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Indian Journal of

CLINICAL PRACTICE 533-584 Pages

March 2011

Volume 21, Number 10

Uropathogens and their Susceptibility Patterns at Tertiary Care Hospital in India

Dr KK Aggarwal

Group Editor-in-Chief

8th World Fellowship of Religions & 11th Perfect Health Parade An Event by WFR & Heart Care Foundation of India to earmark WHO day

Programme

Sunday 3rd April 2011

One day conference on Global warming and ethnic crisis involving all pathies and all religions.

Maulana Azad Medical College Dilli Gate, New Delhi Time: 8 am to 6 pm

Flag Off Time: 10 am Perfect Health Parade Route The Parade will flagged off at 10 am from opp. Maulana Azad Medical College towards Delhi Secretariat) and towards Vikas Marg – Shahdara – Seemapuri – Guru Tegh Bhadur Hospital – Seelampur Pusta – Gandhinagar, to ISBT Kashmiri Gate – Civil Lines – Delhi University North Campus – Azadpur – Punjabi Bagh – Mayapuri – Raja Garden – Janakpuri – Tilak Nagar – Tihar Jail Road – Delhi Cantt. – R.K. Puram – Munirka – IIT Gate – Panchsheel Park – Chirag Delhi Flyover – Nehru Place – Modi Mill Flyover – Ashram – Nizamuddin – Sunder Nagar – Pragati Maidan – ITO – finally culminate at Maulana Azad Medical College at 4 pm.

Conference Time: 11 am - 5 pm A Day-long Conference The 6-8 hours conference will have two sessions firstly involving the religious scholars and secondly the medical experts from all pathies. Address for Correspondence 23, Bhai Veer Singh Marg, Gole Market, Connaught Place, New Delhi 110001, Phone 23340469 E-mail: hcfi.1986@gmail.com For Participation in Conference & Parade Contact: Dr KK Aggarwal 9718336056 Our websites

www.kkaggarwal.com, www.ijcpgroup.com, www.emedinews.in, www.heartcarefoundation.org, www.perfecthealthmela.net Forthcoming events v A day-long “Medifinance” Conference 13th March

v Dil Ka Darbar 4th September, 2011, Sunday.

v 18th Perfect Health Mela, Sunday 16th - 23rd October, 2011

v eMedinewS Revisiting 2011 January 15th, 2012, Sunday

Indian Journal of

Online Submission

Clinical Practice

Volume 21, Number 10, March 2011

Contents

An IJCP Group Publication Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

Dr KK Aggarwal CMD, Publisher and Group Editor-in-Chief Dr Veena Aggarwal Joint MD & Group Executive Editor Anand Gopal Bhatnagar Editorial Anchor IJCP Editorial Board Dr Alka Kriplani Asian Journal of Obs & Gynae Practice Dr VP Sood Asian Journal of Ear, Nose and Throat Dr Praveen Chandra Asian Journal of Clinical Cardiology Dr Swati Y Bhave Asian Journal of Paediatric Practice Dr Vijay Viswanathan The Asian Journal of Diabetology Dr KMK Masthan Indian Journal of Multidisciplinary Dentistry Dr M Paul Anand, Dr SK Parashar Cardiology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty Diabetology Dr Ajay Kumar Gastroenterology Dr Koushik Lahiri Dermatology Dr Georgi Abraham Nephrology Dr Sidharth Kumar Das Rheumatology Dr V Nagarajan Neurology Dr Thankam Verma, Dr Kamala Selvaraj Obs and Gyne Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

From the desk of group editor-in-chief

Smoker in the House, a Risk Factor for Hospitalization of Children with Flu

537

KK Aggarwal

original article

The Role of Diabecon in the Management of Diabetes Mellitus

539

Prabir Kumar Kundu, Deepa HS

clinical study

Anxiety Level Amongst Medical Students

544

Rishi Gautam, Kunal Bhatia, SK Rasania, Dhruv Gupta, Rini Sahewalla

Uropathogens and their Susceptibility Patterns at Tertiary Care Hospital in India

548

Deepak Arora, Pooja Gupta, Rajiv Kumar, Gitanjali

Identification and Ranking of Problems Perceived among Urban School-going Adolescents in Vadodara in India

555

PV Kotecha, Sangita V Patel, VS Mazumdar, RK Baxi, S Misra, KG Mehta, M Diwanji, H Bakshi

case report

A Rare Cause of Iron Deficiency Anemia in an Infant with Atypical Presentation J Julius Xavier Scott, Greg Smith, Ben Saxon

566

Indian Journal of

Clinical Practice

Volume 21, Number 10, March 2011

Contents

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

case report

Condyloma Acuminata with Maggots

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

570

Samarendra Mahapatra, Subhranshu Sekhar Kar, Rajani Dube, Sitanshu Sekhar Kar

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Collodion Baby

573

Seema Sharma 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. 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.

Universal Acquired Melanosis

575

Bhaswati Ghoshal, Anjali Bandyopadhyay

Emedinews Section

From eMedinewS

577

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From the Desk of Group Editor-in-Chief From the Desk of Group Editor-in-Chief

Smokers in the House, a Risk Factor for Hospitalization of Children with Flu

Dr KK Aggarwal

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

large retrospective case-control study reported at the annual meeting of the Infectious Diseases Society of America (IDSA) says that having smokers in the house increases the possibility of a young child with flu needing inpatient care. Data from more than 1,300 laboratory-confirmed cases of children with influenza, collected by 10 sites in the CDC’s Emerging Infections Program in 2005 to 2008 were analyzed to identify risk factors for hospitalization associated with laboratory-confirmed influenza. Analysis showed that if more than half of household members were smokers it doubled the chances a child would have a serious case of flu. According to Nila Dharan, MD, of the division of infectious diseases at the NYU School of Medicine in New York City, a family member who had been vaccinated against flu was protective, even if the child was not fully protected by immunizations. The study included 290 children ages 6-59 months (median age 20 months) with serious cases of flu; 1,089 age- and zip code-matched children with the flu who did not need inpatient care during the three influenza seasons acted as controls. The salient observations were as below. Age of the mother; if ≤26 years, the odds were doubled. The odds ratio (OR) was 2.1, with a 95% confidence interval (CI) from 1.3 to 3.4. The risk was increased if the child’s vaccinations were not up to date. The odds ratio was 1.7, with a 95% CI from 1.1 to 2.7. If more than half of household members smoked, the child’s risk of needing inpatient care was doubled. The OR was 2.3, with a 95% CI from 1.0 to 5.3. The risk was similar to having any pulmonary condition, including asthma. If the child was not fully vaccinated for the flu, having any household member immunized was protective. The OR was 0.5, with a 95% CI from 0.3 to 0.8. Underlying medical conditions also had an important role; presence of a hematologic or oncologic condition increased the risk by a factor of 12. According to Dr Dharan, other researchers have examined a possible association between exposure to smoking and a child’s risk of needing inpatient care for flu, but this is the largest study to date. n Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

n 537

original article

The Role of Diabecon in the Management of Diabetes Mellitus Prabir Kumar Kundu*, Deepa HS**

Abstract Diabetes is associated with mortality and morbidity due to the associated micro- and macrovascular complications and diminished qualityof-life. Though oral hypoglycemic agents (OHAs) and insulin are effective in management of diabetes, they have associated side effects. Diabecon is a polyherbal formulation which has broad-spectrum activities that are useful in diabetes. It has been found to be safe and effective in management of diabetes. The ingredients of Diabecon act synergistically to achieve effective hyperglycemia, which prevents long-term complications. It significantly reduces fasting plasma glucose (FPG), postprandial plasma glucose (PPG) and HbA1c levels; potentiates the benefits of OHAs and insulin, acts as an adjuvant in those insufficiently managed with other OHAs and produces modest improvement in diabetic control in type 2 DM patients who failed to respond to OHAs. Several clinical trials have been conducted to evaluate the efficacy of Diabecon tablet. Two double-blind placebo-controlled clinical trials are summarized for this review.

Key words: Diabetes mellitus, hyperglycemia, Diabecon

iabetes mellitus (DM) is characterized by hyperglycemia and abnormal lipid and protein metabolism due to defects of insulin secretion and/ or increased insulin resistance. Worldwide, there were 171 million people with diabetes in 2000 and this is projected to increase to 366 million by 2030.1 Diabetes is associated with mortality and morbidity due to the associated microand macrovascular complications and diminished qualityof-life. Type 1 DM is due to pancreatic b-cell destruction, which leads to absolute insulin deficiency. There are two forms of type 1 DM. One is an immune-mediated disease with autoimmune markers such as islet cell antibodies (ICAs), insulin autoantibodies (IAAs) and autoantibodies to glutamic acid decarboxylase 65 (GAD65). Strong human leukocyte antigen (HLA) associations also exist. The second form of type 1 DM, now called idiopathic diabetes, has no known cause. Idiopathic diabetes is strongly heritable, but lacks autoimmune markers and is not HLA-associated. Though it can occur at any age, type 1 DM is more common in persons <30 years of age. Type 2 diabetes, formerly called adult-onset diabetes, is the most common form. It has two major pathophysiologic defects: Insulin resistance, which results in increased hepatic glucose production and decreased glucose disposal, and impaired b-cell secretory function (both basal and glucose-stimulated).2 Loss of the acute insulin response to a carbohydrate load, a prototypical defect that occurs early in the natural course of the disease, when fasting plasma glucose (FPG) levels reach 115 mg/dl,3 leads to postprandial hyperglycemia. *Head, Dept. of Endocrine, Nutrition and Metabolic Diseases School of Tropical Medicine, Kolkata **Research Associate, R&D Center, The Himalaya Drug Company Makali, Bangalore Address for correspondence Dr Deepa HS Research Associate, R&D Center The Himalaya Drug Company, Makali, Bangalore, Karnataka E-mail: dr.deepa@himalayaherbalhealthcare.com

Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

The typical symptoms of diabetes are: Thirst, polyuria, blurring of vision and weight loss. In severe forms, ketoacidosis or a nonketotic hyperosmolar state may develop and lead to stupor, coma and, even death in absence of effective treatment. As it may remain asymptomatic, hyperglycemia sufficient to cause pathological and functional changes may be present for a long time before a diagnosis is made. The long-term complications of DM include: Retinopathy, nephropathy and/or neuropathy. Diabetics are at increased risk of cardiovascular, peripheral vascular and cerebrovascular diseases. The 2006 WHO recommendations for the diagnostic criteria for diabetes are FPG â&#x2030;Ľ7.0 mmol/l (126 mg/dl) or 2 hour plasma glucose â&#x2030;Ľ11.1 mmol/l (200 mg/dl). The FPG cut-point for impaired fasting glucose (IFG) is 6.1 mmol/l.4 Glycated hemoglobin (HbA1C) reflects average plasma glucose over the previous 2-3 months in a single measure. It can be done at any time of the day and does not require any special preparation such as fasting. Management of DM includes lifestyle modification, oral hypoglycemic agents (OHAs) and insulin. OHAs and insulin have been effective in the management of DM, they are not without side effects.5 Sulfonylureas may cause chronic hypoglycemia as well as gastrointestinal (GI) side effects (dyspepsia, anorexia, nonspecific abdominal discomfort) and skin rash.6 Lactic acidosis is a major side effect of metformin.7 Profound hypoglycemia may occur due to the accumulation of these drugs, which possess a long half-life, more so, if their elimination is impaired.

Diabecon in the Management of DM Diabecon has broad-spectrum activities viz. insulin secretagogue, insulomimetic, antihyperglycemic, inhibition of a-glucosidase and gluconeogenesis, stimulates glucose utilization, islets of Langerhans regenerative, neuroprotective,

539

original ARticle oculoprotective and renoprotective activities. It also prevents drug-induced DM, and has desirable antihypercholesterolemic, adaptogenic and antioxidant activities. The ingredients of Diabecon act synergistically to achieve effective control of hyperglycemia, which prevents long-term complications. It significantly reduces FPG, postprandial plasma glucose (PPG) and HbA1C levels; potentiates the benefits of OHAs and insulin, acts as an adjuvant in those insufficiently managed with other OHAs and produces modest improvement in diabetic control in type 2 DM patients who failed to respond to OHAs. Each tablet of Diabecon contains the active ingredients as shown below. Extracts

Powders

540

Sanskrit name Guggulu (purified)

Botanical name Balsamodendron mukul (purified)

Quantity 30 mg

Shilajit (purified) Meshashringi Pitasara

– Gymnema sylvestre Pterocarpus marsupium

30 mg 30 mg 20 mg

Yashti-madhu Saptarangi Jambu Shatavari

Glycyrrhiza glabra Casearia esculenta Eugenia jambolana Asparagus racemosus

20 mg 20 mg 20 mg 20 mg

Punarnava Mundatika

Boerhaavia diffusa Sphaeranthus indicus

20 mg 10 mg

Guduchi Kairata Gokshura Bhumyamlaki Gumbhari Karpasi

Tinospora cordifolia Swertia chirata Tribulus terrestris Phyllanthus amarus Gmelina arbórea Gossypium herbaceum

10 mg 10 mg 10 mg 10 mg 10 mg 10 mg

Daru haridara Kumari Triphala Sushavi

Berberis aristata Aloe vera – Momordica charantia

5 mg 5 mg 3 mg 20 mg

Maricha Vishnu priya Atibala Haridra Jungli palak Vidangadi lauham

Piper nigrum Ocimum sanctum Abutilon indicum Curcuma longa Rumex maritimus –

10 mg 10 mg 10 mg 10 mg 5 mg 27 mg

Vanga bhasma Abhrak bhasma Praval bhasma Akika pishti Shingraf Yashad bhasma Trikatu

– -

5 mg 10 mg 10 mg 5 mg 5 mg 5 mg 5 mg

Pharmacological Actions and Principal Herbs Commiphora mukul/Balsamodendron mukul: Morbidity and mortality from cardiovascular disease is greatly increased in DM. Evidence shows that control of serum lipids reduces incidence of coronary heart disease. It is therefore important to understand the effects of treatments used in diabetes on serum lipids and lipoproteins.8 C. mukul renormalizes the serum lipids and cholesterol possibly due to its androgen and glucocorticoid receptor antagonistic activities that is potentially beneficial for diabetics.9 Shilajit: Used as a rejuvenator and an adaptogen as part of traditional systems of medicine in several countries. Its therapeutic properties, including its use in diabetes have been verified by modern scientific evaluation.10 Improvement in glycogen stores in liver by increasing the islet cell superoxide dismutase activity may be due to its antioxidant activity.11 Gymnema sylvestre: Extracts from leaves are one of the triterpene saponins that suppress sweetness by a reversible effect on sweet taste receptors. Pharmacological tests also show decrease in blood sugar. It suppresses rise in blood glucose by inhibiting intestinal reuptake.12 It also provides effective hyperglycemic control, crucial to prevent the complications of DM13 and enhances peripheral glucose utilization.14 Pterocarpus marsupium: It also controls diabeticrelated metabolic alterations besides glucose levels.15 The hypoglycemic action may be due to reduced intestinal glucose absorption.16 Oral intake of P. marsupium extract has potent hypoglycemic activity (both fasting and postprandial) that is comparable with that of tolbutamide.17 Glycyrrhiza glabra: Hydrophobic flavonoids, licorice flavonoid oil have shown abdominal fat-lowering and hypoglycemic effects in an obese diabetic model animal. This activity is probably mediated through peroxisome proliferatoractivated receptor gamma (PPAR-γ) activation.18 Casearia esculenta: An indigenous antidiabetic herb popularly used in South India for DM, it has potent antioxidant and antidiabetic properties, which could be due to the presence of potent antihyperglycemic factors.19 Oral administration of an aqueous extract of C. esculenta lowers blood glucose under normal and glucose load conditions. This effect may be due to inhibition blood glucose absorption from gut.20 Eugenia jambolana: It decreases hepatic glucose production, and prevents hyperglycemia (antihyperglycemic activity).21 Due to a-glucosidase inhibitory activity, it restores altered key metabolic enzymes involved in carbohydrate metabolism;22 thus retards carbohydrate digestion, an alternate means to reduce postprandial hyperglycemia. It enhances peripheral utilization of glucose.23 The neuroprotective actions protects Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

original ARticle from diabetic neuropathies.24 The aldose reductase inhibitory actions25 prevents acceleration of cataract formation in diabetics. An effective adjuvant to conventional OHAs where the resolution of retinopathy is enhanced, Diabecon resolves, prevents and retards retinal and vitreal microaneurysms, and proliferative retinal changes (oculoprotective action). It has potent antihypercholesterolemic activities.26 Diabecon thus effectively reduces coronary artery disease risk factors by modulating lipid profile. It reduces free fatty acids levels and re-normalizes lipid abnormalities associated with noninsulindependent diabetes mellitus (NIDDM). Asparagus racemosus: Extract of A. racemosus root, which contains high amounts of flavonoids, polyphenols and vitamin C, exhibits potent antioxidant activity by scavenging of free radicals, which are implicated in pathophysiology of various diseases and thus has an important role in DM.27 Boerhaavia diffusa: Significant decrease in blood glucose and significant increase in plasma insulin levels were observed in normal and diabetic rats treated with extract of B. diffusa; there was also a significant reduction of HbA1C, which shows its hypoglycemic activity.28 Sphaeranthus indicus: It is a hypoglycemic herb.29 Fasting normal rats treated with alcoholic extract of S. indicus showed significant improvement in oral glucose tolerance test, suggesting its use in DM.30 Swertia chirata: It has potent antioxidant activities, which protect from oxidative damage and improve diabetic vasculopathy.31 Diabecon increases localized superoxide dismutase activity, which prevents oxidative damage (by formation of free radicals) to b-cells of Langerhans, in pancreas, and thereby protects b-cells from destruction. Tinospora cordifolia: Its hypoglycemic activity is possibly due to stimulation of endogenous insulin secretion by altering cell membrane permeability.32,33 It reduced blood glucose significantly in alloxan-induced rabbits.34 Tribulus terrestris: Extracts of T. terrestris significantly decrease FPG, HbA1C, total cholesterol, triglycerides and low-density lipoprotein (LDL) cholesterol.35 Phyllanthus amarus: The fruit of this herb exhibits hypoglycemic activity.36-38 Gmelina arborea: Hydroalcoholic extract of G. arborea shows hypoglycemic activity.39 Gossypium herbaceum: The herb shows its potency in reduction of blood sugar.40 It has therapeutic action against raised blood sugar, cholesterol and triglyceride. Aloe vera: Administration of A. vera gel with high fat diet prevented development of insulin resistance and glucose intolerance.41 Oral administration of processed A. vera prevents progression of type 2 DM-related symptoms.42 It also has hypoglycemic activity and is used in DM.43 Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Triphala: Triphala (Equal proportion of Terminalia chebula, Terminalia belerica and Emblica officinalis) shows hypoglycemic activity.44 Momordica charantia: Isolates and extracts contain hypoglycemic principles called fetidin, momordicin or charantin which are an insulin-like peptide. It has been found useful for management of both type 1 and type 2 DM. The plant extract may mimic or improve insulin action at the cellular level, or it may even possess an extrapancreatic action.45 Extract of M. charantia enhances insulin secretion by the islets of Langerhans, reduces hepatic glycogenesis, enhances peripheral glucose utilization and increases serum protein levels.46 Piper nigrum: The seeds are not only similar to insulin in their hypoglycemic effect, they also check the antioxidant level. This is necessary to control complications arising from glycation and glyco-oxidation of proteins and membranes.47 Ocimum sanctum: The leaf extracts exert prominent stimulatory effects on insulin secretion from the b-cells via physiological pathways.48 It prevents cataract due to concomitant restoration of antioxidant defense system and inhibition of protein insolubilization of rat lenses, and can reverse the changes in diabetic retinopathy along with concurrent administration of vitamin E.49 Abutilon indicum: The leaves have hypoglycemic activity;50 in addition, the plant also has better wound healing activity and helps in management of wounds and other superficial dermatological infestations in DM.51 Curcuma longa: Curcumin, the major yellow phenolic curcuminoid present in turmeric, delays galactose-induced cataract in rats only at very low amounts (0.002%) in the diet.52 It also has a definite antioxidant action and may be helpful in diabetes.53 Rumex maritimus: Root contains Rumarin, and is used for its antipruritic activity to reduce the itching sensation in persons with hyperglycemia.54 The additional neuroprotective effect may help to manage other associated neurological problems.55 Trikatu: Trikatu contains Piper longum, P. nigrum and Zingiber officinale in equal proportions. It increases bioavailability either by promoting rapid GI absorption, or protecting the drug from first pass metabolism in liver, or a combination of these two mechanisms, helping other drugs for better therapeutic activity.56 Abhraka bhasma: It is an effective cellular rejuvenator.57 Pravala bhasma: The purified extract provides adaptogenic activity and may be helpful during leukorrhea.58

541

original ARticle Akika pishti: It is well-known for its cardioprotective action.59 Yashada bhasma: It has antiseptic property.60 Several clinical trials have been conducted to evaluate the efficacy of Diabecon tablet. Two double-blind placebocontrolled clinical trials are summarized for this review.

Clinical Trial 1 Evaluation of Diabecon (D-400) as an antidiabetic agent: A double-blind placebo-controlled trial in NIDDM patients with secondary failure to oral drugs.61 Aim: To evaluate the efficacy of a herbomineral antidiabetic formulation, Diabecon (D-400), in NIDDM patients with secondary failure to OHA.

Conclusion: Results showed that Diabecon (D-400), an Ayurvedic drug in NIDDM patients with secondary failure to OHAs shows modest improvement in diabetic control. A significant decrease in PPG and HbA1C levels was observed. Clinical Trial 2 Evaluation of Diabecon (D-400) an indigenous herbal preparation, in DM.62 Aim: D-400, a herbomineral formulation was evaluated for its effect on patients of DM.

Patients and Method

Inclusion criteria: Patients of either sex aged ≥30 years with mild-to-moderate DM without any complications like retinopathy, neuropathy and nephropathy, failure to respond to OHA even in maximal doses of combination therapy i.e. glibenclamide 15 mg plus metformin 1,000 mg/day for over three months despite good diet control and absence of infections, etc. who were not grossly obese (weight ≤20% of the average) and willing to sign informed consent were included in the study.

Inclusion criteria: Patients of either sex aged ≥20 years who had persistent postprandial hyperglycemia with mild-tomoderate DM without any complications like retinopathy, neuropathy and nephropathy and willing to sign inform consent document were included in the trial.

Exclusion criteria: Pregnant patients and those with serious cardiovascular, cerebrovascular, respiratory, liver or renal disease, severe hypertension or any other disorder were excluded. Subjects with strong history of food or drug allergy of any kind and unwilling to provide informed consent or abide by the study requirements were also excluded. Study procedure: The double-blind, placebo-controlled trial of Diabecon (D-400) included 40 patients with NIDDM. Patients were equally and randomly allocated to either Group A or B. The dose used was two tablets thrice-daily for six months. Patients in both groups received similar diet instructions from the dietician. FPG and PPG were measured every month; while HbA1C, insulin and C-peptide assay were done at baseline, 3 and six months of the trial. Results: There was a decrease in both FPG and PPG levels in the Diabecon (D-400)-treated group, but only the later reached statistical significance (p = 0.004). There was however an increase in plasma glucose levels in the placebo group. HbA1C levels decreased significantly from 9.2 ± 1.2% (p = 0.04) whereas in the placebo group there was no decrease in HbA1C levels. In the Diabecon (D-400)-treated group, the plasma insulin and C-peptide levels (both fasting and stimulated) tended to be maintained, or slightly increased even at the end of six months whereas the same decreased in

542

the placebo group. However, due to small study numbers, these differences did not reach statistically significant level. Except for one patient each, who complained of gastritis and skin rash, there were no other side effects of the drug.

Exclusion criteria: Patients with endocrine causes like Cushing’s syndrome, hypothyroidism with severe hypertension, history of angina, myocardial infarction, cerebrovascular accident or renal failure in the preceding six months, and unwilling to provide informed consent or abide by the requirements of the study were also excluded from the study. Study procedure: Twenty-eight newly diagnosed diabetic cases of either sex and over the age of ≥20 years, who had persistent postprandial hyperglycemia, were selected for the trial. Out of 28 cases, 14 were in the Diabecon-treated group, while the other 14 received identical-looking placebo tablets. The dose of Diabecon as well as of placebo was two tablets twice-daily for six months. Patients in both groups were under dietary restriction as designed by dieticians. The initial FPG and PPG levels were measured in all the cases and then every fortnight for 24 weeks. Body weight was measured at baseline and at the end of 24 weeks. Results: Reduction in fasting and postprandial blood sugar levels was significantly more in the Diabecon (D-400)-treated group. In the placebo-treated group on the other hand, a rise in fasting and postprandial blood sugar was observed after 12 weeks. The weight reduction in both the groups was almost similar at the end of 24 weeks of treatment. No adverse effect was reported during this 24-week trial. Conclusion: Diabecon exhibits beneficial effects in treating potential diabetic cases and during the trial period no adverse effect was observed in any patient. Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

original ARticle Results of the studies showed that Diabecon is useful in management of DM. Its beneficial effects may be due to the constituent herbs, which act in a synergistic and complementary manner to potentiate the therapeutic effects of Diabecon. Diabecon monotherapy, in newly detected type 2 diabetes, significantly reduces FPG, PPG and HbA1C levels. As an adjuvant to insulin or other OHAs, Diabecon helps in reducing their dose and prevents development of tolerance. It is safe for long-term use and has no contraindications. Thus, it can be concluded that Diabecon is a safe, effective, practical and affordable therapeutic modality in management of DM.

References 1. 2.

3. 4.

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

Wild S, et al. Diabetes Care 2004;27(5):1047-53. Kahn SE, Porte D Jr. The pathophysiology of type II (noninsulin-dependent) diabetes mellitus: implications for treatment. In: Ellenberg and Rifkinâ&#x20AC;&#x2122;s Diabetes Mellitus. 5th edition, Porte D Jr, Sherwin RS, (Eds.), Appleton & Lange: Stamford, Conn 1997:487-512. Porte D Jr. Diabetes 1991;40(2):166-80. World Health Organization: Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications: Report of a WHO Consultation. Part 1: Diagnosis and Classification of Diabetes Mellitus. World Health Org., Geneva, 1999. Pickup J, Williams G. Oral agents and insulin in the treatment of non-insulin-dependent diabetes mellitus. In: Textbook of Diabetes. Black-well Scientific Publications 1991;1:467-9. Jackson JE, Bressler R. Drugs 1981;22(3):211-45. Berger W. Horm Metab Res Suppl 1985;15:111-5. Merrin PK, Elkeles RS. Postgrad Med J 1991;67:931-7. Burris TP, et al. Mol Pharmacol 2005;67(3):948-54. Agarwal SP, et al. Phytother Res 2007;21(5):401-5. Mitra SK, et al. Indian J Exp Biol 1996;34(10):964-7. Shimizu K, et al. J Vet Med Sci 1997;59(4):245-51. Baskaran K, et al. J Ethnopharmacol 1990;30(3):295-300. Shanmugasundaram KR, et al. J Ethnopharmacol 1983;7(2): 205-34. Dhanabal SP, et al. Phytother Res 2006;20(1):4-8. Vats V, et al. J Ethnopharmacol 2002;79(1):95-100. Hariharan RS, et al. Diabetologia Croatica 2005;34(1):13-20. Nakagawa K, et al. Biol Pharm Bull 2004;27(11):1775-8. Annamalai P, et al. Polish J Pharmacology 2003;55:43-9. Grover JK, et al. J Ethnopharmacol 2001;76(3):233-8. Prakasam A, et al. Yale J Biol Med 2005;78(1):15-23. Grover JK, et al. J Ethnopharmacol 2000;73(3):461-70. Sridhar SB, et al. Braz J Med Biol Res 2005;38(3):463-8. Grover JK, et al. Indian J Exp Biol 2002;40(3):273-6. Rathi SS, et al. Phytother Res 2002;16(8):774-7. Sharma SB, et al. J Ethnopharmacol 2003;85(2-3):201-6. Velavan S, et al. Phcog Mag 2007;3(9):26-33.

28. Pari L, Amarnath Satheesh M. J Ethnopharmacol 2004;91(1):109-13. 29. Jeychandran R, Mahesh A. Res J Med Plant 2007;1(4):144-8. 30. Prabhu KS, et al. J Pharm Pharmacol 2008;60(7):909-16. 31. Khanom F, et al. Biosci Biotechnol Biochem 2000;64(4): 837-40. 32. Stanely Mainzen Prince P, Menon VP. Phytother Res 2003;17(4):410-3. 33. Prince PS, Menon VP. J Ethnopharmacol 1999;65(3):277-81. 34. Rege N, et al. Indian J Gastroenterol 1993;12(1):5-8. 35. El-Tantawy WH, Hassanin LA. Indian J Exp Biol 2007;45(9):785-90. 36. Aminul Islam, et al. Pharmacologyonline 2008;3:202-9. 37. Raphael KR, et al. Indian J Exp Biol 2002;40(8):905-9. 38. Srividya N, Periwal S. Indian J Exp Biol 1995;33(11):861-4. 39. Asolkar LV, et al. Gmelina arborea. Glossary of Indian Medicinal Plants with Active Principles. CSIR Publication, New Delhi, Second Supplement, 1992;Part I(A-K):p.335. 40. Mitra SK, et al. J Ethnopharmacol 1996b;54(1):41-6. 41. Tanaka M, et al. Biol Pharm Bull 2006;29(7):1418-22. 42. Kim K, et al. Phytomedicine 2009;16(9):856-63. 43. Lans CA. J Ethnobiol Ethnomed 2006;2:45. 44. Sabu MC, Kuttan R. J Ethnopharmacol 2002;81(2):155-60. 45. Ojewole JA, et al. Cardiovasc J S Afr 2006;17(5):227-32. 46. Ferrandes NP, et al. BMC Complement Altern Med 2007;7:29. 47. Kaleem M, et al. Indian J Physiol Pharmacol 2007;49(1): 65-71. 48. Hannan JM, et al. J Endocrinol 2006;189(1):127-36. 49. Halim Eshart E, et al. Indian J Clin Biochem 2006;21(2): 181-8. 50. Seetharam YN, et al. Fitoterapia 2002;73(2):156-9. 51. Roshan S, et al. Phcog Mag 2008;4(15, Suppl 1):S85-8. 52. Palla S, et al. Investig Ophthalmol Visual Sci 2005;46(6): 2092-9. 53. Hideji I, et al. Chin Med 2008;3(11):1-13. 54. Yoganarasimhan SN. Rumex maritmus. Medicinal Plants Tamil Nadu, Bangalore. 2000;1st edition,Vol. 2. p: 471. 55. Modak M, et al. J Clin Biochem Nutr 2007;40(3):163-73. 56. Atal CK, et al. J Ethnopharmacol 1981;4(2):229-32. 57. Buwa S, et al. Indian J Exp Biol 2001;39(10):1022-7. 58. Anonymous. Ayurveda Sangraha. Praval bhasma. Shree Baidyanath Ayurveda Bhawan Ltd., Kolkata. 1996;18th edition, p:118. 59. Anonymous. Ayurveda Sara Sangraha. Akika pishti. Shree Baidyanath Ayurveda Bhawan Ltd., Delhi. 1996; 18th edition, p:93-4. 60. Mishra S, Yashada bhasma. Ayurvediya Rasashastra. Chaukhambha Orientalia, Varanasi. 1997;7th edition, p:588. 61. Mohan V. Indian J Clin Pract 1998;(8)9:18. 62. Dubey GP, et al. Indian J Int Med 1993;(3)6:183-6.

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Anxiety Level Amongst Medical Students Rishi Gautam*, Kunal Bhatia*, SK Rasania**, Dhruv Gupta†, Rini Sahewalla†

Abstract Background: The study aims to assess the levels of stress anxiety in medical students and find any correlation with various causative factors. Objectives: 1. To study the levels of anxiety amongst medical students 2. To compare these levels with different variables and causative factors. Study Design: Cross-sectional study at a premier central government medical college called Vardhman Mahavir Medical College, Safdarjung Hospital, New Delhi using a standard anxiety questionnaire. Participants: Three hundred ten medical students of all batches currently studying in the college. Results: Out of the 310 medical students who participated in the study, 150 (48.4%) were found to have high anxiety levels. The prevalence of abnormally high anxiety levels was maximum in students belonging to the third (66.1%), fifth (47%), ninth (49.3%) semesters. Anxiety levels were significantly higher amongst female students (61.3%) as compared to male students (43.2%) (p < 0.05). Students living in hostel had higher anxiety levels (56.1%) than students living at home (38.9%). Examinations were cited by 66.7% students as the most important cause of high anxiety amongst them. No significant relationship was found between anxiety levels and their medium of schooling, or age. Conclusion: The findings point towards very high prevalence of anxiety amongst medical students, with female students being more prone. Also, examinations instil enormous amounts of stress and anxiety, which is clearly evident from very high anxiety levels amongst the students who had their examinations coming up (students belonging to the third, fifth and ninth semesters). Alcohol and drug abuse are grave consequences that these students are liable to develop and even suicidal ideation. We suggest installation of a psychological support teams in such institutions which would help the students tide over these stressors in a healthy manner and assure them of full confidentiality regarding their problems. Key words: Anxiety, medical students, hostelers, examination, female

nxiety is a normal reaction to stress. It helps one deal with a tense situation in the office, study harder for an exam and keep focused on an important speech. In general, it helps one cope. But when anxiety becomes an excessive, irrational dread of everyday situations, it becomes a disabling disorder.1 Medical students represent a highly educated population under significant pressures. Their academic responsibilities are a major cause of stress and anxiety amongst them. While a moderate amount of anxiety amongst students helps them achieve an optimum performance, high levels on the other hand can have a deleterious effect on their physical as well *Medical Student Vardhman Mahavir Medical College **Professor Dept. of Community Medicine, Vardhman Mahavir Medical College Safdarjung Hospital, New Delhi †Medical Student Manipal College of Medical Sciences, Manipal Address for correspondence Dr SK Rasania Professor, Dept. of Community Medicine,Vardhman Mahavir Medical College, Safdarjung Hospital, New Delhi

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as their mental health. Their sleep is disturbed and they are distressed to the extent that they are lost. Medical students loaded with heavy texts often suffer from anxiety.2 The prevalence rates of anxiety disorders amongst general population in India and South East Asia range between 0.16-0.20/100 population aged between 18-35 years. And there has been an alarming rise in these cases for the past some years.3 Objectives  To study the levels of anxiety amongst medical students.  To compare these levels with different variables and causative factors such as examinations, sex, place of residence and medium of schooling.  To prove or disprove the hypothesis that women are more prone to high anxiety levels. Material and Methods The study was done amongst the medical students studying at Vardhman Mahavir Medical College, Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Clinical study Safdarjung Hospital, New Delhi. It was conducted during August - December 2007. The design was a cross-sectional study. All the batches of medical students were informed about the purpose of interview and confidentiality assured. Out of the total 443 students in the college, 310 consented to participate. Each student was asked to fill a standard anxiety questionnaire: Sinhaâ&#x20AC;&#x2122;s comprehensive anxiety test. The sociodemographic data was collected along with the test questionnaire keeping the identity confidential. The test consisted of 90 questions, to which the subjects had to reply as a yes or a no. Each yes response was awarded 1 point, and in the end, the total score for each subject was evaluated (0 as the minimum score and 90 as the maximum score). Based on these scores the subjects were graded into extremely low (1), low (2), normal (3), high (4), extremely high (5) according to the scoring scale provided along with the test questionnaire. The data collected through the questionnaire was then statistically evaluated using the SPSS software to assess the levels of anxiety and its correlation with various causative factors such as examinations, sex, place of residence medium of schooling. Results Out of the total students, 48.4% of them had abnormally high anxiety levels (Levels 4 and 5). And the rest 51.6% were in the normal to low 40

anxiety levels after evaluation (Fig. 1). Distribution of anxiety levels varied with sex of the students. Association was present between sex and anxiety levels, with females having higher anxiety levels than males (p < 0.05); 61.3% of female students had abnormally high anxiety levels (Levels 4 and 5) (Fig. 2). An association was found between high anxiety levels and students in the third, fifth, ninth semesters, as they had their annual examinations approaching soon (p < 0.05) (Fig. 3). Various causative factors for high anxiety levels are depicted in Figure 4. An association was found between high anxiety levels and examinations, professional future as the major stressors (p < 0.05). Figure 5 shows the distribution of anxiety levels across students living with their family or at home with those living away from the social support or home. An association was found between high levels of anxiety and students living in the Hostels, away from their families (p < 0.05). Variations of anxiety levels in students with prior schooling from an English Medium School as compared to those from a Hindi Medium are shown in Figure 6. The factor was studied to assess if any correlation existed with this aspect, because the standard mode of educational training in medical colleges in India is in English. No significant association was found between anxiety levels and medium of schooling (p > 0.05).

21.6

19.7 12.3

10.3

10 5

50.9

1 1

Students (%)

30 25

Anxiety level Females Males

36.1

2 2

3 4 Anxiety levels

20 10

30.9

27.9

6.6 1 1

8.5

23.6 17.6

11.3 3

2 2

3 Anxiety levels

10.4 12.3 4 4

5 5

Figure 1. Bar chart showing distribution of the students according their anxiety levels.

Figure 2. Bar chart showing sex-wise distribution of anxiety levels.

Key: X axis-Anxiety levels: 1 = Extremely low anxiety, 2 = Low, 3 = Normal, 4 = High, 5 = Extremely high.

Y axis: Percentage of total students tested across all batches.

Y axis-Percentage of students

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545

7.60%

Key: X axis: Semester-wise distribution (First, Third, Seventh, etc.) Y axis: Percentage of students. Bar color coding depicts varying anxiety levels with (1 = Extremely low) to (5 = Extremely high) as graded earlier on a scale of 1-5.

Anxiety level English Hindi

Figure 5. Bar chart showing association between anxiety levels and place of residence. Key: X axis-Anxiety levels: 1 = Extremely low anxiety, 2 = Low, 3 = Normal, 4 = High, 5 = Extremely high. Y axis: Percentage of students. Bar codes: = Percentage of students residing at home, = Percentage of students residing in the hostel.

Discussion and Review of Literature Medical students are repeatedly subjected to rigorous examinations to check their potential to be a doctor as they have to deal with human life every single day. They have chosen a career which demands not only responsibilities but also ethical and legal liability for other’s lives. The onus of this responsibility and sheer volume of syllabus places a medical student under tremendous stress prior to professional exams. This stress

33.3 2

3 Anxiety levels

11.7 16.7

10 5

20.1

36.5

16.7

21.9 19.4

14 10.1

14.6

3 Anxiety levels

Percentage (%)

42.1

10.8 9.9

28.8

25.9

Y axis-Percentage of students. Bar codes: = Exam-related stress, = Family-related stress, = Friends related stress/peer pressure, = Professional future-related anxiety, = Other causes.

3 Anxiety levels

Key: X axis-Anxiety levels: 1 = Extremely low anxiety, 2 = Low, 3 = Normal, 4 = High, 5 = Extremely high.

Figure 4. Bar chart showing relationship between anxiety levels and biggest anxiety causing fears in life.

24.5 24.5 19.3

Percentage (%)

Anxiety level Home Hostel

Friends Future None

Ninth

Figure 3. Bar chart showing association between anxiety levels and semester.

546

Percentage (%)

44.90%

8.90%

14.30%

39.40%

17.90%

Third Fifth Seventh Semester-wise distribution

9.9 13.9

First

Anxiety level Exams Family

70 37.50%

2 4

48.20%

1 3 5

25.30%

50 45 40 35 30 25 20 15 10 5 0

10.80%

Students (%)

Clinical study

Figure 6. Bar chart showing relation between anxiety levels and medium of schooling. Key: X axis-Anxiety levels: 1 = Extremely low anxiety, 2 = Low, 3 = Normal, 4 = High, 5 = Extremely high. Y axis-Percentage of students. Bar code: : English medium of schooling, : Hindi medium of schooling.

may manifest with varying magnitude of anxiety4 and decrease in psychological health.5 Further, test anxiety is associated with lower academic performance.6 Our results point towards significant anxiety amongst medical students with 48.4% having abnormally high levels. Females were found to be suffering from more anxiety than their male counterparts as 61.3% of them had high anxiety levels, in comparison to males, of whom 43.2% fell in this category. This is in agreement with other studies that substantiate presence of sex Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Clinical study differences in exam-related anxiety, with female students having higher test anxiety than male students.7,8 Students living in the hostels away from their parents and family were suffering from greater anxiety (56.1% had abnormally high levels), than students living at their homes, with their family and social support, as only 38.9% of them had higher traits 66.2% of the students who had high anxiety stated examinations and future related problems, as their major cause for anxiety. This is also evident from the findings from the semesterwise variation in the levels of anxiety, with students of the third, fifth, ninth semester having higher anxiety levels as compared to students from the first and the seventh semesters, as they had their examinations around the corner. No significant association was found between anxiety levels and medium of schooling. Alcohol and drug abuse are grave consequences that these students are liable to develop and even suicidal ideation. We suggest installation of a psychological support teams in such institutions which would help the students tide over these stressors in a healthy manner and assure them of full confidentiality regarding their problems. Conclusion A total of 310 medical students were interviewed to assess their anxiety levels. These students were studying in the various semesters of MBBS, Vardhman Mahavir Medical College, New Delhi. The salient findings of our study were:  Prevalence of high anxiety was 48.4% (n = 150)  Maximum anxiety levels were seen in the third semester (66%) followed by the ninth semester (49.3%).  Significantly higher incidence of anxiety was seen in females (61.3%) compared to males (43.2%) (p < 0.05).



Significantly higher incidence of anxiety was seen in hostellers (56%) compared to day scholars (38.9%) (p < 0.05). Cause of anxiety as cited by the students was stress due to examinations.

Thus, we concluded that in a medical college setting, better hostel facilities and more participation by the faculty in terms of mentors for students, counselors on campus, etc. may help reduce anxiety levels in medical students. References 1. Vaidya PM, Mulgaonkar KP. Prevalence of depression anxiety and stress in undergraduate medical students and its co-relation with their academic performance. Indian J Occupational Ther 2007;XXXIX(1):7-10. 2. Inam SN, Saqib A, Alam E. Prevalence of anxiety and depression among medical students of private university. J Pak Med Assoc 2003;53(2):44-7. 3. Mehanza Z, Richa S. Prevalence of anxiety and depressive disorders in medical students. Transversal study in medical students in the Saint-Joseph University of Beirut. Encephale 2006;32(6 Pt1):976-82. 4. Kidson M, Hornblow A. Examination anxiety in medical students: experiences with the visual analogue scale for anxiety. Med Educ 1982;16(5):247-50. 5. Aktekin M, Karaman T, Senol YY, Erdem S, Erengin H, Akaydin M. Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey. Med Educ 2001;35(1):12-7. 6. Zeidner M. Does test anxiety bias scholastic aptitude test performance by gender and sociocultural group? J Pers Assess 1990;55(1-2):145-60. 7. Chapell MS, Blanding ZB, Silverstein ME, Takahashi M, Newman B, Gubi A, et al. Test anxiety and academic performance in undergraduate and graduate students. J Educ Psychol 2005;97(2):268-74. 8. Eller T, Aluoja A, Vasar V, Veldi M. Symptoms of anxiety and depression in Estonian medical students with sleep problems. Depress Anxiety 2006;23(4):250-6.

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clinical study

Uropathogens and their Susceptibility Patterns at Tertiary Care Hospital in India Deepak Arora*, Pooja Gupta*, Rajiv Kumar**, Gitanjali†

Abstract Purpose: To investigate the antibiotic pattern in the most isolated bacteria in urine sample. Material and methods: Two thousand patients were studied over a period of one year. Eight hundred patients showed the symptoms of urinary tract infection (UTI). Results: UTIs are more common in females and the number of cases peaked in post-summer season. Even though the most common bacteria isolated were Escherichia coli, its sensitivity is only 24% showing the development of resistance in it. Amongst the gram-positive cocci, Enterococcus was resistant to most of the drugs used showing the development of multidrug resistance (more than 3 drugs used). Vancomycin and teicoplanin were the most effective against gram-positive cocci (GPC) and amikacin was most effective against gram-negative bacilli (GNB). Conclusion: Increased antibiotic use in hospitals is often associated with increased frequency of resistance. These findings have profound clinical implications for current and future treatment of common bacterial infections. Key words: Urinary tract infections, gram-positive cocci, gram-negative bacilli

he term urinary tract infections (UTIs) denotes several distinct entities with the common feature of significant pyuria and bacteriuria.1 Clinical infection of the urinary tract is said to exist when a significant number of microorganisms, usually >105 cells/ml of urine, are detected in properly collected mid-stream ‘clean catch’ urine or from a catheter specimen.2 Infections of the urinary tract are among the most common infectious diseases in humans, possibly because the urinary tract is in direct contact with the exterior.2,3 UTI has a propensity to recur. The main factors predisposing to UTI have been attributed to poor personal hygiene and culture habit imposition.4 UTI is the most frequent cause of illness in humans after respiratory tract infections. It has been observed that Escherichia coli is the sole causative agent in

*Assistant Professor **Immunologist Dept. of Microbiology Adesh Medical College and Hospital, Bathinda †Assistant Professor Dept. of Biochemistry Faridkot Medical College and Hospital, Faridkot, Punjab Address for correspondence Dr Deepak Arora Assistant Professor Dept. of Microbiology Adesh Medical College and Hospital, Bathinda, Punjab - 151 001 E-mail: drdeepakarora78@gmail.com

548

more than 80% of uncomplicated UTI.5 Nosocomial UTI is common following instrumentation namely, catheterization and cystoscopy. Almost all known bacterial pathogens have been incriminated as possible causative agents of this clinical syndrome.2,3 Like all other infections, outcome of the UTI is an interplay of the virulence factors of the pathogen and the predisposing host factors. The predisposing host factors include urinary obstruction, diabetes mellitus, pregnancy, congenital anomalies of urinary tract and catheterization, vesicoureteral reflux and instrumentation.6 Since, the plasmid-mediated drug resistance can be transferred to related drug sensitive bacteria,7 the multiple drug resistance is increasing at an alarming rate, especially under the selective antibiotic pressure in the hospital environment. The leading causes of acute and uncomplicated UTI in ambulatory patients have been reported to be due to E. coli, Staphylococcus aureus, Proteus spp., Klebsiella spp. and Pseudomonas aeruginosa.8,9 In Nigeria, E. coli, Proteus spp. and Klebsiella spp. have been isolated in 90% of reported UTI cases.10 This study was carried out to investigate the prevalence and antibiotic susceptibility patterns of bacteria isolated from urine samples of some residents in Bathinda and the changing sensitivity pattern and emerging antibiotic resistance amongst the uropathogens. Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Clinical study Material and Methods

Results

Sample Collection

Out of the 2,000 random samples, 800 (40%) showed significant bacteriuria with female-to-male ratio of 2:1 as shown in Table 1.

Mid-stream clean catch specimen of urine was collected in a sterile, screw-capped, wide mouthed battle. Before collecting the sample, male subjects were asked to clean the genital parts with soap and water. The female patients were asked to do the genital toilet using soap and water; the vulva was washed and the labia was carefully separated prior to voiding the urine, in the sterile culture bottle.11 Microscopic

A 3 ml of well-mixed urine sample was centrifuged at 3,000 rpm for 10 minutes. The supernatant was discarded and the deposit was examined microscopically12 under 40x objective for pus cell, red blood cells (RBCs), epithelial cells and any other abnormal findings. Culture

Urine samples were processed within an hour of collection. In cases, where the delay of more than one hour was unavoidable, the samples were refrigerated at 4째C. The bacterial counts in the urine samples were determined by semi-quantitative method using 4 mm internal diameter standard loop (Medical Wire and Equipment Co. Ltd., England). The samples were inoculated on MacConkey and blood Agar plates. After overnight incubation at 37째C culture plates yielding bacterial counts of >105 CFU/ml were considered as significant while counts ranging between 104-105 CFU/ml were taken as doubtful significant and counts below 104 CFU/ml were taken as not significant.13 Antibiotic Susceptibility

The standard antibiotic sensitivity disk were then aseptically placed at reasonable equidistance, on the seeded MHA (in triplicates), and allowed to stand for one hour. The plates were then incubated at 37째C for 18-hour aerobically. The diameter of the zone of inhibition produced by each antibiotic disk was measured using engineer calipers and the result interpreted as earlier described as susceptible (s) or resistance (r) to the antibiotic agent used, depending on the length of zone of inhibition produced compared to reported standard length.14 Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Over the one-year of the study (October 2008September 2009), maximum cases were found in postsummer season from July to September (40%), with month of August (15.6%) leading the calendar as shown in Table 2. Out of a total of 800 uropathogens, the commonest isolate was E. coli (50.7%) followed by Klebsiella spp. (27.6%). Among the gram-positive organisms, S. aureus (1.5%) was the most prevalent. Other organisms isolated were P. aeruginosa, Proteus spp., coagulase-negative Staphylococcus, Candida spp., Enterococci, etc. Sensitivity profile of gram-positive cocci (GPC): S. aureus and coagulase-negative Staphylococcus showed average sensitivity of 67% and 50%, respectively. Teicoplanin and vancomycin retained 100% effectiveness on all the gram-positive organisms. Enterococcus spp. showed resistance to three drugs namely ampicillin, penicillin and gentamicin proving to be the toughest of the three as shown in Table 3. Sensitivity profile of gram-negative bacilli (GNB): In case of the gram-negative isolates, Pseudomonas showed maximum sensitivity to amikacin (45.4%). Average sensitivity of Proteus (17%) and Pseudomonas (20%) was less as compared to other GNB. Even though E. coli was the commonest organism to be isolated, it showed average sensitivity of 24%, demonstrating the development of resistance as shown in Table 4. Table 1. Sex Distribution (Total Positive Samples = 800) Male

Female

No. of cases positive for UTI

267

533

800

Table 2. Month-wise Distribution (Total Positive Samples = 800) October 08

April 09

November 08

May 09

December 08

June 09

January 09

July 09

105

February 09

August 09

125

March 09

September 09

549

Clinical study Table 3. Antibiotic Sensitivity Pattern of GPC (Values Showing the Percentage Sensitivity) Org

S. aureus CNS Enteroccus

Lin

Avg. sensitivity

44.5

100

23.6

19.8

100

37.4

Org: Organism; Nt: Netilmicin; Ak: Amikacin; G: Gentamicin; No: Norfloxacin; Am; Ampicillin; P: Penicillin; Ox: Oxacillin; E: Erythromycin; Te: Teicoplanin; Va: Vancomycin; Lin: Lincomycin; Avg.: Average.

Table 4. Antibiotic Sensitivity Pattern of GNB (Values Showing the Percentage Sensitivity) Org

Cefo

Cefu

Cftz

Pip

Nor/Cip

Avg. sensitivity

25%

11.3

45.4

E. coli

Klebsiella

54.8

Proteous

66.7

33.3

Pseudomonas

Org: Organism; Nt: Netilmicin; G: Gentamicin; Ak: Amikacin; Cefo: Cefotaxime; Cefu; Cefuroxime; Cftz: Ceftazidime; Pip: Piperacillin; Nor: Norfloxacin; Cip: Ciprofloxacin; Avg.: Average.

Discussion Urine is the commonest sample to be received in a microbiology laboratory. Out of the 2,000 samples, 800 (40%) showed significant bacteriuria (102 to >105) of a single pathogen. A large spectrum of organisms has been reported from patients of UTI with E. coli and Klebsiella spp. being the most common. Among 800 uropathogens isolates from patients with UTI, the commonest isolate was E. coli (50.7%) followed by Klebsiella spp. (27.6%). These figures correspond with the study by Tankhiwale et al, which reported a high incidence of 47.4% for E. coli followed by 37.8% for Klebsiella spp.15 as well. It is stated that UTI is predominantly a disease of the females due to a short urethra and proximity to the anal opening. In our study too, there was a female preponderance for this infection, and this also corroborates the previous reports.16 Reports worldwide suggest a significant peak in the incidence of UTI for a few months each year. This rise is generally in the post-summer season. Our study showed maximum number of UTI cases in August month. Anderson et al reported a rise in the incidence of UTI in August.17 They attribute this to hot and humid conditions during these months. In our study, E. coli was the commonest pathogen isolated (50.7%). This corresponds with the studies of Olafsson et al4 and Gupta et al,18 who also found E. coil as the most common isolates in females. The other uropathogens encountered were Klebsiella pneumoniae, 550

Proteus spp., Pseudomonas spp., S. aureus, coagulase-negative staphylocci (CoNS) and Enterococcus spp. E. coli was the common isolate but had a very low average sensitivity (24%) rate. Proteus spp. was found to be the least sensitive organism (17%). Useful antibiotics for GNB were amikacin, cefotaxime and oral drugs like norfloxacin showed good efficacy against all GNB. The sensitivity to norfloxacin may be attributed to the fact that these common antibiotics were not prescribed to the patients by the clinicians due to high level of resistance observed among uropathogens in the previous years. Gram-negative organisms showed sensitivity to aminoglycoside like amikacin proving its efficacy. In addition, most of the gram-negative isolates were moderately sensitive to third-generation cephalosporins viz. cefotoxime. These broad-spectrum antibiotics are used indiscriminately in various types of infections caused by different types of microbes which probably lead to emergence of resistance towards these newer antibiotics within a short span.19 Oral drugs are effective but physicians still use parenteral drugs that are comparatively expensive and are of higher generation as compared to oral drugs so these drugs should be used judiciously. Pseudomonas and Proteus spp., a leading cause of nosocomial UTI, showed least sensitivity to cephalosporin group of drugs. This may be explained by the fact that inadvertent and injudicious use of drug has led to emergence of strains resistant to these drugs. Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Clinical study In contrast to gram-negative uropathogens, grampositive isolates showed moderate sensitivity to oral antibiotics.

7. Diwan N, Sharma KB. Prevalence of serogroups and resistance plasmids in urinary Escherichia coli encountered in Delhi. Indian J Med Res 1978;68:225â&#x20AC;&#x2018;33.

S. aureus had an average sensitivity of 67% while Enterococcus spp. showed a sensitivity of just 37.4% thus showing the development of multi-resistant strains. All gram-positive organisms showed 100% sensitivity to vancomycin and teicoplanin. These findings correlate with the study of Hasan et al20 thus proving that these wonder drugs are still very effective in present scenario and should be used judiciously.

8. Forbes BA, Sahm DF, Weissfeld AS (Eds.). In: Bailey and Scottâ&#x20AC;&#x2122;s Diagnostic Microbiology. 10th edition, Mosby, Inc: Missouri 1998:359-61.

Conclusion Increased antibiotic use in hospitals is often associated with increased frequency of resistance. Changes in antibiotic sensitivity patterns at this hospital reflect all principles of antibiotic resistance already discussed. These findings have profound clinical implications for current and future treatment of common bacterial infections. References 1. Johnson CC. Definitions, classification, and clinical presentation of urinary tract infections. Med Clin North Am 1991;75(2):241-52. 2. Wilkie ME, Almond MK, Marsh FP. Diagnosis and management of urinary tract infection in adults. BMJ 1992;305(6862):1137-41. 3. Bajaj JK, Karyakarte RP, Kulkarni JD, Deshmukh AB. Changing aetiology of urinary tract infections and emergence of drug resistance as a major problem. J Commun Dis 1999;31(3):181-4. 4. Olafsson M, Kristinsson KG, Sigurdsson JA. Urinary tract infections, antibiotic resistance and sales of antimicrobial drugs: an observational study of uncomplicated urinary tract infections in Icelandic women. Scand J Prim Health Care 2000;18(1):35-8. 5. Bhau R, Gowal D, Chaturvedi AP, Jaysheela M, Agarwal P. Prevalence of Escherichia coli serotype in urinary tract infections. Indian J Med Microbiol 1989;7:21-5. 6. Measley RE Jr, Levison ME. Host defense mechanisms in the pathogenesis of urinary tract infections. Med Clin North Am 1991;75(2):275-86.

9. Bauer AW, Kirby WM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Pathol 1966;45(4):493-6. 10. National Committee for Clinical Laboratory Standards. Performance Standards for Antimicrobial Disk Susceptibility Tests. Approved Standard M2A5. 4th edition, Villanova PA. National Committee for Clinical Laboratory Standards, 1993. 11. Lipsky BA, Ireton RC, Fihn SD, Hackett R, Berger RE. Diagnosis of bacteriuria in men: specimen collection and culture interpretation. J Infect Dis 1977:155(5):847-54. 12. Cruickshank R. Medical Microbiology. Vol. 2, 12th edition, Churchill Livingstone: London 1975:587. 13. Kass EH. Asymptomatic infections of urinary tract. Trans Assoc Am Physicians 1956;69:56-64. 14. Farrell DJ, Morrissey I, De Rubeis D, Robbins M, Felmingham D. A UK multicentre study of the antimicrobial susceptibility of bacterial pathogens causing urinary tract infection. J Infect 2003;46(2):94-100. 15. Tankhiwale SS, Jalgaonkar SV, Ahamad S, Hassani U. Evaluation of extended spectrum beta lactamase in urinary isolates. Indian J Med Res 2004;120(6):553-6. 16. Bran JL Levison ME, Kaye D. Entrance of bacteria in the female urinary bladder. N Engl J Med 1972:286(12):626-31. 17. Anderson JE. Seasonality of symptomatic bacterial urinary infections in women. J Epidemiol Community Health 1983;37(4):286-90. 18. Gupta K, Scholes D, Stamm WE. Increasing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in women. JAMA 1999; 281(8):736-8. 19. Milatovic D, Braveny I. Development of resistance during antibiotic therapy. Eur J Clin Microbiol 1987;6(3):234-44. 20. Hasan AS, Nair D, Kaur J, Baweja G, Deb M, Aggarwal P. Resistance patterns of urinary isolates in a tertiary Indian hospital. J Ayub Med Coll Abbottabad 2007;19(1):39-41.

Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

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clinical study

Identification and Ranking of Problems Perceived among Urban School-going Adolescents in Vadodara in India PV Kotecha*, Sangita V Patel**, VS Mazumdar†, RK Baxi‡, S Misra**, KG Mehta#, M Diwanji§, H Bakshi§§

Abstract Objectives: To know the perceptions and identification of the problems, prioritizing them and identifying the persons who help in resolving their problems among adolescents. Material and Methods: A quantitative survey was carried out using a self-administered structured questionnaire among 1,440 (748 girls and 692 boys) students from Classes 6-12 in seven English medium and 23 Gujarati medium schools. Focus group discussions (FGDs), five each with adolescent boys and girls were held along with 5 FGDs with teachers from Gujarati and English medium schools. Results: The most common problem perceived by adolescents was: General health problem. Teachers were preferred for issues related to academics and mothers for healthrelated problems. Over one-fourth of them preferred to talk to friends about all their problems. Conclusions: Most adolescents could identify problems broadly into the category of health and nutrition, academic and physical growth and development. By their choice, they prefer to turn to parents for health problems and teachers for academic problems. Adolescents prefer talking to their peers for all the other problems. The influence of peer group is evident from the study. Key words: Adolescent, ranking of problems, perceptions, urban, India

orld Health Organization (WHO) defines adolescence as the period of life between 10 and 19 years of age. The adolescent experiences not only physical growth and change, but also emotional, psychological, social and mental change and growth.1 Adolescence is a period of increased risk taking and therefore susceptibility to behavioral problems at the time of puberty and new concerns about reproductive health. It is estimated that there are almost 331 million adolescents in India.2 Adolescents constitute about 19% of the total population, yet remain a largely neglected, difficult-to-measure and hard-to-reach population, in which the needs of adolescent girls in particular are often ignored.3 Adolescents are full of energy, have *Technical Advisor Academy for Educational Development, New Delhi **Associate Professor †Professor and Head ‡Professor #Junior Lecturer §Research Associate §§Tutor Dept. of Community Medicine (PSM) Government Medical College, Baroda Address for correspondence Dr Sangita V Patel Associate Professor Dept. of Community Medicine Government Medical College Baroda Baroda - 390 001, Gujarat E-mail: sangita_psm@yahoo.co.in

Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

significant drive and new ideas. They are responsible for its future productivity provided they develop in a healthy manner. Since, mortality in this age group is relatively low, the adolescents are considered to be healthy. However, mortality is a misleading measure of adolescent health. In fact, they do have a range of health problems that cause a lot of morbidity as well as definite mortality.4 They are prone to suffer from reproductive and sexual health, nutritional, mental and behavioral problems.5 Adolescence is a period of ‘storm and stress’. At this stage adolescents need proper care, understanding, guidance and counseling from adults. Through counseling, the adolescents can be equipped with self-help skills and help them to make their own decisions and resolve their problems.6 In view of these issues and to identify the problems perceived by adolescents; we conducted a study among school-going adolescents in Vadodara city (urban). Objectives  To know the perceptions and identification of the problems, which the adolescents feel are important.  To know the perceptions of adolescents about the persons important in their lives.  Identify persons most acceptable to them in helping them to resolve their problems. 555

Clinical study 

Prioritize issues and areas of concern by adolescents themselves in terms of their relative importance, i.e. by ranking them.

Material and Methods The study was carried out among adolescents of the selected urban schools. A quantitative survey was carried out using a self-administered structured questionnaire, either in English or Gujarati, among 1,440 (748 girls and 692 boys) students from Classes 6-12, in seven English medium and 23 Gujarati medium schools. The questionnaire was pre-tested in both the languages. Focus group discussions (FGDs), five each with adolescent boys and girls were held along with 5 FGDs with teachers from both Gujarati and English medium schools. Considering the WHO definition of adolescents as persons in the age group of 10-19 years and the ability of school students to respond to the self-administered questionnaire, it was decided to include students from Classes 6 to 12 in the study. The identified classes were explained the purpose of the study. Participation in the study was voluntary. To ensure confidentiality, the writing of the names was optional. The instruments were collected after checking for completeness. For qualitative survey, the FGDs were conducted class-wise to get an idea regarding the evolving patterns by age and note the differences. It was decided to have eight participants in each FGD. FGD was chosen as the method to obtain the adolescents’ and their teachers’ views on common adolescent problems and possible mechanisms to solve these problems. The study was concerned with the perceptions and identification of the problems, which the adolescents feel are important; and their perceptions about the persons important in their lives and hence, to identify people to whom they would turn to for problem solving. Data Analysis The data so collected was entered into computer using Epi Info (Version 6.04d) software. Data cleaning was carried out and checked for discrepancies and rectified.7 The answers to open-ended questions were grouped according to responses to quantify the emerging patterns. The responses from the FGDs were coded, grouped and analyzed using standard techniques for analyzing FGD and emerging patterns were identified.8 556

Results Common Problems of Adolescents

To help us identify the problems of adolescents, they were asked to rank the five most common problems during adolescence, as perceived by them. Tables 1 and 2 list the problems ranked first by adolescent boys and girls from English and Gujarati medium schools. Most Common Problems

The most common problem perceived by adolescents on the basis of Tables 1 and 2 was: General health problem. Next were height and weight in the students of sixth and seventh standards, but it again reduced in students of High School. Problems related to general health, diet and nutrition, height and weight were noticed somewhat lesser among adolescents of eighth to eleventh standards as compared with adolescents of sixth and seventh standards. Whereas problems like academic performance, issues of boyfriend/girlfriend, career issues were perceived more among adolescents of eighth to eleventh standards as compared with adolescents of sixth and seventh standards. Person(s) whom they turn to for Problem Solving

Adolescents were asked to identify people to whom they would turn to for problem solving. It was found that adolescents prefer to talk to their mothers, teachers, fathers and friends (Table 3). With age, proportion of boys depending on their mothers in case of health problems declined from 57% in the 11-13 years age group to 51% in the 17-20 age group, while an increasing proportion of boys turn to their fathers (from 17% among the 11-13 years olds to 26% among the 17-20 years old boys). Among girls, majority continue to turn to their mothers in case of health problems across all three age groups. Over onefourth of them prefer to talk to friends about their problems. One of the girls from Class 10 commented: “We can talk freely with our friends, but we cannot tell everything to our parents”. The influence of peer group is evident from the study. Discussion There was no difference between the type of problems commonly selected by the adolescents from English Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Clinical study Table 1. Important Problems Faced by Adolescents of English Medium Schools Problem (1st rank)

6th and 7th standards Boys

8th to 11th standards

Girls

Total

Boys

Girls

Total

N = 84

N = 65

N = 149

N = 95

N = 109

N = 204

General health problem

27.3

29.2

28.2

17.9

22.0

20.1

Diet and nutrition

15.4

7.6

12.1

10.5

7.3

8.8

Height and weight

16.6

21.5

18.8

17.9

10.1

13.7

Academic performance

11.9

9.2

10.7

10.5

8.3

9.3

Sexual development

3.5

3.4

9.5

10.1

9.8

Conflict with parents

2.3

2.7

4.2

1.8

2.9

Use of tobacco

7.1

4.0

4.2

2.8

3.4

Stress

5.9

4.6

5.4

4.2

3.7

3.9

Issues of boyfriend/girlfriend

1.1

4.6

2.7

4.2

11.9

8.3

Career issues

3.5

3.4

14.7

19.3

17.2

Table 2. Important Problems Faced by Adolescents of Gujarati Medium Schools Problem (1st rank)

6th and 7th standards Boys

8th to 11th standards

Girls

Total

Boys

Girls

Total

N = 130

N = 131

N = 261

N = 360

N = 428

N = 788

General health problem

33.8

29.7

31.8

110

30.6

124

29.0

234

29.7

Diet and nutrition

17.6

22.9

20.3

8.1

12.6

10.5

Height and weight

17.6

16.9

22.8

11.9

133

16.9

Academic performance

6.1

13.7

17.4

6.7

13.1

10.2

Sexual development

2.3

0.7

2.7

6.1

5.8

6.0

Conflict with parents

0.7

3.8

4.0

0.3

3.5

2.0

Use of tobacco

3.8

1.5

4.7

2.2

1.9

2.0

Stress

2.3

2.0

1.1

1.4

1.3

Issues of boyfriend/girlfriend

0.7

1.3

2.5

0.9

1.6

Career issues

0.7

9.4

12.1

10.9

and Gujarati medium schools except that career issues and issues of girlfriend/boyfriend were higher among the adolescents from English medium schools than the adolescents from Gujarati medium schools. Overall, nearly 70% mentioned general health-related problems. Amongst them, following health problems were perceived in increasing order: Cough/cold, getting tired easily, bodyache/stomachache, headache, acne/pimples, not getting enough sleep, trouble reading blackboards/books, toothache and earache/discharge. A study done by Joseph GA, regarding the general and reproductive health of female adolescents in a rural district in Tamil Nadu found that the most frequently cited health complaints were headaches, body pains, Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

fatigue, palpitations, backache and abdominal pain.9 The second most common problem perceived by them was related to diet and nutrition. Nearly 60% boys and girls had regular breakfast, 30% boys and 40% of girls miss a meal once/twice a week. Regarding diet and nutrition, more than half of them had consumed chocolates, soft drinks and over one-third of them had fast foods as well. A study by the Punjab Agricultural University, Ludhiana on the consumption pattern of fast foods among teenagers noticed that fast foods are most commonly consumed between regular meals.10 A study done by Rao KM regarding the diet and nutritional status of adolescent tribal population in nine states of India observed that the mean intake of all 561

Clinical study Table 3. Persons the Adolescents would Contact for Problems as First Choice Person

Health

Academic

Boys

Girls

Boys

Girls

Boys

Girls

N = 692

N = 748

N = 692

N = 748

N = 692

N = 748

Mother

374

554

74.1

13.7

135

19.5

198

26.5

Father

123

17.8

5.7

115

16.6

134

17.9

10.7

Grandparent

2.2

1.3

2.9

1.1

4.6

4.7

Brother/Sister

1.2

9.2

10.3

10.4

11.2

Teacher

1.3

0.3

248

35.8

329

3.5

1.2

Friend

0.4

2.4

11.6

12.2

142

20.5

201

26.9

Doctor

116

16.8

1.6

4.2

2.9

No one

0.9

0.7

1.7

1.3

9.5

7.5

Others

0.1

0.5

0.6

0.3

1.7

1.5

No response

4.3

2.8

5.8

3.3

106

15.3

11.6

the foodstuffs, especially the income-elastic foods such as pulses, milk and milk products, oils and fats sugar and jaggery and green leafy vegetables were lower.11 Next to diet and nutrition, the problems perceived by them were their height and weight. Regarding their perception about the appropriateness of their height and weight, nearly half of boys and girls felt that they had appropriate height and weight. One-fourth of them perceived themselves to be underweight and other one-fourth thought they were obese. But when we related their body mass index (BMI), nearly 40% boys with normal BMI thought they were not normal and nearly one-third of girls with normal BMI thought they were not normal. A study done by Rao KM, regarding the diet and nutritional status of adolescent tribal population in nine states of India observed that about 63% of adolescent boys and 42% of girls were undernourished (<5th BMI age percentiles of NHANES).11 A study done by Malhotra A regarding diet quality and nutritional status of rural adolescent girl beneficiaries of ICDS in North India assessed that the incidence of thinness (‘BMI for age’ <5th percentile) and stunting (‘height for age’ <3rd percentile) was 30.6% and 29.7%, respectively.12 In quantitative survey, although questions-related to sexual development, ranked as fifth most common problem perceived by adolescents, but during FGDs, it was found that they were more comfortable and were 562

Other

able to understand questions clearly. So, we concluded that amongst adolescent girls: Irregular menses, vaginal discharge, breast size, hair on private parts, while in adolescent boys, erection, ejaculation, wet dreams, were more common. Amongst them we found that there was lack of knowledge regarding reproductive methods, various methods of contraception and knowledge regarding HIV/AIDS. Joseph GA evaluated the general and reproductive health of female adolescents in a rural district in Tamil Nadu. He noted that adequate knowledge regarding menstruation, contraception, nutrition and AIDS were extremely low.9 Preferred Ways of Resolving Problems

Teachers were preferred for issues related to academics and mothers for problems related to health. Besides teachers, boys and girls prefer to turn to their fathers when they have problems related to studies. With age growing, they turn to their friends for help to solve their problems related to studies. For problems other than those related to their studies or their health, they prefer to approach friends. With age, dependence on mothers decreases and dependence on friends increases. For sorting out their problems and issues, adolescents generally preferred to discuss with peers, more than their parents or teachers. Also, during group discussions, when boys and girls were asked who were the persons, who support and understand them the most, majority of the adolescents, more boys than Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Head Office: E - 219, Greater Kailash, Part - 1, New Delhi - 48, India. e-Mail: emedinews@gmail.com, Website: www.ijcpgroup.com

emedinews is now available online on www.emedinews.in or www.emedinews.org From the Desk of Editor in Chief Padma Shri and Dr BC Roy National Awardee

Dr KK Aggarwal

President, Heart Care Foundation of India; Sr Consultant and Dean Medical Education, Moolchand Medcity; Member, Delhi Medical Council; Past President, Delhi Medical Association; Past President, IMA New Delhi Branch; Past Hony Director. IMA AKN Sinha Institute, Chairman IMA Academy of Medical Specialities & Hony Finance Secretary National IMA; Editor in Chief IJCP Group of Publications & Hony Visiting Professor (Clinical Research) DIPSAR

9th March 2011, Wednesday Cleft Palate Risk with Seizure Drug in Pregnancy Clinicians should be extra cautious about prescribing the epilepsy drug topiramate to women of childbearing age because of a risk of cleft palates and lips in their offspring should they become pregnant, the FDA warned. Based on a new review of clinical information, topiramate will now be labeled as Class D, the FDA said. That designation indicates that there is positive evidence of human fetal risk based on human data, but the potential benefits of the drug in pregnant women may outweigh the risks in certain situations. The review found a 1.4% prevalence of oral clefts with topiramate compared with a prevalence of 0.38% to 0.55% in infants exposed to other antiepileptic drugs (AEDs), and a prevalence of 0.07% in infants of mothers without epilepsy or treatment with other AEDs. The prevalence difference in oral clefts translated to a relative risk of 21.3 for topiramate versus the background population of untreated women (95% CI 7.9 to 57.1). In addition, according to the FDA, the UK Epilepsy and Pregnancy Register reported a similarly increased prevalence of oral clefts (3.2%) among infants exposed to topiramate monotherapy, a 16-fold increase in risk compared with the risk in their background population (0.2%). Dr KK Aggarwal Editor in Chief ———————————————————————————— Vitamin K2: Building Bones while Beating Back Arterial Calcification Vitamin K2’s time to shine has come-move over vitamin D! Once only known for its role as a “koagulation” factor in blood clotting, vitamin K2 is emerging as another fundamental anti-aging nutrient. While vitamins D and E have garnered the majority of interest in the last decade, the impact of vitamin K2 on aging bones and hearts demands that we give it equal attention. Whereas most vitamin and mineral supplements use vitamin K in its form of K1 (phylloquinone sourced from plants) because it is easily available and cheap, it is the natural form of K2 (menaquinone sourced from friendly bacteria) that is the most biologically active and shown to enhance both bone formation and vascular health. The full compilation of recent research underscores the idea that K1 and K2 should be appreciated as separate nutrients with distinct physiological actions and benefits. K1 is the more familiar vitamin known for its key role in directing blood–clotting in the body and the one given as a shot at birth (a common practice in many countries to curtail hemorrhage incidents in newborns.) The picture for K2 seems to be a bit more varied and is key in regulating calcium balance. Vitamin K2 acts by activating the bone–building hormone (carboxylating osteocalcin) to clear calcium from the arteries and use it in bone mineralization. It effectively removes calcium that would otherwise end up deposited in arterial plaques. Since protecting arteries and soft tissues from calcification is one of the most important ways to stave off the ravages of aging on the body, consuming enough vitamin K2 daily is key for a long, healthy life. −Dr Monica and Brahm Vasudev

Diabetics have Higher Risk of Death from Cancer Diabetes also ups the risk of dying from many cancers and other diseases said Emanuele Di Angelantonio of Britain’s Cambridge University, who worked on the study as part of an international collaboration. The research, published in the New England Journal of Medicine (NEJM), collated and analyzed data from 97 previous studies involving more than 820,000 people worldwide.

Opioid Pain Relievers may Increase Risk for Certain Birth Defects Consuming opioid pain relievers such as codeine, oxycodone or hydrocodone just before pregnancy or early in pregnancy increases the risk of certain birth defects, especially congenital heart defects, according to a study in the American Journal of Obstetrics and Gynecology. Diabetes may Increase Risk of Dying Prematurely from Ailments other than Heart Attack, Stroke A 50-year-old with diabetes dies six years sooner than someone without the disease, and not just from a heart attack or a stroke, according to an analysis published March 3 in the New England Journal of Medicine. FDA Safety Alert Warns PPIs may Deplete Magnesium FDA is warning that long-term use of proton pump inhibitors (PPIs) may lead to low levels of magnesium. Infertility Update What are the complementary and alternative treatments for infertility? Complementary or alternative female infertility treatments have been scientifically tested, with results published in peer–reviewed medical journals. A 2000 Harvard Medical School study examined the effects of group psychological intervention on infertile women (trying to conceive duration of one to two years). The two intervention groups— a support group and a cognitive behavior group—had statistically significant higher pregnancy rates than the control group. −Dr. Kaberi Banerjee

Medicolegal Update UK Clinical negligence law -Bolam - v - Friern Hospital Management Committee 1957 Sir Liam Donaldson said patients deserve to receive quality healthcare • UK Clinical negligence law defines negligence as any act or omission which falls short of a standard to be expected of “the reasonable man.” • It is necessary to show that whatever the Doctor did or did not do fell below the standard of a reasonably competent Doctor in that field of medicine. • In the leading case of “Bolam – v – Friern Hospital Management Committee 1957,” it was stated that a doctor must act in accordance with a practice which is accepted as proper by a responsible body of men. • There are several acceptable ways of doing something and this may mean that there is no negligence if an alternative method is chosen. • The fact that another person would not have done things in the same way does not automatically mean that there was clinical negligence. • The Doctor will be able to defend the compensation claim successfully, if it can show that a responsible body of reputable Doctors in the relevant field would have acted in a similar manner. • This means that a judge will hear evidence from experts and decide whether the actions taken were appropriate. −Dr Sudhir Gupta

Useful Website KidSurvival http://www.childsurvival.net/?content=com_articles&artid=331

Clinical study girls, said it was their friends. This coupled with their difficulty in saying ‘no’ to the peer group calls for peer group education. As children grow, develop and move into early adolescence, involvement with one’s peers and the attraction of peer identification increases and during adolescence peers typically replace the family as the center of a young person’s social and leisure activities. Next to friends, were parents, siblings and teachers in that order. Preference to turn to friends was due to their ability to communicate frankly with each other, which was not the case with parents.



Peer group matters a lot. Peer group education and using empowered, self-appointed leaders among them to work as change agents for adolescents’ problem-solving appears to be very promising and needs to be prioritized, when Adolescent Friendly Clinic (AFC) takes up training program.

Acknowledgements

I express my sincere thanks to the Government of Gujarat, for funding this study and to Dr Arvind Mathur in particular for providing technical guidance.

Conclusions

References

There was no major difference in the problems perceived by adolescents of English and Gujarati medium schools except that issues of boyfriend girlfriend and career issues are higher among adolescents of English medium schools. The most common was general health problem. For a large majority of them, being students, most of their problems are related to studies and examination-related stress. In terms of height and weight, their perception of health is incomplete and incorrect. Majority of them get to consume regular food daily; one-third of them also consume undesirable fast foods or miss a meal once or twice in a week.

1. Goldenring J. A review provided by VeriMed Healthcare Network. Medline Plus 2004.

Most adolescents could identify problems broadly into the category of health and nutrition, academic and physical growth and development. By their choice, they prefer to turn to parents for health problems and teachers for academic problems. Adolescents prefer talking to their peers for all the other problems. Recommendations  Physical growth, particularly height and weight being ‘body image issue’ and range of normal growth needs to be explained more scientifically.  Nutrition education and counseling is required to promote better nutritional intake among adolescents.  Information on reproductive system, human reproduction and related issues needs special attention. Teacher’s orientation to ‘adolescent care’ and, improving their capacity to talk and explain these topics, within the framework of coursecurriculum is recommended. Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

2. Census of India. New Delhi: Office of the Registrar General 2001. 3. Guidelines on Reproductive Health. UNFPA 1995. 4. Senderowitz J. Adolescent health: reassessing the passage to adulthood. World Bank Discussion Paper No. 272 1995:24. 5. Nath A, Garg S. Adolescent friendly health services in India: a need of the hour. Indian J Med Sci 2008;62(11):465-72. 6. Nair MKC, Paul MK, Venugopal M. Adolescent Counseling. IAP Adolescent Pediatrics Chapter 2003. 7. Dean AG, Coulombier D, Brendel KA, Smith DC, Burton AG, Dicker RC et al. A word processor, Database, and Statistical Programme for Public Health on IBMcompatible Microcomputers. Centers for Disease Control and Prevention. Atlanta, Georgia, USA 2001 Epi Info Version 6.04. 8. Greenbaum TL. The Handbook for Focus Group Research. 2 edition, SAGE Publications, 1992. 9. Joseph GA, Bhattacharji S, Joseph A, Rao PS. General and reproductive health of adolescent girls in rural south India. Indian Pediatr 1997;34(3):242-5. 10. Sadana B, Khanna M, Mann SK. Consumption patternof fast foods among teenagers. App Nutr 1997;22(1):14‑7. 11. Rao KM, Balakrishna N, Laxmaiah A, Venkaiah K, Brahmam GN. Diet and nutritional status of adolescent tribal population in nine States of India. Asia Pac J Clin Nutr 2006;15(1):64-71. 12. Malhotra A, Passi SJ. Diet quality and nutritional status of rural adolescent girl beneficiaries of ICDS in north India. Asia Pac J Clin Nutr 2007;16(Suppl 1):8-16.

565

case report

A Rare Cause of Iron Deficiency Anemia in an Infant with Atypical Presentation J Julius Xavier Scott*, Greg Smith**, Ben Saxon†

Abstract Idiopathic pulmonary hemosiderosis (IPH) is a rare disorder of childhood. Diagnosis of IPH is often problematic due to overlapping clinical features with more common diagnoses and variable clinical course. We present a case of an indigenous infant with idiopathic pulmonary hemosiderosis presenting with chest infections, iron deficiency anemia and hemolysis being mistaken for hemolytic anemia. Pulmonary hemosiderosis should be considered in any child with refractory iron deficiency anemia and persistent pulmonary infiltrates. Key words: Idiopathic pulmonary hemosiderosis, anemia, hemolytic

ron deficiency anemia (IDA) is common in pediatric practice. Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of IDA. Diagnosis of IPH is often problematic due to overlapping clinical features with more common diagnoses and variable clinical course. We present a case of an indigenous infant with idiopathic pulmonary hemosiderosis presenting with chest infections, IDA and hemolysis being mistaken for hemolytic anemia. Case Report A 7-month-old aboriginal boy was referred with a provisional diagnosis of hemolytic anemia and pneumonia. He was first noticed to have a microcytic anemia at three months of age during routine medical examination and was treated with intramuscular iron therapy. At that time he had effortless tachypnea and chest X-ray revealed bilateral infiltrates. He was treated for mild bronchiolitis. One month later, he again had a microcytic anemia and received repeat parenteral iron therapy. At five months, he presented with vomiting, lethargy, fever and increased respiratory effort. Chest X-ray *Consultant, Dept. of Pediatric Hematology and Oncology Sri Ramachandra Medical College Hospital, Porur **Senior Staff Specialist, Dept. of Pulmonary Medicine, Women’s and Children’s Hospital, Adelaide †Medical Director, Canadian Blood Services, Toronto Address for correspondence Dr J Julius Xavier Scott Associate Professor, Dept. of Pediatric Consultant, Dept. of Pediatric Hematology and Oncology Sri Ramachandra Medical College Hospital, Porur E-mail: jxscott@hotmail.com

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revealed bilateral pulmonary infiltrates and parenteral penicillin was administered. His blood count revealed microcytic anemia with hemoglobin 36 g/l. He was treated with red cell transfusion. Investigations are presented in Table 1. A diagnosis of direct antiglobulin test (DAT) negative hemolytic anemia with concurrent with IDA was made. The normal ferritin was attributed to his acute illness. Upon referral to our hospital he had no respiratory distress and was feeding well. There was no history suggestive of hemoptysis. He had unremarkable clinical examination except for a palpable spleen of <1 cm. Post-transfusion investigations were as shown in Table 1. Blood film examination revealed a dimorphic red cell population consistent with transfusion but no spherocytes or fragmentation of red cells was seen. Chest X-ray (Fig. 1) showed bilateral, mixed interstitial and alveolar pulmonary infiltrates. Immunoglobulin studies were normal and HIV serology was negative. Urine spun microscopy was negative and stool occult blood was positive in one out of three specimens. Meckel’s radionucleotide scan was negative. In view of refractory IDA and pulmonary infiltrates a bronchoscopy was done. Bronchoalveolar lavage fluid showed numerous hemosiderin-laden macrophages diagnostic of pulmonary hemosiderosis (Fig. 2). Chloroquine was commenced; however, the patient had a poor response. Despite addition of steroids, his respiratory status continues to deteriorate. Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Case Report Table 1. Investigations before and after Iron Supplementation and Post-transfusion Investigations

Before iron supplementation (3-month-old)

One month after the first intramuscular iron injection (4-month-old)

Two months after the second dose of iron injection (6-month-old) 36

Hb g/l

102

MCV fl

Absolute retic count 109/l

At presentation in our hospital after transfusion

Prior to red cell transfusion 127 81 199

227

Bilirubin Âľmol/l

LDH U/l

543

565

Haptoglobulin g/l

0.08

Ferritin ug/l Direct antiglobulin test

47 Negative

Negative

His Hb studies, B12 and folate studies were insignificant.

Figure 1. Chest X-ray showing bilateral pulmonary infiltrates.

Figure 2. Bronchoalveolar lavage fluid demonstrating hemosiderin-laden macrophages.

Discussion

autoimmune process based on the demonstration of plasma circulating immune complexes.3 A few children with IPH had detectable plasma antibodies (precipitins and immunoglobulin E [IgE]) against cowâ&#x20AC;&#x2122;s milk, which led to the hypothesis of a systemic allergic reaction to milk components.4 A series of articles linking environmental exposure to fungi (especially Stachybotrys atra) in water-damaged houses in Cleveland, OH, USA and infantile pulmonary hemosiderosis led to an extensive investigation of possible infectious or mycotoxigenic pathogenesis. Trichothecenes are potent protein synthesis inhibitors in fungal toxins. These may impede angiogenesis in rapidly forming alveolar membranes, making the acinar region prone to bleeding.5 Subsequent review by the Center for Disease Control and Prevention (CDC; Cleveland) of the S. atra link questioned both

Pulmonary hemosiderosis is a rare disorder of childhood characterized by recurrent or chronic alveolar hemorrhage and accumulation of hemosiderin in the lungs. It may affect the lungs in an isolated form (IPH) or as a manifestation of systemic illness secondary to milk protein allergy, cardiac diseases, bleeding disorders, collagen vascular diseases, systemic vasculitis or rarely celiac disease. Our patient had no features of these associated diseases. IPH may occur in people of any age most commonly in children. Kjellman et al estimated an incidence in Swedish children of 0.24 per million children per year.1 The etiology of IPH remains unknown. Familial clustering of IPH has been described, suggesting hereditary inheritance.2 IPH may be caused by an Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

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Case Report the association with the exposure to moulds, i.e. S. atra (or S. chartarum) and the diagnosis. Clinical features of IPH can be variable and include acute or insidious onset of pulmonary symptoms including cough, hemoptysis, wheezing, cyanosis and dyspnea. The presentation, such as this case, is often one of recurrent or persistent chest infection with concomitant anemia. The anemia is usually iron deficiency but may also have hemolytic characteristics. Yao et al reported a similar case of pulmonary hemosiderosis and anemia mimicking hemolysis.6 It is hypothesized that red cells deposited in the lungs will lead to hemoglobin absorption with a rise in plasma bilirubin and urine urobilinogen. Serum haptoglobin would secondarily be reduced. The DAT remains negative. Other clinical features include IDA, usually refractory to iron supplementation, poor weight gain and fatigue. The long-term course is usually characterized by recurrent episodes of pulmonary hemorrhage with associated fever and tachypnea. Digital clubbing may be present. Hepatosplenomegaly is rarely noted. The respiratory features often mimic chest infections and iron deficiency is regarded as common place in young children. This combination of common clinical findings often leads to a delay in diagnosis. Hemoptysis is unusual in young children as alveolar bleeding does not readily gain access to central airways and the patients swallow their blood-stained sputum. The swallowed blood may lead to hematemesis or may lead to positive stool occult blood which can lead clinicians to investigate for gastrointestinal blood loss and further delays diagnosis of IPH. Laboratory findings include a microcytic hypochromic anemia and low serum iron, rarely eosinophilia. Most patients demonstrate a reticulocytosis during periods of acute bleeding. Plasma ferritin level can be normal or elevated due to acute illness. Bone marrow biopsy would reveal low iron stores. A positive DAT is rare and cold agglutinins are occasionally noted. Leukocytosis and an elevated erythrocyte sedimentation rate (ESR) are rarely found. Children with cow’s milk sensitivity may have elevated levels of serum antibodies to constituents of cow’s milk or positive intradermal skin tests to cow’s milk proteins. 568

Iron-laden macrophages (siderophages) may be demonstrated in specimens from bronchoalveolar lavage, sputum or gastric washings using the Prussian blue reaction. Lung biopsy demonstrates the characteristic pathologic findings of interstitial fibrosis, numerous iron-laden macrophages in the alveoli and interstitium often with increased number of mast cells. Corticosteroids are widely accepted treatment in the acute episode and continued for few months in the chronic phase. Azathioprine, chloroquine, cyclophosphamide and methotrexate have all been used with variable success. Refractory cases have been treated with plasmapheresis, plasma exchange or lung transplantation.7,8 Patients with IPH have shown a mean survival of 2.5-5 years after diagnosis. Sudden death can occur due to massive hemorrhage or after progressive pulmonary insufficiency and right heart failure. Improved outcome is noted with prolonged immunosuppressive therapy.9 Lessons from Practice 



Pulmonary hemosiderosis should be considered in any child with refractory IDA and persistent pulmonary infiltrates. Classical features of hemoptysis and respiratory symptoms could be absent in young children. Stool occult blood could be positive because of swallowed blood mimicking gastrointestinal hemorrhage. Reticulocytosis associated with low haptoglobin in patients with IPH can mimic hemolytic anemia.

References 1. Kjellman B, Elinder G, Garwicz S, Svan H. Idiopathic pulmonary haemosiderosis in Swedish children. Acta Paediatr Scand 1984;73(5):584-8. 2. Beckerman RC, Taussig LM, Pinnas JL. Familial idiopathic pulmonary hemosiderosis. Am J Dis Child 1979;133(6):609-11. 3. Blanco A, Solis P, Gómez S, Linares P, Sánchez Villanes E. C1q-binding immune complexes and other immunological studies in children with pulmonary hemosiderosis. Allergol Immunopathol (Madr) 1984;12(1):37-44. 4. Boat TF, Polmar SH, Whitman V, Kleinerman JI, Stern RC, Doershuk CF. Hyperreactivity to cow milk in young children with pulmonary hemosiderosis and cor pulmonale secondary to nasopharyngeal obstruction. J Pediatr 1975;87(1):23-9. Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Case Report 5. From the Centers for Disease Control and Prevention. Update: pulmonary hemorrhage/hemosiderosis among infants - Cleveland, Ohio, 1993-1996. JAMA 2000; 283(15):1951-3.

derosis treated by plasmapheresis. Thorax 1980; 35(5):399â&#x20AC;&#x2018;400.

6. Yao TC, Hung IJ, Jaing TH, Yang CP. Pitfalls in the diagnosis of idiopathic pulmonary haemosiderosis. Arch Dis Child 2002;86(6):436-8.

8. Calabrese F, Giacometti C, Rea F, Loy M, Sartori F, De Vittorio G, et al. Recurrence of idiopathic pulmonary hemosiderosis in a young adult patient after bilateral single-lung transplantation. Transplantation 2002;74(11):1643-5.

7. Pozo-Rodriguez F, Freire-Campo JM, GutierrezMillet V, Barbosa-Ayucar C, Diaz de Atauri J, Martin-Escribano P. Idiopathic pulmonary haemosi-

9. Saeed MM, Woo MS, MacLaughlin EF, Margetis MF, Keens TG. Prognosis in pediatric idiopathic pulmonary hemosiderosis. Chest 1999;116(3):721-5.

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case report

Condyloma Acuminata with Maggots Samarendra Mahapatra*, Subhranshu Sekhar Kar*, Rajani Dube**, Sitanshu Sekhar Karâ&#x20AC;

Abstract Condyloma acuminata are the epidermal manifestation of human papilloma virus (HPV). The genital warts may be found throughout perineum around the anus, vagina and urethra, as well as the cervical, intravaginal and intra-anal areas. Depending on site of location, symptoms vary and in untreated cases complications like pain, bleeding and superinfection may occur. This is what occurred in this case with obstructive features in anal region and superinfection with maggots. Key words: Maggots, condyloma, human papilloma virus

ondyloma acuminata (mucous membrane warts) are moist fleshy and papillomatous lesions that occur on the perianal mucosa, labia, vaginal introitus, perianal raphe, shaft, corona and glans penis. They are the epidermal manifestations of human papilloma virus (HPV). More than 100 types of HPVs have been identified till date; out of these, more than 30 types invade genital areas.1 Symptoms vary depending on the site of location and in untreated cases, complications like pain, bleeding and superinfection may occur. This is what occurred in this case with obstructive features in the anal region and superinfection with maggots.

He was the second child of his parents, born out of a nonconsanguinous marriage; his mother was aged 26-year and father 30-year-old. He was a full term normal vaginal delivery. The antenatal, intranatal and postnatal periods were uneventful. The developmental milestones were normal for this age. On examination, he was of average body built, afebrile, height 80 cm, weight 10 kg, respiratory rate - 30/min, regular, abdominothoracic, pulse rate - 96/min regular and blood pressure - 80/60 mmHg. He had mild degree of pallor. Respiratory, cardiovascular, gastrointestinal and central nervous

Case Report A 2-year-old male child of lower socioeconomic class family was brought to the OPD with complaints of a mass over perianal region (Fig. 1), difficulty in defecation and passage of maggots for a period of six months. The mass was a black cauliflower mass, which was progressively increasing in size with itching and occasional bleeding on being scratched. Past history suggested that he was being treated with homeopathic medicines without any relief. *Associate Professor Dept. of Pediatrics **Assistant Professor Dept. of Obstetrics and Gynecology Hi-Tech Medical College, Bhubaneswar â&#x20AC; Assistant Professor Dept. of Community Medicine, JIPMER, Puducherry Address for correspondence Dr Subhranshu Sekhar Kar Qrs. No. 8/II, Hi-Tech Medical College Campus Pandara, Bhubaneswar, Odisha - 751 010 E-mail: drsskar@yahoo.co.in, drsskar@gmail.com

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Figure 1. Condyloma acuminate in perianal region.

Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Case Report systems revealed no abnormality. On local examination of perianal area, the mass was cauliflower-like and of size 5 Ă&#x2014; 4.5 Ă&#x2014; 2.5 cm3, nonfriable, fleshy and almost covering the anal opening. It was superinfected with maggots. No warts or mass were found in any other area. Complete blood count and urine examination were normal. Both parents were examined for similar lesions along with family members and all were found to be noninfected. Pathologic examination of lesion was found to be consistent with condyloma acuminata. This case was treated initially with antibiotics and turpentine oil. After disinfecting the mass, the whole lesion was surgically excised. There was no recurrence of the mass at 3-month and 6-month follow-up. Discussion Condyloma acuminata refers to an epidermal manifestation attributed to the epidermotropic HPV. More than 100 types of HPVs have been identified till date by sequence homology.1 Strains are almost species-specific and about 30 of HPV types have been identified from genital tract specimens. Ninety percent of condyloma acuminata are related to HPV types 6 and 11. These two types are the least likely to have a neoplastic potential. Genital HPV infection is mostly sexually transmitted. Most people will experience infection with HPV at some time in their life. The prevalence of viral warts in children and adolescents in the United Kingdom has been between 3.9-4.9%.2 There is no evidence of a sex difference in wart prevalence. The Sexually Transmitted Disease (STD) Clinics data show the prevalence to be 4-13%. The exact incubation time is unknown but most investigators believe that the incubation period is three months. Thus, genital HPV infection is now the most common STD. In pediatric age group (>3 years), sexual abuse must be considered as a possible underlying problem. However, below 3 years of age, infection can be direct - manual or indirectly by fomites or vertical transmission.3 Condyloma acuminata is often asymptomatic and the clinical findings depend on the site of epithelial and mucosal infection.4 The genital warts may be found throughout perineum around the anus, vagina and urethra, as well as the cervical, intravaginal and Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

intraanal areas. Although rare, lesions caused by genital genotypes can also be found on other mucosal surfaces such as conjunctiva, gingiva and nasal mucosa. Laryngeal papillomata may occur through vertical transmission. External genital warts may be flat, dome-shaped, keratotic pedunculated and cauliflowershaped; they may occur singly, in clusters or as plaques.1 On mucosal epithelium, the lesions are softer. The lesions may be pruritic and painful, cause burning with micturition, be friable and bleed or become superinfected. Condyloma acuminata must be differentiated from other warty conditions like epidermodysplasia verruciformis, Bowenoid papulosis, focal epithelial hyperplasia, epithelioma cuniculatum and verrucous carcinoma, all of which are HPV-linked. The differential diagnoses also includes non-HPV linked conditions like corns, lichen planus, epidermal nevi, molluscum contagiosum and condyloma lata.1,4 Diagnosis of warts is usually based on clinical examination but can be suggested by the histological appearances of acanthotic epidermis with papillomatosis, hyperkeratosis and parakeratosis with elongated rete ridges often curving towards the center of the wart. Dermal capillary vessels may be prominent and thrombosed. There may be large keratinocytes with eccentric pyknotic nuclei surrounded by a perinuclear halo (koilocytes). Warts commonly resolve spontaneously over time and do not need treatment. But, warts in adults with a long duration of infection and in immunosuppressed patients are less likely to resolve spontaneously and are more recalcitrant to treatment.5-7 Different types of warts and those at different sites may need differing treatments.8 The various treatment modalities available are: salicylic acid,9 podophyllotoxin 0.5% solution, imiquimod 5% cream, formaldehyde,10 bleomycin,11 retinoids,12 glutaraldehyde, interferon and cimetidine, etc. and ablative treatments like cryotherapy,9 laser therapy13,14 and loop electrosurgical excision. With all forms of therapy, lesions commonly recur and approximately 50% require a second or third treatment. Combination therapy does not improve response but may increase complications. So, periodic follow-up is recommended. 571

Case Report References 1. Anna-Barbara Moscicki. Human papilloma viruses. In: Nelson’s Text Book of Pediatrics. 17th edition 2004:1084‑6. 2. Williams HC, Pottier A, Strachan D. The descriptive epidemiology of warts in British schoolchildren. Br J Dermatol 1993;128(5):504-11. 3. Garrido JL. Human papilloma virus - HPV condyloma. Current studies in diagnosis, treatment and prognosis. Clin Exp Obstet Gynecol 1996;23(2):99-102. 4. Richard C, Richman. Human papilloma virus infections In: Harrison’s Principles of Internal Medicine. 14th Edition 1998:1098-100. 5. Bunney MH, Nolan MW, Williams DA. An assessment of methods of treating viral warts by comparative treatment trials based on a standard design. Br J Dermatol 1976;94(6):667-9.

8. Tackling warts on the hands and feet. Drug Ther Bull 1998;36(3):22-4. 9. Bourke JF, Berth-Jones J, Huchinson PE. Cryotherapy of common viral warts at intervals of 1, 2 and 3 weeks. Br J Dermatol 1995;132(3):433-6. 10. Vickers CF. Treatment of plantar warts in children. Br Med J 1961;2(5254):743-5. 11. James MP, Collier PM, Aherne W, Hardcastle A, Lovegrove S. Histologic, pharmacologic and immunocytochemical effects of injection of bleomycin into viral warts. J Am Acad Dermatol 1993; 28(6):933‑7. 12. Kubeyinje EP. Evaluation of efficacy and safety of 0.05% tretinoin cream in the treatment of plane warts in Arab children. J Dermatol Treat 1996;7(1):21-2.

6. Larsen PO, Laurberg G. Cryotherapy of viral warts. J Dermatol Treat 1996;7(1):29-31.

13. Sloan K, Haberman H, Lynde CW. Carbon dioxide lasertreatment of resistant verrucae vulgaris: retrospective analysis. J Cutan Med Surg 1998;2(3):142-5.

7. Berth-Jones J, Hutchinson PE. Modern treatment of warts: cure rates at 3 and 6 months. Br J Dermatol 1992;127(3):262-5.

14. Jain A, Storwick GS. Effectiveness of the 585nm flash lamp-pulsed dye laser (PTDL) for treatment of plantar verrucae. Lasers Surg Med 1997;21:500-5.

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case report

Collodion Baby Seema Sharma

Abstract Collodion baby is a rare congenital autosomal recessive disorder that resembles Harlequin fetus but is milder in degree. Treatment of this condition poses a considerable challenge. Supportive care is important to prevent mortality. We present herein a case of 4-day-old baby boy who presented with complaint of membrane over the whole body. The baby recovered well with treatment and was discharged with advice for regular emollient application and follow-up. Key words: Collodion membrane, autosomal recessive, icthyosis

Case Report A 4-day-old baby boy presented with complaint of membrane over the whole body, which started breaking on the second day (Fig. 1). The baby was the third issue born by normal delivery at full term to a consanguineous couple. There was history of similar complaint in the second issue who died at the age of 10 days. The babyâ&#x20AC;&#x2122;s weight was 2.3 kg and head circumference was 33 cm. On examination, the whole body was covered with parchment-like membrane resembling collodion and was peeling off on the chest and abdomen. The associated findings included ectropion (Fig. 2), flattening of nose and ears (Fig. 3), claw-like hands and limitation of joint movements. There were no other congenital anomalies. Hair and nails were normal. Sepsis screen turned out to be positive. Baby was treated in humidified environment with intravenous fluids and antibiotics. Emollient was applied to the whole body and systemic retinoids were given for two weeks. Baby recovered well and was discharged with advice for regular emollient application and follow-up (Fig. 4). Discussion Collodion baby is a rare congenital disorder resembling Harlequin fetus but milder in degree.1 Often Assistant Professor Dr Rajendra Prasad Government Medical College and Hospital, Kangra, Tanda Address for correspondence Dr Seema Sharma 23, Block-B, Type V, DRPGMC Campus Kangra, Tanda, Himachal Pradesh - 176 001 E-mail: seema406@rediffmail.com

Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Figure 1.

Figure 2.

it is a manifestation of congenital ichthyosiform erythroderma or lamellar icthyosis. Incidence of this condition is one in 3,00,000 live births.2 Affected babies are born in a collodion membrane, a shiny waxy tight inelastic outer layer to the skin, resembling an oiled parchment or dried collodion (sausage skin), which is subsequently shed within 10-14 days after birth and infrequently, has normal skin after the membrane is shed. This condition is an autosomal 573

Case Report

Figure 3.

Figure 4.

recessive genetic disorder.3 Ichthyosis lamellaris is associated with a deficiency of the enzyme keratinocyte transglutaminase. Genes involved include TGM1, ABCA12 and CYP4F22.4

be cleaned very gently under an operating microscope. Life expectancy and difficulties that the collodion baby faces depend upon the particular underlying condition. With increasing age, the scaling tends to be concentrated around joints in areas such as the groin, the armpits, the inside of the elbow and the neck. The scales often tile the skin and may resemble fish scales. There is also an increased risk of skin infection and mechanical compression, leading to problems like limb ischemia. The affected child usually has deformed auricle-Pinna, narrow external auditory canal filled with keratin debris. There is no associated inner ear nerve hearing loss.

There is presence of ectropion, flattening of ears and nose and fixation of lips in an O-shaped configuration. The hair may be absent or may perforate the horny covering. The collodion membrane is composed of greatly thickened stratum corneum that has been saturated with water. The presence of collodion membrane does not necessarily predict that the baby will develop ichthyosis and spontaneous healing may occur. Skin biopsy of collodion membrane is usually not diagnostic. Most collodion babies do have a form of ichthyosis and majority of them develop features of lamellar ichthyosis, bullous ichthyosis, X-linked ichthyosis, Netherton’s syndrome or Gaucher’s disease.

Newer therapies that have resulted in clinical improvement are topical N-acetylcysteine which has an antiproliferative effect,6 tazarotene topical 0.05%, a receptor selective retinoid7 and calcipotriol, a synthetic derivative of vitamin D. Gene therapy seems to be a novel therapeutic approach to lamellar icthyosis.8

Collodion baby represents a difficult treatment challenge. The complications include cutaneous infections, aspiration pneumonia, hypothermia or hypernatremic dehydration (from excess transcutaneous fluid loss as a result of increased skin permeability).2 Therefore, supportive care is most important to prevent mortality. Treatment initially consists of high fluid intake to avoid dehydration and transepidermal fluid loss and use of heated humidified incubator and emulsifying ointment and retinoids. Refresh tears are used to prevent the eyes from becoming dried out. There is no need to operate immediately for ectropion as it can be corrected by local application of clobetasol in older children.5 The ear canal should

4. William D James, Timothy Berger, Dirk Elston. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th edition, Saunders 2005.

References 1. Nancy BE, Lawrence MS. Congenital and hereditary disorders of the skin. In: Schaffers Diseases of Newborn. 6th edition, (Taeusch, Ballard, Avery [Eds.]), WB Saunders: USA 1991:973-84. 2. Shwayder T, Ott F. All about ichthyosis. Pediatr Clin North Am 1991;38(4):835-57. 3. Dermatology at the Millenium. Delwyn Dyall-Smith, Robin Marks, Informa Health Care 1999:586.

5. Van Gysel D, Lijnen RL, Moekti SS, de Laat PC, Oranje AP. Collodion baby: a follow-up study of 17 cases. J Eur Acad Dermatol Venereol 2002;16(5):472-5. 6. Redondo P, Bauzá A. Topical N-acetylcysteine for lamellar icthyosis. Lancet 1999;354(9193):1880. 7. Stege H, Hofmann B, Ruzicka T, Lehmann P. Topical application of tazarotene in the treatment of nonerythrodermic and lamellar icthyosis. Arch Dermatol 1998;134(5):640. 8. Akiyama M, Shimizu H. An update on molecular aspects of non-syndromic icthyosis. Exp Dermatol 2008;17(5):373-82.

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case report

Universal Acquired Melanosis Bhaswati Ghoshal*, Anjali Bandyopadhyay**

Abstract A 26-month-old male child presented with generalized blackish pigmentation of the skin, tongue and oral mucosa. With histopathological confirmation, the case was diagnosed as universal acquired melanosis, which is a rare entity with an unknown etiopathogenesis. Key words: Melanosis, acquired, universal

mongst hereditary disorders with hypermelanosis, there are a number of unusual syndromes of which pigmentation is the most conspicuous or the only manifestation. The interrelationships, classification and nomenclature of these syndromes, of which few examples have been reported, are not reliably established.1,2 Hereditary universal melanosis is one of them. A number of rare or even unique clinical pictures have been reported with such names as melanosis diffusa congenita, universal acquired melanosis (carbon baby), familial progressive hyperpigmentation, familial diffuse melanosis, generalized pigmentation, dyschromatosis universalis. The relationship between these various entities and their inheritance is often in doubt. Pigmentations usually present from early infancy, but they may be progressive. It is often diffuse and generalized but may later become rather mottled.3 Melanosis diffusa congenita or generalized cutaneous melanosis is thought to be recessively inherited.4 We report herein a rare case of universal acquired melanosis (carbon baby).

feet and then gradually the whole body progressively became black. Born to nonconsanguineous parents, he has one 4-year-old sibling who is apparently normal. There is no significant history of drug intake. On clinical examination, a generalized blackish pigmentation all over the body was observed (Fig. 1). There was dusky black pigmentation of the tongue and oral mucosa. His mental and physical milestones were within normal limits. The patient weighed 10 kg and his blood pressure was 90/60 mmHg. Laboratory studies revealed hemoglobin 8.5 g/dl. Other routine investigations, including the chest X-ray and USG of the abdomen, were normal. Histopathological examination of the skin showed increased melanization

Case Report A 26-month-old male child presented with a history of hyperpigmentation of skin since eight months of age. The pigmentation first involved both hands and *RMO cum Clinical Tutor, Dept. of Pediatrics National Medical College, Kolkata **Associate Professor, Dept. of Pathology RG Kar Medical College, Kolkata Address for correspondence Dr Bhaswati Ghoshal Souhardya Apartment, Bankimpally Madhyamgram, Kolkata - 700 129 E-mail: bhaswatighoshalmailme@yahoo.com

Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Figure 1. The child with generalized pigmentation of the body and tongue.

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Case Report

Figure 2. Photomicrograph of histopathological section of skin demonstrating the melanocytes (Masson-Fontana stain X 400).

in the basal and midepidermal keratinocytes along with presence of melanophages in the superficial dermis. Overall histomorphology was consistent with generalized cutaneous melanosis. The melanocytes were demonstrated by Masson-Fontana method (Fig. 2). Discussion The normal skin color is dependent on hemoglobin, carotenoids and melanin pigment. The major color determinant is melanin and racial and ethnic differences in skin color are related to the number, size, shape, distribution and degradation of melaninladen organelles called melanosomes. Hypermelanosis can be generalized and diffuse or may be localized and circumscribed.3 Universal acquired melanosis is an extremely rare condition, also known as carbon baby syndrome. It is characterized by progressive pigmentation of the skin during childhood.4 Generalized cutaneous hyperpigmentation can be seen in a number of metabolic, endocrine, hepatic and nutritional disorders as well as after application of topical calcipotriene and the intake of certain drugs and heavy metals.5 Hypermelanosis may be a feature of different syndromes like Fanconi’s syndrome, Albright’s syndrome, Addison’s disease and Cushing syndrome. It can be of drug origin or postinflammatory.3 The child did not have any features of those syndromes or relevant history.

Ruiz-Maldonado et al6 reported a case of universal acquired melanosis in a Mexican child who was born white and at the age of 21 months, the whole integument was deep black in the absence of other alterations. Electron microscopy showed a negroid pattern in the epidermal melanosomes characterized by an increase in type III and type IV melanosomes in melanocytes. Braun-Falco et al7 on electron microscopic examination noted increased number of single melanosomes in the keratinocytes. Kint et al8 described dispersion of melanosomes throughout the keratinocyte cytoplasm in these cases. Universal acquired melanosis is included in disorders with basal pigmentation. Mild melanin incontinence is sometimes present. The incidence of universal acquired melanosis is very rare among the different forms of progressive mucocutaneous pigmentations previously described in literature. References 1. Fulk CS. Primary disorders of pigmentation. J Am Acad Dermatol 1984;10(1):1-16. 2. Griffiths WA. Reticulate pigmentary disorders: a review. Clin Exp Dermatol 1984;9(5):439-50. 3. Bleehen SS, Austey AV. (Chapter 39). Disorders of skin colour. In: Rook’s Textbook of Dermatology. Vol 2. 7th edition, Burns T, Breathnach S, Cox N, et al. (Eds.), Blackwell Publishing: Oxford 2004:15-26. 4. Spielvogel RL, Kantor GR. Pigmentary disorders of the skin. In: Lever’s Histopathology of the Skin. Elder DE. (Ed.), Lippincott 2005:705. 5. Disorders of pigmentation. In: Skin Pathology. David Weedon (Ed.) 2002:328-9. 6. Ruiz-Maldonado R, Tamayo L, Fernandez-Diez J. Universal acquired melanosis. The carbon baby. Arch Dermatol 1978;114(5):775-8. 7. Braun-Falco O, Burg G, Selzle D, Schmoeckel C. Diffuse congenita melanosis. Hautarzt 1980;31(6):324-7. 8. Kint A, Oomen C, Geerts ML, Breuillard F. Congenital diffuse melanosis. Ann Dermatol Venereol 1987;114(1):11-6.

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emedinews section

From eMedinewS

New Clinical Practice Guidelines Describe NPPV, CPAP Use in Acute Care Setting New clinical practice guidelines describe the use of noninvasive positive-pressure ventilation (NPPV) and noninvasive continuous positive airway pressure (CPAP) in the acute care setting, according to a review in the Canadian Medical Association Journal. The recommendations describe the use of noninvasive ventilation in the postoperative setting, in immunocompromised patients, in patients being weaned from conventional mechanical ventilation, and in patients at high-risk for respiratory failure after removal of the breathing tube. Among the recommendations, the guidelines say, NPPV should be the first choice for patients with chronic obstructive pulmonary disease (COPD) or cardiogenic pulmonary edema; and patients with a severe exacerbation of COPD, defined as a pH <7.35 and relative hypercarbia, should have NPPV in addition to usual care. Researchers Question Whether Conducting Pelvic Exams in Healthy Women is Necessary In a commentary in the January Journal of Women’s Health, researchers are questioning the need of performing a pelvic exam on healthy patients with no symptoms of disease. Beck notes that the American College of Obstetricians and Gynecologists is re-evaluating its recommendations on routine pelvic exams. The Private Sector Makes Its Voice Heard on Prevention Budget talks are beginning to consume much - if not all - of Capitol Hill dialogue these days, and will continue to do so in the coming weeks and months. In anticipation, the Partnership to Fight Chronic Disease (PFCD), in partnership with WellPoint, Inc., held a briefing to demonstrate the toll chronic disease is taking on healthcare spending, and the cost-saving value of private sector prevention efforts. “With all eyes on the budget and discussions quickly turning to Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

ways to lower federal spending and cut the deficit, it’s a perfect time to have this discussion and collectively show what can be done to lower healthcare costs without compromising quality,” said Dr Ken Thorpe, executive director of PFCD, to Tradingmarkets.com. Currently, preventable and highly manageable chronic diseases consume 75% of healthcare costs. For Medicare and Medicaid specifically, chronic diseases are even more devastating-generating more than 95% of costs. The private sector solutions highlighted at the event demonstrated how targeting prevention and wellness efforts improve individual and community health, as well as reduce unnecessary healthcare spending. The event featured the efforts of healthcare organizations, payers and health and wellness professionals. Smoking may Increase ALS Risk Smoking may increase the risk of the fatal musclewasting disease amyotrophic lateral sclerosis (ALS), according to a study published in the Archives of Neurology. Children with Influenza Coinfections have Worse Outcomes, Longer Hospital Stays Children who are coinfected with influenza have worse outcomes than those without documented influenza coinfection, according to a study reported online in the Archives of Pediatrics and Adolescent Medicine. Dutasteride may not be Cost-effective Chemopreventive Agent The use of dutasteride as a chemopreventive agent is decidedly controversial, and a new study has found that it is not cost-effective. (Study coauthor Yair Lotan, MD, associate professor in the Dept. of Urology at Southwestern Medical School in Dallas, Texas). Two Common HIV Treatment Regimens have Similar Efficacy A study in the Annals of Internal Medicine compared the efficacy of two commonly used HIV treatment regimens (abacavir/lamivudine vs tenofovir emtricitabine). 577

emedinews Section Medicolegal Update

Lab Update

A Death from Respiratory Failure in Surgery Hypoxia is a Potent Precipitating Factor in Cardiac Arrest

Phosphorus

Text mentions that the cardiac arrest is mainly neurogenic and any irritation of the respiratory tract, such as laryngoscope or intubations may cause a lightly anesthetized patient to have a cardiac arrest.  Hypoxia is a factor either from faults in the apparatus or more commonly due to inexperienced anesthetist, especially in handling the equipments with which he is not familiar. An overdose of the anesthetic agent depresses the respiratory center and begins a descending spell of hypoxia.  Airway obstruction is another danger which may be blood, teeth and dentures inside the tract or faults ion the connecting tube, laryngeal spasm, swabs and an abnormal posture of neck.  From the autopsy surgeon’s point of view the finding of gastric contents in the airways must be backed up some clinical evidence of its antemortem origins before making any conclusion because many bodies has some gastric contents in some part of the air passage at the time of autopsy, mostly as a result of postmortem transfer that is a consequence of the dying process and not a cause of death.  Some physical faults in the anesthetic equipment may cause death like faults in the connecting tube which may be internal delaminating not seen from outside.  Flow-meter errors occur, but a more common one is the confusion of bottled or pipe gas supplies or the connection of an empty cylinder.  Any electric appliance is potentially dangerous and defective cauterizes, defibrillators and diathermy equipments have all caused death. Explosion from inflammable gases and vapors during intervention. –Dr Sudhir Gupta, Associate Professor, Forensic Medicine and Toxicology, AIIMS

Laugh a While A Horoscope for the Workplace

Accounting: The only other sign that studied in school, you are mostly immune from office politics. You are the most feared person in the organization; combined with your extreme organizational traits, the majority of rumors concerning you say that you are completely insane. 578

Increased: Hypoparathyroidism, excess vitamin D, secondary hyperparathyroidism, renal failure, bone disease, Addison’s disease. Decreased: Hyperparathyroidism, alcoholism, diabetes, hyperalimentation, acidosis, hypomagnesemia, diuretics, vitamin D deficiency, phosphate-binding antacids. –Dr Arpan Gandhi, Dr Navin Dang

Infertility Update What are the Causes for Female Infertility?

Factors relating only to female infertility include age, smoking, sexually transmitted infections; being overweight or underweight can all affect fertility. Age: Fertility starts declining after age 27 and drops at a somewhat greater rate after age 35. In terms of ovarian reserve, a typical woman has 12% of her reserve at age 30 and has only 3% at age 40. Eightyone percent of variation in ovarian reserve is due to age alone, making age the most important factor in female infertility. –Dr Kaberi Banerjee, Director Precious Baby Foundation

Hepatology Update What is the Role of USG in Diagnosis of Liver Abscess?

Ultrasonography (USG) is the imaging of first choice. It is quick, safe, cheap and accurate in picking a liver lesion. On ultrasound, abscess may be a round or an oval lesion which is usually hypoechoic but may have heterogenous echotexture. A solid or heterogenous lesion often evolves into a hypoechoic lesion on subsequent examination. Majority of the abscess have a well-defined wall which may be thin or irregular. USG may reveal an intra-abdominal precipitating cause for liver abscess. However, USG may miss very small abscesses or abscesses lying in areas of liver difficult to examine when patient cooperation is poor. –Dr Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta - The Medicity

Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Indian Journal of

Clinical Practice

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.

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

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

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Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

Confidence intervals for the measurements should be provided wherever appropriate.

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

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Discussion –

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

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

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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

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.

2. Total number of pages ________________________

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. –

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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.

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

summary, etc.)_______________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________

Indian 1.____________Foreign 1._ _______________

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

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Dr K.K. Aggarwal

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

Indian Journal of Clinical Practice, Vol. 21, No. 10, March 2011

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VOLUME 12, NUMBER 2

Official Voice of Doctors of India

igh doses or long-term use of PPIs or proton-pump inhibitors can lead to an increased risk of bone fractures. This holds especially true for those over the age of 50, and for people on the high dose. The latest warning is based on a FDA review of several studies of the treatment. These epidemiologic studies revealed an elevated fracture risk at the hip, wrist and spine. But the studies do not, definitively prove that PPIs are the cause of the fractures. FDA has instructed the manufacturers of the drugs to change the labels for both the prescription and the over-the-counter versions of the PPIs. The FDA said they should only be taken for 14 days to help ease frequent heartburn and under no circumstances should over-the-counter PPIs be taken for more than three 14-day periods in a year.

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Visceral fat is a hot topic because of metabolic syndrome, which predisposes people to disease. Intra-abdominal fat, or the fat that wraps around the organs in the abdomen and chest, tends to accumulate at midlife and can contribute to developing diabetes, hypertension and heart disease. The fat around the organs is known to be more related to heart disease and diabetes. A woman does not need to appear outwardly heavy to have a potentially troublesome extra ‘tire’ around her organs. Exercise for long has been known to reduce the amount of intra-abdominal fat.

“ Always aim at complete harmony of thought and word and deed. Always aim at purifying your thoughts and everything will be well.

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– Mahatama Gandhi

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Evidence-based Medicine

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iddle-aged women who move around more in their daily life have lower levels of intra-abdominal fat, a risk factor for heart disease. Minor modifications in daily routine such as reducing the time watching TV or increasing the walk time to work, can make a difference in the long-term health.

Make sure that good nursing care and maintenance of skin hygiene is advised first to patients with bed sores, along with topical antibiotics. KK Aggarwal

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Most researchers believe that more fractures are due to decreased calcium absorption from the diet because of the reduced stomach acid. But, it’s also possible that these drugs interfere with bone maintenance. Notably, PPIs have previously been linked to an increased risk of contracting pneumonia and the troublesome bacterium Clostridium difficile, as well as to an increased risk of dementia.

Minor Changes in Lifestyle are All That is Required for Good Health

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