous myomata with areas of hemorrhagic necrosis and congestion of uterine body and its adnexae (Fig. 3). Discussion Uterine torsion is defined as rotation of uterus in its long axis by more than 45°.2 Uterine torsion during pregnancy has been reported in more than 100 cases, but torsion of nongravid uterus is very rare.3 Very few cases of torsion of uterus in postmenopausal women have been reported till date.4 The torsion of uterus

is usually at the level of supravaginal cervix, so that uterine vessels are obstructed leading to gangrenous uterus.3,5 Nongravid uterus undergoes torsion only when the uterus is asymmetrical because of tumor or abnormal müllerian duct fusion.5 As uterine torsion causes vascular damage to uterus leading to rapid clinical deterioration, prompt diagnosis and urgent management are needed.6 In the present case, the woman ignored the symptoms which were going on for 2 months, ultimately resulting in an emergency laparotomy. Uterine torsion should be considered as a differential diagnosis in all ‘acute abdomen’ cases. The other causes of acute abdomen in fibroid uterus apart from torsion of fibroid are uncommon. Red degeneration and sarcomatous degeneration, though rare, are also to be considered.1 Very rarely torsion of fibroids may lead to hemoperitoneum as a result of rupture of veins over the fibroid.1 Cases of torsion of a puerperal uterus with fibroids have also been reported.6

IJCP Sutra 53: If you drink, limiting alcohol to two drinks daily if you're a man and one if you're a woman.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Myomatous uterine torsion is difficult to diagnose preoperatively.7 The clinical spectrum ranges from pain abdomen to distention to shock.7 The differential diagnosis in a postmenopausal woman should include appendicitis, torsion of pelvic tumor and bowel obstruction.

complications like torsion of the uterus, avulsion of the fibroid and hemoperitoneum.8

Management of torsion of fibroid uterus includes prompt diagnosis and immediate laparotomy to save the life. In most of the cases, the operation involves removal of diseased uterus along with its appendages. But in young women who desire to retain fertility, myomectomy is to be considered after assessing the viability of uterus along with detorsion of the uterus.4 The round ligaments and uterosacral ligaments should be plicated to prevent the recurrence of torsion if the uterus is to be conserved.4

2. Luk SY, Leung JL, Cheung ML, So S, Fung SH, Cheng SC. Torsion of a nongravid myomatous uterus: radiological features and literature review. Hong Kong Med J. 2010;16(4):304-6.

In our case, the probable cause of uterine torsion by 360° might be the weight of the subserous fibroids acting on weak musculature of the postmenopausal uterus. Hence, the entire uterus along with fibroids was congested, necrosed and gangrenous. A total hysterectomy with bilateral salpingo-oophorectomy was performed.

5. Norman Jeff Coat. Textbook of Principles of Gynecology. 7th Edition, 2008. p. 305.

Whenever large subserous fibroids are diagnosed, they should be surgically treated even though they are asymptomatic as they are prone to life-threatening

References 1. Dasari P, Maurya DK. Hemoperitoneum associated with fibroid uterus. J Obstet Gynecol India. 2005;55(6):553-4.

3. Omurtag K, Session D, Brahma P, Matlack A, Roberts C. Horizontal uterine torsion in the setting of complete cervical and partial vaginal agenesis: a case report. Fertil Steril. 2009;91(5):1957.e13-5. 4. Daw E, Saleh N. Massive infarction of the uterus and appendages caused by torsion. Postgrad Med J. 1980;56(654):297-8.

6. Chalmers JA. Torsion of the puerperal uterus associated with red degeneration of a fibromyoma. Br Med J. 1954;2(4880):138. 7. Nicholson WK, Coulson CC, McCoy MC, Semelka RC. Pelvic magnetic resonance imaging in the evaluation of uterine torsion. Obstet Gynecol. 1995;85(5 Pt 2):888-90. 8. John A Rock, W Jones III. Te Linde’s Operative Gynecology. 8th Edition, 1996. p.741.

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IJCP Sutra 54: Control high blood pressure.

2018

PEDIATRICS

A Rare Case of Disseminated Tuberculosis with Severe Reactive Thrombocytosis SHRIKRISHNA SAD*, PRIYASHA TRIPATHI†, GUNJAN KELA‡, DEVENDRA BARUA#, HARSHA KUMAWAT¥

Abstract Tuberculosis (TB) is a major public health problem in India. Hematological parameters are useful indicators of severity in TB infection. Here, we report a case of a 15-year-old female child who came to us with severe anemia and disseminated TB (pulmonary and abdominal) with severe reactive thrombocytosis. Antitubercular drugs and broad-spectrum antibiotics (for superadded infection) were added and steroid therapy was concurrently started in view of wet type of abdominal TB. Anemia was treated with blood transfusion and hematinics and steroid therapy was gradually tapered off and then withdrawn. Treatment was monitored, and within a duration of 2-3 weeks of treatment, platelet counts showed a falling trend. The child improved clinically and symptomatically. So, she was discharged and was on regular follow-up. We are reporting this case as in this child, there are two contributing factors (anemia and TB) for thrombocytosis. We would also like to stress upon the fact that thrombocytosis can be used as a marker in TB patients, which is already known. None of the cases reported till now have such high platelet count.

Keywords: Disseminated tuberculosis, severe reactive thrombocytosis, anemia

uberculosis (TB) is a major public health problem in India.1 Every day, nearly 30,000 people fall ill with TB and 4,500 people lose their lives to this preventable and curable disease.2 TB is also the major cause of deaths related to antimicrobial resistance and the leading killer of people with human immunodeficiency virus (HIV). As per the Global TB Report 2017, the estimated incidence of TB in India was approximately 28,00,000, accounting for about a quarter of the world’s TB cases.3 The differential diagnosis of TB should be entertained in patients with some abnormal hematological findings.4 Moreover, hematological parameters are useful indicators of severity in TB infection.5

*Junior Resident (2nd Year) †Junior Resident (1st Year) ‡Associate Professor #Assistant Professor ¥Senior Resident Dept. of Pediatrics Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh Address for correspondence Dr Priyasha Tripathi Junior Resident Dept. of Pediatrics Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh E-mail: drpriyasha21@gmail.com

IJCP Sutra 55: Do moderate exercise 5 times a week.

Reactive thrombocytosis is defined as an increased number of platelets above 450 × 109/L due to a reaction to a stimulus, e.g., an inflammatory condition.6 Thrombocytosis occurs in many chronic inflammatory diseases, including TB.1,6-8 The precise stimulus for increased platelet production in reactive thrombocytosis is not clear, but it is associated with increased numbers of small megakaryocytes in the marrow.6-8 The raised concentrations of serum thrombopoiesis stimulating activity in patients with pulmonary TB suggest the presence of a circulating stimulatory factor, which is in keeping with a previous report of increased thrombopoietin concentrations in patients with TB.9 Reactive thrombocytosis is associated with an increase in erythrocyte sedimentation rate (ESR) and acute phase reactants (fibrinogen, VIII.C, von-Willebrand factor [vWF]:Ag, C-reactive protein and interleukin-6 [IL-6]). Reversible peripheral blood abnormalities are commonly associated with pulmonary TB. Insight into the relationship between hematological abnormalities and mycobacterial infection has come from an understanding of the immunology of mycobacterial infection. The atypical and varied spectrum of clinical presentation of TB poses a diagnostic and therapeutic challenge to the physicians.

PEDIATRICS Case Report A 15-year-old girl presented to us with complaints of low-grade intermittent fever, more during night, since 1½ month with mild productive cough, with history of significant weight loss, weakness and poor appetite. On admission, the patient presented with severe pallor, tachypnea, tachycardia and significant cervical lymphadenopathy. On systemic examination, pleural effusion and ascites were found which were confirmed by investigations (Figs. 1-3). On further work-up, the patient was provisionally diagnosed with disseminated TB (pulmonary and abdominal) with severe anemia and severe reactive thrombocytosis. Anemia was treated and antitubercular therapy was started along with antibiotics for superadded infection. With appropriate treatment, the patient improved clinically and platelet counts came within normal limits (Figs. 4 and 5). The patient was discharged on regular follow-up.

Figure 1. Chest X-ray suggestive of B/L ICD in situ with B/L pleural effusion (left > right) and B/L consolidation.

Figure 2. CECT abdomen - Multiple mild segmental bowel wall thickening in mid and distal ileal loops in infraumbilical region, with mild proximal small bowel dilatation and enlarged necrotic mesenteric/para-aortic lymph nodes. Mid wall thickening is also seen at the ileocecal junction. Mild ascites and bilateral pleural effusion. CECT suggestive of Koch’s abdomen.

Figure 3. 64 Slice MDCT chest - Multiple patchy dense areas of consolidation with adjacent centrilobular nodule seen, scattered in both lung segments with upper lobe predominance. Moderate bilateral pleural effusion and subsegmental collapse seen. IC drain is seen in situ. Multiple discrete lymph nodes are seen in pre- and paratracheal/ subcarinal, bilateral hilar region, upper abdomen para-aortic region, average size 1-2.5 cm.

IJCP Sutra 56: Eat a healthy balanced diet high in fruits and vegetables and low in sodium.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

ESR in patients with pulmonary TB was done in 100 randomly selected patients. Thrombocytosis was reported in 20% of the patients. Therefore, presence of such hematological changes should raise the suspicion of pulmonary TB.13

Platelet count (Lacs)

Hemoglobin (g/dL) 20 15 10 5 0

Figure 4. The course of platelet count and hemoglobin during treatment course for TB. Hemoglobin (g/dL)

Platelet count (Lacs)

30 25

15 10

References

1. Bannerman RG. Blood-plate count in tuberculosis. Lancet. 1924;204(5273):593-5.

0 7-

0 9-

0 1-

0 2-

0 4-

0 6-

0 8-

0 0-

0 2-

0 4-

0 6-

Figure 5. The course of platelet count and hemoglobin during treatment course for TB.

Discussion TB is a major health problem in India. The association between TB and deranged hematological profile (severe anemia and severe thrombocytosis), an uncommon occurrence, has been reported in our study, which is similar to a study done in the year 1987 at the Dept. of Medicine, University of Witwatersrand, Johannesburg, South Africa in 122 patients that suggested a direct correlation between platelet counts and chronic inflammatory disease, like TB.10 In other studies, Olaniyi et al11 and Akintunde et al12 studied the hematological profile of patients with pulmonary TB in Ibadan, Nigeria and reported that thrombocytosis occurred in 12.9% and 18% of patients, respectively. On the other hand, in the study done in Dept. of Hematology, Port Sudan Ahlia College, Port Sudan, Sudan, assessment of reactive thrombocytosis and

The precise stimulus for increased platelet count is not clear but due to inflammatory process, there is increase in megakaryocytes in the bone marrow. In another study done at Baptist Hospital, Miami, 37 patients with positive TB culture were selected out of which, 19 patients had thrombocytosis.15 On the contrary, in our case, there were two stimulatory factors for thrombocytosis - severe anemia and chronic inflammatory disease like TB.

Reactive thrombocytosis is found in a number of infectious diseases like TB. In another study done in the year 2017 in the Dept. of Medicine, Rajiv Gandhi Medical College, Thane, India, 112 TB patients were randomly selected. Out of these, thrombocytosis was detected in 84 (75%) of the TB patients.14 The objective of this study was to prove that thrombocytosis can be used as a marker for TB.

IJCP Sutra 57: Reduce your cholesterol.

pulmonary

2. World Health Organization. Tuberulosis (TB). Available at: http://www.who.int/tb/features_archive/world_TB_ day_2018_campain/e/. 3. Indian TB Report 2018: Revised National TB Control Programme - Annual Status Report. Available at: https:// tbcindia.gov.in/showfile.php?lid=3314. 4. Marchasin S, Wallerstein RO, Aggeler PM. Variations of the platelet count in disease. Calif Med. 1964; 101:95-100. 5. Wintrobe MM, Lee GR, Boggs DR, Bithell TC, Athens JW, Forster J. Clinical Hematology. 7th Edition, Philadelphia: Lea Febiger; 1974. pp. 1103-18. 6. Williams WJ. Thrombocytosis. In: Williams WJ, Beutler E, Erslev A, Lichtman MA, (Eds.). Hematology. 3rd Edition, New York: McGraw-Hill Book Company, 1983. pp. 1342-5. 7. Harker LA, Finch CA. Thrombokinetics in man. J Clin Invest. 1969;48(6):963-74. 8. Tranum BL, Haut A. Thrombocytosis: platelet kinetics in neoplasia. J Lab Clin Med. 1974;84(5):615-9. 9. Shreiner DP, Weinberg J, Enoch D. Plasma thrombopoietic activity in humans with normal and abnormal platelet counts. Blood. 1980;56(2):183-8. 10. Baynes RD, Bothwell TH, Flax H, McDonald TP, Atkinson P, Chetty N, et al. Reactive thrombocytosis in pulmonary tuberculosis. J Clin Pathol. 1987;40(6):676-9.

PEDIATRICS 11. Olaniyi JA, Aken’Ova YA. Haematological profile of patients with pulmonary tuberculosis in Ibadan, Nigeria. Afr J Med Med Sci. 2003;32(3):239-42. 12. Akintunde EO, Shokunbi WA, Adekunle CO. Leucocyte count, platelet count and erythrocyte sedimentation rate in pulmonary tuberculosis. Afr J Med Med Sci. 1995;24(2):131-4. 13. Bashir AB, Ageep Ali K, Abufatima AS, Mohamedani AA. Reactive thrombocytosis and erythrocyte sedimentation

rate in patients with pulmonary tuberculosis. J Med Lab Diagn. 2014;5(3):29-34. 14. Rathod S, Samel DR, Kshirsagar P, Pokar M. Thrombocytosis: can it be used as a marker for tuberculosis? Int J Res Med Sci. 2017;5(7):3082-6. 15. Renshaw AA, Gould EW. Thrombocytosis is associated with Mycobacterium tuberculosis infection and positive acid-fast stains in granulomas. Am J Clin Pathol. 2013; 139(5):584-6.

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Make sure During Medical Practice

Situation:

A 40-year-old man constantly had systolic BP >140 mmHg and diastolic BP >90 mmHg.

Why did you not start antihypertensive medication?

Lesson:

The Eighth Joint National Committee (JNC8) guidelines for the management of high BP in adults recommend initiation of pharmacologic therapy to lower BP at systolic BP ≥140 mmHg and at diastolic BP ≥90 mmHg. JAMA. 2014;311(5):507-20.

IJCP Sutra 58: Maintain a healthy BMI or waist-to-hip ratio.

Medicolegal

Right to Avail Health Insurance is an Integral Part of the Right to Healthcare and the Right to Health, as Recognised in Article 21 of the Constitution of India, 1950 Ira Gupta

he Hon’ble High Court of Delhi in the matter titled as “M/s. United India Insurance Company Limited versus Jai Parkash Tayal, RFA No. 610/2016” has considered the issue of whether persons having genetic disorders can be discriminated against in the context of health insurance. Facts of the case Mr Jai Prakash Tayal, who is the Respondent/Plaintiff in the case (hereinafter referred to as “Plaintiff”), took an insurance policy for himself along with his wife and daughter, from the United India Insurance Company Limited i.e., the Appellant/Defendant in the case (hereinafter referred to as “Defendant”). The said policy is a mediclaim policy where the sum insured is Rs. 5 lakhs per individual. The Plaintiff submits he had first taken a mediclaim on 11th September, 2000 with the National Insurance Co. Ltd. vide policy No. 2000/8100540. The said policy was shifted to Defendant on 10th September, 2004, after which the policy was renewed continuously year to year without break till 10th September, 2012. The Plaintiff suffered from HOCM i.e., Hypertrophic Obstructive Cardiomyopathy (hereinafter referred to as “HOCM”). He was hospitalised on 23rd January, 2004 and 27th February, 2006 and his claims for the said periods have been honoured and payments were made by the Insurance Company. Thereafter, the Plaintiff was again hospitalised for treatment on 27th November, 2011 and was discharged on 30th November, 2011. He made a claim for an amount of Rs. 7,78,864/- with the Defendant. The said claim was rejected vide letter dated 6th February, 2012, where the reasons for rejection were mentioned as– “...We are closing your claim file, on account of the following reasons: TPA Vipun Medcorp P Ltd had repudiated your claim. Since genetic diseases are not

IJCP Sutra 59: Stop smoking and avoid second hand exposure.

payable as per the policy, genetic exclusion clauses.” (extracted verbatim) It is the Plaintiff’s case that the exclusion of genetic disorders was not a part of the initial policy which was availed by him but was added as part of the `Exclusions’ in a later policy document, without specific notice to him and hence the said exclusions do not bind him. However, the stand of the Defendant was that HOCM is a genetic disorder which is clearly excluded and hence the claim is not liable to be entertained. Thereafter the plaintiff issued a legal notice to the Defendant, which was duly replied by the defendant whereby the Defendant refused to pay the claim as the genetic disorders are excluded in the policy document. Thereafter, the plaintiff filed a civil suit for recovery of an amount of Rs. 7,78,864/- against the Defendant. In the said civil suit for recovery, the Learned Trial Court vide judgement held that an insurance policy has to be renewed on the existing terms and conditions, and at the time of renewal, fresh clauses and exclusions cannot be added. The Learned Trial Court held that no advance notice was given to the Plaintiff and that some new clauses have been added to the policy. The Learned Trial Court thereafter went into the question of whether the ailment of the Plaintiff was validly excluded from the mediclaim policy, and if so, had the Defendant acted contrary to law. The Learned Trial Court observed that twice in the past, for the same disease, the claims of the Plaintiff had been approved. The Learned Trial Court thereafter held that there cannot be a discriminatory clause against those persons who suffered from genetic disorders and they are entitled to medical insurance. The Learned Trial Court decreed the suit for a sum of Rs. 5 Lakhs along with interest of 8% per annum and rejected the claim for damages of Rs. 2,78,864/-.

Medicolegal Being aggrieved by the decree and judgement of the Learned Trial Court, the Defendant i.e., United Insurance India Company Limited filed an appeal before the Hon’ble High Court of Delhi. The two clauses from the insurance policy which are relevant to the case at hand are– “1.1 NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions contained herein or endorsed, or otherwise expressed here on the Company undertakes that during the period stated in the Schedule, if any insured person(s) contracts any disease or suffers from any illness (hereinafter called INJURY) and is such disease or injury requires such insured Person upon the advice of a duly qualified Physician/Medical Specialist/Medical Practitioner (hereinafter called MEDICAL PRACTITIONER) or of a duly qualified Surgeon (hereinafter called SURGEON) to incur hospitalisation/domiciliary hospitalisation expenses or medical/surgical treatment at any Nursing Home/Hospital in India as herein defined (hereinafter called HOSPITAL) as an inpatient, the Company will pay through TPA to the Hospital/Nursing Home or the Insured Person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such Insured Person but not exceeding the Sum Insured in aggregate in any one period of insurance stated in the schedule hereto .... 4. EXCLUSIONS:- .... 4.1-4.16 4.17 Genetic disorders and stem cell implantation/ Surgery” Thus, the Insurance Company would pay the sum insured in the policy “subject to” the exclusion clause. If the medical condition is covered by any of the exclusions, the claim is liable to be disallowed. “Genetic disorders” is one such exclusion. The Hon’ble High Court of Delhi considered two questions in the present appeal which are as follows– (i) Whether the exclusion in relation to “genetic disorders” is valid and legal? (ii) Whether the exclusionary clause 4.17 relied upon by the Defendant for rejecting the claim of the Plaintiff applies on facts? Judgement of Hon’ble High Court of Delhi After hearing the submissions and taking into consideration the laws and norms in the foreign jurisdictions and the Indian Position, the Hon’ble High Court of Delhi held that

IJCP Sutra 60: Reduce alcohol intake.

“F.1.To conclude: (i)

Right to avail health insurance is an integral part of the Right to Healthcare and the Right to Health, as recognised in Art. 21 of the Constitution;

(ii) Discrimination in health insurance against individuals based on their genetic disposition or genetic heritage, in the absence of appropriate genetic testing and laying down of intelligible differentia, is Unconstitutional; (iii) The broad exclusion of “genetic disorders” is thus not merely a contractual issue between the insurance company and the insured but spills into the broader canvas of Right to Health. There appears to be an urgent need to frame a proper framework to prevent against genetic discrimination as also to protect collection, preservation and confidentiality of genetic data. Insurance companies are free to structure their contracts based on reasonable and intelligible factors which should not be arbitrary and in any case cannot be “exclusionary”. Such contracts have to be based on empirical testing and data and cannot be simply on the basis of subjective or vague factors. It is for lawmakers to take the necessary steps in this regard. (iv) The Exclusionary clause of “genetic disorders”, in the insurance policy, is too broad, ambiguous and discriminatory - hence violative of Art. 14 of the Constitution of India; (v) Insurance Regulatory Development Authority of India (IRDA) is directed to re-look at the Exclusionary clauses in insurance contracts and ensure that insurance companies do not reject claims on the basis of exclusions relating to genetic disorders. Thus, the Hon’ble High Court upheld the judgement of the Learned Trial Court and held that: “F.2. The Trial Court has rightly held that a person, suffering from a genetic disorder, needs medical insurance as much as others. The suit is decreed for a sum of Rs. 5 lakhs along with interest @12% from the date of filing of the claim with the Appellant Insurance Company till the date of payment; F.3. The Plaintiff has been contesting the appeal for more than one and a half years and though the money has been released to him, he has submitted a bank guarantee to secure the said amount. The suit was filed in the year 2012. The Plaintiff is entitled to costs. Costs of Rs. 50,000/- are awarded. The bank guarantee submitted by the Plaintiff is released. All pending CMs are disposed of.”

Conference Proceedings

69th Annual Conference of the Cardiological Society of India (CSI 2017) Remote Hemodynamic Monitoring in Ambulatory Heart Failure Dr Joy M Thomas, Chennai ÂÂ

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Ambulatory heart failure (HF) patients constitute Heart Failure Groups I and II and Class A, B and C. They may be on conventional standard management, may have a device implanted, had an left ventricular assist device (LVAD) implanted or be a heart transplant recipient. Any of these categories are benefited if we are able to predict when they will be heading for a hospitalization. The hemodynamic parameters that we should look at include left atrial pressure, autonomic adaptation in the form of heart rate and vagal nerve activity, fluid accumulation by thoracic impedance and body weight increase.

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These parameters can be measured with remote monitoring devices and acted upon to treat and delay or avoid the oncoming hospitalization.

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These devices have been tested in clinical trials: COMPASS HF, TELE HF, TIMI HF, HOMEOSTASIS and CHAMPION.

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In monitoring patients with LVADs, there is difficulty in assessing the parameters because of continuous flow devices compared to the natural pulsatile flow that has been seen all along in native hearts. Compromises have been made by assessing Doppler derived pressures whose accuracy is questionable and less than desirable.

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Newer monitoring devices use integrated flow probes that, by a feedback mechanism, are able to control the output monitor data as well.

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Newer challenges will be to create “smart pumps” that are able to integrate right ventricular pressures, filling and flow; and to integrate them with left ventricular functions will be the monitoring device of the future with artificial intelligence thrown in.

An Update on Hypertension Treatment Dr PK Biswas, Kolkata ÂÂ

High blood pressure (BP) is the single largest risk factor for disease burden worldwide.1

IJCP Sutra 61: Identify and treat atrial fibrillation.

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In India, high BP has emerged as a leading risk factor for mortality.1

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It is predicted that the burden of hypertension in India is expected to almost double from 118 million in 2000 to 213.5 million by 2025.2

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The 2017 clinical practice guidelines on hypertension recommend non-pharmacological interventions as the treatment of choice for adults with stage 1 hypertension but otherwise at low risk of atherosclerotic cardiovascular disease (ASCVD).3

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Antihypertensive drug therapy along with nonpharmacological therapy is recommended for adults with stage 1 hypertension at a high risk for ASCVD.3

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The 2017 treatment guidelines suggest a diuretic, angiotensin-converting enzyme inhibitor (ACEI), angiotensin II receptor blocker (ARB) or calcium channel blocker (CCB) as acceptable first stage agents, but identifies thiazide diuretics and CCBs as good options for monotherapy.3

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In spite of various effective treatments hypertension being available, novel therapies required to reduce the elevated BP, improve control, treat resistant hypertension and reduce associated cardiovascular (CV) risk factors.

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Azilsartan is a new ARB with better clinical BPlowering effects compared to other ARBs with good tolerance.4

of are BP the

References: 1Roy A, et al. BMJ Open. 2017;7(7):e015639. 2Kearney PM. Lancet. 2005;365(9455):217-23. 3Whelton PK. JAMA. Nov 20 2017. 4Shetty M, et al. Int J Contemp Med Res. 2017;4(6):1262-4.

PCSK9 Inhibitors as Add-on to Statins: Evidence Base for Current Clinical Utility Prof Dr PC Manoria, Bhopal ÂÂ

PCSK9 is a new validated target for lipid management. PCSK9 is an enzyme expressed in the liver and produces lysosomal degradation of lowdensity lipoprotein cholesterol (LDL-C) receptors, which are the prime pathway for hepatic clearance of LDL-C from the blood. PCSK9 inhibition will

Conference Proceedings therefore decrease LDL-C and atherogenicity. Two fully humanized monoclonal antibodies against PCSK9 (evolocumab and aliorcumab) have been approved for clinical use and they have consistently decreased LDL-C by 40-60% in various trials. They have a favorable effect on other lipoproteins also and interestingly they also decrease lipoprotein(a) [Lp(a)] by ~25%. Evolocumab is given as 1 mL subcutaneous (SC) injection 140 mg biweekly or 420 mg monthly. Aliorcumab is used in doses 75 mg biweekly or 150 mg monthly. Bococizumab trials SPIRE I and II have been prematurely terminated because of neutralizing antibodies, but the later trial had shown reduction in CV events by 21%. ÂÂ

The landmark secondary prevention FOURIER trial with evolocumab released in 2017 has passed on three unprecedented big messages: It has evoked a new concept of super low LDL i.e., 25 mg/dL never heard before; evolocumab has incredible safety; evolocumab showed incremental benefit on top of statins.

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There was an incremental 15% reduction in the primary efficacy endpoint of CV death, myocardial infarction (MI), stroke and hospitalization for unstable angina or coronary revascularization and a 20% reduction in secondary efficacy endpoint of CV death, MI or stroke. All subsets of patients benefited. The curves were divergent so that number needed to treat (NNT) at 1 year was 74 and at 2 years it dropped to 50. It seems that if the trial was followed for a longer period of time, the benefit would have increased further.

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Surgical Options for HOCM Dr Ganeshakrishnan Iyer, Bengaluru ÂÂ

Septal myectomy is the gold standard, where expertise is available.

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Septal myectomy has better long-term benefits.

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Alcohol septal ablation is an alternative for patients who are poor surgical candidates.

IV Iron, Not Oral, Improves Functional Capacity in HF Patients Dr Puneet Rastogi, Gwalior Last year, two new studies testing iron supplementation in patients with HF yielded opposite findings. The two studies - IRONOUT with oral iron and EFFECTHF with IV ferric carboxymaltose - evaluated similar endpoints. A convenient and easy-to-use oral iron supplement failed to show any improvement in functional capacity and other endpoints, while IV iron complex tested in HF patients with and without anemia significantly improved peak oxygen uptake (VO2) when compared with standard of care. Oral iron does not work in patients with HF because it is not adequately absorbed. In addition to EFFECT-HF, two previous studies, FAIR-HF and CONFIRM-HF, have shown that IV iron supplementation can improve 6-minute walk distance and quality-of-life and decrease HF hospitalizations. Nuclear Imaging is Passé: CMR is the New “Gold Standard” Dr Johann Christopher, Hyderabad

PCSK9 monoclonal antibodies have emerged as a new star on the horizon of lipid management. They are indicated in three subsets of patients: Patients with ASCVD not achieving LDL-C goals, familial hypercholesterolemia, statin intolerance.

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Valvular regurgitation can be assessed by multiple imaging modalities.

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2D Echo is the first-line investigation for valvular regurgitation. It has complex algorithms and significant inter-observer variability.

As per WHO, dyslipidemia accounts for 50% of all CV events. We know from CTT meta-analysis that high-intensity statin therapy decreases LDL-C by 1 mmol and this translates into reduction of CV events by 20-24%. PCSK9 inhibitors decrease LDL-C by additional 1 mmol and they will decrease CV events by another 20%. Thus, when used together, they will decrease CV events by 40-45% and we will able to minimize lipid atherogenicity to very great extent. Thus, after witnessing the statin era for last 30 years, we are now heading for another revolution after statin therapy.

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Magnetic resonance imaging (MRI) has a very simple algorithm of the regurgitant volume being the difference of the total stroke volume (LV/RV) and the forward volume (AO/PA), both of which are directly measured without any geometric assumptions. MRI scanners are now available across the length and breadth of the country. The scan requires only 1 hour and is extremely cost-effective.

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Cardiac MRI is a noninvasive and nonradiationbased technique. It looks at wall thickness, myocardial perfusion, delayed enhancement and contractile reserve.

IJCP Sutra 62: Prevent exposure to dust mites. These are tiny insects and one of the most common asthma triggers.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

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I would consider cardiac MRI as the gold standard for the assessment of valvular regurgitation.

Cardiovascular Polypill: Rationale, Evidence and Progress to Date

by its blood level and incidence of coronary heart disease (CHD). This finding (besides the ease of its measurement) has placed HDL-C in the position of an important risk factor. ÂÂ

However, two streams of information suggest that though it may be epidemiologically related to cardiovascular disease (CVD), it is not causally related. Thus although it is an important risk marker, it may not be a causally related risk factor.

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One is the series of negative therapeutic trials and the other is multiple Mendelian randomization studies, which have shown lack of correlation between levels of HDL-C and incident CHD. In fact, these studies have shown that it is not the ‘amount’ of cholesterol with HDL that is related to CHD incidence but four factors related to the HDL particle that impact the risk of coronary artery disease (CAD) namely, composition, function, size and number of HDL particles.

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Hence future efforts at preventing CHD should concentrate on modifying these aspects of HDL particles, rather than modifying the amount of HDL-C.

Dr Mark Huffman, Chicago ÂÂ

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Rather than being a panacea for all, polypills represent the most effective and scalable intervention for improving adherence to multidrug therapy for initiation, step-up or substitution indications. Polypill trials have been generally designed to demonstrate bioequivalence rather than differences in clinical outcomes; high quality “usual care” seen in trials limits power. Polypills are essential medicines for secondary ASCVD prevention, especially among low adherers, and the growth of polypill suggests an opening of the marketplace for these combinations.

Chemotherapy-induced Cardiac Dysfunction: How to Prevent It? Prof Dr Geetha Subramanian, Varanasi ÂÂ

Choose the less cardiotoxic drugs or the less cardiotoxic combinations (including radiotherapy).

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Choose chemotherapy doses with less risk of cardiotoxicity.

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Accumulative dose and the schedule of chemotherapy are important factors for cardiotoxicity.

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Controversies in Lipid Management Dr Devendra Prasad Singh, Bhagalpur ÂÂ

Prepare chemotherapy with a lower potential cardiotoxicity effect, for instance in anthracyclines with continuous infusions or altered delivery systems (i.e., Liposomal doxorubicin).

For decades, statin therapy has been the cornerstone in the management of dyslipidemia. But numerous studies failed to demonstrate a mortality benefit in CVDs.

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In contrast, Mediterranean diet consistently lowers CV events without lowering cholesterol level.

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Try to detect and properly control CV risk factors.

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Start CV treatment with an ACEI (or ARB) and a β-blocker in high-risk patients or in patients with low normal heart function, as well as in patients with a reduced or recovered ejection fraction.

Framingham studies have shown association of high cholesterol and triglycerides with CVDs. It has been argued that association does not mean causation and many trials show that statins are no good; hence, the controversies.

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Dexrazoxane has been shown to prevent LVEF in patients treated with doxorubicin, and should be considered in high-risk patients.

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Statins are not without side effects; 30% patients taking statins have muscle aches and rarely rhabdomyolysis. Long-term statin therapy causing type 2 diabetes mellitus (T2DM) and dementia, further questions the utility of statin therapy.

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Recent controversy is regarding dosing approach. Fixed-dose-treatment vs. titrating-to-target level neither of these approaches is inferior.

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CAD is an extremely complex malady. Until the controversies of cholesterol hypothesis vs. alternate mechanism of pathogenesis of atherosclerosis are

HDL and CVD Risk: The Current Understanding Dr Akshay Mehta, Mumbai ÂÂ

Observational studies have shown an inverse relationship between the amount of high-density lipoprotein cholesterol (HDL-C) represented

IJCP Sutra 63: It is important to keep all these things dust free.

Conference Proceedings procedures is pivotal for ensuring patient safety and procedure outcomes and follow-up.

settled, statin therapy will stay along with healthy lifestyle, Mediterranean diet and aspirin in the prevention of CVDs.

Vaccinations in HF can Make a Lot of Difference Myocardial Involvement in Rheumatic Fever: Does it Occur and What is its Relevance? Prof A George Koshy, Trivandrum Traditionally, acute rheumatic fever (ARF) is known to produce pancarditis (endocarditis, myocarditis and pericarditis). Histopathological studies have demonstrated interstitial myocardial infiltrates and Aschoff bodies in ventricular myocardium but significant necrosis is not known to occur. Echocardiographic studies have shown that HF in ARF and carditis is due to endocarditis and consequent mitral and aortic regurgitation. Aortic regurgitation (AR) does not occur in the absence of mitral regurgitation (MR). It is due to a combination of valvulitis, chorditis and annulitis. The LV systolic function is normal in ARF unlike in viral myocarditis. The left ventricular ejection fraction (LVEF) and shortening fraction are normal. HF and LV dilatation tend to normalize within a short period following valve surgery. Chordal inflammation can lead to lengthening and sometimes rupture leading to prolapse of the anterior mitral leaflet. Chordal rupture can produce flail anterior mitral leaflet and acute severe MR. High sensitivity cardiac troponins, which are highly sensitive markers of myocardial necrosis, are not significantly elevated in rheumatic carditis. Limited cardiac magnetic resonance studies during the acute phase have also failed to demonstrate significant myocarditis. Studies from South Africa have demonstrated that valve reconstruction and replacement are effective and safe life-saving options in sick children with severe HF following ARF. Clinically significant myocarditis does not occur in acute ARF. Optimizing Outcomes of TAVR: Role of Imaging Dr Partho P Sengupta, USA ÂÂ

Ensure patient suitability and selection of device size.

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While computed tomography (CT) remains gold standard, echo can be used for device sizing in selective situation when CT is suboptimal or cannot be done.

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Transthoracic echocardiogram/transesophageal echocardiogram (TTE/TEE) guidance during transcatheter aortic valve replacement (TAVR)

IJCP Sutra 64: Restrict the child’s contact with pets especially if he/she is allergic.

Dr Vitull K Gupta, Punjab Vaccination has proved to be one of the most costeffective disease prevention strategies. Adult vaccination program in India has been at crossroads and is the most ignored area with negligible coverage. Protecting adults by vaccination is yet to be recognized as a preventive strategy in India. HF patients are at increased risk of CV and respiratory related hospitalizations compared with the general public. Vaccination coverage in HF patients is poor and requires sensitization regarding vaccination efficacy and safety. The evidence to date suggests that vaccination represents a low-cost intervention that may be able to prevent the significant morbidity, mortality and system-wide costs associated with HF. HF patients should receive routine adult immunization to decrease the incidence of vaccine-preventable disease. India needs to immediately address the challenge of adult immunization. In the absence of specific vaccination guidelines or schedule for people with cardiac disorders, adult vaccination must become a part of routine immunization because these vaccines can save millions of lives in India alone, especially in chronic diseases including HF. HYPERTENSION During Pregnancy: Mechanisms and Therapeutic Options Dr Vitull K Gupta, Punjab ÂÂ

Hypertensive disorders of pregnancy, including pre-eclampsia, complicate up to 10% of pregnancies, constituting one of the greatest causes of maternal and perinatal morbidity and mortality.

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Placenta plays a central role in the pathogenesis of pre-eclampsia. The reduced uteroplacental perfusion, which develops as a result of abnormal cytotrophoblast invasion of spiral arterioles, triggers the cascade of events leading to the maternal disorder. Placental ischemia leads to release of soluble placental factors, many of which are classified as anti-angiogenic or pro-inflammatory. Once these ischemic placental factors reach the maternal circulation, they cause widespread activation and dysfunction of the maternal vascular endothelium that results in enhanced formation of endothelin-1 and superoxide, increased vascular sensitivity to angiotensin II and decreased formation of vasodilators such as nitric oxide.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

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Current therapy does not ameliorate the placental pathology nor alter the pathophysiology or natural history of pre-eclampsia. Treatment of hypertension in pregnancy does not cure pre-eclampsia but is intended to prevent cerebral hemorrhage and eclampsia and perhaps delay progression of proteinuria. Delivery is the definitive management and is followed by resolution, generally over a few days but sometimes much longer.

Recent Advances in Lower Limb Interventions AND Peripheral BRS Technology

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The superficial femoral artery (SFA) is a challenging artery to treat. Key developments in SFA intervention range from percutaneous transluminal angioplasty (PTA), atherectomy, stent/stent grafts to drugeluting stents (DES) and drug-coated balloons.

A team approach, involving obstetrician, midwife, neonatologist, anesthetist and physician provides the best chance of achieving a successful outcome for mother and baby. Regular and ongoing reassessment of both the maternal and fetal condition is required.

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Indications for stenting include: > Fontaine IIb claudication, non-healing ulcer, limb salvage in cases of impending gangrene.

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Alternative technologies/devices for femoropopliteal artery intervention include covered stent, DES, cryoplasty, excimer laser angioplasty, atherectomy.

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Some trials involving different SFA endovascular therapies include RESILIENT, DURABILITY, ZILVER PTX, IN.PACT SFA, LEVANT 2, DEFINITIVE LE.

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A stent with interwoven nitinol design that is selfexpanding and has high radial force and flexibility, can be used for calcified SFA lesions. Stem cell therapy is an emerging treatment modality for management of critical limb ischemia (CLI) in cases where revascularization is not possible.

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Lithoplasty for treatment of calcified SFA/popliteal disease was studied in DISRUPT PAD trial. Potential benefits of bioresorbable scaffolds (BRS) include absence of rigid metallic cage, late lumen enlargement and restoration of vasomotor tone.

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Limitations of first-generation BRS include lower modulus leading to higher recoil, lower yield strength and lower tensile strength leading to increased susceptibility to fractures. Nextgeneration BRS is designed to improve on all these aspects, with reduced strut thickness.

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Drug-eluting balloon (DEB) efficacy has been proven in short (<9-10 cm) noncalcified de novo lesions. DEB could be the first-line strategy for Trans-Atlantic Inter-Society Consensus (TASC) A, B and C de novo lesions. For long lesions, the combination of atherectomy and DEB could be a good option.

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Newer percutaneous treatment options are associated with much lower procedural complications and good long-term outcomes.

Different Bleeding Scores: A Comparison

Dr NN Khanna, New Delhi

Dr U Kaul, New Delhi Pharmacological treatment for patients with CVD, especially acute coronary syndrome (ACS) has considerably improved during the past years. As most drugs which reduce ischemia by way of preventing thrombosis increase bleeding, a balance needs to be maintained. There are several scores to risk stratify these events. The Bleeding Academic Research Consortium (BARC) bleeding score is one of the consensus documents to maintain uniformity in reporting bleeding events. Models are needed to assess a patient’s risk for predicting bleeding as well as ischemic complications to assess therapies. Which NOAC for which Patient with VTE? Dr Karthikeyan G, Chennai Non-vitamin K antagonist oral anticoagulants (NOACs) are better alternatives than traditional anticoagulants in the treatment of venous thromboembolism (VTE). Parenteral anticoagulation can be overlapped with an NOAC instead of warfarin. NOACs are effective in the treatment of acute VTE and prevention of recurrence in the long-term and extended-term. But remember, patients with progressive deep vein thrombosis/ pulmonary embolism (DVT/PE) with unstable hemodynamics still require conventional therapy with a heparin/fondaparinux with warfarin.

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IJCP Sutra 65: Maintain a healthy weight and encourage good eating habits.

AROUND THE GLOBE

News and Views Investing in NCD Control Generates Major Financial and Health Gains, Says WHO A new World Health Organization (WHO) report “Saving lives, spending less: a strategic response to noncommunicable diseases (NCDs)” has shown that the world’s poorest countries can gain US$350 billion by 2030 by scaling up investments in preventing and treating chronic diseases, like heart disease and cancer, that cost an additional US$1.27 per person annually. Such actions would save more than 8 million lives over the same period. The report also reveals for the first time, the financing needs and returns on investment of WHO’s costeffective and feasible “best buy” policies to protect people from NCDs, the world’s leading causes of ill health and death. It shows that for every US$1 invested in scaling up actions to address NCDs in low- and lower-middle-income countries (LLMICs), there will be a return to society of at least US$7 in increased employment, productivity and longer life. If all countries use these interventions, the world would move significantly closer to achieving Sustainable Development Goal (SDG) 3.4 to reduce premature death from NCDs by one-third by 2030. Among the most cost-effective “best buy” interventions are increasing taxes on tobacco and alcohol, reducing salt intake through the reformulation of food products, administering drug therapy and counseling for people who have had a heart attack or stroke, vaccinating girls aged 9-13 years against human papillomavirus and screening women aged 30-49 years for cervical cancer… (WHO, May 16, 2018)

Resistance Exercise Reduces Symptoms of Depression A meta-analysis of 33 clinical trials published online May 9, 2018 in JAMA Psychiatry has shown that resistance exercise training significantly reduces the symptoms of depression regardless of the duration, frequency of the sessions and amount of exercise.

US FDA Approves Daratumumab + VMP for Newly Diagnosed Multiple Myeloma Patients The US Food and Drug Administration (US FDA) has approved the use of daratumumab in combination

IJCP Sutra 66: Include plenty of fruits, vegetables and whole grains in their diet.

with bortezomib, melphalan and prednisone (VMP) for the treatment of patients with newly diagnosed multiple myeloma who are ineligible for autologous stem cell transplant (ASCT).

Shorter Treatment Duration of Trastuzumab for HER2-positive Breast Cancer as Effective as Standard Duration Taking trastuzumab for 6 months was noninferior to the current standard of 12 months in women with HER2-positive, early-stage breast cancer. The diseasefree survival rate at 4 years was 89.4% with 6 months of therapy and 89.8% with 12 months of therapy. Cardiac side effects were fewer with shorter duration as only 4% of women in the 6-month arm stopped trastuzumab early because of cardiac problems, compared with 8% in the 12-month arm. These results were presented at the 2018 American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago.

Disruptions in Circadian Rhythms Increase Risk for Bipolar Disorder and Depression Poor sleep and disruptions in circadian rhythm are associated with a higher risk for bipolar disorder and major depressive disorder, according to a study published May 15, 2018 in The Lancet Psychiatry. Circadian rhythm disruption was also linked to a higher risk for greater mood instability, more loneliness, lower health satisfaction and happiness and higher neuroticism.

A Better Diet may Prevent Brain Shrinkage in Older Adults People who eat a diet rich in vegetables, fruits, nuts and fish may have bigger brains, according to a study published online May 16, 2018 in Neurology. Those who consumed a better diet had an average of 2 mL more total brain volume as compared to those who did not. Having a brain volume that is 3.6 mL smaller is equivalent to 1 year of aging.

The First Non-opioid Treatment for Management of Opioid Withdrawal Symptoms in Adults The US FDA has approved lofexidine hydrochloride for the mitigation of withdrawal symptoms to facilitate abrupt discontinuation of opioids in adults. While lofexidine hydrochloride may lessen the severity of

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

withdrawal symptoms, it may not completely prevent them and is only approved for treatment for up to 14 days. Lofexidine hydrochloride is not a treatment for opioid use disorder (OUD), but can be used as part of a broader, long-term treatment plan for managing OUD.

A New Rapid Test for Rabies The Centers for Disease Control and Prevention (CDC) has developed a new rabies test 'LN34 test' designed for use in animals, which can more easily and precisely diagnose rabies infection, according to a study published May 16, 2018 in PLoS One. In the pilot study, it produced no false negatives, fewer false positive and fewer inconclusive results. The test may help doctors and patients to make better informed decisions about who needs treatment for rabies.

First FDA-approved Preventive Treatment for Migraine The US FDA has approved erenumab-aooe for the preventive treatment of migraine in adults. Given as once-monthly self-injections, it is the first FDAapproved preventive migraine treatment in a new class of drugs that work by blocking the activity of calcitonin gene-related peptide, a molecule that is involved in migraine attacks.

One in 3 Swimming-related Disease Outbreaks Occur at Hotels According to a report published May 17, 2018 in CDC’s Morbidity and Mortality Weekly Report, one-third of treated recreational water-borne disease outbreaks such as diarrhea, respiratory illnesses and skin rashes during 2000 through 2014 occurred in hotel pools or hot tubs. The most common pathogens involved are Cryptosporidium, Pseudomonas and Legionella.

AHA Recommends Eating Two Servings of Fish Per Week A new scientific advisory reaffirms the American Heart Association’s recommendation to eat fish, especially those rich in omega-3 fatty acids twice a week to help reduce the risk of heart failure, coronary heart disease, cardiac arrest and stroke (ischemic). The advisory is published May 17, 2018 in the journal Circulation. Emphasis should be placed on eating oily fish like salmon, mackerel, herring, lake trout, sardines or albacore tuna, which are all high in omega-3 fatty acids.

Clopidogrel and Aspirin Combination Therapy may Prevent Stroke Results from a trial published May 17, 2018 in the New England Journal of Medicine show that compared to aspirin alone, combining aspirin and clopidogrel following a small stroke or experiencing minor stroke symptoms decreases risk of a new stroke, heart attack or other ischemic event within 90 days. However, combination therapy was associated with a greater risk of hemorrhage.

High-intensity Exercise does not Prevent Cognitive Impairment in Patients with Dementia A moderate- to high-intensity aerobic and strength exercise training program does not slow cognitive impairment in patients with mild-to-moderate dementia even as it improves physical fitness, according to the findings of the Dementia And Physical Activity (DAPA) trial published online May 16, 2018 in the BMJ.

WHO “Triple Billion” Targets After 1 year in office, WHO Director-General, Dr Tedros Adhanom Ghebreyesus opened the 71st World Health Assembly in Geneva with an ambitious agenda for change that aims to save 29 million lives by 2023. Ministers of Health and other delegates from WHO’s 194 Member States met to discuss a range of issues, including the 13th General Program of Work, which is WHO’s 5-year strategic plan to help countries meet the health targets of the SDGs. “This is a pivotal health Assembly. On the occasion of WHO’s 70th Anniversary, we are celebrating 7 decades of public health progress that have added 25 years to global life expectancy, saved millions of children’s lives, and made huge inroads into eradicating deadly diseases such as smallpox and, soon, polio,” said Dr Tedros. “But the latest edition of the World Health Statistics, shows just how far we still have to go. Too many people are still dying of preventable diseases, too many people are being pushed into poverty to pay for healthcare out of their own pockets and too many people are unable to get the health services they need. This is unacceptable,” he added. The WHO General Program of Work, designed to address these challenges and accelerate progress towards the SDGs, is the result of 12 months of intensive discussion with countries, experts and partners, and centers on the “triple billion” targets: ÂÂ

1 billion more people benefiting from universal health coverage

IJCP Sutra 67: Avoid exposure to smoke. Expectant mothers should quit smoking altogether as this is one of the major risk factors for development of asthma in children.

AROUND THE GLOBE ÂÂ

1 billion more people better protected from health emergencies

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1 billion more people enjoying better health and well-being. (WHO, May 18, 2018)

Most Heavy Smokers are not Screened for Lung Cancer Despite Recommendations The United States Preventive Services Task Force (USPSTF) and ASCO recommend screening current or former heavy smokers for lung cancer. However, a new analysis of 1,800 lung cancer screening sites across the US has found that only 1.9% of more than 7 million current and former heavy smokers were screened for lung cancer in 2016. These findings were presented at the 2018 ASCO Annual Meeting in Chicago.

US FDA Approves Sodium Zirconium Cyclosilicate for Hyperkalemia The US FDA has approved sodium zirconium cyclosilicate, a highly-selective, oral potassiumremoving agent for adults with hyperkalemia. The drug has been shown to reduce potassium levels in patients with chronic kidney disease, heart failure, diabetes and those taking renin-angiotensin-aldosterone system (RAAS) inhibitors.

ACOG Recommends Individualized Approach to Postpartum Pain Management A new guideline released by the American College of Obstetricians and Gynecologists (ACOG) recommends an individualized ‘stepwise’ approach to postpartum pain management that would first employ non-opioid therapies such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) in addition to nonpharmacologic approaches.

Heart Attacks are More Common in Winters Than in Summers A study presented May 18, 2018 at the Asian Pacific Society of Cardiology (APSC) Congress 2018 has found that the number of heart attacks fluctuated with the seasons, with more attacks occurring in winter compared to summer. Heart attacks increased dramatically when the temperature dropped below 15oC.

Cerebral microbleeds are indicative of risk of Intracranial Hemorrhage in AF Patients on anticoagulation In patients with atrial fibrillation (AF), who are on anticoagulation after recent ischemic stroke or

transient ischemic attack, cerebral microbleed presence is independently associated with symptomatic intracranial hemorrhage risk and could be used to inform anticoagulation decisions, according to results of the Clinical Relevance of Microbleeds in Stroke (CROMIS-2) observational trial published online May 16, 2018 in The Lancet Neurology.

Environment Ministry’s "Green Good Deeds" Initiative Gets Global Recognition Green Good Deeds, the societal movement launched by Environment, Forest and Climate Change Minister Dr Harsh Vardhan to protect environment and promote good living has found acceptance by the global community. "The BRICS Ministerial on Environment has agreed to include “Green Good Deeds” in its official agenda in the next Ministerial in Brazil and another meeting in Russia," said Dr Harsh Vardhan. Earlier, in his opening remarks at the Ministerial, Dr Harsh Vardhan had urged the grouping to jointly work for developing a movement around "Green Good Deeds". The Minister had launched a nationwide social movement to protect the environment and promote healthy living in January 2018. The Ministry of Environment, Forest and Climate Change had drawn up a list of over 500 Green Good Deeds and asked people to alter their behavior to Green Good Behavior to fulfil their Green Social Responsibility. These small positive actions to be performed by individuals or organizations to strengthen the cause of environmental protection, were put on a mobile application named “Dr Harsh Vardhan App”… (Press Information Bureau, Ministry of Environment, Forest and Climate Change, May 19, 2018)

FDA Cautions About Risk of Neural Tube Birth Defects with dolutegravir In a drug safety communication, the US FDA has cautioned about the potential risk of neural tube birth defects with dolutegravir used to treat human immunodeficiency virus (HIV) in women, who received the drug at the time of becoming pregnant or early in the first trimester. The FDA has advised healthcare professionals to get a pregnancy test before starting dolutegravir and inform women of childbearing age about the potential risk of neural tube defects with this drug.

Study Identifies Risk Factors for Decreased Survival in Metastatic Thyroid Carcinoma A study presented at the annual meeting of the American Association of Clinical Endocrinologists (AACE) in

IJCP Sutra 68: Breastfeed your infant. This will increase immunity and help ward off potential complications.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Boston has identified risk factors associated with decreased rate of cancer-specific survival in patients with well-differentiated metastatic thyroid carcinoma namely, multiple metastatic locations, older age upon diagnosis, other metastases on follow-up, incomplete/ unknown tumor resection, bone metastases on followup and higher MACIS scores (measurement of distant Metastasis, patient Age, Completeness of resection, local Invasion and tumor Size).

AKI During Hospitalization Linked with Higher Risk of Heart Failure Post-discharge A new study published in the Clinical Journal of the American Society of Nephrology (CJASN) reveals that acute kidney injury (AKI) is linked with a 44% higher risk of cardiovascular events, especially heart failure, in patients even after they are discharged from the hospital.

Differences in parent-identified Behavior may Lead to Falsely Negative ASD Diagnosis A study published in the June 2018 issue of Pediatrics of infants aged 18 months found multiple differences in parent-identified behavior between infants who did not receive a later diagnosis of autism spectrum disorder (ASD), versus those who did. These differences included delays in social interaction, communication and motor ability - all features associated with autism spectrum disorder.

Reducing Risk Factors for Heart Disease Reduces Frailty in Older Adults According to a study published in Journal of Gerontology: Medical Sciences, even small reductions in risk factors for heart disease reduce frailty, as well as dementia, chronic pain and other disabling conditions of old age such as incontinence, falls, fractures.

Cognitive Training Reduces Severity of Freezing of Gait in Patients with Parkinson’s Disease

Obesity Exacerbates Symptoms in Patients with Lupus

A randomized controlled trial published May 18, 2018 in npj Parkinson’s Disease has shown that cognitive training can reduce severity of freezing of gait in patients with Parkinson’s disease while on dopaminergic medication. Cognitive training also improved cognitive processing speed and reduced daytime sleepiness.

Being obese and/or overweight was associated with aggravation of disease activity in patients with lupus along with worsening of symptoms of pain and fatigue and depression. The study published May 10, 2018 in Arthritis Care & Research suggests that lifestyle interventions to reduce body weight may reduce the severity of symptoms.

Eliminating Job Stress can Prevent Future Onset of Mental Disorders High job demands, low job control and high job stress were found to be associated with greater probability of onset of common mental disorders in midlife. The study published online May 10, 2018 in Lancet Psychiatry suggests job stress as a modifiable workrelated risk factor and that eliminating it can prevent 14% of new cases of depression, anxiety, and other common mental disorders.

Acupuncture and Cognitive Behavioral Therapy Improve Insomnia in Cancer Survivors A Patient-Centered Outcomes Research Institute (PCORI)-supported randomized clinical trial of cancer survivors presented at the 2018 ASCO Annual Meeting in Chicago has shown that 8 weeks of either acupuncture or cognitive behavioral therapy for insomnia (CBT-I) decreased the severity of insomnia among cancer survivors, though improvements were greatest among patients receiving cognitive behavioral therapy.

Study Shows Low-risk of CV Events with Alendronate Treatment in Patients with Hip Fracture Alendronate significantly reduces the risk of cardiovascular events (incident myocardial infarction, stroke) and mortality in patients treated with the bisphosphonate following a hip fracture, suggests a study published online May 9, 2018 in the Journal of Bone and Mineral Research.

Nodule in Upper Part of Thyroid Gland More Likely to be malignant Nodules located in the upper pole of the thyroid gland may carry a greater risk for malignancy than those in the lower pole, according to new research presented May 19, 2018 at the AACE 2018 Annual Scientific and Clinical Congress in Boston.

AAP Recommends Inactivated Influenza Vaccine Over Nasal Spray Flu Vaccine for the Flu Season The American Academy of Pediatrics (AAP) will advise families to choose the inactivated influenza vaccine (IIV) when they vaccinate their children this fall. The

IJCP Sutra 69: It is important to eat a heart-healthy and cholesterol-lowering diet.

AROUND THE GLOBE decision was made by the AAP Board of Directors after reviewing data on the effectiveness of the flu shot compared with the nasal spray flu vaccine, which has not worked as well in recent flu seasons. AAP will publish its formal policy statement on flu prevention and treatment in September.

Women with Pregnancy-related Diabetes may be at Risk for Chronic Kidney Disease Gestational diabetes may predispose women to earlystage kidney damage, a precursor to chronic kidney disease, according to a study published May 21, 2018 in Diabetes Care. Women who had gestational diabetes were more likely to have a high glomerular filtration rate.

A New Drug for Chronic Liver Disease Patients with Thrombocytopenia Undergoing a Medical Procedure The US FDA has approved avatrombopag tablets to treat low blood platelet count (thrombocytopenia) in adults with chronic liver disease who are scheduled to undergo a medical or dental procedure. This is the first drug approved by the FDA for this use.

CPAP Reduces Heart Rate in Patients with Prediabetes and Obstructive Sleep Apnea A study presented at the American Thoracic Society annual meeting in San Diego has shown that allnight continuous-positive airway pressure (CPAP) treatment reduces 24-hour resting heart rate in patients with prediabetes and obstructive sleep apnea thereby reducing their cardiovascular risk.

Sustained Virological Response Reduces Extrahepatic Mortality in Patients with Hepatitis C Infection Extrahepatic manifestations of chronic hepatitis C virus (HCV) infection improve or resolve after patients achieve sustained virological response (SVR), resulting in a 56% reduction in extrahepatic mortality as reported in a study published online April 27, 2018 in the journal Gut.

At Global Health Forum, UN Officials Call for Strong, People-focused Health Systems Everyone, everywhere must have equal access to quality healthcare, said top United Nations officials urging greater focus on comprehensive health and well-being. In a video message to the opening of the 71st Session of the World Health Assembly in Geneva, SecretaryGeneral António Guterres reiterated that the enjoyment of the highest attainable standard of health is a fundamental human right. The World Health Assembly is the highest decisionmaking body of the WHO. It determines the agency’s polices, supervises financial policies, and reviews and approves the proposed program budget. Ensuring that everyone, everywhere has access to quality healthcare and services, is also vital for the achievement of the SDGs, stressed the UN chief. In particular, SDG 3, has specific targets to ensure healthy lives and promote well-being at all stages in life. In addition, health improvements feature prominently in many of the other ambitious Goals. Tedros Adhanom Ghebreyesus, WHO’s DirectorGeneral, also addressed the Assembly, emphasizing the importance of universal health coverage, as illustrated by the Ebola outbreak in the DRC. Dr Tedros also highlighted critical upcoming events focussed on global health, including two high-level meetings; on NCDs and on tuberculosis at the upcoming session of the UN General Assembly which begins in September… (UN, May 21, 2018)

Low PTH and Calcium Levels Increase Risk of Hypoparathyroidism Post-thyroidectomy Low parathyroid hormone (PTH) levels and low calcium levels are associated with increased risk (~30%) of hypoparathyroidism after thyroidectomy, reported a study presented at the AACE Annual Meeting in Boston.

Microvascular Changes in Retina on OCT Angiography Suggestive of Early Alzheimer’s Disease

Achieving A1c, LDL-C and BP Targets Reduces Complications in Type 2 Diabetes

Microvascular changes in the retina detected by using noninvasive optical coherence tomography (OCT) angiography align well with imaging and biomarker evidence of preclinical Alzheimer’s disease, suggests a new study presented April 23, 2018 at the American Academy of Neurology (AAN) 2018 Annual Meeting in Los Angeles. These patients had a significantly increased size of the foveal avascular zone.

Achieving triple treatment targets of HbA1c <7%, LDL-C <100 mg/dL and blood pressure (BP) <140/90 mmHg reduces the risk for macrovascular complications, mortality, and microvascular complications in patients with type 2 diabetes, according to a study published May 21, 2018 in Diabetes Research and Clinical Practice. Compared to A1c and BP, achieving LDL-C goal was more likely to reduce risks.

IJCP Sutra 70: Exercising for about 30 minutes a day can raise HDL levels (the good cholesterol). Aerobic exercise can help in improving insulin sensitivity, HDL, and triglyceride levels and may thus reduce the risk of heart disease.

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

Denosumab is FDA-approved for Steroid-induced Osteoporosis The US Food and FDA has approved denosumab for the treatment of glucocorticoid-induced osteoporosis in men and women at high risk of fracture defined by history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy.

Discharge from a Crowded Hospital Ward Increases Re-hospitalization Risk In a new research presented May 20, 2018 at the American Thoracic Society 2018 International Conference in San Diego, discharge from a crowded hospital ward was found to be associated with increased odds of re-hospitalization within a month.

Left Ventricular Assist System Recall labeled as Class I Recall A Left Ventricular Assist System was recalled due to a potential malfunction that may lead to graft occlusion leading to serious adverse events such as blood clots and death. The US FDA has identified this recall as Class I, the most serious type of recall, because of the risk for serious injury or death.

TIA Patients at Sustained Risk of Recurrent Stroke A follow-up study of patients who had a transient ischemic attack (TIA) or minor stroke has shown a sustained risk of cardiovascular events over a period of 5 years, with half of the events occurring between second and fifth years. The study published May 16, 2018 in the New England Journal of Medicine recommends secondary prevention measures to prevent stroke recurrence.

Researchers Identify a New Type of Vertigo that can be Treated A new type of vertigo where treatment may be effective has been reported May 23, 2018 online in the journal Neurology. Called recurrent spontaneous vertigo with head-shaking nystagmus, the condition has no known cause. Those who were found to have the new type of vertigo were more likely to have severe motion sickness than those with other types of vertigo.

AAP Policy Statement on Life Support Training for Children Including Adults A policy statement from the AAP published online May 23, 2018 advocates life support training of children, parents, caregivers, school personnel and the public. The AAP recommends that pediatricians hone their

own skills and stay up to date on cardiopulmonary resuscitation (CPR) and life-support skills. The academy also recommends: ÂÂ

Supporting age-appropriate life support training for children as part of the school curriculum in schools, beginning in the primary grades.

ÂÂ

Providing life support training to all school personnel, parents, caregivers and the public.

ÂÂ

Placing an automated external defibrillator (AED) for adults and children in every school in the community and near every school athletic facility - and training staff and children on how to use them.

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Advocating for funding and legislation to promote the training.

Social Isolation Increases Risk of Adverse Outcomes in Heart Failure Patients New research published May 23, 2018 in the Journal of the American Heart Association reports that compared to more socially connected patients with heart failure, those who felt socially isolated were at 3.7 times or greater increased risk of death, 1.7 times increased risk of hospitalization and 1.6 times higher risk of emergency department visits.

Poor sleep Quality Linked to Less Physical Activity in Patients with Knee Osteoarthritis Analysis of data from the Osteoarthritis Initiative shows that poor sleep quality is associated with less physical activity in persons with knee osteoarthritis or those who are at risk for developing it. These findings are published May 22, 2018 in the journal Arthritis Care & Research. The study suggests that this association may be mediated by depression or low energy levels.

Naloxone Found to be Most Effective Drug for Opioid-induced Constipation Naloxone followed by naldemedine were found to be the most effective treatments for opioid-induced constipation, according to a systematic review and network meta-analysis published in the journal Gut. Naloxone was also the safest of all drugs investigated.

ACOG Publishes Guidelines for Care of Women with Eating Disorders A new Committee Opinion from the ACOG “Gynecologic care for adolescents and young women

IJCP Sutra 71: Smoking increases HDL levels and therefore, you should quit immediately.

AROUND THE GLOBE with eating disorder” - includes guidance for Ob-Gyns in identification and treatment of eating disorders in adolescents or young women. As per the statement, adult and adolescent females with eating disorders may present with gynecologic concerns or symptoms, including irregular menses, amenorrhea, pelvic pain, atrophic vaginitis, and breast atrophy.

Nepal Becomes the First Country in South-East Asia to Eliminate Trachoma The WHO has validated Nepal for having eliminated trachoma as a public health problem - a milestone, as the country becomes the first in WHO’s South-East Asia Region to defeat the world’s leading infectious cause of blindness … (WHO, May 21, 2018).

4th International Yoga Day Celebrations Main Event to be Organized in Dehradun Mass yoga demonstration, the main event of 4th International Yoga Day celebrations (IDY-2018) on 21st June this year will be held at Dehradun in Uttarakhand… (Ayush, PIB, May 28, 2018).

Higher Male-to-female Hormone Ratio Increases Risk of Heart Disease in Postmenopausal Women A higher blood level of a male hormone (testosterone) and a higher ratio of the male- to female-type (estrogen) of hormones in postmenopausal women is associated with a higher risk of heart disease later in life, according to research published May 30, 2018 in the Journal of the American College of Cardiology.

A New Treatment Option for Moderately to Severely Active Ulcerative Colitis The US FDA has expanded the approval of tofacitinib to include adults with moderately to severely active ulcerative colitis. Tofacitinib is the first oral medication approved for chronic use in this indication. Other FDA-approved treatments for the chronic treatment of moderately to severely active ulcerative colitis must be administered through an intravenous infusion or subcutaneous injection.

ACS Recommends Screening for Colorectal Cancer to Start from Age 45 New updated guidelines from the American Cancer Society (ACS) published online May 30, 2018 in CA: A Cancer Journal for Clinicians recommend that screening

for colorectal cancer should begin at a younger age than 50 years, which is currently recommended.

Daily Intellectual Activities Reduce Risk of Dementia Findings of a longitudinal, observational study of older Chinese adults followed for 7 years published online May 30, 2018 in JAMA Psychiatry show that actively engaging in daily intellectual activities such as reading or playing cards reduces the risk of dementia.

New Guidelines on Management of Diabetes in the Very Frail Elderly New guidelines on management of diabetes in the elderly according to their frailty status have been published in April 2018 issue of Diabetic Medicine. For the first time, these guidelines include recommendations on how to and when to stop diabetes treatments in particularly frail adults.

Obesity is a Risk Factor for Heart Disease Even in Metabolically Healthy Women Obese but metabolically healthy women are still at higher risk for heart disease compared to metabolically healthy women of normal weight, according to findings of a 30-year follow-up from a prospective cohort study of more than 90,000 women published May 30, 2018 in The Lancet Diabetes & Endocrinology. Most metabolically healthy women converted metabolically unhealthy despite normal body weight.

FDA Approves First Artificial Iris The US FDA has approved the first stand-alone prosthetic iris in the United States, a surgically implanted device to treat adults and children whose iris is completely missing or damaged due to a congenital aniridia or other damage to the eye. Congenital aniridia is a rare genetic disorder in which the iris is completely or partially absent.

Insufficient Vitamin D Linked to Miscarriage Among Women with Prior Pregnancy Loss Among women planning to conceive after a pregnancy loss, those who had sufficient levels of vitamin D were more likely to become pregnant and have a live birth, compared to women with insufficient levels of the vitamin, according to an analysis published online May 30, 2018 in The Lancet Diabetes & Endocrinology.

■■■■

IJCP Sutra 72: Losing even a little bit of weight can help in managing cholesterol levels.

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Spiritual Update

The Right Action KK aggarwal

harma is the path of righteousness and living one’s life according to the codes of conduct as described by the Vedas and Upanishads. Its western equivalents might include morality, ethics, virtue, righteousness and purity. The term ‘dharma’ can best be explained as the “law of being” without which things cannot exist. The word ‘dharma’ is derived from dhri, which means “to hold”. It literally means “that which holds” the people of this world and the whole creation. The same is described in the Vedic Text, in Atharva Veda as: Prithivim dharmana dhritam, i.e., “this world is upheld by dharma”. In Hinduism, Dharma is the very foundation of life. Tulsidas, the author of Ramcharitmanas, defined the root of dharma as compassion. Buddha has also described this principle in his book Dhammapada. According to Hindu philosophy, it’s GOD who holds us through “Truth” and/or “Love”. “Dharma prevails” or “truth prevails” is the essence of Hinduism. In order to achieve good karma, Vedas teach that one should live according to dharma (the right action). This involves doing what is right for the individual, the family, the class or caste and also for the universe. According to the Bhagavata Purana, righteous living or life on a dharmic path has four pillars: truthfulness (satya), austerity (tap), purity (shauch) and compassion (daya). It further adds that the adharmic or unrighteous life has three main vices: pride (ahankar), bad company (sangh) and intoxication (madya). Manusmriti prescribes 10 essential rules for the observance of dharma: Patience (dhriti), forgiveness (kshama), piety or self-control (dama), honesty (asteya), sanctity (shauch), control of senses (indriyanigrah), reason (dhi), knowledge or learning (vidya), truthfulness (satya) and absence of anger (krodha). Manu further writes, “Non-violence, truth, noncoveting, purity of body and mind, control of senses are the essence of dharma”.

Group Editor-in-Chief, IJCP Group

IJCP Sutra 73: Don’t use tobacco in any form. If you use tobacco, quit.

In Bhagavad Gita, Lord Krishna says that in the society dharma is likely to fall from time to time, and to bring dharma back, a GOD representative is born from time to time. The shloka “parithraanaaya saadhoonaam vinaasaaya cha dhushkrithaam/dharma-samsthaapanaarthaaya sambhavaami yuge yuge” (Chapter IV - 8)” says that “For the protection of the virtuous, for the destruction of evildoers, and for establishing the rule of righteousness (Dharma), I am born from age to age [in every age]”. Another shloka “yada yada hi dharmasya glanir bhavati bharata abhyutthanam adharmasya tadatmanam srjamy aham” means that O descendant of Bharata “Whenever and wherever there is a decline in religious practice, and a predominant rise of irreligion—at that time I descend Myself”. Deepak Chopra, in his book Seven Spiritual Laws of Success, talks about the “Law of ‘Dharma’ or Purpose in Life”. According to him, everybody should discover his or her divinity, find the unique talent and serve humanity with it. With this, one can generate all the wealth that one wants. According to him, when your creative expressions match the needs of your fellow humans, then wealth will spontaneously flow from the unmanifest into the manifest, from the realm of spirit to the world of form. In spiritual terms, this is an attempt to find out whether one’s life is progressing as per the Laws of Dharma (Dharma in Sanskrit means ‘purpose in life’) which, according to the scriptures, is said to be the sole purpose for a human being to manifest in this physical form. For one to achieve ‘DHARMA’ he suggests the following affirmative exercises: ÂÂ

Today, I will lovingly nurture the God or Goddess in embryo form that lies deep within my soul. I will pay attention to the spirit within me that animates both my body and my mind. I will awaken myself to this deep stillness within my heart. I will carry this consciousness of timeless, eternal being in the midst of time-bound experiences.

ÂÂ

I will make a list of my unique talents. Then, I will make a list all the things I love to do while

Indian Journal of Clinical Practice, Vol. 29, No. 1, June 2018

ÂÂ

expressing my unique talents. When I express my unique talents and use them in the service of humanity, I lose track of time and create abundance in my life as well as in the lives of others.

In Jainism also, the wheel of Dharma (Chakra) with 24 spokes represents the religion preached by the 24 Tirthankaras consisting of nonviolence (Ahimsa) and other virtues.

I will ask myself daily, ‘How can I serve?’ and ‘How can I help?’ The answers to these questions will allow me to help and serve my fellow human beings with love.

The very first word of the Gita is “Dharma”. The Gita concludes with the word “Mama”. The whole of Bhagavad Gita is contained in the two words ‘Mama’ and ‘Dharma’. When you join these two words it becomes mamadharma, meaning ‘your true Dharma’. This is what the Gita teaches. ‘What is your Dharma?’

Karma, dharma and samsara are three fundamental aspects of Hinduism. Buddhism, Jainism and Hinduism are all built on these aspects. Dharma is one’s appropriate role or attributes. Karma measures how well one performs one’s dharma, explains why one is born where he or she is, and why there is suffering and seeming injustices. Samsara is the continuous cycle of birth, death and rebirth, and the context for all experience.

How to achieve your dharma? ÂÂ

Do unto others what you do unto yourself and satisfy your conscience. That is your Dharma.

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The word ‘Living Dharma’ signifies right action in every moment of the life.

ÂÂ

Do not follow the dictates of body, and do not indiscriminately follow the mind, for the mind is like a mad monkey. Hence, follow the conscience.

Dharma sutras from Dharma Shãstras are the basic texts, which talk about the morality of individuals and the society. Most Indian laws are made from these Shãstras. ■■■■

IJCP Sutra 74: Always use lip balm with SPF 30 or higher.

(Disclaimer: The views expressed in this write up are my own).

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lighter reading

Don’t get too comfortable The CEO of a large TPA dies and goes to heaven. St. Peter shows him to a lovely villa, wonderful music, great views, full staff of servants, gourmet meals, etc. The CEO says, “This is terrific!” “Don’t get too comfortable,” says St. Peter. “You’re only approved for a three–day stay.” Doctor complaining to mechanic A doctor is talking to a car mechanic, “your fee is several times more per hour then we get paid for medical care.” ‘Yeah, but you see, doc, you have always the same model! It hasn’t changed since Adam. But we have to keep up to date with new models coming every month” Can I help you? A young businessman had just started his own firm. He had just rented a beautiful office and had it furnished with antiques. He saw a man come into the outer office. Wishing to appear the hot shot, the businessman picked up the phone and started to pretend he had a big deal working. He threw huge figures around and made giant commitments. Finally he hung up and asked the visitor, “Can I help you?” “Yeah, I’ve come to activate your phone lines.”

Inspirational

HUMOR

Lighter Side of Medicine Steps to Happiness Everybody Knows: You can’t be all things to all people. You can’t do all things at once. You can’t do all things equally well. You can’t do all things better than everyone else. Your humanity is showing just like everyone else’s. So: You have to find out who you are, and be that. You have to decide what comes first, and do that. You have to discover your strengths, and use them. You have to learn not to compete with others, because no one else is in the contest of *being you*. Then: You will have learned to accept your own uniqueness. You will have learned to set priorities and make decisions. You will have learned to live with your limitations. You will have learned to give yourself the respect that is due. And you’ll be a most vital mortal. Dare To Believe: That you are a wonderful, unique person… That you are a once-in-all-history event… That it’s more than a right, it’s your duty, to be who you are… That life is not a problem to solve, but a gift to cherish. And you’ll be able to stay one up on what used to get you down.

Dr. Good and Dr. Bad Situation: A 39-year-old man whose HbA1c level had increased from the past 2 years (from 5.7% to 6.4%) was told that he is at risk of developing type 2 diabetes.

Jogging Shoes Deciding to take up jogging, the middle–aged man was astounded by the wide selection of jogging shoes available at the local sports shoe store.

Type 2 diabetes cannot be predicted on the basis of HbA1c level

HbA1c estimation is a reliable method to predict diabetes

“What’s this little pocket thing here on the side for?” “Oh, that’s to carry spare change so you can call your wife to come pick you up when you’ve jogged too far.”

IJCP Sutra 75: Eat lots of fruits and vegetables.

While trying on a basic pair of jogging shoe, he noticed a minor feature and asked the clerk about it. Lesson: The investigators have demonstrated the role of HbA1c

in predicting type 2 diabetes in different situations. It can be used for determining people at high risk of developing type 2 diabetes in both short- and long-term. Diabetes Care. 2018;41(1):60-8.

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RNI number 50798/1990.

The Medical Council of India (UGC, ICI)

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

IJCP Sutra 76: Make sure to not skip any medications. Consume a healthy diet and exercise regularly.

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 –

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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.

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All pages should be numbered consecutively beginning with the title page.

name of the corresponding authors, acknowledgment of financial support and abbreviations used. – The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary. – A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included. – The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page. – A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text. Summary – The summary of not more than 200 words. It must convey the essential features of the paper. – It should not contain abbreviations, footnotes or references. Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives. Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others. – Ethical guidelines followed by the investigations should be described. Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected. – Method of selecting the sample (cases, subjects, etc. from the statistical universe). – Method of allocating the subjects into different groups. – Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.

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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,

– These should be concise and include only the tables and figures necessary to enhance the understanding of the text.

IJCP Sutra 77: Avoid smoking or quit if you are in the habit.

Confidence intervals for the measurements should be provided wherever appropriate.

Results

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.

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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.

IJCP Sutra 78: If you wear any type of denture, clean it each day.

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

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R.N.I. No. 50798/1990 Date of Publication 13th of Same Month Date of Posting 13-14 Same Month

POSTAL REGISTRATION NO. DL (S)-01/3200/2018-2020 Posted in N.D. PSO New Delhi