IJCP May 2014

Indexed with IndMED

ISSN 0971-0876

www.ijcpgroup.com

Volume 24, Number 12

May 2014, Pages 1101-1200

Peer Reviewed Journal

zz American Family Physician zz Cardiology zz Community Medicine zz Clinical Psychology zz Drug zz ENT zz Gastroenterology zz Obstetrics and Gynecology

an i c i ys ians

zz Orthopedics

Phly Physic y l mi ami

zz Pediatrics

Fademy of F n ica Aca

zz Preventive Medicine

er merican m A eA

zz Respiratory Diseases

ingurnal of th t a or d Jo

zz Medilaw

rp-reviewe o c In eer AP

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IJCP Group of Publications Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor

Volume 24, Number 12, May 2014 from the desk of THE group editor-in-chief

1105 Guidelines on How to Frame Guidelines

Dr Deepak Chopra Chief Editorial Advisor Padma Shri, Dr BC Roy National & DST National Science Communication Awardee

Dr KK Aggarwal Group Editor-in-Chief

Dr Veena Aggarwal MD, Group Executive Editor

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

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

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

KK Aggarwal

American Family Physician

1109 Evaluation and Treatment of the Acutely Injured Worker

Greg Vanichkachorn, Brad A. Roy, Rita Lopez, Rebecca Sturdevant

1116 Practice Guidelines 1118 Photo Quiz CARDIOLOGY

1120 Isometric Handgrip Strengthening Exercise and Hemodynamic Responses in Mild Hypertensive Females in Indian Population

Manu Goyal, Arajit Das, Monika Bansal, Manoj Goyal

Community Medicine

1126 Effects of Electromagnetic Waves Emitted from Mobile Phone on Vestibular Function

K Singh

Clinical psychology

1132 Impact of Perceived Stress and Locus of Control on Conflict Resolution Styles

Sachin, Krishan Kumar, Rajeev Dogra

Drug

1143 Combating Antimicrobial Resistance with First-Generation Antibiotics Like Amoxicillin

Prachi Garg

ENT

1146 Foreign Body in the Nasopharynx: An Occupational Hazard

Ginni Datta, Nitish Baisakhiya, Dalbir Singh, Vandana Mendiratta

1148 Interval Tonsillectomy: 27 Cases of Peritonsillar Abscesses Managed in a Medical College Hospital

Sudhir M Naik, Sarika S Naik

GASTROENTEROLOGY

1153 Hypoxic Hepatitis in Acute Exacerbation of COPD: A Case Report

Varun Vijay Mahajan, Iesha Pargal

Obstetrics and Gynecology

1155 A Rare Case of Spinal Muscular Dystrophy/Atrophy

Sunanda Kulkarni, Savitha C

1157 Mammoth Myoma - Challenges in Management

Vembu Radha, Narayanan Palaniappan, Diviya Nanchil Kumaran

1160 Posterior Reversible Encephalopathy Syndrome in Postpartum Normotensive Woman: A Rare Presentation

Siva Sundari, KS Rajeswari, Nandhini Elumalai

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

1162 Role of Intravenous Amino Acids in Oligohydramnios and IUGR Complicated Pregnancy

Namrata Tiwari, Laxmi Maru, Anupama Dave

1167 Efficacy of Dry Cupping Therapy in the Management of

Spasmodic Dysmenorrhea: A Comparative Clinical Study

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

Yasmin Kotagasti, Wasia Naveed, Nasar Mohammad, Tabassum K

orthopedics

Š Copyright 2014 IJCP Publications Ltd. All rights reserved.

1174 Ellis-van Creveld Syndrome: A Case Report and Review of Literature

The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

Jaishree Ghanekar, Sujata Sangrampurkar, Raman Hulinaykar, Tariq Ahmer

PEDIATRICS

1178 A Randomized, Double-blind, Placebo-Controlled Study of a

Synbiotic (Bifilac) in Children with Acute Diarrhea in South India

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.

B Vishu Bhat, B Adhisivam

Preventive Medicine

1182 Pharmaceuticals in the Environment: An Unforeseen Disaster

Manoj Goyal, Monika Bansal, Shailesh Yadav, Shinu P, Jasbir Singh, Kamlesh Garg

RESPIRATORY DISEASES

1086 Masked Large Subpulmonic Effusion: An Atypical Presentation

Monika Maheshwari, Tarachand Saini, Rajesh Jain

1088 Round Pneumonia: An Unusual Presentation of Lung Infection

Sanjivani J Keny, Uday C Kakodkar, Durga J Lawande

AROUND THE GLOBE

1190 News and Views mediLAW

1193 Is there a Violation of Guidelines for Preparation of Medicolegal Report?

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.

eMEDI QUIZ

1195 Quiz Time LIGHTER READING

1196 Lighter Side of Medicine

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Guidelines on How to Frame Guidelines Guidelines are not the law. They are guidelines. Do they have to be followed? Of course, they have to be followed, but they are not legally binding. That is why they are guidelines and not the Law. They have to be applied according to circumstances.

Medical care varies markedly in every specialty. Despite the availability of the same scientific data, there is often a lack of uniformity in the management of various diseases. This leads to the need for medical guidelines as they have the potential to improve and update knowledge of the medical personnel and, thereby, produce higher standards in delivery of care. However, this desirable outcome will only be achieved if they are, indeed, implemented.

Definition of guidelines Doctors have recognized the importance of guidelines as living, dynamic information or communication tools intended by the authors to assist practitioners in optimizing the care of their individual patients.

The 28th Bethesda Conference1,2 provided specific definitions of a variety of guidelines, Guidelines; Healthcare Guidelines, Clinical Practice Guidelines, Care Plan, Care Module and Clinical Pathway.

Guidelines were defined as "a related set of generalizations derived from past experience arranged in a coherent structure to facilitate appropriate responses to specific situations". A Clinical Practice Guideline was defined as "A guideline developed to aid practitioner and patient pursuit of the most appropriate healthcare responses to specific clinical circumstances".

In his book titled "Clinical Guidelines and the Law. Negligence, Discretion and Judgment”, which was published in the UK in 1998, Brian Hurwitz1,3 described a number of related terms in use such as Protocol, Practice Policies, Medical Review Criteria, Performance Measures, Codes of Practice; Guidance. According to him, "Guidelines (compared to text books) are more concerned with specifying treatment strategies for certain patient types, with healthcare quality, and the reduction of unjustifiable clinical variability and costs". He further stated that "another way of looking at a guideline is as a collection of recommendations embodying certain standards of clinical management". He defined the Codes of Practice as "recommendations encompassing the safety and efficacy of clinical practices" and indicates that "codes of practice offer mechanisms for facilitating ethically acceptable and sociably sensitive practice".

According to the US Institute of Medicine,1,4, guidelines are "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical circumstances".

The US Evidence-Based Medicine Working Group defined guidelines1,5 as follows: "Guidelines . . .like overviews . . . gather, appraise and combine evidence. Guidelines, however, go beyond most overviews in attempting to address all the issues

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from the desk of THE group editor-in-chief relevant to a clinical decision and all the values that might sway a clinical recommendation. Like decision analysis, guidelines refine clinical questions and balance trade-off".

Legal status of guidelines Guidelines have an increasing significance in the legal arena. ÂÂ Guidelines are developed to aid the practitioner in pursuing the most appropriate healthcare response for the

clinical circumstances of a specific patient.

ÂÂ They are expected to be up-to-date in terms of medical science, highlighting critical clinical information and

provide statements on common and accepted evidence-based medical practice.

ÂÂ Most colleges, associations, societies are developing and publishing guidelines written by renowned experts

and they are thoroughly peer reviewed.

ÂÂ It is true that guidelines coming from associations may have no specific legal authority and are in no way

legally binding but they may have potential legal significance to the extent that they represent the state-of-theart.

ÂÂ Guidelines can serve legislators in the regulation of difficult clinical or medico-ethical activities. They may

also form the basis of expert evidence adduced either for the plaintiff or the defendant in civil cases involving claims of medical negligence.

ÂÂ National legislators sometimes get drawn into drafting legislation (statute law) on very complex medical subject

matters. It is not surprising, therefore that Governments and Parliaments turn to learned and ‘independent’ bodies to carry the responsibility for preparing the detailed technical documentation underpinning legislation in these areas.

For example in Netherlands, very strict guidelines on physician assisted death have been drawn up by the Royal Dutch Medical Association and incorporated in a legislative directive, allowing doctors intentionally to terminate the lives of their patients only if this is done in accordance with these strict guidelines. A doctor faced with prosecution can rely upon strict adherence to the guidelines as providing immunity from being found guilty of murder or manslaughter.

In 1990, the UK Parliament established a special Authority, called the Human Fertilization and Embryology Authority, to develop and enforce in vitro fertilization (IVF) techniques. A carefully researched and drafted ‘Code of Practice’, was proposed regulating both the ethical and clinical parameters of this treatment. The decision of the Authority to restrict the number of fertilized eggs, which can be placed in a woman’s uterus to three during treatment by IVF is a clear example of a guideline emanating from ethical, scientific, safety and cost considerations.

As Hurwitz has pointed out "This particular guideline is unambiguously clear, and its mandatory nature is made clear by enforceable penalties. Noncompliance could result in revocation of the license required to practice IVF treatment"1,3 Guidelines issued by professional medical and/or scientific organizations do not have a direct legal status in Germany. However, they may easily gain an indirect legal character (mittelbare Verrechtlichung), if the courts determine that they represent standards of care for medical practice. This would mean that if a physician does not follow such guidelines in a specific situation, there might be a strong requirement to justify any deviation from the established standard.

Most guidelines have better credibility with the public in that they are generally well-researched and based on all available expert opinion.

Negligence claims based on guidelines ÂÂ The differing national approaches to the law of tort (negligence) whether based on common law, the Code

Napoleon, or with origins in Roman law, indicate important differences in determining the burden of proof; the role of precedent; the admissibility of evidence—all this militates against a country specific analysis.

ÂÂ In common law systems, such as exist in the UK and US, a plaintiff’s claim as to negligence in medical practice

is to be found in proving three key matters: That the plaintiff was owed a duty of care (and this is generally the

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from the desk of THE group editor-in-chief case in patient/doctor relationships), that this duty was breached by failure to provide the required standard of care, and that the plaintiff was actually caused harm by this failure. ÂÂ Every claim of negligence is determined according to the facts of each individual case and by the weight of

evidence and the credence that can be given to evidence tested in court. Therefore, it is in the area of the presentation of evidence relating to the required standard of care—a reasonable test—in every case, that may lead to the consideration and review of a guideline and its applicability.

The Hurwitz book reviews a number of cases brought before English Courts1,5 and discusses a number of key questions: ÂÂ Does the existence of protocols and guidelines affect the standard of care required under the law of negligence? ÂÂ Does deviation from guidelines constitute negligence? ÂÂ Can adherence to guidelines protect doctors from liability? ÂÂ What if there is a lack of professional consensus or ‘competing’ guidelines?

He concluded: "The mere fact that a Protocol or Guideline exists for the care of a particular condition does not of itself establish that compliance with it would be reasonable in the circumstances, or that non compliance would be negligence".

As guideline-informed healthcare increasingly becomes customary, so acting outside the guidance of guidelines could expose doctors to the possibility of being found negligent, unless they can prove a special justification in the circumstances’.

Case Study In a case involving a patient in the United States with chest pain, who developed a coronary artery aneurysm as a result of vessel wall laceration during coronary catheterization and requiring emergency bypass surgery, the ACC guidelines provided objective, inculpatory evidence against the cardiologist who was sued for performing a procedure that was not medically indicated. Prior to the catheterization, the patient had a normal resting ECG and no exercise test was done. The guidelines of the ACC state that mild, stable chest pain or atypical chest pain alone does not warrant catheterization.

Medical discretion Guidelines represent the state-of-the-art (based on clinical trials and expert knowledge) of effective and appropriate patient care at the time of their creation. Guidelines cannot be appropriate for all clinical situations. The decision to follow or not follow a recommendation from a guideline must be made by the physician on an individual basis, taking into account the specific conditions of the patient.

Guidelines may be considered as a corridor which helps physicians to separate necessary from unnecessary items.

Deviations from guidelines for specific reasons are possible. Guidelines should not be understood as restrictions of therapeutic freedom but they should be considered as a chance for orientation in a healthcare system characterized by rationalization and rationing.

Guidelines for creation of guidelines: Key attributes 1,5-7 ÂÂ Face credibility: The guidelines should be credible to the ones for whom they are designed and those who

generate them should be respected for their expertise. The experts should represent a wide range of subdisciplines and the diverse cultures of the Continent.

ÂÂ Validity: The validity of guidelines is evaluated by determining whether they lead to the better management

and outcome of patients.

ÂÂ Reproducibility: Many organizations are now involved in developing guidelines, i.e., national associations,

pharma companies, government agencies, councils, federations, etc. Inconsistency between the different guidelines leads to confusion and lack of credibility. Inevitably, some discrepancies will occur because of different audiences and conditions, but attempts should be made to review guidelines from the various authorities before generating new ones, and efforts made to achieve consensus.

ÂÂ Representativeness: Those who develop guidelines should be free from bias and are seen to be so.

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from the desk of THE group editor-in-chief ÂÂ Clinical applicability and flexibility: Guidelines should "pertain to significant health problems and specific

patient groupings, defined in accordance with scientific, medical and health economic criteria. Identification of valid exceptions to recommendations, and suggestions for how patient preference can be incorporated into decision-making will help to ensure that guidelines allow for appropriate flexibility of application."1,3

ÂÂ Clarity: Ambiguity and imprecision must be avoided. Clarity is essential. ÂÂ Reliability: It is essential that guidelines are interpreted by different health professionals in different

environments in the same way.

ÂÂ Transparency: In order to establish the authority of guidelines, it is necessary that the process by which they

were generated is made public. Thus, the final document should include not only the names of the Task Force members and the way that they operated, but the organizations and individuals consulted, and the use made of evidence based and opinion-based information.

ÂÂ Scheduled review: To maintain the authority of guidelines, it is essential that they are updated at appropriate

intervals. It is proposed that a complete revision of an ESC guideline should be undertaken at intervals of not <3 and not >5 years. However, each year, the Chairman of the relevant Task Force should be consulted as to whether addenda should be added in the light of important new research. It is suggested that no Chairman should serve in this capacity for more than two editions, and that the composition of Task Forces should be partially changed (perhaps by half its members) for each edition.

Dissemination Guidelines need to have a wide circulation if they are to influence clinical practice. National societies can help to disseminate the guidelines among the medical fraternity.

References 1. Schwartz PJ, Breithardt G, Howard AJ, et al. Task Force Report: The legal implications of medical guidelines-a Task Force of the European Society of Cardiology. Eur Heart J 1999;20(16):1152-7.

2. Proceedings of the 28th Bethesda Conference Practice guidelines and the quality of care. Bethesda, Maryland, October 21-22, 1996. J Am Coll Cardiol 1997;29(6):1125-79.

3. Hurwitz B. Clinical guidelines and the Law. Negligence, discretion and judgment. Abingdon: Radcliffe Medical Press, Ltd., 1998.

4. Field MJ, Lohr KN, (Eds.). Clinical practice guidelines: directions for a new program. Institute of Medicine. National Academy Press: Washington, DC 1990.

5. Hayward RS, Wilson MC, Tunis SR, et al. Users’ guides to the medical literature. VIII. How to use clinical practice guidelines.

A. Are the recommendations valid? The Evidence-Based Medicine Working Group. JAMA 1995;274(7):570-4.

6. Field MJ, Lohr KN, (Eds.). Institute of Medicine Guidelines for Clinical Practice: from development to use. National Academy Press: Washington, DC 1992.

7. Grimshaw J, Russell I. Achieving health gain through clinical guidelines. I. Developing scientifically valid clinical guidelines.

Qual Health Care 1994;2(4):243-8.

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American Family Physician

Evaluation and Treatment of the Acutely Injured Worker GREG VANICHKACHORN, BRAD A. ROY, RITA LOPEZ, REBECCA STURDEVANT

Abstract Approximately 3 million work-related injuries were reported by private industries in 2011, and primary care physicians provided care for approximately one out of four injured work­ers. To appropriately individualize the treatment of an injured worker and expedite the return to work process, primary care physicians need to be familiar with the workers’ compensation system and treatment guidelines. Caring for an injured worker begins with a medical history documenting preexisting medical conditions, use of potentially impairing medications and substances, baseline functional status, and psychosocial factors. An understanding of past and current work tasks is critical and can be obtained through patient-completed forms, job analy­ses, and the patient’s employer. Return to work in some capacity is an important part of the recovery process. It should not be unnecessarily delayed and should be an expected outcome communicated to the patient during the initial visit. Certain medications, such as opioids, may delay the return to work process, and their use should be carefully considered. Accurate and legible documentation is critical and should always include the location, date, time, and mecha­nism of injury.

Keywords: Work-related injuries, private industries, primary care physicians, medical history, return to work, documentation

T

he evaluation and treatment of the injured worker has become a com­mon challenge in the practice of medicine. In 2011, about 3 million workplace injuries were reported in pri­vate industries.1 More than one-half of these involved an injury severe enough that work restrictions, job transfer, or time off from work was required.1 The occupations with the most injuries requiring time off were laborers (construction trades), nursing aides/atten­dants, and janitors/cleaners.2 Persons 45 to 54 years of age had the highest incidence of injuries, with sprains, strains, and tears the most common diagnoses, accounting for 38% of all injuries requiring time off work.2 The back (36%), shoulder (12%), and knee (12%) were most often injured.2 In 2007, the costs for workers’ compensation care in the United States was approximately $50 billion, about four times the cost of breast cancer treatment.3

physicians annually.4 With the shortage of occupational medicine spe­cialists, primary care physicians are often tasked with evaluating injured workers. Overall, 25% of patients with work-related conditions are cared for by primary care physicians, providing nearly three times as many visits for injured workers compared with occupational medicine specialists.5

Occupational medicine is one of the small­est medical specialties, producing about 130 board-eligible

It is important to note that, in some circum­ stances, employers and workers’ compensation insurance providers have arranged for injured employees to be evaluated by specific clini­cians. The injured worker may not be aware of such an arrangement. Ideally, employers should be contacted before or at the time of worker presentation to ensure eligibility for care and to discuss the need for additional services, such as postaccident drug testing.

GREG VANICHKACHORN, MD, MPH, is the medical direc­tor for the Occupational Health Services Clinic at Kalispell (Mont.) Regional Healthcare.

BRAD A. ROY, PhD, FACSM, FACHE, is an administrator/executive director at Kalispell Regional Healthcare. He is responsible for the Summit Medical Fitness Center, Occu­pational Health Services Clinic, and a number of other hos­pital departments.

RITA LOPEZ, MSN, APRN-BC, is a nurse practitioner in the Occupational Health Services Clinic at Kalispell Regional Healthcare.

REBECCA STURDEVANT, MSN, APRN-BC, is a nurse practitioner in the Occupational Health Services Clinic at Kalispell Regional Healthcare.

Source: Adapted from Am Fam Physician. 2014;89(1):17-24.

Evaluation The evaluation of the injured worker extends beyond determining an appropriate diagno­sis and treatment plan. The evaluation also assesses how related the condition is to work, the hazards within the work and nonwork environments, and the patient’s functional abilities, pertinent psychosocial factors, and occupational history.

Medical History The assessment of an injured worker begins with a medical history.6 Workers can be exposed to many

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American Family Physician hazards, and a high suspi­ cion for serious medical conditions is prudent, especially following acute injuries. Common sources of fatal injuries in the workplace from a 2012 census included motor vehicle crashes, falls and trips, strikes by equipment or objects, acts of violence, and exposure to harmful substances or environments.7 A detailed medical history is necessary for two reasons.

First, preexisting medical conditions can make workers more prone to certain injuries and can impact recovery.

Transparency of such a history is necessary for proper treatment (Table 1).8-20 Second, one of the primary goals of treating the injured worker is the return to preinjury medical status. A description of preexisting function, specifically in regards to activi­ties of daily living, and comparison with functional deficits following an injury are useful in assessing recovery and setting fea­sible treatment goals.

Medications (prescription and over the counter), illicit substances (e.g., marijuana), and alcohol can contribute to work-related injuries or hazards and impair recovery. This is the impetus for the postaccident drug and alcohol testing required by many employ­ers. When documenting the medication regimen, special attention should be made to dosing schedules. Medications used while away from work (e.g., at night only) do not necessarily affect work safety.

Psychosocial risk factors may be associated with work-related injuries and can affect recovery.6,13,14,21-23 Psychiatric comorbidities and maladaptive pain coping behaviors are associated with delayed recovery from low back pain.24 A stressful work environment has been associated with increased risks of shoulder injuries and pain.18 Guidelines from the American College of Occupational and Environmental Medicine describe psy­ chosocial factors that should be assessed6 (Table 26,13,21,23,25). The presence of these

Table 1. Factors Associated with Common Work Injuries Injury

Occupational factors

Nonoccupational factors

Carpal tunnel syndrome8-11

Potentially excessive hand vibration, large grip force, repetitive wrist motion

Obesity, previous wrist fracture, rheumatoid arthritis, diabetes mellitus, genetics

Injury from slips and falls12

Poor lighting, weather, slippery surfaces, clutter

Inappropriate footwear, fatigue, advanced age

Low back pain13-16

Repetitive motion, heavy lifting, bending and twisting of the trunk, whole body vibration

Obesity, psychiatric disorders, family history, advanced age

Rotator cuff injuries/ shoulder pain17-20

Prolonged shoulder flexion, repetitive and forceful onehanded lifting, awkward work positions, repetitive motion, work above shoulder height

Advanced age, overhead sports activities, previous shoulder injuries

Information from references 8 through 20.

Table 2. Psychosocial Factors Affecting Recovery from Work-Related Injuries and Potential Treatments Psychosocial factors

Potential treatments

Excessive stress

Fear avoidance behavior training

Family, friends, or peers receiving disability compensation

Inpatient pain rehabilitation

Fear avoidance behaviors (e.g., self-imposed limitation in spine range of motion)

Medical management of anxiety and depression

Heavy labor position

Pain counseling

Job dissatisfaction Legal representation Mental health conditions Monotonous work Poor relationship with supervisors and fellow employees Information from references 6, 13, 21, 23, and 25.

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Neuropsychological assessment Physical activity

American Family Physician fac­tors warrants consideration of additional treatment options, such as fear avoidance behavior training, and a neuropsychological evaluation. It is important to note that psy­chosocial factors may operate consciously and subconsciously, and their presence does not equate to malingering in cases of delayed improvement.23

Occupational History Occupational history is an often overlooked component of the medical history. Only 28% of patients have their work history recorded by physicians.26 An understand­ing of a patient’s work and occupational his­tory is critical for clarifying how related the injury is to work, preventing future injuries, and maximizing the return to work pro­ cess.27 Typically, the most accessible source of occupational information is the patient. Although obtaining an occupational his­ tory can be time-consuming, this can be alleviated by the use of patient-completed forms administered before the evaluation13,28 (Table 3 6,13,25). Another important source of information is the job analysis. Job analy­ses provide details of work tasks, physical requirements, necessary skills, and potential exposures to hazardous materials or envi­ ronments. The employer is also a valuable resource for work information, and consul­ tation is recommended if permitted.27 Treatment There are a variety of common work-related injuries; a discussion of specific treatments is outside the scope of this article. Consen­ sus guidelines, such as those published by the American College of Occupational and Environmental Medicine,6 can be consulted for treatment details. However, there are tenets of care that can be applied across a variety of injuries to maximize recovery.

Patient Communication and Engagement Uncertainty of the treatment course and prognosis can impair and prolong the recov­ery process. Efficient and succinct patient education on diagnosis, expected time to improvement, and long-term prognosis can improve outcomes.23,29,30 Setting a return to work date and informal education on how to prevent reinjury were both associated with early return to work.31 However, some written education materials such as “back books” have not been shown to produce consistent improvements.32 In the absence of serious pathology, the patient should be reassured of a likely favorable outcome.6,29 Treatment goals, including functional abilities, should be clearly stated. Frequent reassessments are recommended to

facilitate monitoring of recovery and the effectiveness of treatment modalities.6,23

Return to Work Work participation helps maintain physi­ cal conditioning, self-confidence, quality of life, and function.6,27,33Absence from work is associated with poor outcomes, includ­ ing increased morbidity, financial loss, and increased workers’ compensation costs.6,27,33 To maximize outcomes and minimize pro­ longed disability, prompt and safe return to work, even if duties are modified, is critical. Of those patients who have remained off work for more than three months, only 50% return to employment.23 Motivated by their desire to support the patient, many physicians place unnecessary work restrictions on injured workers.34 Thus, successful return to work requires a para­digm shift. Effective return to work begins at the initial visit by stressing the importance of work in the treatment process.27 Physi­cians should also emphasize that pain is part of the healing process and that returning to work in some capacity, even at a reduced activity level, should not be delayed until pain has resolved.6,27 Thus, employers should be encouraged to provide temporary alterna­tive or reduced duties and workplace accom­modations to facilitate a prompt return to work when patients cannot perform their usual tasks.

Effective communication and collabo­ration between the physician and various stakeholders are of paramount importance.30 Stakeholders can include the employer, insurance representatives, and family members.

Before communicating with an employer about a work-related injury, it is imperative that the physician understands what information may be transmitted to an employer. Typically, only information necessary to describe work restrictions and capabilities should be disclosed. Regulations regarding the sharing of workrelated injury information vary between jurisdictions.

Local policies should be clarified with the applicable workers’ compensation insurance representatives or legal counsel before any information is disclosed.27 Activity recommendations for the return to work should include a detailed descrip­ tion of abilities, restrictions, limitations, safety concerns, schedule changes, neces­sary assistive devices, and duration of rec­ommendations6 (Table 4).27 In addition, describing social and environmental limita­ tions or restrictions may be necessary with some injuries. Such information

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American Family Physician Table 3. Brief Occupational History Inquiries

Rationale and use

Screening questions regarding how related the injury is to the patient’s work Do your symptoms change between work and home?

Have you had symptoms like this at other jobs?

Symptoms that do not vary with work hours may indicate a non–workrelated etiology.

Did you have symptoms while on vacation?

Current or recent job description Title Time at job

Toxic exposures must be considered. In addition, poor compliance with safety devices, such as respirators and hearing protection, can lead to injury.

Shift work details Tasks Products made Potentially hazardous exposures (environmental, substances) Assistive devices/protective equipment used Work changes/events Changes in materials or products made Occurrence of unusual events

Changes in tasks can lead to new exposures. Similar symptoms among employees can help pinpoint a work-related etiology.

Symptoms in other employees Work history Previous jobs and time of employment Previous work-related injuries Part-time or secondary jobs

Conditions may be related to a job different than the worker’s primary position. A history of similar symptoms can provide useful treatment options, as well as establish a functional baseline.

Questions regarding psychosocial factors How are your relationships with supervisors and fellow employees?

Stress at work and poor work relationships can affect return to work and recovery.

How stressful is your job?

Do you enjoy your job?

Nonoccupational factors to consider Hobbies (e.g., hunting, carpentry, painting) Sports activities Alcohol and illicit drug use

Although patients may assume their condition is related to work, activities such as hobbies and sports must be considered as possible causes of symptoms.

Home activities and projects (e.g., yard work, home remodeling) Information from references 6, 13, and 25.

may be communicated in a variety of ways, includ­ing through letters and standardized forms.

Medications

pain management is not just to decrease pain, but also to improve physical and emotional functioning.35 In most patients, acute pain can be controlled adequately with the use of acetaminophen or ibuprofen.36

With the high prevalence of musculoskel­etal conditions in patients with work-related injuries, the management of acute pain is a common occurrence. The purpose of

Occasionally, severe acute pain may require stronger medications such as opioids. The use of opioids for the treatment of non–cancer-related pain has increased

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American Family Physician Table 4. Return to Work Prescription Component Capabilities

Description Activities the patient can do safely

Example May lift up to 25 lb from floor to waist height occasionally

Restrictions

Activities the patient cannot do without possibly causing harm to themselves or others

Restricted from driving until impairing medications are not required

Limitations

Activities the patient is unable to do

Cannot lift with the right arm above shoulder height (because of a rotator cuff tear)

Schedule modifications

Changes required in the patient’s schedule

Begin reduced work hours at four hours per day, five days per week

Duration

Time frame in which recommendations are expected to last (e.g., three weeks, permanent, temporary)

Above restrictions in place until next appointment on 3/21/14

Note: An example of a medical status form can be downloaded at http://erd.dli.mt.gov/med-status-form.html.

Information from reference 27.

significantly in recent years, and a similar trend has occurred in the treatment of injured workers. For example, between 1999 and 2007, opioid use increased by 50% in Wash­ington’s workers’ compensation cases.37 Early opioid use in the treatment of work-related back injuries has been associated with prolonged disability, higher medical costs, increased risk of surgery, and long-term opioid use.36 Opioids may also limit an injured worker’s ability to return to work. Opioids, as well as benzodiazepines and muscle relaxants, are associated with reduced alertness, sedation, and cognitive limitations. Although current research is inconclusive regarding the poten­ tial impairments on function associated with opioids, numerous employers have adopted policies that prevent employees from work­ing while using impairing medications.35 Job tasks should be considered when prescrib­ ing medications. Any potential work safety concerns secondary to the use of impairing medications should be discussed with the patient and, with adequate permission, the patient’s employer.

Specialized Examinations The management of work-related injuries, especially in the setting of workers’ com­pensation, can often require the input of additional clinicians. Such input can consist of unique examinations and reports, many of which are unfamiliar to primary care physicians.

One common evaluation is the independent medical examination. It is an extensive one-time evaluation performed by a clinician or a panel of clinicians not involved in the care of the patient. Inde­pendent medical examinations serve several purposes, such as to review treatment and assess how related the injuries are to work.

Another type of examination that may be needed is the functional capacity evaluation, which assesses functional ability using one of several validated instruments.38 Functional capacity evaluations are usually performed by a physical or occupational therapist and can provide useful information about the ability of the patient to undertake essential job-related physical demands.

An impairment rating is also commonly performed for work injuries. It is a consensus-based estimation (represented as a percent­age) of anatomic, physiologic, and psycho­ logical changes in function.38 Also accounted for is the effect of these changes on activities of daily living.39 Impairment rating assess­ ments are typically performed by physicians and utilize the American Medical Associa­tion’s Guides to the Evaluation of Permanent Impairment. There are six editions of the guides, and different jurisdictions use dif­ferent editions.39 Impairment ratings can provide useful information about functional abilities and medical history, but it should be noted that impairment does not necessarily correlate with disability.39 A neuropsychological examination can provide information on psychiatric disor­ders, personality traits, and psychosocial factors that may affect treatment and recov­ery. This examination includes an array of tests to help develop a detailed psychological profile of a patient. It is usually performed by a clinical psychologist or psychiatrist over several hours.6,39 Documentation Significant legal and financial ramifications can be associated with a work-related injury, and it should be expected that documenta­tion pertaining to the injury will be scru­tinized by multiple stakeholders including

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American Family Physician nurse case managers, claims adjusters, medi­cal peer reviewers, and attorneys. Clinical documentation is used by claims adjust­ers and insurance providers to determine the extent of medical coverage. Failure to adequately document an injury can severely limit a worker’s legitimate access to care.

In addition, accurate documentation can help control rising workers’ compensation costs by better conveying how related an injury is to work.34 Documentation must include a list of potential injuries and sources of pain, and detailed physical examination findings. For acute injuries, the location, date, time, and mechanism of injury should be recorded clearly. The necessary history elements in an acute work-related injury can be recalled by using the American College of Occupa­tional and Environmental Medicine’s four W’s (where [location of event], when [time and date], who [witness and other persons involved], and what [mechanism of injury and circumstances]).6 REFERENCES 1. Workplace injuries and illnesses–2011 [news release].

Washington, DC: Bureau of Labor and Statistics, U.S. Department of Labor; October 25, 2012. http://www.bls.gov/ news.release/osh.nr0.htm. Accessed November 15, 2012.

2. Nonfatal occupational injuries and illnesses requiring days away from work, 2011 [news release]. Washing­ton, DC: Bureau of Labor and Statistics, U.S. Depart­ment of Labor; November 8, 2012. http://www.bls.gov/news. release/osh2.nr0.htm. Accessed March 14, 2013.

3. Leigh JP, Marcin JP. Workers’ compensation benefits and shifting costs for occupational injury and illness. J Occup Environ Med. 2012;54(4):445-450.

4. Michas MG, Iacono CU. Overview of occupational medicine training among US family medicine residency programs. Fam Med. 2008;40(2):102-106.

5. Won JU, Dembe AE. Services provided by family phy­ sicians for patients with occupational injuries and ill­ nesses. Ann Fam Med. 2006;4(2):138-147.

in patients with carpal tunnel syndrome. Ann Plast Surg.

2002;48(3):269-273.

10. Hakim AJ, Cherkas L, El Zayat S, MacGregor AJ, Spec­tor TD. The genetic contribution to carpal tunnel syn­drome in women: a twin study. Arthritis Rheum. 2002;47(3):275-279.

11. Barcenilla A, March LM, Chen JS, Sambrook PN. Carpal tunnel syndrome and its relationship to occupation: a meta-analysis. Rheumatology (Oxford). 2012;51(2):250-261.

12. National Institute for Occupational Safety and Health.

Preventing slips, trips, and falls in wholesale and retail trade establishments. http://www.cdc.gov/niosh/ docs/2013-100/pdfs/2013-100.pdf. Accessed March 5, 2013.

13. Taiwo OA, Mobo BH Jr, Cantley L. Recognizing occu­ pational illnesses and injuries. Am Fam Physician.

2010;82(2):169-174.

14. Webb R, Brammah T, Lunt M, Urwin M, Allison T, Sym­ mons D. Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general pop­ ulation. Spine (Phila Pa 1976). 2003;28(11):1195-1202.

15. Videman T, Battié MC, Parent E, Gibbons LE, Vainio P, Kaprio J. Progression and determinants of quantita­ tive magnetic resonance imaging measures of lumbar disc degeneration: a five-year follow-up of adult male monozygotic twins. Spine (Phila Pa 1976).

2008;33(13):1484-1490.

16. Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine (Phila Pa 1976). 2005;30(13):1541-1548; discussion 1549.

17. Silverstein BA, Bao SS, Fan ZJ, et al. Rotator cuff syndrome: personal, work-related psychosocial and physical load factors. J Occup Environ Med. 2008;50(9):1062-1076.

18. Pope DP, Silman AJ, Cherry NM, Pritchard C, Macfar­ lane GJ. Association of occupational physical demands and psychosocial working environment with disabling shoulder pain. Ann Rheum Dis. 2001;60(9):852-858.

19. van der Windt DA, Thomas E, Pope DP, et al. Occupa­ tional risk factors for shoulder pain: a systematic review.

Occup Environ Med. 2000;57(7):433-442.

20. Rotator cuff injuries. Epocrates Online. https://online. epocrates.com. Accessed March 2, 2013.

6. American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guidelines.

3rd ed. http://www.acoem.org/practiceguidelines.aspx.

Accessed October 15, 2012.

21. Soklaridis S, Ammendolia C, Cassidy D. Looking upstream to understand low back pain and return to work: psy­chosocial factors as the product of system issues. Soc Sci Med. 2010;71(9):1557-1566.

7. Census of fatal occupational injuries–2012 [news release].

Washington, DC: Bureau of Labor and Statistics, U.S. Department of Labor; August 22, 2013. http://www.bls.gov/ news.release/cfoi.toc.htm. Accessed November 26, 2013.

22. Shaw WS, Pransky G, Patterson W, Winters T. Early dis­ ability risk factors for low back pain assessed at outpa­ tient occupational health clinics. Spine (Phila Pa 1976).

2005;30(5):572-580.

8. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hub­ bard R. Risk factors in carpal tunnel syndrome. J Hand Surg Br. 2004;29(4):315-320.

23. Derebery J, Anderson JR. Low Back Pain: An EvidenceBased, Biopsychosocial Model for Clinical Management.

2nd ed. Beverly Farms, Mass.: OEM Press; 2008:61-77.

9. Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease

24. Chou R, Shekelle P. Will this patient develop persis­tent disabling low back pain? JAMA. 2010;303(13):1295-1302.

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American Family Physician 25. Nguyen TH, Randolph DC. Nonspecific low back pain and return to work. Am Fam Physician. 2007;76(10):14971502.

26. Politi BJ, Arena VC, Schwerha J, Sussman N. Occupa­ tional medical history taking: how are today’s physicians doing? A cross-sectional investigation of the frequency of occupational history taking by physicians in a major US teaching center. J Occup Environ Med. 2004;46(6):550-555.

27. American College of Occupational and Environmen­tal Medicine. The personal physician’s role in helping patients with medical conditions stay at work or return to work. http://www.acoem.org/PhysiciansRole_ReturntoWork. aspx. Accessed November 1, 2012.

28. Harber P, Merz B. Time and knowledge barriers to rec­ ognizing occupational disease. J Occup Environ Med. 2001;43(3):285-288.

29. Dasinger LK, Krause N, Thompson PJ, Brand RJ, Rudolph L. Doctor proactive communication, return-to-work rec­ ommendation, and duration of disability after a workers’ compensation low back injury. J Occup Environ Med. 2001;43(6):515-525.

30. Anema JR, Van Der Giezen AM, Buijs PC, Van Mechelen W. Ineffective disability management by doctors is an obstacle for return-to-work: a cohort study on low back pain patients sicklisted for 3-4 months. Occup Environ Med. 2002;59(11):729-733.

31. Kosny A, Franche RL, Pole J, Krause N, Côté P, Mus­tard C. Early healthcare provider communication with patients and their workplace following a lost-time claim for an occupational musculoskeletal injury. J Occup Rehabil.

2006;16(1):27-39.

32. Derebery J, Giang GM, Gatchel RJ, Erickson K, Fog­arty TW. Efficacy of a patient-educational booklet for neckpain patients with workers’ compensation: a ran­domized controlled trial. Spine (Phila Pa 1976). 2009;34(2):206-213.

33. Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: a systematic review and meta-analysis of unemployment and all-cause mortality. Soc Sci Med. 2011;72(6):840-854.

34. Newman LS. Occupational illness. N Engl J Med. 1995;333(17):1128-1134.

35. American College of Occupational and Environmental Medicine. ACOEM guidelines for the chronic use of opi­ oids. http://www.acoem.org/Guidelines_Opioids.aspx.

Accessed October 1, 2012.

36. Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976).

2007;32(19):2127-2132.

37. Swedlow A, Ireland J, Johnson G. Prescribing patterns of schedule II opioids in California Workers’ Compen­ sation. Oakland, Calif.: California Workers’ Compensa­ tion Institute; 2011. http://www.cwci.org/document. php?file=1438.pdf. Accessed November 15, 2012 38. Taiwo OA, Cantley L. Impairment and disability evalua­ tion: the role of the family physician. Am Fam Physician.

2008;77(12):1689-1694.

39. Rondinelli RD, Genovese E, Brigham CR. Guides to the Evaluation of Permanent Impairment. 6th ed. Chicago, Ill.: American Medical Association; 2008:5.

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American Family Physician

Practice Guidelines ACS Releases Guideline on Screening for Lung Cancer with Low-Dose Computed Tomography In late 2010, results from the National Lung Screening Trial showed that lung cancer mortality was significantly reduced in highrisk adults who received annual screenings using low-dose computed tomography (CT).

After these results were announced, the American Cancer Society (ACS) joined with the American College of Chest Physicians, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network to produce a systematic review on the evidence for screening for lung cancer using low-dose CT. The review focused on the following key questions: What are the potential benefits and harms of using low-dose CT to screen persons at high risk of lung cancer? Which groups are likely to benefit? And in what setting would screening be most effective?

The ACS used the findings from the sys­ tematic review to create recommendations for a process of informed and shared decision making between physicians and patients that should occur before any decision is made to initiate screening.

The recommendations focus on the potential benefits, limitations, and harms associated with lung cancer screening using low-dose CT. If access to a high-volume, high-quality lung cancer screening and treatment center is available, physicians should discuss screening with patients 55 to 74 years of age who are in relatively good health and have a smoking history of 30 pack-years or more, who currently smoke, or who have quit within the past 15 years. Physicians should not discuss lowdose CT screening with patients who do not meet these criteria.

If screening is requested by a patient who does not meet the criteria, he or she should be told that there is too much uncertainty about the balance of

Source: Adapted from Am Fam Physician. 2014;89(1):56-57.

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harms and benefits in persons younger or older than 55 to 74 years who have less lifetime exposure to tobacco smoke, and that screening is therefore not recommended.

Physicians should ask about current and past smoking in all patients 55 to 74 years of age, and discuss the following benefits, uncertainties, and harms of lung cancer screening with those who meet the eligibility criteria above: ÂÂ Low-dose CT screening substantially reduces the risk of dying from lung cancer. ÂÂ Low-dose CT will not detect all lung cancers,

and not all patients who have can­cer detected will avoid dying from lung cancer. ÂÂ There is a significant chance of a false-positive result, which requires additional testing and, in some cases, an invasive pro­cedure to determine whether the abnormal­ ity is actually lung cancer. Fewer than one in 1,000 patients with false-positive results has a major complication resulting from a diagnostic workup.

Helping patients clarify their personal val­ ues can facilitate effective decision making. Those who value the opportunity to reduce their risk of dying from lung cancer and who are willing to accept the risks and costs associated with low-dose CT and the rela­ tively high likelihood of the need for further testing may opt for annual screening. Those who place greater value on avoiding test­ing that carries a high risk of false-positive results and a risk of complications, and who accept that they are at greater risk of death from lung cancer than from screening com­plications, may opt not to be screened.

Smoking cessation counseling remains a high priority for patients who smoke. Current smokers should be informed of their risk of lung cancer and referred to a smoking cessation program. Lung cancer screening is not an alternative to smoking cessation.

Adults who opt to be screened should be tested annually until 74 years of age. Chest radiography should not be used for lung can­ cer screening.

Whenever possible, patients should enter a program at an institution with expertise in low-dose CT screening, with access to a multidisciplinary team

American Family Physician skilled in the evaluation, diagnosis, and treatment of abnormal lung lesions.

the risks are sufficiently high that screening is not recommended.

If such a program is not available but the patient strongly wishes to be screened, he or she should be referred to a center that performs a reasonably high volume of lung CT, diagnostic testing, and lung cancer surgeries. If such a setting is not available and the patient is not willing or able to travel to one,

At this time, few government or private insurance programs provide coverage for the initial low-dose CT to screen for lung cancer. Physicians who offer screening should tell patients how much the initial test will cost and help them determine whether they must pay for it themselves.

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American Family Physician

Photo Quiz Multiple Bullae on the Trunk A 62-year-old man with no significant medi­cal history presented with multiple bullae on his trunk that had been present for one week. The rash was painful but not pruritic. He did not have a fever or sore throat, and had not used any new medications. Physical examination revealed multiple vesicles, flaccid bullae, and erosions with crust formation on the chest, abdomen, and back (Figures 1 and 2). Mucosal erosions and the Nikolsky sign were also present. There was no lymphadenopathy.

Biopsy of a blister showed suprabasal acantholysis with intraepidermal blister formation and follicu­ lar involvement. Direct immunofluorescence revealed intercellular deposits of immuno­ globulin G and C3 within the epidermis.

Question Based on the patient’s history and physical examination findings, which one of the fol­lowing is the most likely diagnosis?

Figure 1.

Figure 2.

A. Bullous impetigo.

B. Bullous pemphigoid.

C. Dermatitis herpetiformis.

D. Pemphigus vulgaris.

SEE THE FOLLOWING PAGE FOR DISCUSSION.

Source: Adapted from Am Fam Physician. 2014;89(1):7-8.

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American Family Physician Summary Table Condition Bullous impetigo

Bullous pemphigoid

Clinical characteristics Most common in neonates and infants; usually appears in perioral and perinasal areas, and in body folds; bullae are thin-walled and flaccid with subsequent rupture and crust formation Onset between 60 and 80 years of age; tense blisters on extremities and trunk; mucous membranes less involved; usually pruritic

Dermatitis herpetiformis

Symmetrical, intensely pruritic papulovesicles on extensor surfaces and buttocks; associated with gluten sensitivity

Pemphigus vulgaris

Onset between 40 and 60 years of age; flaccid and easily ruptured blisters with subsequent erosions and crust formation; usually appears on the face, scalp, trunk, intertriginous areas, and mucosal areas; usually painful; positive Nikolsky sign

Discussion The answer is D: pemphigus vulgaris. Pemphigus vul­ garis is an autoimmune blistering disease of the skin and mucous membranes. It presents as flaccid, easily ruptured blisters arising on normal skin, with subse­ quent erosions and crust formation. It often appears on the face, scalp, trunk, intertriginous areas, and mucosal areas. The lesions are usually painful but rarely pruritic.

The mean age of onset is 40 to 60 years. The Nikolsky sign is typically present. Pemphigus vulgaris is caused by the loss of the nor­ mal cell-to-cell adhesion in the epidermis because of autoantibodies against desmogleins.

The histologic findings are suprabasal acantholysis with intraepider­ mal blister formation and frequent follicular involve­ment.

Direct immunofluorescence reveals intercellular deposits of immunoglobulin G and/or C3 within the epidermis. Detection of circulating antibodies against desmogleins by indirect immunofluorescence or enzyme-linked immunosorbent assay may help to make a diagnosis. Myasthenia gravis and thymoma are associated with pemphigus vulgaris. Without treatment, pemphigus vulgaris leads to death; however, the mortality rate is markedly reduced with the use of systemic steroids and immunosuppressive agents.1 Bullous impetigo is a superficial cutaneous infection caused by Staphylococcus aureus. It most commonly affects neonates and infants, but also occurs in older children and adults. The thin-walled, flaccid bullae usually arise on grossly normal skin in perioral and perinasal areas, and in body folds. The bullae contain clear yellow fluid that subsequently turns turbid and dark yellow. Brown to yellowish crusts may form after the bullae

Histologic characteristics Subcorneal blisters filled with neutrophils, grampositive cocci, and occasional acantholytic cells Subepidermal blister with dermal infiltrates of lymphocytes and eosinophils; linear deposits of immunoglobulin G and C3 along the dermoepidermal junction on direct immunofluorescence Microabscesses containing neutrophils in the dermal papillary tips; pathognomonic granular immunoglobulin A deposits at the dermoepidermal junction on direct immunofluorescence Suprabasal acantholysis with intraepidermal blister formation and frequent follicular involvement; immunoglobulin G and/or C3 deposits within the epidermis on direct immunofluorescence

rupture. Patients may have fever and malaise. Histologically, patients have subcorneal blisters filled with neutrophils, gram-positive cocci, and occasional acantholytic cells.1,2 Bullous pemphigoid is an autoimmune disease charac­terized by tense blisters filled with serous or hemorrhagic fluid.

The blisters usually appear on the extremities and trunk, although widespread eruption is possible. Mucosal lesions occur in approximately 10% to 35% of patients. Urticarial papules and plaques may predominate in the early stage of the disease. There is usually marked pru­ritus. The typical age of onset is 60 to 80 years. Histo­logically, patients have a subepidermal blister with dermal infiltrates of lymphocytes and eosinophils. Direct immu­nofluorescence shows linear deposits of immunoglobulin G and C3 along the dermoepidermal junction.1 Dermatitis herpetiformis is an autoimmune disor­der associated with gluten sensitivity. It presents as intensely pruritic papulovesicles symmetrically located on the extensor surfaces and buttocks. The character­ istic microscopic feature is microabscesses containing neutrophils in the dermal papillary tips. Direct immu­ nofluorescence showing immunoglobulin A deposits at the dermoepidermal junction is pathognomonic.3 REFERENCES 1. Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medi­cine. 7th ed. New York, NY: Mcgraw-Hill; 2008.

2. Sladden MJ, Johnston GA. Current options for the treatment of impe­tigo in children. Expert Opin Pharmacother. 2005;6(13):2245-2256.

3. Suárez-Fernández R, España-Alonso A, Herrero-González JE, Mascaró-Galy JM. Practical management of the most common autoimmune bul­lous diseases [in Spanish].

Actas Dermosifiliogr. 2008;99(6):441-455

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Cardiology

Isometric Handgrip Strengthening Exercise and Hemodynamic Responses in Mild Hypertensive Females in Indian Population Manu Goyal*, Arajit Das†, Monika Bansal‡, Manoj Goyal#

Abstract The purpose of the study was to determine the effect of isometric handgrip exercise program on mild hypertensive female patients in Indian population. A total of 100 patients (all females) were selected as subjects and they were further divided into two groups. Each group comprising of 50 subjects. The results of the present study suggest that there was an improvement in the mean values of systolic blood pressure (mmHg) diastolic blood pressure (mmHg) and mean arterial pressure (mmHg) after treatment in both groups. But, it was found that an improvement was statistical significant more in an experimental group than nonexperimental group. It was concluded that isometric handgrip exercise should be incorporated in the management strategies of the mild hypertensive female patients.

Keywords: Isometric handgrip exercise, blood pressure, mean arterial pressure, hypertension

H

ypertension is one of the most prevalent and powerful risk factors for cardiovascular disease (CVD). It is estimated to effect nearly one-quarter of the adult population, and results in 7.1 million deaths each year.1,2 According to European Society of Cardiology guidelines Stage 1 hypertension or mild hypertension is classified as systolic blood pressure (SBP) 140-159 mmHg and diastolic blood pressure (DBP) 90-99 mmHg.3

Further discouraging is the prospect that the prevalence of hypertension is projected to increase 60% by 2025.4 It has been predicted that by the year 2020, there will be an increase by almost 75% in the global CVD burden. The situation in India is more alarming. It was reported that of a total of 9.4 million deaths in India in 1990, CVD caused 2.3 million deaths. It has been

*Principal †MPT Student MM Institute of Physiotherapy and Rehabilitation, Mullana, Ambala, Haryana ‡Associate Professor Dept. of Physiology #Associate Professor Dept. of Pharmacology Maharishi Markandeshwar Institute of Medical Sciences and Research Mullana, Ambala, Haryana Address for correspondence Dr Manu Goyal Principal MM Institute of Physiotherapy and Rehabilitation Mullana, Ambala, Haryana E-mail: manu_goyal1902@yahoo.co.in

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predicted that by 2020, there would be a 111% increase in cardiovascular deaths in India.5 A total of 1.2 million deaths are due to coronary heart disease (CHD) and 0.5 million are due to stroke.6 However, a four-fold higher prevalence of hypertension in postmenopausal women than in premenopausal women has been reported.7 After adjusting for age and body mass index (BMI), postmenopausal women were still more than twice as likely to have hypertension as premenopausal women.8 Hypertension is directly responsible for 57% of all stroke deaths and 24% of all CHD deaths in India. This fact is important because hypertension is a controllable disease and a 2 mmHg population-wide decrease in blood pressure (BP) can prevent 1,51,000 stroke and 1,53,000 CHD deaths in India.9 The prevalence rates in India are now almost comparable to those in the USA.10,11 According to the National Institute for Health and Clinical Excellence (NICE) guideline hypertension is a major risk factor for ischemic and hemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.12 The first-line therapy for hypertension should consist of lifestyle modification (i.e., exercise, diet, smoking cessation, etc.) with the aim of reducing hypertension risk factors. The ineffectiveness of hypertension therapies has necessitated the need

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Cardiology to investigate novel therapeutic alternatives.13 Results from the Framingham Heart Study showed that the benefit of reducing BP by only a few mmHg, leads to significant reductions in the risk of CHD and stroke incidents.14 Mild to moderate intensity exercise may be more effective in lowering BP than higher intensity exercises.15 Handgrip exercise is a simple form of exercise with relatively low-risk to hypertensive patients.16 Thus, in patients recommended for traditional exercise therapies, low intensity isometric exercise (<30% maximum voluntary contraction [MVC]) is well-tolerated and acceptable. The purpose of the present study was to determine the effect of long-term isometric handgrip (IHG) exercise on hemodynamic responses on BP in mild hypertensive female patients in Indian population.

Material and Methods A total number of 100 mild hypertensive females in the age range of 40-60 years were selected by means of simple random sampling after obtaining their consent based on the inclusion and exclusion criteria as mentioned below. Physician diagnosed the patients with mild hypertension and referred to an outpatient physical therapy clinic in MM Institute of Physiotherapy and Rehabilitation (MMIPR), Mullana, Ambala, Haryana for the treatment. Patient of this study were the residents of Haryana, who volunteered for the study. The patients were randomly allocated by means of sealed opaque envelopes into two groups: Group A and Group B respectively.

Inclusion Criteria ÂÂ

Mild hypertensive patients diagnosed by the physician having SBP – 140-159 mmHg and DBP – 90-99 mmHg.

ÂÂ

Patient with mean arterial pressure (MAP) – 106.7119.0 mmHg as diagnosed by the physician.

ÂÂ

Females on antihypertensive medications.

ÂÂ

Females with FIT index range from 8 to 10.

ÂÂ

BMI – 23 to 25 (overweight).

Exclusion Criteria ÂÂ

Patients with any other CVD or cerebrovascular diseases and diabetes.

ÂÂ

Patients who have secondary form of hypertension with complete history of physical examination.

ÂÂ

Patients with moderate and severe hypertension.

ÂÂ

Patients with neurological conditions.

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ÂÂ

Patients with musculoskeletal conditions like arthritis in hands, carpal tunnel syndrome, etc.

ÂÂ

Patients with other pain syndromes where device may trigger, unnecessary pain.

Variables ÂÂ

Independent variables: IHG hypertensive medications.

exercises,

anti-

ÂÂ

Dependent variables: BP (SBP and DBP), MAP.

Protocol and Procedure All the subjects received verbal explanation of the procedure, its purpose and benefits and an informed consent was taken from all the subjects.

Group A All the patients in this group had received IHG training under the complete supervision as follows: The following instructions were given to all the patients prior to handgrip training Proper demonstration was given to each patient regarding the handgrip training. Familiarization sessions were given to the subjects with hand-held dynamometer until they mastered the techniques.

Before starting the training, pretest BP (SBP, DBP and MAP) readings of each patient were measured.

According to Volland et al, individuals should sit with their shoulders adducted and neutrally rotated, elbow flexed at 90º, forearm in neutral position and wrist between 0º and 30º dorsiflexion and between 0º and 15º ulnar deviation. The hand dynamometer should be set to the second handle position from the inside and you should lightly hold around the readout dial to prevent inadvertent dropping. After the individual is positioned properly, say, “Squeeze as hard as you can... harder...harder...relax”.17 According to “Jamar Hydraulic Hand Dynamometer Owner’s Manual”, the recorded scores of three successive trials of dominant hand were tested.

The average scores of the three trials were compared to the normative data on the left, which is in pounds.

From a statistical perspective, scores within two standard deviations (SD) of the mean were considered within normal limits. In addition, the individuals’ ability to use their hand functionally was considered a grip strength performance was interpreted.18 In the present study, firstly, handgrip training was performed which was excluded from the training time period, and then the isometric hand grip training

Cardiology was started with hand-held dynamometer. According to Ray and Carrasco, each subject attended four training session per week. During each session, 50 mild hypertensive female patients performed three; 3-minute bouts of unilateral IHG of the dominant arm at 30% MVC, while sitting with the working arm extended toward the front for a total of 5 weeks. Each bout was separated by a 5-minute rest period.19 Preand post-test readings of BP and MAP were measured in dominant limb on first day of training and again at the end of the 5th week.

Group B Fifty mild hypertensive female patients held the handgrip dynamometer in dominant hand, but they are generating no force during the exercise bout. Pre- and post-test readings of BP and MAP were measured in dominant limb on the first day of training and again at the end of the 5th week. Each exercise bout was 3min for three times for 4 days/week for 5 weeks.

Statistical Analysis The data was analyzed using statistical computer software ‘SPSS-16 free trial version’. The mean, SD and t-test was used. The level of significance was p < 0.05.

Results The mean age and BMI of the subjects of Group A and Group B was 51.94 ± 5.626 years, 51.10 ± 6.351 years, 26.94 ± 1.434 kg/m2 and 27.32 ± 1.449 kg/m2, respectively. It was found that the difference in the mean values of age and BMI between Group A and Group B was not statistical significant (Table 1).

Table 2 shows comparison of the baseline measurements Table 1. Comparison of Age and BMI Group A

Group B

t value

Age (years)

51.94 ± 5.626

51.10 ± 6.351

1.98

BMI (kg/m2)

26.94 ± 1.434

27.32 ± 1.449

1.98

*Significant p < 0.05.

Table 2. Comparison of Baseline Measurement of SBP (mmHg), DBP (mmHg), MAP (mmHg) between the Group A and Group B Group A

Group B

t value

SBP (mmHg)

147.30 ± 5.246 148.46 ± 4.978

1.134

DBP (mmHg)

93.58 ± 2.374

94.50 ± 2.652

1.828

MAP (mmHg)

111.49 ± 2.946

112.49 ± 2.666

1.780

*Significant p < 0.05.

of the mean ± SD of SBP (mmHg), DBP (mmHg), MAP (mmHg) in both the Group A and Group B. It is seen that there is no significant difference between the groups in terms of outcomes.

Table 3 shows statistical significant improvement in the scores of SBP (mmHg), DBP (mmHg), MAP (mmHg) in both the Group A and Group B. Table 4 shows that unpaired sample t-test has been used to compare the post values of SBP (mmHg), DBP (mmHg), MAP(mmHg) between the Group A and Group B along with their mean differences having p < 0.05.

The results revealed a significant difference between both the Group A and Group B after 5 weeks of intervention.

Discussion The aim of this study was to determine the effect of IHG exercise program on mild hypertensive female patients in Indian population. The result of this study suggests that there is improvement in mean values of measurement of SBP, DBP and MAP after treatment in both the groups (Table 3 and 4). But, when evaluated with statistical measures between the groups, it is shown that the improvement is more significant in IHG exercise group (Table 4).

The results obtained did not support the null hypothesis and thus it was rejected and the alternate hypothesis was accepted.

The results of the present study are consistent with the finding obtained in the study conducted by Cook et al who showed that unilateral IHG training elicits reductions in DBP and MAP at rest. A 2 mmHg drop in diastolic would lead to 17% decrease in hypertension as well as 6% reduction in CHD and a 15% reduction in stroke related events. The results of the present study in term of DBP and MAP at rest are 3.74 mmHg and 4.03 mmHg respectively. The study of Cook et al, which showed the decrease in DBP = 5 mmHg and decrease in MAP at rest. Albeit, the reduction in DBP and MAP appears modest but the recent studies indicates that small reductions in diastolic arterial pressure in the population would have significant health benefits.14,20 Study by Millar et al21 demonstrated that the decrease in SBP 5.7 mmHg and DBP 3 mmHg respectively supporting the present study results which showed the decrease in SBP 4.60 mmHg and DBP 3.74 mmHg, respectively. The decrease in BP and MAP may be attributed to the mechanism of blood flow and oxygen in tissue cells. So, it has been hypothesized that endothelin-1 (ET-1) is involved in BP control and plays

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Cardiology Table 3. Paired t-test of SBP (mmHg), DBP (mmHg), MAP (mmHg) within the Group A and Group B Group A Before

t value

Group B

After 5th week

Before

t value

After 5th week

SBP (mmHg)

147.30 ± 5.24

142.70 ± 5.195

53.667

148.46 ± 4.978

144.76 ± 4.745

11.014

DBP (mmHg)

93.58 ± 2.374

89.84 ± 2.629

21.874

94.50 ± 2.652

91.10 ± 2.375

13.928

MAP (mmHg)

111.49 ± 2.946

107.46 ± 3.007

31.528

112.49 ± 2.666

108.99±2.179

17.358

*Significant p < 0.05

Table 4. Unpaired t-test of SBP (mmHg), DBP (mmHg), MAP (mmHg) between the Group A and Group B Group A

Group B

t-value

Mean diff.

P value

SBP (mmHg)

142.70 ± 5.195

144.76 ± 4.745

2.070

2.060

0.0411

DBP (mmHg)

89.84 ± 2.629

91.10 ± 2.375

2.514

1.260

0.0136

MAP (mmHg)

107.46 ± 3.007

108.99 ± 2.179

2.907

1.527

0.0045

*Significant p < 0.05

a pathophysiologic role in the development of clinical hypertension. The response to handgrip produced increased ET-1 plasma levels and resulted in a sustained ET-1 release into the bloodstream during recovery compared with offspring of normotensive patients.

It was reported that long-term physical exercise improves endothelium-dependent vasorelaxation through an increase in the release of nitric oxide in normotensive as well as hypertensive subjects. Millar et al stated that in comparison to dynamic exercise (exhausting treadmill walking protocol), sustained handgrip contractions elicited lower SBP and heart rate responses. Thus, in hypertensive patients, low-intensity isometric exercise (<30% MVC) is well-tolerated and acceptable.

Taylor et al showed the attenuation in the resting arterial pressure (SBP, DBP and MAP) and it was associated with a corresponding change in sympathovagal balance. The results of this study are consistent with the findings of the present study.22 Study by Carter et al demonstrated that by whole body resistance training for 8 weeks, there was decrease in systolic (130 ± 3 to 121 ± 2 mmHg; p = 0.01), diastolic (69 ± 3 to 61 ± 2 mmHg; p = 0.04), and mean (89 ± 2 to 81 ± 2 mmHg; p = 0.01), whereas the present blood pressure study showed that by 5 weeks of IHG training, there was a decrease in the level of systolic (147.30 ± 5.246 to 142.70 ± 5.195 mmHg; p = 0.001), diastolic (93.58 ± 2.374 to 89.84 ± 2.629 mmHg; p = 0.001), and mean (111.49 ± 2.946 to 107.46 ± 3.007; p = 0.001) BP.23 Wiles et al showed in their study, the comparison of the effects of leg isometric training in low-intensity

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and high-intensity for 8 weeks and it has performed 4 times 2 min exercise bouts for 3 days in a week but there were no significant changes in SBP, DBP, MAP were observed by isometric training where as the present study results showed the differences in outcome measures.24 Lack of monitoring of continuous BP during the exercise period and this additional information on blood pressure fluctuating could be useful to enhance our understanding of the hemodynamics of the handgrip exercise in BP regulation. No specific causes of mild hypertension were considered in this study.

These are the few limitations that were noticed in the present study. These should be considered in the future randomized trials.

It is concluded that the IHG exercise is effective in reducing the SBP, DBP and MAP in mild hypertensive females. Therefore, it should be incorporated in the management strategies of the mild hypertensive patients.

References 1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Hypertension 2003;42(6):1206-52.

2. World Health Organization. The World Health Report 2002: Risks to Health. World Health Organization: Geneva; 2002.

Cardiology 3. Duerden MG; British Hypertension Society. Guidelines from the British Hypertension Society: BHS is set to bankrupt NHS. BMJ 2004;329(7465):569-70; author reply 570-1.

15. Zhang J. Effect of isometric handgrip exercise training on resting hemodynamics: a pilot study. J Chiropr Med 2003;2(4):153-6.

4. Kanavos P, Ostergren J, Weber MA. High blood pressure and health policy: where we are and where we need to go next? Ruder Finn Inc: New York, USA; 2007.

16. Koltyn KF, Trine MR, Stegner AJ, Tobar DA. Effect of isometric exercise on pain perception and blood pressure in men and women. Med Sci Sports Exerc 2001;33(2): 282-90.

5. Gupta R. Trends in hypertension epidemiology in India.

J Hum Hypertens 2004;18(2):73-8.

6. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study.

Lancet 1997;349(9061):1269-76.

7. Staessen J, Bulpitt CJ, Fagard R, Lijnen P, Amery A. The influence of menopause on blood pressure. J Hum Hypertens 1989;3(6):427-33.

8. August P, Oparil S. Hypertension in women. J Clin Endocrinol Metab 1999;84(6):1862-6.

9. Rodgers A, Lawes C, MacMahon S. Reducing the global burden of blood pressure-related cardiovascular disease.

J Hypertens Suppl 2000;18(1):S3-6.

10. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med 1993;153(2):154-83.

11. Whelton PK. Epidemiology of hypertension. Lancet 1994;344(8915):101-6.

12. NICE Clinical Guideline 127. Hypertension: clinical management of primary hypertension in adults. 2011: p.1-36.

17. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations.

J Hand Surg Am 1984;9(2):222-6.

18. Rolyan PS. Jamar Hydraulic Hand Dynamometer Owner’s Manual. Ability One Home Craft Ltd.2003; Part no.70523:1-8.

19. Halberstein RA. Blood pressure in the Caribbean.

Hum Biol 1999;71(4):659-84.

20. Ray CA, Carrasco DI. Isometric handgrip training reduces arterial pressure at rest without changes in sympathetic nerve activity. Am J Physiol Heart Circ Physiol 2000;279(1):H245-9.

21. Millar PJ, Bray SR, McGowan CL, MacDonald MJ, McCartney N. Effects of isometric handgrip training among people medicated for hypertension: a multilevel analysis. Blood Press Monit 2007;12(5):307-14.

22. Taylor AC, McCartney N, Kamath MV, Wiley RL. Isometric training lowers resting blood pressure and modulates autonomic control. Med Sci Sports Exerc 2003;35(2):251-6.

13. Millar PJ, Paashuis A, McCartney N. Isometric handgrip effects on hypertension. Curr Hypertens Rev 2009;5(1): 54-60.

23. Carter JR, Ray CA, Downs EM, Cooke WH. Strength training reduces arterial blood pressure but not sympathetic neural activity in young normotensive subjects. J Appl Physiol (1985) 2003;94(6):2212-6.

14. Cook NR, Cohen J, Hebert PR, Taylor JO, Hennekens CH. Implications of small reductions in diastolic blood pressure for primary prevention. Arch Intern Med 1995;155(7):701-9.

24. Wiles JD, Coleman DA, Swaine IL. The effects of performing isometric training at two exercise intensities in healthy young males. Eur J Appl Physiol 2010; 108(3):419-28.

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Diagnosis of Hypertension in Childhood Requires Repeated BP Measurements One needs to confirm presence of hypertension based on three blood pressure (BP) measurements at separate clinical visits.

Normative BP percentiles are based upon data on gender, age, height, and BP measurements from the National Health and Nutrition Examination Survey and other population-based studies.

In a study initial BP measurement was normal (below the 90th percentile), prehypertensive (systolic or diastolic BP between the 90th or 95th percentile) and hypertensive (systolic or diastolic BP ≥95th percentile) in 82, 13, and 5% of children.

At follow–up, subsequent hypertensive measurements were observed in only 4% of the 10,848 children who had initial hypertensive values. In the cohort, the overall prevalence of hypertension was 0.3%.

Source: Lo JC, Sinaiko A, Chandra M, et al. Prehypertension and hypertension in community–based pediatric practice. Pediatrics 2013;131:e415.

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Community Medicine

Effects of Electromagnetic Waves Emitted from Mobile Phone on Vestibular Function K Singh

Abstract Ear is exposed more to the electromagnetic radiation (EMR), emitted from mobile phone (MP) compared to the other organs of the body. It consists of both cochlea, concerned with hearing and vestibular organ, concerned with maintenance of balance.

This vestibular organ is special in that it is situated deep inside the ear and is very sensitive to local temperature difference.

So, functions of vestibular system were assessed by using tests for dizziness, nystagmus and balance before and after exposure to EMR emitted from MP. It was seen that not a single subject reported dizziness, vertigo, fall, nystagmus or vestibular gait, although they were using the MP for last 5-8 years and per day exposure was more than 30 minutes.

Keywords: Electromagnetic radiation, mobile phone, dizziness, vertigo, fall, nystagmus, vestibular gait

M

obile phone (MP) uses electromagnetic radiation (EMR) in the microwave range, which may cause â&#x20AC;&#x2DC;microwave effectâ&#x20AC;&#x2122; producing damage by heating of tissues (thermal effect).

EMR may also interfere with metabolism and functional activities of cells (i.e., nonthermal effect).1 Amount of energy absorbed depends on limit of exposure and distance from the source.

Since ear is the closest organ exposed to the MP, while it is being used, this may cause high energy deposition in the ear compared to the other parts of body.

This affects hearing and also causes sensation of burning or warmth around the ear, within the ear or on the face.2 It also produces headache, sleep disturbances.3 etc.

The inner ear vestibular system is a very important contributor to balance control. This vestibular part of inner ear is also very sensitive for local temperature difference. Nystagmus during MP use indicates local thermal effect >0.1oC. Sensory cells of peripheral vestibular organ may be disturbed by electromagnetic emission and nystagmus may appear,1 which indicates stimulation of horizontal semicircular canal, together with some kind of dizziness. If one side is altered, imbalance occurs, that will be indicated by nystagmus.1

Professor Dept. of Physiology PGIMS, Rohtak, Haryana Address for correspondence Dr K Singh 6J-11, Medical Campus, Rohtak -124001, Haryana

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The symptoms of dizziness, nystagmus and imbalance may be sequelae of deficit of vestibular function, which can be assessed by balance testing.

So, it is planned to study the effect of EMR emitted from MP on vestibular function.

Material and methods The study was conducted on 15 male subjects in age group of 20-40 years. After explaining the procedure, consent was taken from each subject. Functions of vestibular system were assessed by balance testing (history of dizziness, vertigo, fall, nystagmus and vestibular gait). Participants were asked to walk in a straight line with eyes closed (to eliminate visual input) keeping the upper limbs straight forward. Subjects were then exposed to MP for about 10 minutes.4 After exposure, they were again asked to perform same test, nystagmus was noted and asked for any complaint (i.e. headache, dizziness, vertigo and fall). Balance testing was scored on a pass/fail basis.

Test failure was defined as participants needing to open their eyes, moving their arms or feet to achieve stability or beginning to fall or require intervention to maintain balance within 30 seconds interval.

Participants were excluded from balance testing, if they were unable to stand on their own, were having dizziness sufficient to cause unsteadiness, having heavy weight, were totally blind or visually impaired to require assistance in walking, or have foot or leg problems, history of dizziness and fall during the past 12 months, history of smoking

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Community Medicine (≥20 pack-years), heavy tobacco use, hypertension and diabetes.

Result The study was conducted in 15 males (to avoid effect of gender, although vestibular function does not significantly differ by sex) healthy subjects in the age group of 20-40 years (to avoid effect of age as prevalence of vestibular dysfunction increased markedly with age and associated with catastrophic fall),5 mean height - 157 ± 38.09 (152-180) cm, mean weight - 62 ± 8.93 (52-80) kg, mean duration of exposure to MP was 6.8 ± 2.3 minutes (duration of usual phone call).

Subjects were using the MP for last 5-8 (6.2 ± 2.2) years, per day exposure to MP was 2.86 ± 2.3 hours (30 minutes to 9 hours), duration of per call varies from 2 to 30 (10.2 ± 3.75) minutes.

It was observed that no subject had history of dizziness, vertigo or fall in last 12 months before exposure to MP, although they were using the MP for the last 5-8 years.

After exposure to EMR, again not a single subject reported dizziness, vertigo, fall, nystagmus or vestibular gait (Table 1).

Table 1. Anthropometric Data and Effect of EMW Emitted from MP on Vestibular Function Age (years) Sex Height (cm) Weight (kg) Mean duration of exposure to MP during experiment (min) Duration of use of MP (years) Exposure to MP/day Duration of call Dizziness after exposure to MP Vertigo after exposure to MP

20-40 Male 152-180 52-80

Mean 28.2 ± 2.1 Mean 157 ± 38.09 Mean 62 ± 8.93 6.8 ± 2.3

5-8

6.2 ± 2.2 years

30 min to 9 hours 2-30 min

Mean 2.86 ± 2.3 hours Mean 10.2 ± 3.75 min Negative Negative

History of fall after exposure to MP Nystagmus after to MP

Negative

Vestibular Gait after exposure to MP

Negative

Negative

EMW = Electromagnetic waves; MP = Mobile phone.

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Discussion MP receives and transmits high frequency microwave radiation, which excites molecular structures, particularly water molecules, causing nonthermal effects.

EMR emitted from the MP can penetrate organic tissues, causing temperature rise in deeper layers, preferably in tissues with high water content.1 EMR is potentially hazardous to health.6 Ear is a sense organ concerned with hearing and maintenance of balance of body. Because of its proximity to the radiation source during MP use, there occurs high impact of radiation on this specific organ.

The vestibular part of inner ear is a very sensitive measuring system for local temperature differences.1 Nystagmus during MP use could mean a local thermal effect >0.1oC. If the sensory cells of the peripheral vestibular organ are disturbed in any way by the EM emission, nystagmus should occur. The complete vestibular system is very complex, sensitively balanced between the vestibular organs of both ears (dysfunction of it cannot be directly observed, but can be inferred from assessment of vestibulo-ocular and vestibulospinal reflex).1 If one side is altered in any way, the imbalance will be indicated by nystagmus and vestibular gait. In this study, nystagmus was not demonstrated in our subjects after exposure to MP (also during the use of MP).

This indicates that single exposure of short duration does not cause rise in temperature, i.e., thermal effect or any other damaging effect toward the unilateral stimulation of vestibular system, as right ear is found to be dominating ear in this study. Finding is similarly reported by others.1 While Van Leeuwen et al7calculated that MP emission causes rise of brain temperature of 0.1oC. The thermographic experiments demonstrated that use of MP leads to heat development in tissues near to the MP, can be seen during application of ‘high power fields’ (2W/continuous mode).

Which explains warm or burning sensation occurring at the pinna, occiput or facial skin. This small development of heat does not affect the structure deep in the skull like the vestibular part of the inner ear.8 However, if hearing is compared with vestibular function, since cochlea and vestibular apparatus, both are the parts of inner ear, scientists8 failed to demonstrate any effect on otoacoustic emissions representing inner ear function by MP radiation.

Community Medicine Moreover, no adverse effect on brainstem auditory evoked potential (BAEP) was demonstrated by MP radiation.8,9 Subjects were using the MP for the last 5-8 years, but they had not reported any history of dizziness or vertigo or fall during mobile phone use or thereafter. Imbalance and vestibular gait had not occurred by the use of MP. So, it is concluded that although MP are being increasingly used, short exposure of MP does not affect the functions of vestibular organ.

References 1. Pau HW, Sievert U, Eggert S, Wild W. Can electromagnetic fields emitted by mobile phones stimulate the vestibular organ? Otolaryngol Head Neck Surg 2005;132(1):43-9.

2. Salford LG, Brun AE, Eberhardt JL, Malmgren L, Persson BR. Nerve cell damage in mammalian brain after exposure to microwaves from GSM mobile phones. Environ Health Perspect 2003;111(7):881-3; discussion A408.

3. Preece AW, Goodfellow S, Wright MG, Butler SR, Dunn EJ, Johnson Y, et al. Effect of 902 MHz mobile

phone transmission on cognitive function in children.

Bioelectromagnetics 2005;Suppl 7:S138-43.

4. Hladký A, Musil J, Roth Z, Urban P, Blazková V. Acute effects of using a mobile phone on CNS functions. Cent Eur J Public Health 1999;7(4):165-7.

5. Gazzola JM, Ganança FF, Aratani MC, Perracini MR, Ganança MM. Clinical evaluation of elderly people with chronic vestibular disorder. Braz J Otorhinolaryngol 2006;72(4):515-22.

6. Wainwright P. Thermal effects of radiation from cellular telephones. Phys Med Biol 2000;45(8):2363-72.

7. Van Leeuwen GM, Lagendijk JJ, Van Leersum BJ, Zwamborn AP, Hornsleth SN, Kotte AN. Calculation of change in brain temperatures due to exposure to a mobile phone. Phys Med Biol 1999;44(10):2367-79.

8. Arai N, Enomoto H, Okabe S, Yuasa K, Kamimura Y, Ugawa Y. Thirty minutes mobile phone use has no shortterm adverse effects on central auditory pathways. Clin Neurophysiol 2003;114(8):1390-4.

9. Ozturan O, Erdem T, Miman MC, Kalcioglu MT, Oncel S. Effects of the electromagnetic field of mobile telephones on hearing. Acta Otolaryngol 2002;122(3):289-93.

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Dramatic Rise in Extensively Drug-resistant Tuberculosis Almost half (43.7%) of patients with multidrug-resistant (MDR) tuberculosis in 8 countries studied were resistant to at least 1 second-line drug, and 6.7% had extensively drug-resistant (XDR) tuberculosis, according to a study published online August 30 in The Lancet by Tracy Dalton, PhD, a senior service fellow in the Division of Tuberculosis Elimination at the Centers for Disease Control and Prevention in Atlanta, Georgia. MDR tuberculosis is caused by Mycobacterium tuberculosis that is resistant to at least isoniazid and rifampicin. XDR tuberculosis is caused by M. tuberculosis strains that are resistant to isoniazid, rifampicin, and at least 1 drug within the fluoroquinolones and 1 antituberculosis injectable drug. Fluoroquinolones and injectable drugs are second-line antituberculosis drugs.

Most international recommendations for tuberculosis control have been developed for (MDR) tuberculosis prevalence of up to around 5%. Yet we now face prevalence up to 10 times higher in some places, where almost half of the patients with infectious disease are transmitting MDR strains of M. tuberculosis.

According to data from the World Health Organization, 5.4% of patients with MDR tuberculosis have XDR tuberculosis.

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Clinical psychology

Impact of Perceived Stress and Locus of Control on Conflict Resolution Styles Sachin*, Krishan Kumar†, Rajeev Dogra‡

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

The results indicated more perceived stress, agitation and anxious behavior in girls as compared to their male counterparts.

Avoiding coping styles showed a positive correlation with the level of stress. External LOC also showed a positive correlation with high level of perceived stress.

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

S

tress is part of life in a fast-paced society. Stress is the physical, mental and chemical adjustments that our body makes in accordance to the circumstances of our life. In other words, stress is a response to what is happening around us. Too much stress results in uncomfortable and prolonged emotions. This causes psychological and physiological problems like loss of confidence, sleeplessness, raised blood pressure, back pain, rapid loss or gain of weight, heart disease and stroke, digestive disorders and irrational fears.

The word ‘stress’ is derived from the Latin term ‘Stringers’ which means, ‘to draw tight’. Some define stress as the nonspecific response of the body to any demands made on it. When the demands on an individual exceed his capability and adjustment resources stress occurs. All situations positive and negative that require adjustment can be stressful. Neufeld (1990) has pointed out that “stress is a by product of poor or inadequate coping”. There are various definitions of stress, and this is further complicated because we all intuitively understand what stress is–although different people feel stress very differently. The most commonly accepted definition (mainly attributed to Richard S

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

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Lazarus) is that “Stress is experienced when a person perceives that demands exceed the personal and social resources that the individual is able to mobilize”.

Stress is different from anxiety which is a state of uncertainly. It is also different from agitation, which is the physical part of anxiety. Stress also differs from frustration, which is blocked goal attainment. Stress is a pressure condition causing hardship; it is an internal phenomenon and a mental attitude. If stress is an imbalance in condiment salt relationship, the result is implantable. Stress is generally believed to have a deleterious effect on health and performance.

But a minimum level of stress is necessary for effective functioning and peak performance. It is the individual’s reaction to stress which makes all the difference. Whether something is felt to be stress or not depends on the individual’s point of view. The common symptoms of stress can be physical, mental, emotional or behavioral:ÂÂ

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

ÂÂ

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

ÂÂ

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

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Clinical psychology ÂÂ

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

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

It is analogous to, but distinct from, attributions.

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

Males tend to be more internal than females

ÂÂ

As people get older they tend to become more internal

ÂÂ

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

In addition, some psychological and educational interventions have been found to produce long-term shifts towards internal LOC (e.g., outdoor education programs; Hans, 2000; Hattie, Marsh, Neill & Richards, 1997).

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However, its important to warn people against lapsing in the naive notion that internal LOC is good and external LOC is bad (two legs good, four legs bad). There are important subtleties and other factors involved. For example, if one has internal orientation it usually needs to be matched by skills and competence so that the person is able to act successfully on their sense of personal responsibility. Overly internal people who lack confidence and efficacy in their abilities can become neurotic, anxious and depressed. On the other hand, there are many people with an external orientation who lead easy-going, relaxed, happy lives.

It seems to psychologically healthy to perceive that one has control over those things which one is capable of influencing. In general, psychological research has found that people with a more internal LOC seem to be better off, e.g., they tend to be more achievement oriented and to get better-paid jobs. Sometimes LOC is seen as a personality construct, but this may be misleading, since the theory and research indicates that LOC is largely learned. Seligman’s research on learned helplessness is an example, where he found that animals and people would learn to simply give up trying when they experience having no control over what happens to them. In prolonged circumstances without control, developing an external LOC is an adaptive response. However, if circumstances change, having learned helplessness (external LOC) is maladaptive.

Conflict A dictionary gives the following semantic range for the word conflict: Conflict n. (Konflikt): i) A struggle between opposing forces; battle. ii) Opposition between ideas, interests, etc. controversy. iii) Psychological opposition between two simultaneous but incompatible wishes or impulses, sometimes leading to emotional tension. iv) To come into opposition; clash. v) To fight. Struggle...battle...tension...are words the Collins English Dictionary uses to define conflict. Conflict is an important concept in modern management. Most psychology books suggest that conflicts come from two tendencies: approach and avoidance. To approach is to have a tendency to do something or to move in a direction that will be pleasurable and satisfying.

To avoid is to resist doing something, perhaps because it will not be pleasurable or satisfying. These two categories produce three kinds of conflicts: ÂÂ

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

ÂÂ

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

Clinical psychology ÂÂ

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

feel defeated and demeaned, the distance between people increases. A climate of mistrust and suspicion develops, discussion replaces cohesion.

Loser indulges in non co-operation and pay scant attention to the needs and interests of other group members.

Positive consequences of conflict: ÂÂ

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

ÂÂ

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

ÂÂ

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

ÂÂ

ÂÂ

Cohesion and satisfaction: Inter group conflict and competition drives group closer together. Under conditions of mild inter group conflict; group membership can be very satisfying to members.

The whole purpose and internal unity of athletic group, for example, would disappear if there were no conflict. In the face of a common enemy, group members close ranks and put aside former disagreement.

A minimum level of conflict is optional: Conflict is necessary to the organizational life. It is necessary for the internal stability of organizations.

The occasional flare up of inter group conflict serves to balance power relationship between departments. It also helps individuals in reducing accumulated ill-feelings and tensions between them. A good fight clears the air.

Negative consequences of conflict: ÂÂ

Conflict creates stress in people: Conflict exacts its role on the physical and mental health of the combatants. An intense conflict generates feeling of anxiety, guilt, frustration and hostility. Winners try to injure the feelings of the defeated. Losers

ÂÂ

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

ÂÂ

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

Review of Literature Hamarat et al (2000) findings indicate that perceived stress level predicts life satisfaction among American college students. Interestingly, they found that for middle aged and older adults combining a measure of perceived stress with a measure of coping resource effectiveness provided a better predictor of life satisfaction than did perceived stress alone. For younger adults perceived stress alone was the best predictor of life satisfaction. While investigations of life satisfaction among college students have been conducted in other cultures, for instance in New Zealand university studies, previous studies have not tested the ability of coping resource levels and its effectiveness and perceived stress to predict college student’s subjective well-being, or satisfaction with life as did Hamarat et al (2001).

Using the same measure, Hamarat et al assessed this relationship in north Americans across three age groups, one of which was college students. The focus of their research was on coping with stress and life satisfaction among Turkish college students. Both separate and joint affects of perceived stress and coping resource availability upon life satisfaction were examined.

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Clinical psychology It was hypothesized that the combination of coping resources availability and perceived stress would be better predictors of life satisfaction than either of the two. Researches have found that women react to stress differently than men. They reviewed numerous studies and developed a broad model of how women deal with stressors in their life. When women are confronted with stressors, be it a predator or a bad day at office, they tend to respond by turning to their children and providing caring as well as seeking out contact and support from them. The support they seek was usually from other women. This ‘tend and befriend’ behavior has been tentatively linked with the hormone oxytoxin, which is released by the body during stress. It has been shown to make both rats and humans calmer, less fearful, and more social. While men do secrete oxytoxin, male hormones reduce the effect of oxytoxin in their bodies.

Female hormones on the other researches have found that women react to stress differently than men.

Dongyoung Sohn and John D. Leckenby (2001) examined the social-psychological factor of LOC in relation to perceived interactivity on the internet. To this point in the study of this new medium and concept of interactivity, most social science research has studied the psychological dimension of the individual’s relation to the Internet. This research focuses on the individual’s relation to group experience in relation to perceptions of the Internet through use of the LOC concept. Results of the study of 121 individuals recruited online and who completed an online questionnaire show that perceived interactivity of the Internet can be partially explained by the LOC variable. Those internal in their orientation to the world tend to view the Internet as more interactive than those external in their orientation.

In addition, perceived reliability of the web and time spent using the web are direct, powerful predictors of perceived interactivity? Implications for theory and practice are provided. The current study examined the relationships between Internet usage and the social contexts to which people belong. Using a socialpsychological factor (LOC), the influences of social contexts on Internet usage behavior, the perceived interactivity of the web, the perceived reliability of commercial information from Internet advertising, and attitude toward Internet advertising in general were studied. The association between stress and disease is not a new one. In fact, this relationship has been held to be intuitively true for ages. But medical science does not take kindly to the use of intuition as a means of gaining knowledge. However, some health professionals are convinced of an intangible link between stress and

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disease. The seeds of clinical understanding were first planted by observations made by Hans Selye, giving rise to general adaptation syndrome. In 1977, Kenneth Pelletier estimated in his book, Mind as Healer Mind as Slayer, that between 50 and 70% of all disease and illness is stress related. By 1992, estimations were even higher, indicating that between 70 and 80% of health related problems are either precipitated or aggravated by stress. The list of such disorders is nearly endless, ranging from common cold to cancer.

Katz, Blumler and Gurevitch (1974), the ideal user shown in uses and gratifications theory is an active and self-reliant gratification seeker. This person’s attitudes, perceptions, and behaviors are not influenced or manipulated directly by any content or message from the mass media. “The media can have little or no impact on persons who have no use for them; that media fare is selected rather than imposed, and that particular media offerings are chosen because they are meaningful to those who choose them” (Johnstone, 1974). The active users are able not only to recognize their internal needs by themselves, but also to use media consciously to satisfy their needs. These people selectively perceive and respond to the messages from the mass media, as well as responding to their individual needs. From this perspective, psychological motives including needs and gratifications would be central problems of research.

Another study identifies family sources of stress and conflicts are critical variables in the well-being of adolescents. This paper assesses the relationship of coping resources to negative emotions produced by parental conflict after controlling for social desirability; age; financial resources and measures of parental attachment and family functioning. Undergraduate students (n = 304) in a large Southwestern university were given four instruments: Inventory of Parental and Peer Attachment (IPPA); Family Adaptability and Cohesion Scale II (FACES II); Coping Resources Inventory for Stress (CRIS) and Parental Conflict Emotions. Four separate models were created for: (1) Male participants describing maternal conflict; (2) male participants describing parental conflict; (3) female participants describing maternal conflict and (4) female participants describing parental conflict.

The results provide support for the literature that a person’s family background and coping resources are related to emotional functioning in the context of family relationships. The emergence of social desirability as a statistically significant predictor of variance at step one of each model was noted. The pattern of results with respect to female participants included more predictors emerging as statistically significant.

Clinical psychology METHOD Objective: The objective behind this research study was to study the impact of perceived stress on various conflict resolution styles and to study the impact of LOC on various conflict resolution styles.

Sample: The present study was carried over on a sample of 300 adolescents (age range 15-18 years) consisting of 150 boys and 150 girls. The sample was taken from various schools of Hisar district.

Instruments Perceived Stress Scale: Cohen, Kamarck and Mermlstein (1983). It measures the degree to which one’s life situations and circumstances are perceived as stressful. This measure calls for the individual to self appraise the level of stress, so the perceived stress scale (PSS) accounts for individual differences in the assessment of environmental demands. The scale has three versions, with 4-items 10-items or 14-items.

The 10-item version was used because of maximum reliability. This appraisal-based measure of stress was selected because current status of assessment researchers tends to favor such measures over checklist assessments. The PSS is an empirically established appraisal based index (Cohen, Kessler, Gordon, 1995) very few of which measure global stress experience.

The PSS has strong psychometrics with coefficient alpha reliability ranging between 0.84-0.86. The measure correlates with physical and depressive symptomatology measures between 0.52 and 0.70 and 0.65 and 0.76, respectively. The scale assesses the amount of stress in one’s life rather than in response to a specific stressor and has been used widely in studies of both mental and physical health.

Rotter’s LOC Scale (1966): It is a generalized measure of internal versus. external LOC and it continues to be widely used to assess perceived control in several organizational and health related researches. It’s a 29-item scale. All the items are forced choice items and the subject will have to choose only 1-item from the alternatives provided in each item. One choice represents an internal LOC orientation while the other represents an external LOC orientation. There are 23-items in the scale designed to measure the LOC expectancies and 6 are filler items. A total LOC score is obtained by counting the number of external alternatives chosen. Scores range from 0 to 23; with increasing score a person emerges as the one with external LOC, whereas a person with lower scores is considered to have an internal LOC. Satisfactory test retest coefficients have been reported by Rotter (1966).

Thomas-Kilmann Conflict Handling Mode Instrument (TKI) (1973): The TKI is designed to assess an individual’s behavior in conflict situations i.e., situations where the concerns of two people appear to be the incompatible.

This instrument contains 30-items. In such situations, we can describe a person’s behavior along two basic dimensions: ÂÂ

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

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Cooperativeness: The extent to which the individual attempts to satisfy the other person’s concerns.

These two basic dimensions can be used to define specific methods of dealing with conflicts. These five basic “conflict handling modes” are shown below: zz

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

zz

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

zz

Avoiding: This is an unassertive and uncooperative style. When avoiding, an individual does not immediately neglect his or her own concerns or those of the other person.

He or she does not address the conflict.

Avoiding might task the form of diplomatically sidestepping an issue, postponing it until a better time or simply withdrawing from a threatening situation.

zz

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

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Clinical psychology or confronting and trying to find a creative solution to an interpersonal problem. zz

Compromising: This is intermediate in both assertiveness and cooperativeness. When compromising, the objective is to find an expedient, mutually acceptable solution that partially satisfies both parties. Compromising falls on a middle ground between competing and accommodating, giving up more that competing but less than accommodating.

Likewise, it addresses an issue more directly than avoiding but doesn’t explore it as much as depth as collaborating.

Procedure First of all, school principals were contacted and informed about the importance and the purpose of the study to get the approval of the school administration for the data collection. When the approval was granted, days were fixed for data collection. During the actual data collection, proper information regarding filling the questionnaire were given to students and their willingness to participate in the study was obtained.

They were told to give true responses and were assured that there identity would be kept confidential.

Statistical Analysis Statistical package for social sciences for windows version 11.1 was used in this study. Descriptive statistics, Pearson product moment correlation and One-way ANOVA were applied as per basic assumptions.

Table 1. Descriptive Statistics of the Total Sample Variables

Minimum Maximum

Mean

Perceived stress scale

9.00

34.00

20.84

Locus of control

0.00

18.00

7.37

Competing

0.00

11.00

5.66

Accomodating

0.00

11.00

5.71

Avoiding

2.00

10.00

5.60

Collaborating

0.00

11.00

6.54

Compromising

0.00

11.00

6.33

Table 2. Descriptive Statistics of Boys Variables

Minimum

Maximum

Mean

Perceived stress scale

9.00

30.00

20.30

Locus of control

1.00

18.00

6.62

Competing

0.00

11.00

5.58

Accomodating

0.00

11.00

5.68

Avoiding

2.00

10.00

5.72

Collaborating

0.00

11.00

6.63

Compromising

0.00

11.00

6.28

Table 3. Descriptive Statistics of Girls Variables

Minimum

Maximum

Mean

Perceived stress scale

10.00

34.00

21.37

Locus of control

0.00

16.00

8.12

Competing

0.00

11.00

5.75

RESULTS

Accomodating

0.00

9.00

5.74

The total sample of 300 students, out of which 150 were boys and 150 were girls participated in the study.

The mean perceived stress of the whole sample came out to be 20.84, with maximum value being 34.00 and minimum score being 9.00. The mean perceived stress score amongst girls was 21.37, with maximum 34.00 and a minimum score of 10.00 whereas for boys, the mean score was 20.30 with maximum of 30.00 and minimum score of 9.00.

Avoiding

2.00

10.00

5.48

Collaborating

2.00

11.00

6.44

Compromising

0.00

11.00

6.38

The results indicated that the boys had lower levels of perceived stress in their life as compared to girls. This implied that the boys viewed their life in a positive light, whereas the girls view it in a negative light. The girls showed more agitated anxious and anticipating behavior as compared to boys. On computing, Pearson product moment correlation between all of the seven variables the results were as follows: Correlation between PSS and LOC came out to be 0.36, between Competing

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style and PSS, 0.08; between PSS and Accommodating style, it came out to be 0.11, between PSS and avoiding style –0.15, between PSS and Collaborating style it was, -0.03; between PSS and Compromising style it was –0.42. Out of these only the correlation between PSS and avoiding style was significant at 0.01 level.

The correlation between LOC and competing style is 0.04, with accommodating style it was –0.10; with avoiding style it was –0.00 with collaborating style it was 0.22 and with compromising style it was –0.013.

This implies that if the person tends to adopt an avoiding coping style, he is likely to have higher levels of stress, as it has been held since ages that the best

Clinical psychology Table 4. Intercorrelational Matrix of Variables Variables

PSS

LOC

COM

ACO

AVOID

COLL

COMP

Perceived stress scale

1.00

0.036

0.008

0.110

–0.15**

–0.033

–0.042

Locus of Control

-

1.00

0.004

–102

–.002

0.22

–.013

Competing

-

-

1.00

0.12

–.104

–.182

–.231

Accomodating

-

-

-

1.00

–.162

–.098

–.238

Avoiding

-

-

-

-

1.00

–.165

–.037

Collaborating

-

-

-

-

-

1.00

0.55

Compromising

-

-

-

-

-

-

1.00

way to solve a problem is to confront it directly. So, in a way avoiding the stressful situation or the conflict causes stress in the individual. LOC and perceived stress go hand in hand. If the person tends to have a highly external LOC, he is likely to get stressed and internal LOC leads to lower levels of stress but not if it is in extreme.

On computing ANOVA there was 100% significant difference between the LOC of boys and that of girls; whereas, there was 96% significant difference between the perceived stress score of boys and girls. This shows that the girls have higher levels of perceived stress in their lives as compared to their male counterparts. This is also evident from the table of means of both these scales. In case of boys, their mean score on PSS was 20.30 and on LOC it was 6.62 and in case of girls the mean score on PSS was 21.37 and on LOC it was 8.12.

This indicates that the girls have more external LOC as compared to that of boys. As it had been expected in the beginning of the research that lowers the scores on LOC lower will be the level of perceived stress.

DISCUSSION Prof. Ahmed Rushali (1990) conducted a research on the stress events and coping strategies of Turkish adolescents and young adults. Gender and type of school (secular and nonsecular) were also considered. Subjects were 1032 students taken from two high schools and a university in Ankara. Ages of subject varied between 10 and 25. Subjects described the most stressful event of the last 6 months and responded to the items of the ways of coping inventory (Folkman and Lazarus, 1980) results indicated that the most frequently reported stress events were related to interpersonal problems, followed by academic problems, loss of a significant other hand finally health-related problems. Age, sex and school variations occurred in the reported frequencies for these event categories. Factor analysis of responses

to the item of The ways of coping inventory yielded an 8-factor structure for the instrument. Results of analysis on the factor scores in dictated that seeking refuge in fate, optimistic approach, withdrawal, self-blame and seeking refuge in supernatural forces were more frequent among male and helpless approach and social support were more frequent among females. High school student’s having secular education employed active coping and optimistic approach more frequently than students having semi-secular education. The latter sub sample has a significantly higher usage frequency than the first for seeking refuge in fate strategy. Significant event by strategy interactions were also obtained; seeking refuge in fate, social support, optimistic approach, and withdrawal strategies were more frequent with the event category of loss whereas self-blame was most frequent with academic problems.

Every day individuals are forced to be aware of their appearance. Media images seen on television, in magazines and even advertisements portray the nation that beautiful is good and are a constant reminder that society judges its members based on their body size (which emphasizes thinness). This ideal can cause a decrease in self-esteem because individuals, especially women, constantly compare themselves with the cultural ideal of beauty and may feel that they do not measure up and lose confidence in their abilities. This concept is detrimental because a loss of self-esteem may affect adjustment to new situations, especially for the college freshman. Going to college for the first time is exciting but can also cause anxiety. The college freshman needs to adapt to a new place with new people and new sets of academic rules. They must deal with room-mates and being away from their parents for the first time.

They must have confidence in their abilities to make new friends and learn new time management skills because there is no one to tell them when to eat or when to study. This current study attempts to find if

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Clinical psychology a relationship exists among the variables adaptation to college, body satisfaction and self-esteem. Adaptation to college refers to the student’s ability to cope with the stress that college brings in terms of academics roommates and social situations.

Wintre and Yaffe (2000) studied adaptation to college in relation to parental relationships, and psychological well-being variables in both male and female freshmen.

It was hypothesized that the current relationship between parent and student and psychological well being (depression, perceived stress and self-esteem) would affect student adaptation and achievement.

Results indicated an increase in depressive symptomatology predicted poorer adaptation for both male and female students. It also indicated that selfesteem in winter was a positive indicator of female adjustment because after six-months of being at college high self-esteem females experienced higher adaptation even if their initial reaction was not positive.

Suggested Reading 1. Cohen, Sheldon; Kamarck, Tom; Mermelstein, Robin (1983). A global measure of perceived stress. Journal of Health and Social Behavior. Vol 24(4), 385-396.

2. Dongyoung Sohn, John D. Leckenby. (2001). Locus of control and interactive advertising. In: Proceedings of the American Academy of Advertising: 265-271.

3. Dongyoung Sohn, John D. Leckenby. (2002). Social dimensions of interactive advertising. In: Proceedings of the American Academy of Advertising: 89-96.

4. Aysan,F.,Herrington,A.,Gfroerer,C.A.,Thomson,D. (2000).

Coping resources, perceived stress and life satisfaction among Turkish and American university students.

International Journal of Stress Management, 9(2), 81-97.

5. Hamarat, E., Thompson, D., Zabrucky, K., Steele, D, Matheny, K., & Aysan, F. (2001). Perceived stress and coping resource availability as predictors of life satisfaction in young, middle aged, and older adults. Experimental Aging Research. 27, 181-196.

6. Hans, T. (2000). A meta-analysis of the effects of adventure programming on locus of control. Journal of Contemporary Psychotherapy, 30(1), 33-60.

7. Hattie, J. A., Marsh, H. W., Neill, J. T. & Richards, G. E. (1997). Adventure Education and Outward Bound: Outof-class experiences that have a lasting effect. Review of Educational Research, 67, 43-87.

perspectives on gratifications research (pp. 19-34). Beverly Hills, CA: Sage.

10. Kilmann, R. H., & Thomas, K. W.(19773). A forcedchoice measure of conflict-handling behavior: the MODE Instrument. Working Paper No. 54, Graduate School of Business, University of Pittsburgh, 11. Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle aged community sample. Journal of Health & Social Behavior, 21, 219-239.

12. Lange, C., & Byrd, M. (1998). The relationship between perceptions of financial distress and feelings of psychological well-being in New Zealand university students. International Journal of Adolescence and Youth, 7, 193-209.

13. Lazarus, R. S. (1966). Psychological stress and coping processes. New York: McGraw-Hill.

14. Mamlin, N., Harris, K. R., Case, L. P. (2001). A Methodological Analysis of Research on Locus of Control and Learning Disabilities: Rethinking a Common Assumption. Journal of Special Education, Winter.

15. Neufeld, R. W. J. (1990), Coping with stress, coping without stress, and stress with coping: On inter-construct redundancies. Stress Medicine, 6: 117–125.

16. Pelletier, K. R. (1977). Mind as Healer, Mind as Slayer. Dell Publishing. New York, NY. 17. Rotter, J. (1973). Internal-External Locus of Control Scale. In Robinson and Shaver (2nd Ed.), Measures of Personality and Social Psychological Attitudes, pp 227-234.

18. Rotter, J. B.(1966).Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 30, 1-26.

19. Rotter, J.B. (1966).Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 33(1), 300-303.

20. Rotter, J. (1966). Generalized expectancies for internal versus external control of reinforcements, Psychological Monographs, 80, Whole No. 609.

21. Rotter, J. B. (1970).Some implications of a social learning theory for the practice of psychotherapy. In D. J. Levis (Ed.), Learning approaches to therapeutic behavior change. Chicago: Aldine.

22. Rotter, J. B., Liverant, S. and Crowne, D. (1961).The growth and extinction of expectancies in chance controlled and skilled tasks. Journal of Psychology, 52, 161-177.

8. Johnstone, J.W.C. (1974). Social Integration and Mass Media Use Among Adolescents: A Case Study, in Blumler & Katz, eds., The Uses of Mass Communications, Beverly Hills, California:

23. Thomas, K. W., & Kilmann, R. H.( 1973.). Some properties of existing conflict behavior instruments. Working Paper No. 73-11, Human Systems Development Center, Graduate School of Management, UCLA.

9. Katz,E., Blumler,J., & Gurevitch,M.(1974). Utilization of mass communication by the individual. In J.Blumler & E. Katz (Eds.), The uses of mass communication: Current

24. Wintre, M. G., & Yaffe, M. (2000). First-year students’ adjustment to university life as a function of relationships with parents. Journal of Adolescent Research, 15, 9–37.

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GASTROENTEROLOGY

Indian IndianJournal JournalofofClinical ClinicalPractice, Practice,Vol. Vol.24, 24,No. No.3,12, August May 2014 2013

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Drug

Combating Antimicrobial Resistance with First-Generation Antibiotics Like Amoxicillin Prachi Garg

Abstract Antimicrobial resistance (AMR) is the resistance of a microorganism to an antimicrobial medicine to which it was originally sensitive. AMR to drugs is a natural and unavoidable consequence of treating infectious diseases. Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in prolonged illness and greater risk of death.

The death rate for patients with serious infections treated in hospitals is about twice that in patients with infections caused by nonresistant bacteria. Data from around the world show that the threat of AMR is global and is increasing, both in healthcare settings and in the community and requires action at local, national and global level. Evaluation and prudent use of old antibiotics is one of the most promising ways to tackle AMR. Data from recent studies have shown that clinical outcomes and costs are not different when treatment with first-generation antibiotic is compared with newer generation antibiotic therapy.

Moreover, the first-generation antibiotics such as amoxicillin and cephalexin, still are the drugs of choice, effective when it comes to commonly encountered infections. These antibiotics, which were earlier manufactured by chemical processes that were not ecofriendly, are now being produced by unique enzymatic technology and are available as environmentally safe antibiotics, which is an additional advantage.

Keywords: Antimicrobial resistance, first-generation antibiotics, amoxicillin, enzymatic technology, environmentally safe

I

nspite of great technological advancement, infectious diseases are a cause of substantial deaths worldwide. Continuing progress in the treatment of many infections is now threatened by the increasing numbers and widening distribution of pathogens resistant to antimicrobial drugs.1 Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial to which it was originally sensitive.

Data from around the world show that the threat of AMR is global and is increasing, both in healthcare settings and in the community.2 AMR cannot be eradicated but a multidisciplinary approach involving a wide range of stake holders will limit the risk of AMR and minimize its impact for health at present and in the future.3 This necessitates a global partnership to ensure sharing of good practices, provision of scientific and technical assistance and the political commitment to underpin optimum surveillance, effective and relevant research, accelerated innovation and access to rational and prudent infectious disease management for all. Coupled to this, the development pipeline for new antibiotics is at an all-time low. We must therefore conserve the pool of antibiotics we have, by using

Senior Medical Associate Moolchand Medcity, New Delhi

them optimally. Evaluation and use of first-generation antibiotics such as amoxicillin is one of the most promising ways to make progress in this direction.

Steps to Overcome Antimicrobial Resistance Increasing awareness of AMR and promoting the rational use of antibiotics among prescribers and the general public are the keys to combating the irrational use of these drugs. Globally, major efforts have been initiated to tackle the menace of AMR. Antibiotics Smart Use (ASU) was introduced in 2007, as an innovative model to promote the rational use of medicines and counteract AMR.4 An alliance against multidrug-resistant organisms (World Alliance against Antibiotic Resistance [WAAR]) has been created recently, which includes healthcare professionals, consumers, health managers and politicians. It receives support of 50 learned societies or professional groups in France and throughout the world.5 The scientific committee is composed of 80 international physicians of considerable repute.

The ‘Chennai Declaration,’ is the consensus that evolved out of the meeting of medical societies in India on issue of developing a plan to formulate a road-map to tackle the global challenge of AMR from the Indian perspective.6 The aim of the ‘Chennai Declaration’ was to initiate efforts to formulate a national policy

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Drug to control the rising trend of AMR, after consultation with all relevant stake holders and to take all possible measures to implement the strategy. It included six international experts who shared action plans in their respective regions. According to the ‘Chennai Declaration’, India needs an implementable antibiotic policy and efforts should be made to frame it as soon as possible.

Advantages of first-generation Antibiotics The use of broad-spectrum antibiotics such as secondgeneration macrolides, cephalosporins, quinolones as first-line therapy encourages the development of resistant strains and substantially adds to costs. One of the major advantages of first-generation antibiotics against the current, more widely used and newer ones is actually the fact that their use has been largely limited in recent years.7 Of late, there has been a decrease in the use of first-generation antibiotics. As a result, the pathogens are becoming more susceptible to first-generation antibiotics, as compared to the newer generation.

Alternatively, we can say once again ‘old is gold’ and first-generation antibiotics are to be used as drugs of first choice against infections. They will be major lines of defense when it comes to battle against multidrugresistant pathogens. In addition, newer technologies for quicker diagnosis and to facilitate targeted treatment must be developed on priority.

It is pertinent to add that amoxicillin, a first-generation antibiotic is still a drug of choice in various infections such as acute otitis media in children and most episodes of acute bacterial sinusitis. Amoxicillin at higher doses 500 mg-1.0 g t.i.d. remains the preferred agent for community-acquired pneumonia, acute exacerbations of chronic obstructive pulmonary disease (COPD), Group A streptococcal (GAS) pharyngitis, skin and soft-tissue infections (SSTIs) and dental infections.

First-Generation Antibiotics vs Newer Generation Antimicrobial Therapy Studies done in the recent past to compare the effectiveness of empiric treatment with first-generation antibiotics versus newer generation antibiotic therapy have shown that clinical outcomes and costs with both first-generation antibiotic coverage and newer generation antibiotic therapy are similar.8,9 A study was undertaken recently in the Dept. of Oral and Maxillofacial Surgery, Panineeya Dental College, Hyderabad to assess the most common microorganisms

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Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

causing orofacial infections and their antimicrobial susceptibility to routinely used antibiotics.10 Sixty-eight patients with orofacial infection were selected on the basis of a series of predefined inclusion and exclusion criteria. Samples were collected under aseptic conditions and subjected to culture and antibiotic susceptibility testing. A total of 64 aerobic and 87 anaerobic strains were isolated.

The predominant bacteria were Streptococcus viridans (64%), Prevotella (43%), Peptostreptococcus (26%), Porphyromonas (7%) and Fusobacterium (14%). The isolated strains seemed to be highly sensitive to the routinely used antibiotics such as amoxicillinclavulanate and amoxicillin alone, clindamycin and levofloxacin. The investigators came to the conclusion that amoxicillin still possesses powerful antimicrobial activity against major pathogens in orofacial odontogenic infections.

Ecofriendly and Environmentally Safe production of antibiotics With the advent in technology and focus on sustainability, the production of antibiotics has also evolved over a period of time. From a pure chemical process with 20 steps, now the first-generation antibiotics like amoxicillin are being manufactured by an enzymatic process having five steps.11 Hence, there is lesser energy consumption, lesser production waste and lesser emissions to the environment as compared to conventional chemical process. Thus, the amoxicillin produced by enzymatic process is safe and ecofriendly.

The absence of solvents in the enzymatic process offers a better quality of amoxicillin, making it more effective. The reduced toxicity owing to the absence of most residual solvents is an aspect, which is highly valued by doctors and patients.

The enzymatic amoxicillin tastes better due to the absence of most residual solvents. Especially for suspensions and syrups the taste of the bulk drug can be dominant and formulations based on enzymatic amoxicillin are valued over alternatives based on chemically produced ingredients. Hence, the absence of the chemicals makes the antibiotics safer and more palatable, thereby reducing the need of sweeteners and masking agents in the final formulations.

Hence, the truly enzymatic amoxicillin offers the following advantages to the patients: ÂÂ

Better efficacy as the assay is more than 99.5%

Drug ÂÂ

Enhanced safety and tolerability, as there is less chemical load

3. https://www.gov.uk/.../20130902_UK_5_year_AMR_ strategy.pdf.

ÂÂ

Increased compliance due to better taste.

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

Over and above, the enzymatic amoxicillin also offers better stability of the formulation throughout the shelflife of the formulation. Thus giving better efficacy.

Conclusions AMR is one amongst most important healthcare issues across the globe impacting individuals and society.

The threat of AMR is increasing, both in healthcare and in the community. There is a growing need to optimize the use of older antibiotics to treat infections.

Recent studies done to compare the effectiveness of empiric treatment with first-generation antibiotics versus newer generation of antibiotics have shown that clinical outcomes and costs with both first-generation antibiotics and newer generation of antibiotics are similar. Amoxicillin, a first-generation antibiotic is still a drug of choice in various respiratory tract infections. Moreover, first-generation antibiotics such as amoxicillin which were earlier manufactured by chemical processes and were not ecofriendly, are now being produced by unique enzymatic technology and available as environmentally safe antibiotics.

References

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

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

7. Falagas ME, Grammatikos AP, Michalopoulos A. Potential of old-generation antibiotics to address current need for new antibiotics. Expert Rev Anti Infect Ther 2008;6(5):593-600.

8. Williams DJ, Hall M, Shah SS, Parikh K, Tyler A, Neuman MI, et al. Narrow vs broad-spectrum antimicrobial therapy for children hospitalized with pneumonia.

Pediatrics 2013;132(5):e1141-8.

9. Queen MA, Myers AL, Hall M, Shah SS, Williams DJ, Auger KA, et al. Comparative effectiveness of empiric antibiotics for community-acquired pneumonia.

Pediatrics 2014;133(1):e23-9.

1. Fears R, ter Meulen V. What do we need to do to tackle antimicrobial resistance? Lancet Global Health 2014;2(1):e11-2.

10. Chunduri NS, Madasu K, Goteki VR, Karpe T, Reddy H. Evaluation of bacterial spectrum of orofacial infections and their antibiotic susceptibility. Ann Maxillofac Surg 2012;2(1):46-50.

2. WHO. The evolving threat of antimicrobial resistance: options for action. World Health Organization: Geneva, 2012.

11. Schroën CGPH, Van Roon JL, Beefink HH, Tramper J, Boom. RM. Membrane applications for antibiotics production. Desalination 2009;236(1-3):78-84.

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ENT

Foreign Body in the Nasopharynx: An Occupational Hazard Ginni Datta*, Nitish Baisakhiya†, Dalbir Singh‡, Vandana Mendiratta#

Abstract Foreign body in the nasopharynx, in the elderly is rare. We are presenting a case of a 60-year-old carpenter with a nail stuck in the nasopharynx. This case is presented due to rare incidence of foreign bodies in the nasopharynx and more so in the elderly.

Also interesting to note is the manner in which it was impacted in the nasopharynx and how it can be an occupational hazard.

Keywords: Nasopharynx, foreign body, occupation

T

here are plenty case reports of unusual foreign bodies in the upper aerodigestive tract in the otolaryngologic literature. The common sites include the larynx, pharynx, esophagus and the tracheobronchial tree; however, lodgement of foreign body in the nasopharynx is very unusual and extremely uncommon.1 One gets awestruck to see the variety of objects and also the manner in which things get stuck inside the nose. Sharp foreign bodies pose a greater danger as they can pierce the soft tissues of the nose and pharynx and lead to fatal complications. Although, the literature regarding foreign body supports the idea that most of the victims are children under 10 years of age, cases have been reported where adults have fallen a prey to them. In our case report, the occupation of the patient as a carpenter landed him on our operation theater (OT) table.

in the nose or throat and referred the case to ENT emergency. On taking history, it was revealed that the patient was a carpenter by occupation and was trying to fix a nail in the roof with a hammer. He was in a natural barking dog position and while fixing the nail he held a few extra nails in between his lips. Suddenly, one nail slipped inside his throat, which was followed by a bout of cough and the nail then hit hard and high in his nose.

The patient complained of pain and foreign body sensation high up in the area of back of nose and also gave history of nasal bleed. On anterior rhinoscopy no foreign body was seen, but on intraoral digital palpation a hard foreign body could be felt in the nasopharynx.

X-ray of the nasopharynx (Fig. 1) and paranasal sinuses (Fig. 2) was done, which confirmed the presence of the

Case report A 60-year-old male patient presented in the emergency department with history of accidental slippage of foreign body a few hours back. He went to a private practitioner who could not trace the foreign body

*Assistant Professor †Professor ‡Professor and Head #PG-IIIrd Year Dept. of ENT Maharishi Markandeshwar Institute of Medical Sciences and Research Mullana, Ambala, Haryana Address for correspondence Dr Ginni Datta Assistant Professor, Dept. of ENT Maharishi Markandeshwar Institute of Medical Sciences and Research Mullana, Ambala, Haryana E-mail: mksaint9@gmail.com

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Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

Figure 1. X-ray STN- lateral view showing a metallic foreign body in the nasopharynx.

ENT Nevertheless we would like to emphasize that casual fiddling with pointed objects such as nails, etc. should be avoided, because these things can get accidentally impacted anywhere in the respiratory tract in conscious adults.7 A potentially fatal complication of a foreign body lodged in the nasopharynx is sudden airway obstruction due to descent of the object into the lower respiratory tract during its removal, playing or forceful snuffing.2,8 The safest and best way to remove the nasopharynx foreign body is general anesthesia by securing the airway via endotracheal intubation.2 In some cases, it may need lateral rhinotomy, transpalatal or midfacial degloving approach for its removal.9 Figure 2. X-ray paranasal sinuses showing a metallic foreign body in the S.

nail in the nasopharynx. The patient was also advised high-resolution computed tomography (HRCT) nose but the patient could not afford it. The patient was taken up under general anesthesia, airway was secured with a cuffed endotracheal tube. The foreign body was visualized with the help of an endoscope. In view of the large size of the nail it was thought that it would be difficult to negotiate it through the nose, therefore it was removed through oral cavity. Soft palate was retracted with the help of suction catheter and the nail was removed transorally. Bleeding was controlled by postnasal packing. The pack was removed on the first postoperative day and the patient was discharged with a promise not to use his lips as a substitute for his pocket.

Discussion

conclusion In conclusion, the interesting mode of slippage of nail followed by a bout of cough and impaction in the nasopharynx in a carpenter while fixing the nail in the roof makes this case report unique. This case is a warning in future to others not to hold sharp objects in the mouth as there is always a chance of it getting lodged into the aerodigestive system.

References 1. Yadav SP, Goel HC, Chowdhary D, Jain L. Marble in the nasopharynx. Indian Pediatr 1991;28(2):183-4.

2. Ozer C, Ozer F, Sener M, Yavuz H. A forgotten gauze pack in the nasopharynx: an unfortunate complication of adenotonsillectomy. Am J Otolaryngol 2007;28(3):191-3.

3. Briggs RD, Pou AM, Friedman NR. An unusual catch in the nasopharynx. Am J Otolaryngol 2001;22(5):354-7.

4. Sangeeta MM, Greval RS, Singh D. Paediatric nasopharyngeal foreign bodies. Indian J Otolaryngol Head Neck Surg 1999; 51(Suppl 1):80-2.

Nasopharynx is an exceptional anatomical location for foreign body impaction.2 In spite of dealing with nearly 2,000 cases of aerodigestive foreign bodies, Chevalier Jackson had only two cases of nasopharynx foreign bodies.3 The rare incidence of foreign body in the nasopharynx may be due to its large capacity and also the fact that the preceding narrow nasal cavity is a favorite destination. It is unusual for a foreign body taken orally to reach the nasopharynx.

5. Ransome J. Foreign bodies in the nose. In: Scott-Brown’s Otolaryngology. 5th edition, Kerr AG, Groves J (Eds.), Butterworths: London 1987:p.276-9.

Various reasons for such an occurrence include attempts at digital removal,4 regurgitation due to vomiting or coughing5 or if the foreign body is put into the mouth in lying down position with the neck extended making the nasopharynx dependent.6

8. Oysu C, Yilmaz HB, Sahin AA, Külekçi M. Marble impaction in the nasopharynx following oral ingestion.

Eur Arch Otorhinolaryngol 2003;260(9):522-3.

6. Majumder PK, Sinha AK, Mookherje PB, Ganguly SN. An unusual foreign body (10 N. P. COIN) in nasopharynx.

Indian J Otolaryngol Head Neck Surg 1999;52(1):93.

7. Bir Singh G, Abrol R, Dass A. An unusual foreign body in the larynx in an adult. Otolaryngol Head Neck Surg 2005;133(4):639.

9. Eghtedari F. Long lasting nasopharyngeal foreign body.

Otolaryngol Head Neck Surg 2003;129(3):293-4.

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ent

Interval Tonsillectomy: 27 Cases of Peritonsillar Abscesses Managed in a Medical College Hospital Sudhir M Naik*, Sarika S Naikâ&#x20AC;

Abstract Background and objectives: Peritonsillar abscess (quinsy) is the most common deep infection of the head and neck.

The surgical treatment whether abscess tonsillectomy or interval tonsillectomy should be done is a subject of controversy, which still remains unresolved. Setting: Dept. of ENT, Head and Neck Surgery, KVG Medical College, Sullia, Karnataka.

Material and methods: This was a comparative case series analysis study done in our department during the study period of 54 months from January 2007 to June 2011. Twenty-seven patients with clinical features of peritonsillar abscess who underwent medical line of treatment with incision and drainage and later interval tonsillectomy were included in the study.

Results: The mean age was 30.4 years, mean hospital stay during incision and drainage was 3.51 days. The patient turned up for surgery within a mean duration of 9.4 months. The mean blood loss during the procedure was 100.5 mL and the mean visual analog scale (VAS) scores after interval tonsillectomy were 4.78. Mild-to-moderate difficulty was seen during the dissection of the abscess scarred tonsillar bed. Conclusion: Interval tonsillectomy is the standard treatment for managing peritonsillar abscess in many institutions. We recommend interval method of tonsillectomy done after a minimum of 6 weeks after incision and drainage of the peritonsillar abscess.

Keywords: Peritonsillar abscess, interval tonsillectomy, quinsy tonsillectomy, incision and drainage

P

eritonsillar abscess (quinsy) is the most common deep infection of the head and neck.1 It is seen commonly in young adults but now it is also seen frequently in older individuals.2,3 Incidence is higher in the age group 20-40 years.2,3 Children in the younger pediatric age group are seldom affected unless immunocompromised but if it occurs, it causes significant airway obstruction and morbidity.2,3 Males and females are equally affected.2,3 The incidence increases during the months of November to December and April to May because of highest incidence of streptococcal pharyngitis and exudative tonsillitis.4,5 This infection begins as a superficial tonsillar infection and progresses into tonsillar cellulitis forming an abscess at the most advanced stage.1 Abscess is always a polymicrobial infection, but Group A streptococcus is the predominant organism.1 Usually a combination of aerobic and anaerobic organisms is seen on culture.2 Early diagnosis and

*Dept. of ENT, Head and Neck Surgery â&#x20AC; Dept. of Anesthesia KVG Medical College, Sullia, Karnataka

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initiation of therapy is important to avoid potential serious complications.6 Symptoms include progressively worsening sore throat with severe odynophagia, with difficulty to swallow his own saliva. Odynophagia is often localized to one side with constitutional symptoms of fever, malaise, dysphagia and otalgia.1 Clinically the tonsils look swollen, erythematous, edematous pillars with purulent exudates on the tonsils and contralateral uvular deviation.1 Trismus and a hot potato muffled voice with cervical lymphadenopathy are seen.1 Ultrasonography and computed tomography (CT) scanning are useful in confirming the diagnosis.1 Needle aspiration remains the gold standard for diagnosis and treatment of peritonsillar abscess.1 The management includes immediate abscess drainage and administering broad-spectrum antibiotic therapy for aerobes and anaerobes. Also, electrolyte imbalance should be corrected and analgesics given for pain.1 Group A streptococcus and oral anaerobes sensitive antibiotics should be the first-line of therapy.7 Steroids may be helpful in reducing symptoms and speeding recovery.8 Here in our study, a series of 27 patients who underwent interval tonsillectomy 6 weeks after incision and drainage for peritonsillar abscess were retrospectively studied.

ent Material and methods This was a comparative case series analysis study done in our department during the study period of 54 months from January 2007 to June 2011. Twenty-seven patients with clinical features of peritonsillar abscess who underwent medical line of treatment with incision and drainage were included in the study. All the 27 patients underwent interval tonsillectomy 6 weeks after incision and drainage. The age group ranged from 13

Figure 1. Left-sided peritonsillar abscess in a young boy being drained.

Figure 3. Left-sided peritonsillar abscess in a old man being drained.

to 58 years and the youngest patient was a 13-year-old male student (Figs. 1 and 2) and the oldest, a 58-yearold male farmer (Figs. 3 and 4). Tonsillectomies done for other indications were excluded from the study.

Peritonsillar abscesses drained and those who did not turn up for surgery were excluded.

All the abscesses drained were sent for culture and sensitivity. All the 27 cases were drained in the OPD with 15% lidocaine spray and St Clair Thompson

Figure 2. Inflamed tonsillar tissue after abscess drainage.

Figure 4. Patient having relief after incision and drainage.

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

1149

ent peritonsillar abscess draining forceps. The abscess was redrained on next 2 days till the abscess dried off.

The patients who were having absolute dysphagia, unable to swallow their own saliva, had immediate symptomatic relief after the procedure. All the patients were discharged after the pain and swelling subsided.

They were advised to undergo interval tonsillectomy after 6 weeks. The patients underwent tonsillectomies after a month in our institution with scalpel cautery method.

It is believed to be a part of a clinical modality that progresses from acute tonsillitis to peritonsillar cellulitis and finally to peritonsillar abscess.12 Early diagnosis, with drainage of the abscess, is crucial to prevent perforation into the parapharyngeal/retropharyngeal space and further spread along the neck vessels to the mediastinum and skull base.12 The abscess may be aspirated causing severe upper airway obstruction, epiglottic or laryngeal edema if the treatment is delayed.12

Results

Although unilateral peritonsillar abscess is a common complication of acute bacterial tonsillitis, bilateral peritonsillar abscesses are quite rare.13 In most bilateral cases, an unsuspected contralateral abscess is discovered during tonsillectomy.13 The basic management strategy consists of systemic antibiotics covering Group A β-hemolytic streptococci, which is reported to be the most common offending organism, and subsequent drainage of the pus.14 Abscess draining can be done by wide bore needle aspiration, or incision drainage or immediate tonsillectomy, which is called abscess, hot or quinsy tonsillectomy.15 The method of surgical treatment, whether abscess or interval tonsillectomy, is a subject of controversy, which still remains unresolved.15

Our study consisted of nine females and 18 males with a mean age of 30.4 years. Eight patients had right-sided abscess and 19 had left-sided. No bilateral case was seen in our study. The average stay in the hospital during incision and drainage was 3.51 days. The average time after incision and drainage that the patients turned up for interval tonsillectomy was 9.4 months. All the patients were operated under general anesthesia with endotracheal intubation.

The degree of difficulty while dissecting the abscess scarred tonsil was graded as Grade 0 - no difficulty, Grade 1 - mild difficulty, Grade 2 - moderate difficulty, Grade 3 - severe difficulty. The average difficulty score was 1.51 with score of 3 seen in only three patients. The average blood loss during the surgery was 100.5 mL. The pain scores were measured at 8, 16, 24 and 48 hours using 10 cm visual analog scale (VAS) and an average score of 4.78 was found (Table 1). The blood loss and VAS score are as less as seen in tonsillectomies for chronic tonsillectomy cases and so we recommend interval tonsillectomy after 6 weeks of incision and drainage for peritonsillar abscess.

Discussion Peritonsillar abscess and peritonsillitis are two of the commonest ENT emergencies.9 They are collections of purulent material that develop outside the tonsillar capsule near the superior pole.9 They may develop as the most frequent complications of acute tonsillitis, when the infection spreads from the crypts to the loose areolar peritonsillar tissues.9 They are mainly situated in the upper pole and involve the soft palate pushing the tonsils forwards and towards the midline.9 The condition is usually unilateral and mostly affects young adults.10 Edinger et al in their study noted a male dominance up to 2:1 and higher number of young adults.10 Papacharalampous et al reported 1.6:1 times higher incidence in males in their 10-year series study and higher incidence in 20-40 years age group.11

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Immediate tonsillectomy is an easy to perform, onestage surgical procedure assuring quick relief of trismus and pain, and total evacuation of the pus.16 On the contrary, incision and drainage, which is also supported by many authors, is an awkward procedure, very unpleasant for the patient that could often lead to incomplete evacuation of the abscess cavity.16 That is the reason why the procedure is often necessary to be repeated several times.16 Besides, if an interval tonsillectomy is planned, such an operation could be technically more difficult because of the fibrosis of the tonsillar bed usually developed.16 On the other hand, initial conservative (nonsurgical treatment) is still supported by some authors in selected cases, before taking the risk of surgical drainage.17 This strategy is reported to be involved especially in cases of inferior pole peritonsillar abscess, provided that the patient is immunocompetent and has no significant systemic diseases.18 Kristensen and Tveteras in a retrospective study reported no significant difference in postoperative hemorrhages in quinsy tonsillectomy as well as interval tonsillectomy groups.19 Bonding et al found no significant difference in the rates of postoperative hemorrhage between quinsy tonsillectomy and routine tonsillectomy.20 Risks of general anesthesia are more in quinsy tonsillectomy as difficult intubation

ent Table 1. Description of the Patientsâ&#x20AC;&#x2122; Treatment Records Sex

Age

Laterality

Duration of stay after I & D (days)

Interval tonsillectomy done after I & D (weeks)

Blood loss at interval tonsillectomy (mL)

Difficulty in dissection

Average VAS score for 48 hours post-op

M

13

L

4

6

110

1

5.3

M

23

L

3

5

60

1

4.6

M

29

L

5

8

55

2

4

F

32

L

3

12

100

1

4.6

F

36

L

4

11

150

2

5.3

M

58

L

2

12

180

3

6

M

54

R

4

5

60

2

5.3

M

43

R

5

6

60

2

5.3

M

45

L

3

12

80

3

6

F

32

L

2

10

80

1

4.6

F

25

L

3

12

60

1

5.3

M

18

R

4

14

70

1

4

M

19

R

5

12

80

1

4.6

F

37

L

2

10

70

1

4.6

M

18

L

2

9

70

2

5.3

M

20

R

3

9

80

1

4

M

23

L

3

8

100

2

4

F

22

L

4

8

110

2

5.3

M

24

R

4

12

150

2

5.3

F

22

L

5

12

110

1

4

M

18

L

5

11

110

1

4.6

M

22

R

3

6

120

1

4

F

23

L

3

8

90

1

4

M

23

L

4

8

90

3

6

M

52

R

3

9

100

1

4.6

M

44

L

3

8

180

1

4

F

46

L

4

11

190

1

4.6

3.51

9.40

100.55

1.51

4.78

Mean

30.40

or aspiration due to abscess rupture may be seen during the procedure.21 The overall incidence of quinsy in the adult population varies in different studies and a recurrence of peritonsillar abscess varies from 5% to 23% depending on the follow-up period.22 Herbild

and Bonding reported a recurrence rate of 22% in 131 patients over a 5-year period.23 Savolainen et al reported a 17% recurrence rate in a prospective study of 98 patients over a 5-year period, while another study reported a 8.5% recurrence rate.24

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1151

ent Conclusion Interval tonsillectomy is the standard treatment for managing peritonsillar abscess in many institutions.

As quinsy tonsillectomy has no advantages over interval method, less risky interval method is recommended.

Quinsy tonsillectomy has disadvantages of aspiration and difficulty during anesthesia. We recommend interval method of tonsillectomy with surgery done after a minimum of 6 weeks after incision and drainage.

References 1. Galioto NJ. Peritonsillar abscess. Am Fam Physician 2008;77(2):199-202.

2. Steyer TE. Peritonsillar abscess: diagnosis and treatment.

Am Fam Physician 2002;65(1):93-6. Erratum in: Am Fam Physician 2002;66(1):30.

3. Khayr W, Taepke J. Management of peritonsillar abscess: needle aspiration versus incision and drainage versus tonsillectomy. Am J Ther 2005;12(4):344-50.

4. Belleza WG, Kalman S. Otolaryngologic emergencies in the outpatient setting. Med Clin North Am 2006;90(2): 329-53.

5. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH; Infectious Diseases Society of America.

Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis 2002;35(2):113-25.

6. Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105(8 Pt 3 Suppl 74):1-17.

7. Brook I. The role of beta-lactamase producing bacteria and bacterial interference in streptococcal tonsillitis. Int J Antimicrob Agents 2001;17(6):439-42.

8. Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol 2004;118(6):439-42.

9. Richardson KA, Birck H. Peritonsillar abscess in the pediatric population. Otolaryngol Head Neck Surg 1981;89(6):907-9.

10. Edinger JT, Hilal EY, Dastur KJ. Bilateral peritonsillar abscesses: a challenging diagnosis. Ear Nose Throat J 2007;86(3):162-3.

11. Papacharalampous GX, Vlastarakos PV, Kotsis G, Davilis D, Manolopoulos L. Bilateral peritonsillar abscesses: a case presentation and review of the current literature with regard to the controversies in diagnosis and treatment. Case Rep Med 2011;2011:981924.

12. Dalton RE, Abedi E, Sismanis A. Bilateral peritonsillar abscesses and quinsy tonsillectomy. J Natl Med Assoc 1985;77(10):807-12.

13. Simons JP, Branstetter BF 4th, Mandell DL. Bilateral peritonsillar abscesses: case report and literature review.

Am J Otolaryngol 2006;27(6):443-5.

14. Kristensen S, Juul A, Nielsen F. Quinsy: a bilateral presentation. J Laryngol Otol 1985;99(4):401-2.

15. Fasano CJ, Chudnofsky C, Vanderbeek P. Bilateral peritonsillar abscesses: not your usual sore throat. J Emerg Med 2005;29(1):45-7.

16. Kanesada K, Mogi G. Bilateral peritonsillar abscesses.

Auris Nasus Larynx 1981;8(1):35-9.

17. Mehanna HM, Al-Bahnasawi L, White A. National audit of the management of peritonsillar abscess. Postgrad Med J 2002;78(923):545-8.

18. Su WY, Hsu WC, Wang CP. Inferior pole peritonsillar abscess successfully treated with non-surgical approach in four cases. Tzu Chi Medical J 2006;18(4):287-90.

19. Kristensen S, Tveterås K. Post-tonsillectomy haemorrhage.

A retrospective study of 1150 operations. Clin Otolaryngol Allied Sci 1984;9(6):347-50.

20. Bonding P. Tonsillectomy à chaud. J Laryngol Otol 1973;87(12):1171-82.

21. Fagan JJ, Wormald PJ. Quinsy tonsillectomy or interval tonsillectomy - a prospective randomised trial. S Afr Med J 1994;84(10):689-90.

22. Raut VV, Yung MW. Peritonsillar abscess: the rationale for interval tonsillectomy. Ear Nose Throat J 2000;79(3):206-9.

23. Herbild O, Bonding P. Peritonsillar abscess. Arch Otolaryngol 1981;107(9):540-2.

24. Savolainen S, Jousimies-Somer HR, Mäkitie AA, Ylikoski JS. Peritonsillar abscess. Clinical and microbiologic aspects and treatment regimens. Arch Otolaryngol Head Neck Surg 1993;119(5):521-4.

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GASTROENTEROLOGY

Hypoxic Hepatitis in Acute Exacerbation of COPD: A Case Report Varun Vijay Mahajan*, Iesha Pargalâ&#x20AC;

Abstract Abnormal liver functions are caused by a number of causes which include viral hepatitis, alcohol intake, nonalcoholic fatty liver disease, autoimmune liver diseases, hereditary diseases, hepatobiliary malignancies and infections, gallstones and druginduced liver injury. However, the liver may be involved in systemic diseases that mainly affect other organs. Therefore, in a patient without etiology of the liver injury by screening serology and diagnostic imaging, but who have systemic diseases, the abnormal liver function tests may be caused by the systemic disease. In most of these patients, the systemic disease should be treated primarily. The chronic obstructive pulmonary disease (COPD) is one of the most important systemic disease resulting in hepatitis mainly due to hypoxia. COPD patients may present with hypoxic hepatitis and the liver functions return to normal with the treatment of the primary disease.

Keywords: Chronic obstructive pulmonary disease, hepatitis, hypoxia

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case of hepatitis in a case of chronic obstructive pulmonary disease (COPD) is described here. Pulmonary complications of chronic liver disease such as hepatopulmonary syndrome, portopulmonary hypertension and hepatic hydrothorax are well-known, and have been described extensively in literature. Conversely, hepatobiliary manifestations of primary pulmonary disease also occur with high-frequency, but have been studied less frequently. Abnormal liver functions are caused by a number of causes which include viral hepatitis, alcohol intake, nonalcoholic fatty liver disease, autoimmune liver diseases, hereditary diseases, hepatobiliary malignancies and infections, gallstones and druginduced liver injury. However, the liver may be involved in systemic diseases that mainly affect other organs. Therefore, in a patient without etiology of the liver injury by screening serology and diagnostic imaging, but who have systemic diseases, the abnormal liver function tests may be caused by the systemic

*Senior Resident Dept. of Medicine Chintpurni Medical College, Pathankot, Punjab â&#x20AC; Senior Resident Dept. of Forensic Medicine and Toxicology Government Medical College, Jammu Address for correspondence Dr Varun Vijay Mahajan H. No: 211, Sector-1, Channi Himmat, Jammu - 180 015 E-mail: dr.varun7@yahoo.com

disease. In most of these patients, the systemic disease should be treated primarily.

Case Report An 85-year-old female with history of COPD presented to the emergency department of Gian Sagar Medical College, Ramnagar, Patiala, Punjab with history of an episode of breathlessness. She was a diagnosed case of COPD with forced expiratory volume in 1 second/ forced vital capacity (FEV1/FVC) ratio of 52%. She presented with an acute exacerbation of COPD with breathlessness, cough and expectoration.

On examination, the pulse rate was 92/min, regular and a blood pressure (BP) of 130/86 mmHg. She was cyanosed with pursed lip breathing and asteraxis was present.

Chest examination revealed bilateral rhonchi, cardiovascular system (CVS) and abdomen examination was unremarkable. There was no pedal edema, jugular venous pressure (JVP) was not raised.

On investigations, her hemogram revealed a hemoglobin level of 15 g/dL and erythrocyte count was 6 million/mm3, total leukocyte count (TLC) was 11,200/ mm3, platelet count was 70,000. Chest radiograph was consistent with COPD. Arterial blood gas (ABG) analysis was done and showed pCO2 of 90.6% and PaO2 of 67.0 with a pH of 7.210 diagnosed as type 2 respiratory failure. Renal function tests (RFTs) were normal and liver function tests (LFTs) revealed a serum

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GASTROENTEROLOGY bilirubin level of 0.8 and raised transaminases i.e., serum glutamic oxaloacetic transaminase (SGOT) was 3,020 and serum glutamic-pyruvic transaminase (SGPT) was 2,016, alkaline phosphatase was 199, her serum albumin was 3.5. After 2 days of treatment for COPD and of invasive ventilation and oxygen therapy, SGOT was 1,000, SGPT was 876, lactate dehydrogenase (LDH) was 658.

The pressure-time integral (PTI) was 56.8% and international normalized ratio (INR) was 1.76, which after 2 days of treatment of COPD was 90%. The LFT pattern suggested the presence of liver injury. Viral markers for hepatitis A, B, C and E were negative. The antinuclear antibody (ANA) was negative.

The ultrasound for hepatobiliary system was normal.

There was no history of any joint pains and/or any features suggestive of autoimmune hepatitis. There was also no history of intake of any hepatotoxic drugs or herbal/indigenous drugs. Serum LDH was evaluated and it was 1,000 units.

Discussion Pulmonary complications of chronic liver disease such as hepatopulmonary syndrome, portopulmonary hypertension and hepatic hydrothorax are well-known, and have been described extensively in literature.

Conversely, hepatobiliary manifestations of primary pulmonary disease also occur with high-frequency, but have been studied less frequently.1 In our case report, we are reporting such a case in which hypoxic hepatitis was due to the hypoxia, which is not a very commonly labeled entity. As we observed that the LFT started declining as the treatment of the COPD was started and on Day 7 of the admission, the LFT were all normalized except LDH, which was 350 units that was typical of the hypoxic hepatitis.

Hypoxic injury to liver is a largely reversible condition occurring in at least 1% of critically-ill patients and accounting for more than 50% large increase in serum aminotransferases identified in hospital admissions.2 In recent years, various mechanisms of the hypoxic liver injury have been identified such as the noncardiogenic shock and the respiratory failure giving rise to the more inclusive term ‘hypoxic hepatitis (HH)’.1 Hypoxic hepatitis may be grouped on the basis of the primary pathophysiology: (1) decreased oxygen uptake (e.g., respiratory failure); (2) reduced oxygen delivery (e.g., hypotension); (3) decreased oxygen availability (e.g., sepsis) and (4) increased oxygen consumption

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(e.g., hypothermia). Our patient had massive increase in SGOT and SGPT and serum LDH with normal serum bilirubin levels, which further supported the hypoxic hepatitis as laboratory testing in a case of hypoxic hepatitis shows a characteristic increase in serum transaminases 10-100 times the upper limit of the normal. Serum LDH is significantly increased as well.

Hyperbilirubinemia is characteristically mild and rarely exceeds 5 mg/dL.2,3 The PTI in our patient was initially 56.8%, which after 2 days was normalized. In hypoxic hepatitis, coagulopathy is usually not significant and the serum prothrombin time peaks within the initial 24-48 hours of the insult with subsequent normalization.2-4 Initially in our patient, we thought of the presence of viral hepatitis. The serological viral markers were all negative, the transaminases showed a declining trend with treatment of the respiratory failure, which was suggestive of the hypoxic hepatitis. Important distinguishing features of hypoxic hepatitis from toxininduced liver injury and viral hepatitis include rapid reversal of the increased transaminase levels, lower alanine transaminase (ALT)/LDH ratio, low-degree of coagulopathy and bilirubinemia, and lower incidence of renal dysfunction.1,4 Ultrasonography in our patient showed a normal liver and biliary system, had it been due to congestive heart failure, there would have been congestive hepatomegaly.

Imaging study may be normal or may show hypoechoic areas on ultrasonography that resolve completely in time.4 Moreover, our patient clinically had no signs of heart failure, JVP was not raised, no pedal edema was there.

Close correlation between enzymatic changes and severity of arterial hypoxemia, and lack of correlation between enzymatic changes and clinical signs of right heart failure, appear to indicate that severe hypoxia per se plays a major role in the development of liver injury rather than mechanical factors due to increased venous pressure.5 Since, our patient was a female, so the possibility of autoimmune hepatitis was also considered but there was no feature suggestive of autoimmune diseases and also the ANA and the anti-LKM antibodies were negative.

Liver ischemia was initially thought to be the main mechanism responsible for hypoxic hepatitis. But more recently, Henrion et al found that arterial hypoxemia when severe may lead to hypoxic hepatitis even in the absence of cardiac and circulatory failure.6 Cont’d on page 1177...

obstetrics and gynecology

A Rare Case of Spinal Muscular Dystrophy/ Atrophy Sunanda kulkarni*, Savitha C†

Abstract Spinal muscular atrophy (SMA) is an autosomal recessive disease caused by a genetic defect in the SNM1 gene which encodes SNM, a protein expressed in the yolk sac cells, which is necessary for survival of motor neurones. It causes muscular weakness leading to increased morbidity and mortality. Early recognition and MTP saves the agony of the parents. We report a case of spinal muscular dystrophy in a 28-year-old female with a history of amenorrhea of 3 months.

Case is reported because of its rarity and to enhance the awareness of the condition.

Keywords: Spinal muscular atrophy, genetic defect, chorionic villus sampling, SNM1 gene, medical termination of pregnancy

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pinal muscular atrophy (SMA) is a rare genetic disease, which causes muscular weakness leading to increased morbidity and mortality. Early recognition and medical termination of pregnancy (MTP) saves the agony of the parents. Case is reported because of its rarity and to enhance the awareness of the condition.

Case Report A 28-year-old by name M, G2P1L1 came to OPD with history of amenorrhea of 3 months. Her past cycles were regular. Her married life of 5 years, was nonconsanguineous. She had undergone lower-segment cesarean section (LSCS) for premature rupture of membranes (PROM) for the first baby, which was a female baby weighing 3.75 kg.

As baby had delayed milestones and was not able to walk even after 1 year, they had consulted the pediatrician.

Muscle biopsy and genetic DNA was done, which confirmed the diagnosis of SMA. There was deletion of exon 7 of SNM1 gene.

Menstrual history - cycles were regular. Family history revealed that husband’s 2nd cousin had a female baby

*Professor Dept. of Obstetrics and Gynecology Adichunchanagiri Institute of Medical Sciences, Bellur, Karnataka †Professor Dept. of Obstetrics and Gynecology Bangalore Medical College, Bangalore

with similar complaints but the diagnosis was not confirmed. Past and personal history did not reveal anything significant.

On examination, the patient’s vitals were normal, and pelvic examination showed pregnancy about 12 weeks.

Investigations: All routine investigations were within normal limits. Ultrasound confirmed pregnancy and fetus was corresponding to gestational age.

In view of the SMA of the first baby - chorionic villus sampling (CVS) was done and it was confirmed that this fetus also had homozygous deletion of exon 7 of SNM1 gene. Couple were counseled for MTP for which they readily agreed.

MTP was carried out with mifepristone 200 mg and three doses of misoprostol 200 mg 4-hourly and patient expelled after 16 hours.

Fetal postmortem was done. Autopsy showed that anthropometry was corresponding to the age of the fetus and there was no dysmorphic features and no associated anomaly. Brain and spinal cord was normally developed.

Discussion SMA is an autosomal recessive disease caused by a genetic defect in the SNM1 gene which encodes SNM, a protein expressed in the yolk sac cells, which is necessary for survival of motor neurones. Deficiency of this protein leads to death of neuronal cells of anterior horn of spinal cord and subsequent muscle wasting leading to atrophy.

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obstetrics and gynecology It manifests from newborn to adulthood. Depending on the age of onset and appearance of symptoms, it is classified into three types. Infantile type is from 0 to 6 months (Werdnig-Hoffmans disease), intermediate type from 6 to 18 months, (Dubowitz disease), where baby cannot stand and walk and life expectancy is also short. Juvenile Kugelberg-Welander disease is seen in children >18 months, where children can walk with support and life expectancy is near normal. Lastly, adult-onset manifests in 3rd decade of life. It affects extremities rendering the patient to wheelchair but life expectancy is not affected.

Treatment needs respiratory, nutritional, mental health, cardiac and orthopedic care.

SMA is a rare hereditary disease and it could also be due to mutation of gene. Incidence is 1:10,000 live birth.

Approximately 90% of patient’s suffering is from lack of two copies of SNM gene on exon SNM1 on 7 and 8.

It is slow progressive disease and there is no specific treatment. Disease can be diagnosed by clinical tests of motor disabilities, serum creatinine kinase, EMG testing for muscle atrophy. Muscle biopsy is absolutely necessary when genetic investigation is not confirmatory. In the present case, genetically though it was confirmed by CVS, autopsy did not show the same results as the disease may manifest in later weeks of pregnancy.

Prenatal diagnosis of SMA may be diagnosed by genetic analysis of circulating fetal cells from maternal blood.1 Ultrasound evaluation of fetal movements in pregnancy at risk of SMA in first-trimester were not confirmatory.2 If both parents were carriers or any family member had SMA, prenatal diagnosis by denaturing high performance liquid chromato-

graphy (DHPLC) using DNA extracted from blood, chorionic villi and amniotic fluid can be done.3 DNA from amniocytes and CVS can be analyzed and MTP can be done, if disease is confirmed.4 SMA can also be diagnosed by polymerase chain reaction (PCR) and MTP can be advised.5 Conclusion If there is family history of SMA, CVS should be done to confirm the disease by genomic studies. If the disease is confirmed the couple should be counseled for MTP to save them from agony and reduce burden to the society.

References 1. Béroud C, Karliova M, Bonnefont JP, Benachi A, Munnich A, Dumez Y, et al. Prenatal diagnosis of spinal muscular atrophy by genetic analysis of circulating fetal cells.

Lancet 2003;361(9362):1013-4.

2. Parra J, Martínez-Hernández R, Also-Rallo E, Alias L, Barceló MJ, Amenedo M, et al. Ultrasound evaluation of fetal movements in pregnancies at risk for severe spinal muscular atrophy. Neuromuscul Disord 2011;21(2): 97-101.

3. Shaw SW, Cheng PJ, Chang SD, Lin YT, Hung CC, Chen CP, et al. Rapid prenatal diagnosis of spinal muscular atrophy by denaturing high-performance liquid chromatography system. Acta Obstet Gynecol Scand 2008;87(9):960-8.

4. Kocheva SA, Plaseska-Karanfilska D, Trivodalieva S, Kuturec M, Vlaski-Jekic S, Efremov GD. Prenatal diagnosis of spinal muscular atrophy in Macedonian families. Genet Test 2008;12(3):391-3.

5. Wu T, Ding XS, Li WL, Yao J, Deng XX. Prenatal diagnosis of spinal muscular atrophy in Chinese by genetic analysis of fetal cells. Chin Med J (Engl) 2005;118(15):1274-7.

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A large population-based study published online March 27 in the American Journal of Obstetrics and Gynecology has reported that about 1 in 4 stillbirths may be due to maternal obesity. The risk gets higher as gestational age and obesity levels increase.

The study authors analyzed records databases for stillbirths and singleton live births without severe fetal anomalies between 20 and 42 weeks’ gestation in Texas from 2006 to 2011 and Washington from 2003 to 2011.

In all, 2,868,482 singleton births were identified, including 9,030 stillbirths.

The risk for stillbirth was found to increase with increasing maternal weight compared with normal-weight women (hazard ratio, 1.36 with overweight; 1.71 with Class 1 obesity, 2.00 with Class 2 obesity, 2.48 with Class 3 obesity and 3.16 for women with a BMI >50 kg/m2).

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obstetrics and gynecology

Mammoth Myoma – Challenges in Management Vembu Radha*, Narayanan Palaniappan†, Diviya nanchil Kumaran‡

Abstract Giant leiomyomas are known to arise from uterus and very rarely from the broad-ligament. The surgical management of these cases can pose a challenge. We report a case of giant broad-ligament fibroid weighing 8,500 g posing problems in diagnosis and management. With the clinical examination, investigatory modalities, a diagnosis of malignant ovarian tumor was made but it turned out to be a broad-ligament fibroid. Intraoperatively, patient went into coagulopathy, which was effectively managed by timely abdomino-pelvic packing.

Keywords: Leiomyoma, broad-ligament fibroid, abdomino-pelvic packing

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xtrauterine fibroid though do occur, but are not as common as uterine fibroids. Among them the most common is a broad-ligament fibroid although its overall incidence is rare.¹ It can pose diagnostic difficulties causing an error in final diagnosis and management due to rarity of this condition.

We are reporting an unusual case operated with a preoperative diagnosis of malignant ovarian tumor, which turned out to be a giant broad-ligament fibroid confirmed by histopathological examination.

Intraoperatively, we encountered coagulopathy in which was managed successfully.

case report A 50-year-old parous, postmenopausal for 1 year, presented with abdominal distension for 2 months, rapidly increasing over the past 1 week. It was associated with pain abdomen, epigastric discomfort, breathlessness, decreased appetite and swelling of the legs for 1 week. She had no history of weight loss, bladder or bowel disturbance.

On examination, vitals were normal, she had bilateral pitting peal edema, no pallor or lymphadenopathy.

*Associate Professor †Professor and Unit Chief ‡Assistant Professor Dept. of Obstetrics and Gynecology Sri Ramachandra University, Chennai, Tamil Nadu Address for correspondence Dr Vembu Radha Associate Professor Dept. of Obstetrics and Gynecology Sri Ramachandra University, Chennai - 600 116, Tamil Nadu E-mail: ganesh_radha@yahoo.in

Body mass index (BMI) was 26 kg/m² with weight being 65 kg. Systemic examination was normal. Abdomen examination showed a mass arising from the pelvis occupying all the quadrants corresponding to 36 weeks, varied consistency, restricted mobility and no free fluid.

Speculum examination revealed normal cervix and vagina. On bimanual examination, cervix was drawn up, uterus was of normal size and a firm mass was felt through all the fornices. Per rectal examination was normal.

Preoperative investigations were normal. Ultrasound abdomen and pelvis showed a huge heterogenous solid mass lesion with areas of cystic changes occupying the entire abdomen with marked vascularity. Both ovaries were not visualized. The lesion was causing posterior displacement of liver, spleen, kidneys. There was no free fluid in the peritoneal cavity. Computed tomography (CT) scan (Fig. 1) showed a well-defined heterogenous mass of 32 × 27 × 21 cm with solid and cystic components with septations in the abdomen and pelvis. Probably ovarian mass with prominent para-aortic lymph nodes of 9 mm. Cancer antigen-125

Figure 1. CT scan-abdomen and pelvis showing the mass occupying the entire abdomen.

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obstetrics and gynecology the course of ureters. The mass measured 32 × 27 × 21 cms weighing 8,500 g.

Figure 2. Broad-ligament fibroid weighing 8,500 g.

Intraoperatively, there was a continuous ooze from myoma bed and hemoglobin dropped from 11 to 3.3 g/dL, rapid international normalized ratio (INR) was 2.15. Patient was transfused 3 units packed cells, 4 units fresh frozen plasma (FFP) and 2 units platelets. As generalized ooze continued, we proceeded with abdomino-pelvic packing using 2 long abdominal packs soaked in warm saline, tied at the edges and one of the edges was brought out through a separate incision on the anterior abdominal wall (Fig. 3). Total duration of surgery was 3 hours and 15 minutes.

Postoperatively, patient was managed in intensive care unit (ICU), was transfused 3 units packed cells, 4 units FFP and 4 units of platelets. Hemoglobin improved to 9.9 g/dL. Once the general condition of the patient was stable, pack was removed after 48 hours, rectus sheath of the pack site was sutured, and patient was extubated.

Skin was sutured on postoperative day (POD) 4. All the skin sutures were removed on POD 10 and the patient was discharged on POD 12 in a stable condition. Postsurgery, the patient weighed 54 kgs (weight loss of 11 kg). Histopathology report confirmed leiomyoma (broad-ligament fibroid-based on its location).

DISCUSSION

Figure 3. Exit point of the abdomino-pelvic pack through a separate incision.

(CA-125) and CA 19.9 were 17.8 and 4.2 U/mL, respectively which were within normal limits.

Considering the age, rapid progression of symptoms, ultrasound and CT scan report, a probable diagnosis of malignant ovarian tumor was made and planned for staging laparotomy and procedure.

Intraoperatively, there was no free fluid, a huge rightsided broad-ligament, solid and cystic mass occupying all the quadrants up to the under surface of the diaphragm and extending into the retroperitoneal space was noted (Fig. 2). Appendix, omentum and bowel loops were adherent. Bilateral tubes and ovaries were normal. The specimen sent for frozen section revealed spindle cell tumor probably leiomyoma.

We proceeded with total abdominal hysterectomy with bilateral salpingo-oophorectomy after delineating

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Giant leiomyomas are known to arise from the uterus but very rarely from broad-ligament.

Veronica et al² in a case report have reported a broad-ligament fibroid of 2,800 g. Probably, ours is one of the largest broad-ligament fibroid of 8,500 g reported in the literature. The broad-ligament fibroid unlike in our case usually presents with pressure symptoms. Larger fibroids distort the pelvic anatomy, compress the ureters causing hydroureteronephrosis.

So, delineation of the ureteric course is very important to avoid ureteric injury. Abdominal packing is most commonly used for uncontrollable hemorrhage in hepatic surgeries³ in the face of hypothermia, acidosis and coagulopathy. This may be a life-saving procedure even though the morbidity and mortality is high due to continued hemorrhage, abscess, compartment syndrome, small bowel obstruction. The decision for abdomino-pelvic packing is based on the surgeon’s opinion that coagulopathy has developed or that the patient is too unstable to undergo further blood loss. In our case, as the hemoglobin dropped grossly with the onset of coagulopathy, the decision to proceed with abdomino-pelvic packing was

obstetrics and gynecology considered in addition to timely blood and blood products administration, which saved the life of the patient. Only few studies have reported the role of packing in cesarean hysterectomies4 and during pelvic posterior exenteration in gynecological surgeries.5 The role of uterine artery embolization, internal iliac artery ligation prior to the surgery to reduce the vascularity could not be considered in view of the suspicion of malignant ovarian tumor and giant size of the mass.

The timing of removal of pack and the route varies. Usually, the pack is removed only after the cardiopulmonary function, coagulation factors, hypothermia and acidosis are stabilized.³ In our case, as the patient was stable after 48 hours, the decision to remove the pack was considered. Many reports have suggested the need for relaparotomy 1-7 days after primary surgery.³ In our case, as the pack had a separate exit point, it was removed without a need for relaparotomy.

CONCLUSION The broad-ligament fibroid, even though being uncommon, can grow to a large size and can be

a nightmare in the diagnosis and management.

So, timely decision of abdomino-pelvic packing with other resuscitative measures can be a life-saving measure.

REFERENCES 1. Bhatla N. Tumors of corpus uteri. In: Jeffcoats Principles of Gynecology. 6th edition., Arnold Printers: London 2001:p.470.

2. Yuel VI, Kaur V. broad-ligament fibroid - an unusual presentation. JK Science 2006;8(4):217-8.

3. Sharp KW, Locicero RJ. Abdominal packing for surgically uncontrollable hemorrhage. Ann Surg 1992;215(5):467-74; discussion 474-5.

4. Ghourab S, Al-Nuaim L, Al-Jabari A, Al-Meshari A, Mustafa MS, Abotalib Z, et al. Abdomino-pelvic packing to control severe haemorrhage following caesarean hysterectomy. J Obstet Gynaecol 1999;19(2):155-8.

5. Wydra D, Emerich J, Ciach K, Dudziak M, Marciniak A. Surgical pelvic packing as a means of controlling massive intraoperative bleeding during pelvic posterior exenteration - a case report and review of the literature.

Int J Gynecol Cancer 2004;14(5):1050-4.

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Many Mothers have Untreated PTSD After Perinatal Death Mothers who lose a child prenatally have extraordinarily high rates of depression and anxiety, and receive limited treatment for these conditions. This is particularly true for black women, who have the worst pregnancy outcomes in the United States. “Moms who were bereaved had much higher odds of depression and PTSD,” said Katherine Gold, MD, MSW, MS, from the University of Michigan in Ann Arbor. Dr. Gold presented results from the Michigan Mother’s Study here at the American Congress of Obstetricians and Gynecologists 2014 Annual Clinical Meeting. The research won third prize from among 600 submitted abstracts and was featured during a plenary section.

In the survey, 377 bereaved mothers whose children were stillborn or died in infancy were matched with 232 mothers whose children lived. The women were asked about their mental, physical and reproductive health outcomes and were screened for specific mental health disorders.

Fewer Women Dying During Childbirth Globally; US Lagging The global community is making steady progress in reducing the number of women who die during childbirth.

Worldwide, since 1990, maternal deaths have dropped 45%, according to a report released today by the World Health Organization (WHO) and other United Nations agencies. The report estimates that 2,89,000 women died in 2013 because of complications in pregnancy and childbirth, down from 5,23,000 in 1990.

A related report from the WHO looks at global causes of maternal deaths and finds that 1 in 4 maternal deaths are caused by pre-existing medical conditions such as diabetes, HIV, malaria and obesity, whose health effects can all be aggravated by pregnancy. This is similar to the proportion of deaths during pregnancy and childbirth resulting from severe bleeding, according to a WHO news release. This report was published online May 6 in the Lancet Global Health.

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obstetrics and gynecology

Posterior Reversible Encephalopathy Syndrome in Postpartum Normotensive Woman: A Rare Presentation Siva Sundari*, KS Rajeswari†, Nandhini Elumalai‡

Abstract Posterior reversible encephalopathy syndrome (PRES) is a rare acute neurologic condition characterized by headache followed by deterioration, including confusion, seizures or cortical visual disturbances. Our case is a rare presentation of PRES in a postpartum normotensive woman after an uneventful cesarean delivery under spinal anesthesia.

Keywords: Posterior reversible encephalopathy syndrome, spinal anesthesia

P

osterior reversible encephalopathy syndrome (PRES) has occurred in patients with hypertensive encephalopathy, renal failure, immunosuppression and postpartum eclampsia.1,2 We report a case of PRES, which occurred in the postpartum period with normal blood pressure (BP) and managed successfully.

Case Report A 26-year-old primigravida, booked, normotensive was induced at 37 weeks of gestation in view of obstetric cholestasis of pregnancy. She underwent emergency lower-segment cesarean section under spinal anesthesia in view of fetal distress. Postoperatively, her blood pressure was normal.

On second postoperative day, patient developed bifrontal headache, particularly when in an erect position, it was relieved by being recumbent.

Headache improved (visual analog scale [VAS] 1/10) after supportive therapy including oral analgesics (paracetamol, 2 g/day), intravenous (IV)

*Associate Professor † Professor ‡III Year MS Postgraduate Dept. of Obstetrics and Gynecology Sri Ramachandra University, Porur, Chennai, Tamil Nadu Address for correspondence Dr Siva Sundari L-170, Marvel Apoorva Apartments 4/12, Kalacsathaman Koil Street Ramapuram, Chennai - 600 089, Tami Nadu E-mail: sivasundaridr@yahoo.com

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hydration and bed rest. Her BP was 120/70 mmHg. On third postoperative day, patient complained of severe throbbing headache (VAS 10/10) over the occipital area, which was no longer postural. BP was 130/70 mmHg, treated conservatively with analgesics and IV hydration. After 2 hours, she developed blurring of vision followed by one episode of generalized tonic and clonic convulsions.

During postictal period, she had total loss of vision.

Neurologist opinion was obtained. Patient was treated in intensive care unit with magnesium sulfate (Zuspan’s regime) for 24 hours, injection levetiracetam 1 g IV b.i.d. for 48 hours and injection mannitol 100 mL infusion t.d.s for 24 hours.

Magnetic resonance imaging (MRI) brain FLAIR T2 weighted axial images showed bilateral symmetric hyperintense areas involving the bilateral frontal, parietal subcortical white matter, bilateral basal ganglia, occipital and cerebellar hemispheres suggestive of PRES (Fig. 1 a and b). MR venogram was normal.

Fundus-normal.

Throughout the BP was 130/70 mmHg. There was no proteinuria, renal function test, liver function test, serum electrolytes and serum calcium were normal.

She completely regained her vision after 24 hours.

Her neurological symptoms completely resolved by 48 hours. She was discharged on 8th postoperative day with anticonvulsant medications for 1 month. She was followed up for almost 5 months and she is free of neurological symptoms.

obstetrics and gynecology cerebellum are involved.3 However, irreversible brain damage can sometimes occur due to late-recognition or incorrect treatment.4,5 Importantly, treating the underlying problem usually leads to symptom resolution without neurological deficit. Acute treatment for cerebral vasospasm is essential.6

a

Nimodipine, a calcium antagonist, has been shown to be associated with a reduced rate of infarction because of cerebral vasospasm, but the efficacy of magnesium, a drug with calcium antagonist properties in treating cerebral vasospasm is comparable to that of nimodipine.6 Several clinical studies have shown that intravascular magnesium sulfate safely relieved maternal cerebral vasospasm.7-9 Conclusion We report this case due to rare presentation of PRES in a postpartum normotensive woman after spinal anesthesia and successful appropriate management.

REFERENCES 1. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334(8):494-500.

b Figure 1 a and b. MRI brain FLAIR T2 weighted axial images showing bilateral symmetric hyperintense are a s i n vo l v i n g t h e b i l a t e r a l fr o n t a l , p arie tal subcortical white matter, bilateral basal ganglia, occipital and cerebellar hemispheres.

DISCUSSION PRES is a rare acute neurologic condition characterized by headache followed by deterioration, including confusion, seizures or cortical visual disturbances.

PRES has been reported to be reversible.1

2. Lamy C, Oppenheim C, MĂŠder JF, Mas JL. Neuroimaging in posterior reversible encephalopathy syndrome.

J Neuroimaging 2004;14(2):89-96.

3. Naqi R, Ahsan H, Azeemuddin M. Posterior reversible encephalopathy syndrome: a case series in patients with eclampsia. J Pak Med Assoc 2010;60(5):394-7.

4. Stott VL, Hurrell MA, Anderson TJ. Reversible posterior leukoencephalopathy syndrome: a misnomer reviewed.

Intern Med J 2005;35(2):83-90.

5. Antunes NL, Small TN, George D, Boulad F, Lis E. Posterior leukoencephalopathy syndrome may not be reversible. Pediatr Neurol 1999;20(3):241-3.

6. Ho CM, Chan KH. Posterior reversible encephalopathy syndrome with vasospasm in a postpartum woman after postdural puncture headache following spinal anesthesia.

Anesth Analg 2007;105(3):770-2.

PRES refers to a clinicoradiological entity with characteristic features on neuroimaging and nonspecific symptoms comprising headache, confusion, visual disturbances and seizures.3 The lesions in PRES are thought to be due to vasogenic edema, predominantly in the posterior cerebral hemispheres and reversible with appropriate management.3

7. Belfort MA, Moise KJ Jr. Effect of magnesium sulfate on maternal brain blood flow in preeclampsia: a randomized, placebo-controlled study. Am J Obstet Gynecol 1992;167(3):661-6.

The typical MRI findings of PRES are most apparent as hyperintensity of FLAIR images in the parieto-occipital and posterior-frontal cortical and subcortical white matters. Less commonly brainstem, basal ganglia and

9. Naidu S, Payne AJ, Moodley J, Hoffmann M, Gouws E. Randomised study assessing the effect of phenytoin and magnesium sulphate on maternal cerebral circulation in eclampsia using transcranial Doppler ultrasound. Br J Obstet Gynaecol 1996;103(2):111-6.

8. Belfort MA, Saade GR, Moise KJ Jr. The effect of magnesium sulfate on maternal and fetal blood flow in pregnancy-induced hypertension. Acta Obstet Gynecol Scand 1993;72(7):526-30.

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obstetrics and gynecology

Role of Intravenous Amino Acids in Oligohydramnios and IUGR Complicated Pregnancy Namrata Tiwari*, Laxmi Maru†, Anupama Dave‡

Abstract Introduction: Oligohydramnios and intrauterine growth retardation (IUGR) is a late sign of fetal malnutrition. It is quite often associated with impaired fetal growth, fetal anomaly and malpresentation. Objectives: To study incidence of oligohydramnios and IUGR, to evaluate effect of parenteral nutrition supplementation on amniotic fluid index (AFI) and body weight and to evaluate maternal and perinatal outcome. Material and methods: The study was done to see whether maternal nutrition plays any role in maintaining the fetal environment. For the present study, 60 patients each were assigned to control and case group respectively who were clinically and sonographically proven cases of oligohydramnios and/or IUGR in third trimester of pregnancy. They were admitted and followed up till delivery. Study group received intervention in the form of intravenous (IV) fluids and IV amino acids 200 cc on alternate days for 10 days. The control group did not receive any IV amino acid infusion. Subject were selectedbased on specific inclusion and exclusion criteria. Outcome was noted in the form of mode of delivery, fetal outcome, Apgar score, fetal birth weight, maturity, admission to nursery. Results: There was significant increase in AFI and birth weight at the time of delivery in case group after alamine infusion at 2nd and 4th weeks.There was also obvious increase in vaginal delivery and perinatal outcome in the case study. Conclusions: Maternal nutrition was improved by parenteral amino acid infusion. A significant improvement was observed subsequently as the AFI was seen to increase and less operative intervention was needed.

A lesser perinatal mortality was as well seen.

Keywords: Pregnancy, intrauterine growth retardation, intravenous amino acid, oligohydramnios, amniotic fluid

T

he amniotic fluid serves as a physiologic buffer and an extension of the fetal extracellular compartment.1 The volume peaks between the 36 and 38 weeks of gestation.2,3

Oligohydramnios complicates 0.5-8% of pregnancies and the prognosis for pregnancies complicated by oligohydramnios is gestational age dependent.4 The most common etiology of oligohydramnios is premature rupture of membranes (PROM).

Oligohydramnios in the second trimester is usually the result of preterm PROM, uteroplacental insufficiency and urinary tract malformations (bilateral renal agenesis, multicystic or polycystic kidneys, or

*PG Resident †Professor and Head ‡Associate Professor Dept. of Obstetrics and Gynecology MGM Medical College and MY Hospital, Indore, MP Address for correspondence Dr Namrata Tiwari C/O: Dr Mahesh Tiwari 106, Post Office Road, Mhow, Indore, MP E-mail: drnamrata28@gmail.com

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urethral obstruction) and twin- to-twin transfusion.5 Oligohydramnios with intact membranes warrants a comprehensive evaluation to detect possible fetal and placental abnormalities, growth restriction or aneuploidy.4 Demonstration of early symmetrical intrauterine growth retardation (IUGR) with marked oligohydramnios suggest the possibility of an underlying chromosomal disorder, notably trisomy 18 or triploidy.5 Other causes of oligohydramnios include maternal dehydration,6 medications as calcium channel blockers, nonsteroidal anti-inflammatory drugs (NSAIDs) that inhibit renal vascular flow and decrease glomerular filtration rate,7 and angiotensinconverting enzyme inhibitors that reduce fetal blood pressure, decrease renal perfusion and subsequently result in oligohydramnios.8 In post-term pregnancies, oligohydramnios is a common complication, and is associated with diminished placental function.5 IUGR is suspected when the estimated fetal weight falls below the 10th percentile for the expected gestational age.9 Oligohydramnios in early pregnancy is attended by serious consequences to the fetus.

Subjected to pressure from all sides the foetus

obstetrics and gynecology assumes a peculiar appearance and musculoskeletal deformities such as club foot, talipes and wry neck may be seen. The skin of fetus appears dry, leathery and wrinkled. Pulmonary hypoplasia is common with oligohydramnios.10 Diminished liquor is quite often associated with impaired fetal growth, fetal anomalies and malpresentations. It is also associated with abnormal fetal heart rate (FHR) pattern and meconiumstaining of liquor, which often requires cesarean section and results in perinatal mortality and morbidity.

The prognosis and the possibility of management of oligohydramnios depend upon the etiology. Attempts at therapy focus on restoring the amniotic fluid to allow continued development of the lungs during the canalicular phase.11 Maternal hydration by oral or intravenous (IV) administration12,13 helps to maintain amniotic fluid volume in oligohydramnios, 17% amino acids have shown an increase in the birth weight with some reduction in perinatal mortality in undernourished mothers. Amino acids also has a positive influence on IUGR. The combination of oligohydramnios and IUGR portends a less favorable outcome, and early delivery should be considered.14,15 Generally, if the pregnancy is at 36 weeks or more, the high-risk of intrauterine loss may mandate delivery.

Material And Methods The present study entitled “Role of Parenteral Amino Acids Supplementation in Oligohydramnios and IUGR Complicated Pregnancies” was conducted in the Dept. of Obstetrics and Gynecology, MGM Medical College and MY Hospital, Indore (MP) during the period of August 2008 to April 2009. In all 120 patients were included in this study. Sixty patients each were assigned to control and case group, respectively.

Study Design The patients were divided into two groups: ÂÂ Group 1 (Case Group): Sixty women who were clinically and sonographically proven cases of oligohydramnios and/or IUGR in third trimester of pregnancy admitted at our institution as booked cases and were followed up till delivery. ÂÂ Group 2 (Control Group): Sixty women who were clinically and sonographically proven cases of oligohydramnios and/or IUGR in third trimester of pregnancy, who came as emergency cases, did not receive any IV amino acid infusion.

Inclusion Criteria ÂÂ

Clinically or sonographically proven cases of oligohydramnios/IUGR; fluid is decreased if AFI <10 cm and markedly decreased if AFI <5 cm.

ÂÂ

Gestational age >28 weeks up to term.

Exclusion Criteria ÂÂ

Patients having congenital anomalies in the fetus were excluded from the study.

ÂÂ

Patients having PROM as a cause of reduced amniotic fluid volume were excluded from the study.

ÂÂ

Patients having major respiratory, CVS or abdominal pathologies were also excluded from the study.

Plan of activity and time chart were formulated after taking verbal consent from the woman and/or relatives.

Patients’ sociodemographic data were obtained. Other potential explanatory variables were obtained including maternal age, booking status, pregnancy-induced hypertension (PIH) and other risk factors at the time of admission were recorded. Detailed clinical history including obstetric, menstrual, past and personal history were taken. Thorough general, systemic and obstetric examination was conducted. Woman’s hematological profile was done. USG at the time of admission was recorded including fetal biometry and amniotic fluid volume.

Study group received intervention in the form of IV fluids and IV amino acids 200 cc on alternate days for 10 days. On the other days, 3 units of IV fluids were infused.

Repeat USG was performed at the end of 2 weeks and 4 weeks. Daily fetal movements count and twice-daily FHS charting was done to ascertain fetal well-being during the intervention period. Repeat infusions were given if required after 3-4 weeks. Oral iron, calcium and multivitamins were also given. Women were followed up till their delivery. During the intervention period, if the fetal status was non-reassuring (CTG), elective cesarean section was performed.

Outcome was noted in the form of mode of delivery, fetal outcome, Apgar score, fetal birth weight, maturity, admission to nursery and postnatal complications, if any.

All the information was entered in the proforma and analyzed and observations were noted and accordingly discussion and recommendations were made.

RESULTS Fetal growth retardation ranks third after prematurity and malformations as a cause of perinatal deaths.

Clinical acumen combined with USG testing will identify no more than 70% growth retarded fetuses.

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obstetrics and gynecology During the study period of 9 months from May 2010 to February 2011, there here 3,868 admissions, out of which, total deliveries were 2,000. Four hundred ninety Patients had oligohydramnios and 220 patients had oligohydramnios associated with IUGR. Incidence of oligohydramnios with IUGR was 5.68% among hospital admissions, whereas, 12.66% patients had IUGR.

Incidence The incidence of oligohydramnios is comparable to similar various other studies, according to which oligohydramnios complicates 0.5-8% of pregnancies.

Incidence of IUGR varies from region-to-region and even in the same region, it varies in different subpopulation. In India, according to recent UNICEF surveys, the incidence of IUGR is 25-30%. The classification of patients according to AFI on admission is given in Table 1.

Age In our study 5% of the patients in case group were <20 years as compared to 6.66% patients in control group. 1.66% cases were >30 years, whereas, 3.33% controls were >30 years of age. Most of the patients, diagnosed as having oligohydramnios and IUGR were in age group of 21-30 years.

Literacy Only 8.35% illiterate patients were diagnosed oligohydramnios and IUGR early and received medical care early, compared to 92% patients who were literate and received treatment (Table 2).

Table 1. Classification of Patients according to AFI on Admission AFI

Cases (n = 60)

Controls (n = 60)

No.

%

No.

%

Moderate oligohydramnios

40

66.66

42

70

Severe oligohydramnios

20

33.33

18

30

Total

60

100

60

100

Table 2. Distribution of Patients according to Education Education

Cases

Controls

No.

%

No.

%

Illiterate

5

8.33

12

20.00

High School (up to 8th)

26

43.33

21

35.00

Senior Secondary (9-12th)

18

30.00

25

41.66

Graduate

7

11.66

2

3.33

Postgraduate

0

0

0

0

Table 3. AFI Before and After Infusion AFI

At admission

At 2 weeks follow-up

At 4 weeks follow-up

No.

%

No.

%

No.

%

<5 cm

20

33.33

15

25.00

12

20

5.1 - 10 cm

40

66.66

26

43.33

18

30

>10 cm

0

0

19

31.66

30

50

Total

60

100

60

100

60

100

Socioeconomic Status Only 11.66% patients in case group and 5% in the control group belonged to Class II of P Kumar classification, showing that among well-to-do classes, incidence of oligohydramnios and IUGR was less. More than 80% of the patients belonged to poor socioeconomic status in both the case and control group.

Parity Out of 60 patients in case group, 63.33% patients were para 0 as compared to 48.33% patients in control group.

Body Mass Index Among the cases, five out of 60 (8.33%) were underweight and seven out of 60 controls (11.66%) were overweight or obese. Only 78% patients had Body mass index (BMI) in the normal range.

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Table 4. Mode of Delivery Mode of delivery

Cases (n = 60) No.

%

Controls (n = 60) No.

%

LSCS

12

20

20

33.33

Vaginal delivery

48

80

40

66.66

Table 5. Distribution of Cases and Controls according to Perinatal Mortality Cases group

Control group

No.

%

No.

%

Operative morbidity

12

20.00

20

33.33

Neonatal morbidity

5

8.33

28

46.66

obstetrics and gynecology vaginal delivery, whereas 40 out of 60 (66.66%) controls delivered vaginally (Table 4).

70.00% 60.00%

AFI and Pregnancy Outcome

50.00% <5 cm

40.00%

5.1-10 cm

30.00%

>10 cm

20.00% 10.00% 0.00%

At admission

At 2 weeks

At 4 weeks

Figure 1. Number of patients according to amniotic fluid index in USG before infusion (at admission) and after infusion at 2 weeks and 4 weeks.

According to the study of Robert E. Black et al (2008),16 maternal under nutrition i.e., BMI <18.5 kg/m2 ranges from 10% to 19% in most countries. Low BMI is prevalent in almost 40% women in India, maternal short stature and low BMI have independent adverse effects on pregnancy outcomes.

Relationship of AFI to IUGR

Among 30 patients with severe oligohydramnios, nine (30%) patients had preterm delivery. Nine (30%) had term delivery and 12 (40%) had cesarean delivery for fetal distress and meconium-stained liquor.

In patients, with AFI 5.1-10 cm, 66% patients had term delivery showing that improvement of AFI correlates with normal term delivery sand only 25% patients had LSCS.

Indications for LSCS In the treated group, out of 12 patients who had LSCS, only two (16.66%) patients had section for fetal distress and meconium-stained liquor.

Whereas, out of 20 patients, who had never received IV amino acids, 12 (60%) patients had section for fetal distress and meconium-stained liquor.

Other indications for LSCS in our study were oligohydramnios, malpresentation, primi breech, cephalopelvic disproportion and previous section.

94.73% patients with AFI <5 cm had IUGR associated with it, showing that almost all the patients with severe oligohydramnios had IUGR, whereas, 52.43% patients with moderate oligohydramnios had IUGR. These findings were very much similar to those of Abida Ahmed (2006),17 where all the patients with severe oligohydramnios had IUGR and 60% patients with moderate oligohydramnios had IUGR.

AFI and Fetal Outcome

AFI Before and After Infusion

Apgar Score at Birth

Table 3 shows the improvement we had during the course of treatment. After 2 weeks of amino acids, patients with AFI <5 cm were down from 20 to just 15 and after 4 weeks, there were only 12 patients with AFI <5 cm. Similarly, there was a reduction in number of patients with AFI 5.1-10 cm from 40 to 18 at the end of 4 weeks. Out of 60 patients, who had oligohydramnios at the time of admission, 30 patients improved and had normal amount of liquor, showing 50% improvement (Fig. 3. and Table 3).

Out of 30 patients with severe oligohydramnios, 14 (46.66%) patients had very low birth weight (VLBW) babies, whereas in patients with AFI >10 cm, no patient had very VLBW baby, 28 (93.33%) patients had babies and birth weight in normal range and just two (6.66%) patients had babies with low birth weight (LBW).

Only 18 out of 60 patients, who received treatment, had Apgar score <5 at the end of 1 minute, whereas in control group, there were 38 out of 60 patients.

Morbidity Neonatal morbidity was 46.66% in untreated group and 8.33% in treated group, showing definite improvement in pregnancy outcome in those who received IV amino acid infusion (Table 5).

Mode of Delivery

DISCUSSION

Twelve out of 60 patients (20%) who had received IV amino acids had lower-segment cesarean section (LSCS); whereas 20 out of 60 patients (33.33%) patients who had never received IV amino acids had cesarean section. Forty-eight out of 60 patients (80%) had

An important cause of IUGR and associated complications is said to be inadequate nutrition So, improving the maternal to mother.18 nutritional status during pregnancy shall improve the pregnancy outcome. Various studies have tried IV

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obstetrics and gynecology infusion of large amounts of glucose and amino acids to the mothers.19 Mothers carrying IUGR babies have been infused with IV fluids and amino acid solutions.20 Pregnant patients with oligohydramnios also have been infused with amino acids for improvement of fetal outcome.21 Improved maternal nutritional status

by IV amino acid infusion appears to improve the AFI. CONCLUSION IUGR may occur even when the mother is not apparently ill or without any identifiable underlying pathology.

One most important reason for this is poor maternal nutrition. A number of studies have examined different forms of treatment for IUGR. Improved maternal nutritional status by IV amino acid infusion appears to improve AFI. This improvement may not have been achieved with diet alone, because of noncompliance and poor socioeconomic status. Hence, IV amino acid and IV fluids improve both maternal nutrition and the amount of liquor amnii.

From the study conducted, there is considerable evidence to suggest the beneficial role of IV infusion of amino acids and glucose and pregnancies complicated with oligohydramnios and IUGR. Regular antenatal and intranatal monitoring should be done to diagnose any fetal compromise at the earliest. Termination of pregnancy according to the balance of risk of intrauterine asphyxia against those of prematurity should be done to obtain the best outcome. Cesarean section is more liberally indicated specially, if there are associated adverse factors as the fetus does not tolerate the reduced oxygen supply and birth trauma encountered during vaginal delivery.

REFERENCES 1. Taweevisit M, Thorner PS. Maternal floor infarction associated with oligohydramnios and cystic renal dysplasia: report of 2 cases. Pediatr Dev Pathol 2010;13(2):116-20.

2. Kilby MD, Platt C, Whittle MJ, Oxley J, Lindop GB. Renin gene expression in fetal kidneys of pregnancies complicated by twin-twin transfusion syndrome. Pediatr Dev Pathol 200;4(2):175-9.

3. Scarcella A, Pecoraro C, Dâ&#x20AC;&#x2122;Agnello MR, Sole AN. Renal tubular dysgenesis without pulmonary hypoplasia. Pediatr Nephrol 1994;8(2):216-7.

4. Vohra N, Rochelson B, Smith-Levitin M. Threedimensional sonographic findings in congenital (harlequin) ichthyosis. J Ultrasound Med 2003;22(7):737-9.

5. Lam H, Leung WC, Lee CP, Lao TT. Amniotic fluid volume at 41 weeks and infant outcome. J Reprod Med 2006;51(6):484-8.

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6. Mulvihill SJ, Stone MM, Debas HT, Fonkalsrud EW. The role of amniotic fluid in fetal nutrition. J Pediatr Surg 1985;20(6):668-72.

7. Magann EF, Kinsella MJ, Chauhan SP, McNamara MF, Gehring BW, Morrison JC. Does an amniotic fluid index of </=5 cm necessitate delivery in highrisk pregnancies? A case-control study. Am J Obstet Gynecol 1999;180(6 Pt 1):1354-9.

8. Ott WJ. Reevaluation of the relationship between amniotic fluid volume and perinatal outcome. Am J Obstet Gynecol 2005;192(6):1803-9; discussion 1809.

9. Kilbride HW, Yeast J, Thibeault DW. Defining limits of survival: lethal pulmonary hypoplasia after midtrimester premature rupture of membranes. Am J Obstet Gynecol 1996;175(3 Pt 1):675-81.

10. Bain AD, Scott JS. Renal agenesis and severe urinary tract dysplasia: a review of 50 cases, with particular reference to the associated anomalies. Br Med J 1960;1(5176):841-6.

11. Atiyeh B, Husmann D, Baum M. Contralateral renal abnormalities in multicystic-dysplastic kidney disease. J Pediatr 1992;121(1):65-7.

12. Christianson C, Huff D, McPherson E. Limb deformations in oligohydramnios sequence: effects of gestational age and duration of oligohydramnios.

Am J Med Genet 1999;86(5):430-3.

13. Fisk NM, Ronderos-Dumit D, Soliani A, Nicolini U, Vaughan J, Rodeck CH. Diagnostic and therapeutic transabdominal amnioinfusion in oligohydramnios.

Obstet Gynecol 1991;78(2):270-8.

14. Beall MH, van den Wijngaard JP, van Gemert MJ, Ross MG. Amniotic fluid water dynamics. Placenta 2007;28(8-9):816-23.

15. Brace RA. Physiology of amniotic fluid volume regulation. Clin Obstet Gynecol 1997;40(2):280-9.

16. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010;375(9730):1969-87.

17. AhmedA.Amino-acid infusion in oligohydramnious.

JK Practitioner 2001;3(3); 140-1.

18. Roa AP. Monograph of IUGR. 1981:18.

19. Mehta AC. Monograph of IUGR. 1981:131.

20. Bonerjee SK, Gupta MD. Monograph of IUGR. 1981:140.

21. Joshi U, Sapre S. Role of intravenous amino acid infusion in cases of oligohydranmios in improving pregnancy outcome. J Obstet Gynecol India 2001:51(4).

obstetrics and gynecology

Efficacy of Dry Cupping Therapy in the Management of Spasmodic Dysmenorrhea: A Comparative Clinical Study Yasmin Kotagasti*, Wasia Naveed†, Nasar Mohammad*, TABASSUM K‡

Abstract Introduction: Tashannuji Usre Tams (spasmodic dysmenorrhea), which means painful menstruation, is one of the major gynecological problems. It is a single commonest cause of the female absenteeism from school, college and work places.

The pain is spasmodic and occurs in lower abdomen, low back or in the thighs. Regiminal therapies often prove to be helpful in pain relief. Local application of dry cupping (Hijamat bila Shurt) below the umbilicus relieves the menstrual pain.

Objective: To compare the efficacy and safety of dry cupping therapy with oral use of Unani Herbal Formulation in the management of Tashannuji Usre Tams. Material and methods: This study was designed to observe the efficacy of dry cupping therapy in the management of Tashannuji Usre Tams. The study consisted of 30 patients each in test and in comparative groups.

Patients between 12-26 years of age with the complaint of pain in lower abdomen during menstruation were included in the study. Treatment was given i.e., local application of dry cupping in test group, whereas in comparative group Hab Mom and Safoof Zanjabeel was given 2 days before onset of menstruation and continued for 3 days after for three consecutive cycles and follow up was done after 1 month. Intensity of pain was assessed by visual analog scale (VAS) score before and after giving treatment for three consecutive menstrual cycles. Outcome Measures: The severity of dysmenorrhea was assessed using a VAS. Results: Results were assessed by using the student ‘t’ test and two groups were compared regarding pain relief by x2 test. The result of the study showed a significant reduction in pain by both test (p < 0.05) and comparative groups (p < 0.01). Conclusion: These finding suggest that local application of dry cupping was effective in relief of pain.

Keywords: Tashnnuji Usre Tams, spasmodic dysmenorrhea, crampy suprapubic pain, cupping therapy, unani formulation

D

ysmenorrhea, which means painful menstruation, occurs more frequently during the teenage and early twenties.1 It is common in unmarried than in married women.2 It is estimated that the prevalence of dysmenorrhea is 20-90% and the prevalence rate begins to decline after the age of 30 years. It can be classified into primary and secondary dysmenorrhea.3 Primary dysmenorrhea usually begins in adolescence after the establishment of ovulatory cycles.4 It is caused by myometrial activity resulting in uterine ischemia. This myometrial activity is modulated and augmented by prostaglandin synthesis. Uterine

*Lecturer Dept. of General Medicine †Principal and Head ‡Reader Dept of Obstetrics and Gynecology National Institute of Unani Medicine, Bangalore Address for correspondence Dr Tabassum K E-mail: drtabassum.nium@gmail.com

contractions can last many minutes and may produce uterine pressures >60 mmHg.5 The onset and severity of primary dysmenorrhea mimics the menstrual flow itself, beginning with in a few hours of the onset of flow and reaching maximal severity during peak flow.6 The incidence of dysmenorrhea is affected by social status, occupation and age, so groups of schoolgirls, college students, factory workers and women members of the armed forces each provide different statistics.7,8 The degree of severity of symptoms and the limitations on daily function also varies.9 In primary dysmenorrhea pain starts 1-2 hours before the onset of menses, continues for first 12-24 hours and then gradually decreases and ceases on stoppage of menses. Pain is colicky and cramp like at the hypogastric region and radiates to the thighs. There may be low backache also. Cycles are regular and ovulatory and intermenstrual period is free from any pain, constitutional symptoms include nausea, vomiting, diarrhea, headache,

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obstetrics and gynecology sometimes fainting due to severe pain may occur.

Patient may be in poor state of health, often thin and anxious; per abdomen no abnormality is detected, on rectal examination uterus and adnexa are felt normal. Women suffering from primary dysmenorrhea are expected to have a normal pelvic examination. However, a normal pelvic examination does not systematically rule out the presence of a pelvic pathology.10 Medical management for primary dysmenorrhea is directed toward reducing the production or action of the causative prostaglandins. Indeed, in this way it is possible to refer to pain prevention, rather than to pain relief.11 The common side effects for the NSAIDs include autoimmune hemolytic anemia, rash, edema, fluid retention, dizziness, headache, blurred vision, nervousness and ulcer formation.

The surgical management could be conservative or radical, but is not commonly advocated except in severe cases. Application of heat over the painful areas especially the back, lower abdomen and thighs often produce relief. Acupuncture and acupressure often prove to be helpful especially in women who have a strong psychological factor and those who have a strong faith in alternative remedies.12 According to the Unani system of medicine, regiminal therapies often prove to be helpful in pain relief. Hijamat bila shurt (dry cupping) below the umbilicus relieves the pain especially in young girls.

Cupping therapy works on the principles of Tanqiyae Mawad (evacuation of morbid humors) and Imalae Mawad (diversion of humors). Tanqiyae Mawad means the resolution and excretion of morbid humors and excess fluids from the body, thereby maintaining the homeostasis in the quality and quantity of four body humors, which are responsible for the maintenance of normal health. Imalae Mawad refers to the diversion of the morbid fluids from the diseased site to the site where from it is easily expelled from the body tissues.13 Based on this holistic approach, cupping therapy was selected for the management of Tashannuji Usre Tams (spasmodic dysmenorrhea) and also compared with Unani Herbal Formulation in its efficacy.

The oral treatment with unani medicine offers the best option because of better acceptability, safety and efficacy, potency and low cost with least side effects. Keeping in view the above consideration in comparative group Hab Mom and Safoof Zanjabeel were selected for the clinical trial to validate their efficacy and safety in patients with Tashannuji Usre Tams.

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Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

Objective To compare the efficacy and safety of Dry cupping therapy locally with Unani Herbal Formulation orally in the management of Tashannuji Usre Tams.

Material and Methods The clinical study entitled â&#x20AC;&#x153;Efficacy of dry cupping therapy in the management of Tashannuji Usre Tams - a comparative studyâ&#x20AC;? was carried out in the Dept. of Amraze Niswan wa Qabalat, Govt. Nizamia Tibbi College and Hospital during the year of 2009-2011.

Initially, 80 unmarried girls between 12-26 years of age with lower abdominal pain during menstrual cycle were included in the study. Out of 80 patients, 60 completed protocol duration and 20 dropped out for unknown reason. Included patients were randomly divided into test and comparative group. A detailed history regarding age, age at menarche, socioeconomic status, educational status, present complaint with onset and duration was noted in case record form (CRF).

Medical, past and family histories were also recorded.

Menstrual history was taken in detail along with intensity, location, duration and radiation of pain and the data was recorded. Other symptoms like backache, nausea, vomiting, diarrhoea were also enquired.

Patients were thoroughly examined for assessment of their general health to rule out any other diseases and routine laboratory investigations along with USG were done before trial. After taking informed consent patients were included in the trial. Before and at the end of the each cycle subjects were provided a visual analog scale (VAS) for pain rating. Before starting the trial Ethical Committee approval was taken.

In test group three medium sized cups were applied below the umbilicus for 15 minutes once-daily, starting 2 days before due date of menses and continued for 3 days during menstrual period for three consecutive cycles, whereas in comparative group Hab Mom 500 mg and Safoof Zanjabeel 5 g was given orally oncedaily starting 2 days before due date of menses and continued for three days during menstruation for three cycles. Follow-up was done at the end of each cycle.

After 1 month of completion of the trial follow-up was done to observe any recurrence or adverse effects. The study outcome measures were recorded at baseline and following completion of trial at the end of third menstrual cycle. Relief in pain was measured by VAS score in both groups. A statistical analysis was done to compare pre- and post-intervention pain relief in both groups and inter group comparison was made.

obstetrics and gynecology

Study design: Randomized comparative clinical study.

Duration of Study: One year Sample size: 30 subjects in each group Method of collection of data: By sign and symptoms and VAS for pain rating.

Selection Criteria Inclusion criteria ÂÂ

All unmarried girls between the age group of 12-26 years with history of pain during menstruation.

ÂÂ

Regular menstrual cycle with duration of 25-35 days.

ÂÂ

Severity of pain more than Grade I.

Exclusion Criteria Patients with history of any systemic illness like diseases of CVS, CNS, RS and any pelvic pathology like endometrial polyp or fibroid uterus or all congenital malformations of uterus.

Criteria for efficacy ÂÂ

Relieved: More than 50% relief of symptoms and pain by VAS rating score.

ÂÂ

Partially relieved: More than 25% relief of symptoms and pain by VAS rating score.

ÂÂ

No response: No relief of symptoms and pain by VAS rating score.

Results and Discussion This study was carried out to observe the efficacy of dry cupping in the management of Tashannuji Usre Tams (spasmodic dysmenorrhea). In this study pain was managed by application of cups below the umbilicus and was compared with oral Unani Herbal Formulation. The effects were assessed by using VAS. Many patients do not use medication in adequate dose, it is essential to inquire about the way every medication was utilized. Campbell and McGrath reported that in a group of high school girls aged 14-21 years using overthe-counter medications for menstrual discomfort, only 31% took them at the recommended daily dosage. Of those using a prescription drug, 13% reported using

less than the prescribed dose. In the same study, participants waited a median of 30 minutes after the onset of dysmenorrhea before taking their medication and only 16% of them took it prophylactically.14,17 Many patients who state that oral contraceptives are ineffective did not try them for a long enough period to obtain the maximum effectiveness in pain relief.15,18 In this it was observed that in test group, with cupping therapy 24 patients (80%) got complete pain relief and 6 (20%) patients got partial pain relief, whereas in comparative group, with Unani Herbal Formulation 22 (73.33%) patients got complete pain relief and 8 (26.66%) patients got partial relief in pain. However, the pain relief got by cupping and oral Unani Herbal Formulation when analyzed statistically, it was seen that both the therapies were almost equally effective in the management of pain due to Tashannuji Usre Tams (p < 0.001) (Table 1 and Fig. 1). Adverse reactions, which were often indistinguishable from the symptoms of Tashannuji Usre Tams, were infrequent during the trial. One patient complained of scar on the application site and three patients (10%) reported mild headache during application of cups. All these reactions were considered possibly due to pressure in the cups.

In this study, the symptoms were recorded for all patients. In test group, before treatment all 30 patients (100%) complaint of hypogastric pain, 22 (73.33%) had referred pain in thighs, 26 (86.67%) had low Table 1. Response of the Drugs in the Test and Comparative Group (n = 60) Groups

Total (%)

x2 value

80

Partial pain relief 6

20

36.73

73.33

8

26.66

31.7

Complete pain relief

Total (%)

Test group

24

Comparative group

22

p <0.001 Response in both group regarding pain relief Complete relief of pain Partial relief of pain 25 No. of patients

A five point VAS was used to estimate the pain.

According to severity, patients were divided into five categories i.e, Grades 0, I, II, III, IV and V. VAS higher than one were included. The result of the study showed a significant reduction in severity of pain in both test group (p < 0.05) and in comparison group (p < 0.01).

80% (24)

20

73.33% (22)

15 10 5 0

20% (6) Test group

26.66% (8)

Comparative group

Pain relief in test and comparative groups

Figure 1. Response of the drugs in the test and comparative group.

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

1169

obstetrics and gynecology backache, 22 (73.33%) had nausea and the other less constant symptoms were vomiting in 10 (33.33%) and headache in 5 (16.67%) patients. After treatment 9 (30%) patients had pain in hypogastrium, 10 (33.33%) patients had pain in thighs, 5 (16.67% ) patients had low backache, 4 (13.33%) patients had nausea, 3 (10%) patients complained of vomiting and none of the patients had headache (Table and Fig. 2).

In comparative group all patients 30 (100%) had complaint of pain in hypogastrium, 26 (86.67%) patients

had pain in thighs, 28 (93.33%) patients had low backache, 19 (63.33%) patients had nausea, 10 (33.33%) patients had vomiting and 10 (33.33%) patients had headache. After treatment 16 (53.33%) patients had pain in hypogastrium, 4 (13.33%) patients had pain in thighs, 4 (13.33%) patients had low backache, 5 (16.67%) patients had nausea, 2 (6.67%) patients had vomiting and only 1 (3.33%) patient had headache (Table 3 and Fig. 3).

Regarding the severity of pain in dysmenorrhea, out of 60 cases before treatment, one patient had pain of Grade II, in Grade “III” there were 12 patients, in

Table 2. Relief of Symptoms of Dysmenorrhea in Test Group Symptoms

Test group Before trial

Pain in hypogastrium

30

Percentage (%) 100

9

Percentage (%) 30

Pain in thighs

22

73.33

10

33.33

Low backache

26

86.67

5

16.67

Nausea

22

73.33

4

13.33

Vomiting

10

33.33

3

10

Headache

5

16.67

-

-

No. of patients

30

Before treatment

30

After treatment

26 22

25

22

20 15

9

10

5

5 0

10

10 4

5

3

0

Abd pain Pain in Backache Nausea Vomitings Headache thighs Symptoms of dysmenorrhea

Figure 2. Relief of symptoms of dysmenorrhea in test group.

After trial

Grade “IV” there were 25 patients and in Grade “V” 22 patients were found respectively. After treatment maximum patients were found in Grade “0” i.e 24, in Grade “I” 17 patients, in Grade “II” 17 patients, in Grade “III” 2 patients were found respectively.

There was no patients in Grade “IV” and “V” (Table 4 and Fig. 4). In one study conducted by Jerry et al, no patients were reported in Grade 0, I and II.14,16 Similarly in present study only one patient was of Grade II and all the reaming patients were in higher than Grade II. In test group, 63.33% (19) patients were with pain severe enough for them to cause absenteeism from college at every menstruation, 30% (9) were absent from classes in alternate menstrual cycle and

Table 3. Shows Relief of Symptoms of Dysmenorrhea in Comparative Group Symptoms

Comparative group Before trial

Percentage (%)

After trial

Percentage (%)

Pain in hypogastrium

30

100

16

53.33

Pain in thighs

26

86.67

4

13.33

Low backache

28

93.33

4

13.33

Nausea

19

63.33

5

16.67

Vomiting

10

33.33

2

6.67

Headache

10

33.33

1

3.33

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Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

obstetrics and gynecology 35 30 No. of patients

Before trial

30

28

26

25 20

After trial 19

16

15

4

5 0

10

10

10

5

4

2

1

Abdominal Pain in Low Nausea Vomitings Headache pain thighs backache Symptoms of dysmenorrhea

Figure 3. Relief of comparative group.

symptoms

of dysmenorrhea in

6.67% (2) were absent from work occasionally and no patients was found in never absenteeism, whereas after treatment 76.67% (23) patients had recovered completely, they were never absent from work or school, 13.33% (4) patients were absent from work even after three months of treatment. Ten percent (3) patients were absent either occasionally or in alternative cycles due to persistence of pain. (Table 5 and Fig. 5). One study showed that 14% subjects frequently missed school, in that black students missed more classes than white students. Another study reported that ability to perform work was affected in up to 52% of female adolescents.15.17

Table 4. Severity of Dysmenorrhea Before and After Treatment in Test and Comparative Group.

Grades of dysmenorrhea

Test group

Comparative group

No. of patients and percentage

No. of patients and percentage

Total no. of pt. and % (n = 60)

BT

%

AT

%

BT

%

AT

%

Grade 0

0

0

10

33.33

0

0

14

46.66

0

24

Grade I

0

0

11

36.66

0

0

6

20

0

17

Grade II

1

3.33

9

30

0

0

8

26.66

1

17

Grade III

7

23.33

0

0

5

16.66

2

6.66

12

2

Grade IV

10

33.33

0

0

15

50

0

0

25

0

Grade V

12

40

0

0

10

33.33

0

0

22

0

Before trial 24

25 No. of patients

After trial 25

20

17

22

17

15

12

10 5 0

0

0

1

2

0

0

Grade 0 Grade I Grade II Grade III Grade IV Grade V Severity of dysmenorrhea

Figure 4. Dysmenorrhea ranked in order of severity.

BT

AT

Regarding the frequency of absenteeism from work as a result of pain in Comparative Group before treatment out of 30 cases 20 (66.67%) participants had symptoms which were severe enough for them to cause absenteeism from college at every menstruation, 8 (26.67%) were absent from classes at alternate menstruation and 2 (6.67%) were absent from work occasionally and no patients was found in never absenteeism. Whereas after treatment 21 (70%) patients had recovered completely, 6 (20%) patients were absent either occasionally or in alternative cycles due to persistence of pain, 3(10%) patients were absent from work even after three months

Table 5. Frequency of Absenteeism Related to Severity of Dysmenorrhea Before and After Treatment in Test Group (n = 30) Absence of work

No. of patients and percentage Before trial

Percentage (%)

After trial

Percentage (%)

Every menstruation

19

63.33

4

13.33

Alternate menstruation

9

30

1

3.33

Occasionally

2

6.67

2

6.67

Never

-

-

23

76.67

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

1171

obstetrics and gynecology Before treatment 25 No. of patients

Summary and Conclusion

After treatment 23

19

20 15

9

10 4

5 0

2

1

Every Alternate menstruation menstruation

2

0

Occasionally Never from absenteeism work or school

Figure 5. Frequency of absenteeism related to severity of dysmenorrhea before and after treatment.

Table 6. Frequency of Absenteeism Related to Severity of Dysmenorrhea Before and After Treatment in Comparative Group (n=30) Absence from work/ school

No. of patients and percentage Before trial Percentage After Percentage (%) trial (%)

Every menstruation

20

66.67

3

10

Alternate menstruation

8

26.67

1

3.33

Occasionally

2

6.67

5

16.67

Never

-

-

21

70

On the basis of above observations, it is concluded that the disease is the commonest gynecological problem.

Its prevalence is high in the age group of 17-21 years i.e. 44 cases. Early onset of menarche seems one of the responsible factors. Regarding the severity of pain in dysmenorrhea after treatment in both groups 41 patients were found in Grade “0” and “I” and no patient was found in Grade IV and V. Regarding the frequency of absenteeism from work or school, in test group 23 patients were never absent from the work or school after treatment, whereas in comparative group 21 patients were never absent from the school. In this study, it was found that 43 patients had positive family history. Regarding the result of the study out of 30 cases in each group, in test group 80% cases got satisfactory pain relief, whereas in comparative group, 73.33% patients got satisfactory pain relief. Results of the study showed a significant reduction in pain both in test (p < 0.05) as well as in comparative groups (p < 0.01). Local application of dry cupping was found more significant as compared to oral use of Unani Herbal Formulation as it was used once daily and reduction of pain was without any systemic medication. In this sense it is more safe and free from any type of drug interaction and adverse effect on the body. It prevents exposure of the body to foreign substance. It can be used alone or an adjuvant with other therapies.

Acknowledgment Before treatment

After treatment

No. of patients

25 20

21

20

References 1. Clinical Obstetrics and Gynecology, M. Yusuf, Dawood,M.D, Vol 33, No.1, March 1990, p.no. 168-169

15 8

10 5 0

3

2. Pratt GJ, Wood DP, Almas BP, A clinical hypothesis primes, New yark, Wiley and Sam, 1998

5 1

2

Every Alternate Occasionally menstruation menstruation absenteeism

0 Never from work or school

Figure 6. Frequency of absenteeism related to severity of dysmenorrhea before and after treatment.

of treatment (Table 6 and Fig. 6). A study conducted in Turkey showed that cause of absenteeism from school in 25.6% girls was dysmenorrhea.16,18

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The authors are thankful to Dr. Zulkifle, Reader, NIUM, Bangalore and Mr. Raheed, R.O(Chemistry), CRIUM, Hyderabad for their support.

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

3. Rapkins, Bonica, JJ. Organization and function of a clinic, In Bonica JJ, ed Advances in neurology, Vol 4, New York,, Ravenpress, 1974 4. Akerland M. Pathophysiology of dysmenorrhea. Acta Obstet Gynecol 1979;87(Suppl):27–32.

5. Management of common problems in Obstetrics and Gyanecology, Daniel,R., Mishell, Jr.T.Murthy, Goodwin, Paul,F.Brenner, 4th edtion, Balckwell Publishing, Chapter56,p.no.236.

6. Chorasia,B.D, p.no. 311-319.

7. Text Book of Gynaecology, D.C.Dutta, 14th edition, New

obstetrics and gynecology central Book Agency (P)Ltd, Calcutta, edited by Hiralal Kumar, Chapter 12, p.168-169 8. Jeff Coat, Principles of Gynaecology, 7th edition, Cahpter3,p.no.617 9. Guzinski, S.M, Advances in the diagnosis and treatment of chronic pelvic pain, Int. J of Psychiatry Med,1982-1983, p.no. 129 10. C. S Raws, Text Book of Gynecology, contraception, Demographic data, 14th edition, p.no. 83 11. Text Book of Gynaecology, Howkins and Boure, V.G.Padubidri, Sirish N. Daftary, Chapter 1, 14th edition, P.no.7-12, 265,410 12. Campbell MA, McGrath PJ. Use of medication by adolescents for the management of menstrual discomfort, Archi Pediatr Adolesc Med 1997;151:905–13p.

13. Ibne Sina. Al Qanoon Fit Tib. Vol. 1st New Delhi: Institute of History of Medicine and Medical Research. 1981; 323p.

14. Campbell MA, McGrath PJ. Use of medication by adolescents for the management of menstrual discomfort.

Archi Pediatr Adolesc Med 1997;151:905–13.

15. Essentials of Gynecology, edited by Sabaratnum, Drukumaran,V.Sivanesa Ratnam, Alokananda Chatterjee, Pratap Kumar, Jaypee Brothers Medical Publisher Private Ltd, New Delhi, 2005, 1st edition, part I, chapter7, p. 55-5 16. R Jerry, MD Klein, F Iris, MD Litt. Grades of Adolescent Dysmenorrhea. Pediatrics 1981; 68: 661–664) .

17. Banikarim C, Chacko MR, Kelder SH. Prevalence and impact of dysmenorrhea on Hispanic school girls. Arch Pediatr Adolesc Med 2000; 154: 1226–1229) 18. Filippi V, Marshal T, Bulut A, et al. Asking question about women`s reproductive health: validity and reliability of survey finding from istanbul. Trop Med Int Health. 1997; 2(1):47-56.

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orthopedics

Ellis-van Creveld Syndrome: A Case Report and Review of Literature Jaishree Ghanekar*, Sujata Sangrampurkar†, Raman HuLinaykar‡, Tariq Ahmer#

Abstract Ellis-van Creveld (EVC) syndrome or chondroecto­dermal dysplasia is a rare autosomal recessive disorder. It is a tetrad of chondrodysplasia, ectodermal dysplasia, polydactyly and congenital heart disease. In several case reports, dysplasia involving other organs has also been identified. The exact prevalence is unknown, but the syndrome seems more common among the Amish community. Many Indian cases have also been reported. This report describes a classical case of EVC syndrome in a 22-year-old woman of Indian origin born of a consanguineous marriage. The patient had chondrodysplasia of tubular bones resulting in disproportionate dwarfism, postaxial polydactyly, severely dystrophic nails, partially absent teeth, pectus excavatum with narrow chest, knock knees and atrioventricular (AV) canal defect.

Keywords: Ellis-van Creveld syndrome, chondroecto­dermal dysplasia, autosomal recessive disorder, polydactyly, congenital heart disease

C

hondroectodermal dysplasia is a rare mesenchymal-ectodermal dysplasia first described in 1940 by Ellis and van Creveld now known as EVC syndrome.1 It is also known as mesvectodermal dysplasia. Majority of cases were characteristically seen in one particular inbred population from the Amish community of Lancaster County, Pennsylvania, US.

EVC syndrome is thought to be due to mutation in EVC and EVC-2 genes located in chromosome 4p16, characterized by short-limbed dwarfism, postaxial polydactyly, dysplastic teeth and nails and cardiac defects.1,8,9 Other features include partial harelip and multiple frenulae in lips; short ribs and narrow chest; genital abnormalities like epispadias, hypospadias, and cryptorchidism; low iliac wings with spur-like projections at acetabula and genu valgum. Although most patients have normal intelligence, occasional

*Professor and Head †Lecturer ‡Senior Resident #Junior Resident Dept. of Medicine MGM Medical College and Hospitals, Navi Mumbai Address for correspondence Dr Jaishree Ghanekar Professor and Head Dept. of Medicine MGM Medical College and Hospitals Sector- 78, Kamothe, Navi Mumbai - 410 209

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Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

central nervous system anomalies or mental retardation have been reported.

Case history A 22-year-old young female presented to us with chest pain, exertional dyspnea and easy fatigability of 2-month duration. She had no significant illness in the past except that she was born with short limbs and six fingers in each hand and had frequent respiratory tract infections. She had short stature that was apparent from year of age. Her school performance was average.

She attained menarche at the age of 17 years and was having normal menstrual cycles once in 2 months since then. Her younger brother also, was having short stature. Her four other siblings and parents had normal height.

On examination, she was found to have a short stature with a height of 126 cm (Fig. 1). Examination of hands revealed six digits in each (Figs. 2 and 3).

The finger and toe nails were small and brittle. Oral cavity examination revealed absent incisors and the rest were natal teeth (Fig. 4). The patient had knock knees with pectus excavatum. The patient had severe pallor.

Examination of cardiorespiratory system revealed narrow chest and on auscultation she was found to have a prominent diastolic thrill at the apex, a loud S1 with a low-pitched Grade 4/6 mid-diastolic rumbling murmur and a pan systolic murmur in the mitral area.

The S2, was widely split, fixed with a loud P2. There

orthopedics

Figure 4. Prenatal teeth and absent incisors.

Figure 1. Short stature.

Figure 5. Craniofacial disproportion.

was a Grade 3/6 ejection systolic murmur over the left second intercostal space. Other systems were normal.

Figure 2. Postaxial polydactyly.

Figure 3. Postaxial polydactyly.

On investigation, the hematological parameters were as follows: Hemoglobin 5.3 g/dL, TLC 5,700/mm3, platelet count 4.4 lacs/mm3, with peripheral smear having dimorphic blood picture and 4% band forms. Liver and kidney function tests were within normal limits.

Thyroid function tests were normal.

Skeletal radiology of upper limb revealed short metacarpals, thick 5th metacarpal, ulnar polydactyly and subluxation of right inferior radioulnar joint (Fig. 3). X-ray skull showed craniofacial disproportion (Fig. 5). Radiological examination of the lower limb revealed depressed and flattened lateral compartment of upper end of tibia on both sides giving rise to genu valgum. Chest X-ray showed cardiomegaly (Fig. 6). Echocardiography showed cardiomegaly and atrioventricular (AV) canal defect (Figs. 7 and 8). USG abdomen was normal with incidental finding of a single, small right ovarian cyst.

Chromosomal analysis done was normal.

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

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orthopedics

Figure 6. Cardiomegaly.

Figure 7 and 8. 2D echo showing cardiomegaly and AV canal defect.

Discussion This syndrome was first described by Richard WB Ellis of Edinburgh and Simon van Creveld of Amsterdam in 1940.1 In general population, the incidence is reported as one per 60,000 live births with an increased incidence of five per 1,000 live births in old Amish population of Pennsylvania.2 The frequency of carriers in this population may be as high as 13%. The sex predilection of this syndrome is the same in males and females. It has an autosomal recessive inheritance and EVC gene has been mapped to chromosome band 4p16 using linkage analysis of nine inter-related Amish pedigrees and in three unrelated families from Mexico, Ecuador and Brazil6 with 25% chance in each pregnancy.

EVC belongs to the short rib-polydactyly group (SRP) and these SRPs, especially type III (Verma-Naumoff syndrome), are discussed in the prenatal differential diagnosis. Postnatally, the essential differential diagnoses include Jeune dystrophy, McKusick-Kaufman syndrome, and Weyers syndrome.

EVC syndrome, a form of short-limbed dwarfism having autosomal recessive inheritance affects the

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Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

skeleton and skin. Lower limbs are primarily affected and deformed due to mesomelic shortening. It may also be associated with knock-knees or genu valgum, which requires surgical correction. The hands are short and wide exhibiting polydactyly with additional finger next to fifth finger or pinkie finger, which is found in 100% of cases as compared to 10-25% of cases having additional finger present on the feet.3 These characteristic limb anomalies were reported in our case. Other associated limb anomalies include short broad middle phalanges, hypoplastic distal phalanges, malformed carpals, and hypoplasia of upper lateral tibia with knock knees. Congenital heart defects5 occur in about 50-60% of cases, the most common anomaly being common atrium found in 40% of patients. Our patient had cardiomegaly with AV canal defect.

Oral manifestations include fusion of middle portion of upper lip to the maxillary gingival margin eliminating the normal mucolateral sulcus. Intraorally, presence of natal and neonatal teeth and congenital absence of teeth particularly in mandibular anterior segment can be seen. Tooth eruption is delayed and those erupted are generally malformed or are affected early by caries.

In this case, prenatal teeth with absent incisors were present but there was absence of fusion of upper lip with alveolar ridge. Other uncommon findings include Dandy-Walker malformation, urinary tract abnormalities, congenital cataracts, cryptorchidism, and hypospadias.

A third of these patients die of cardiac or respiratory distress in infancy. Prenatal diagnosis in regard to intrauterine growth retardation, skeletal malformations and cardiac defects can be depicted on ultrasound images. Diagnosis is also positive using chorionic villi or amniotic fluid using linked-microsatellite markers, if a previously affected sibling has been identified.

A multidisciplinary approach is advocated involving a clinical geneticist, cardiologist, pulmonologist, orthopedician, urologist, physical and occupational therapist, dentist, psychologist, developmental pediatrician and pediatric neurologist for proper management and rehabilitation of such cases.

SUGGESTED READING 1. Ellis RW, van Creveld S. A syndrome characterized by ectodermal dysplasia, polydactyly, chondrodysplasia and congenital morbus cordis: report of three cases. Arch Dis Child 1940;15(82):65-84.

2. Ide SE, Ortiz de Luna RI, Francomano CA, Polymeropoulos MH. Exclusion of the MSX1 homeobox

orthopedics gene as the gene for the Ellis van Creveld syndrome in the Amish. Hum Genet 1996;98(5):572-5.

van Creveld syndrome is located on chromosome 4p16.

Genomics 1996;35(1):1-5.

3. Kurian K, Shanmugam S, Harsh Vardah T, Gupta S. Chondroectodermal dysplasia (Ellis van Creveld syndrome): a report of three cases with review of literature. Indian J Dent Res 2007;18(1):31-4.

9. Popli MB, Popli V. Ellis-van Creveld syndrome. Indian J Radiol Imaging 2002;12(4):549-50.

4. Kushnick T, Paya K, Mamunes P. Chondroectodermal dysplasia: Ellis-van Creveld syndrome. Am J Dis Child 1962;103:77-80.

5. McKusick VA, Egeland JA, Eldridge R, Krusen DE. Dwarfism in the Amish. Ι. The Ellis-van Creveld syndrome. Bull Johns Hopkins Hosp 1964;115:306-36.

6. Mody P, Garg P, Lall KB. Ellis van Creveld syndrome.

Indian J Pediatr 1998;65:1046-8.

7. Phatak SV, Kolwadkar PK, Phatak MS. Ellis van Creveld syndrome: report of two cases. Indian J Radiol Imaging 2003;13(4):393-4.

8. Polymeropoulos MH, Ide SE, Wright M, Goodship J, Weissenbach J, Pyeritz RE, et al. The gene for the Ellis-

10. Ruiz-Perez VL, Tompson SW, Blair HJ,EspinozaValdez C, Lapunzina P, Silva EO, et al. Mutations in two nonhomologous genes in a head-to-head configuration cause Ellis-van Creveld syndrome. Am J Hum Genet 2003;72(3):728-32.

11. Shilpy S, Nikhil M, Samir D. Ellis van Creveld syndrome.

J Indian Soc Pedod Prev Dent 2007;25(5):5-7.

12. Ye X, Song G, Fan M, Shi L, Jabs EW, Huang S, et al. A novel heterozygous deletion in the EVC2 gene causes Weyers acrofacial dysostosis. Hum Genet 2006;119 (1-2):199-205.

13. Winter GB, Geddes M. Oral manifestations of chondroectodermal dysplasia (Ellis-Van Creveld syndrome). Report of a case. Br Dent J 1967;122(3):103-7.

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...Cont’d from page 1154 Hypoxic hepatitis is the most common cause of sharp, transient increase in serum transaminases in hospitalized patients and 15-20% of these patients may have respiratory failure as the underlying cause.

The overall prognosis in these cases is poor because of the comorbidities and poor clinical condition, and management involves the treatment of the underlying cause and supportive care.1 Thus, the treating physician must be aware of the association of the liver injury with the respiratory failure as the treatment of the underlying cause is the only remedy in these cases.

References 1. Kochar R, Fallon MB. Pulmonary diseases and the liver.

Clin Liver Dis 2011;15(1):21-37.

2. Birrer R, Takuda Y, Takara T. Hypoxic hepatopathy: pathophysiology and prognosis.

Intern Med 2007;46(14):1063-70.

3. Henrion J, Schapira M, Luwaert R, Colin L, Delannoy A, Heller FR. Hypoxic hepatitis: clinical and hemodynamic study in 142 consecutive cases. Medicine (Baltimore) 2003;82(6):392-406.

4. Ebert EC. Hypoxic liver injury. Mayo Clin Proc 2006;81(9):1232-6.

5. Refsum HE. Arterial hypoxaemia, serum activities of GOt, GP-t and LDH, and centrilobular liver cell necrosis in pulmonary insufficiency. Clin Sci 1963;25:369-74.

6. Henrion J, Colin L, Schapira M, Heller FR. Hypoxic hepatitis caused by severe hypoxemia from obstructive sleep apnea. J Clin Gastroenterol 1997;24(4):245-9.

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Pediatrics

A Randomized, Double-blind, PlaceboControlled Study of a Synbiotic (Bifilac) in Children with Acute Diarrhea in South India B Vishnu Bhat*, B Adhisivam†

Abstract Objective: To evaluate the safety, efficacy and tolerability of synbiotic on reducing the frequency and the duration of acute diarrhea in children. Methods: A total number of 113 children of both sexes, in the age group of 6 months to 10 years, with acute diarrhea of <3 days duration were randomized into two groups - Group A and Group B. While both the groups received standard treatment (ORS plus zinc), Group A received placebo and Group B received synbiotic (Bifilac dry syrup). Results: After 24 hours of therapy with synbiotic (Bifilac) in children with acute diarrhea, the mean number of stools reduced to 2.84/day, whereas in placebo group the frequency remained at 3.59/day. Similarly, after 48 hours of therapy with synbiotic, the frequency had further reduced to 1.26/day, whereas in the placebo group it was 2.46/day. Conclusion: Children treated with synbiotic (Bifilac dry syrup) along with ORS and zinc for 7 days did better than children with only ORS and zinc in the management of acute diarrhea. Moreover, it was noticed that the children tolerated the synbiotic (Bifilac dry syrup) well and no adverse events were reported.

Keywords: Synbiotic, acute diarrhea, bifilac dry syrup, ORS, zinc

D

iarrheal disease is the second leading cause of death in children under 5 years of age. Diarrhea can last several days, and can lead to loss of water and salts that are necessary for survival. Most children who die from diarrhea actually die from severe dehydration and fluid loss.1-3

Diarrhea is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral and parasitic organisms. Infection is spread through contaminated food or drinking water, or from person-to-person as a result of poor hygiene.1 Diarrhea due to infection is widespread throughout developing countries. In developing countries, children under 5 years of age experience on average three episodes of diarrhea every year.1,3 Malnutrition, illiteracy, poor hygiene, lack of safe drinking water and sanitation are the leading factors for diarrhea in developing world. One out of every five children who die of diarrhea worldwide is an Indian.4 Though diarrhea may be caused by an array of viruses, bacteria and parasites, rotavirus constitutes the predominant cause for diarrhea in children.

*Professor and Head †Associate Professor Dept. of Pediatrics Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry

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Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

Repeated episodes of diarrhea in children can result in long-term deleterious effects on nutritional status, possibly due to intestinal damage. Each episode deprives the child from the basic nutrition necessary for growth. As a result, diarrhea is a major cause of malnutrition, and malnourished children are more likely to fall ill from diarrhea.1 The highly selective use of a judgmental method, in correlation with laboratory tests for the varied etiologic agents, depending on the clinical and epidemiologic settings, is justified in the appropriate management of infectious diarrhea. Oral rehydration and zinc supplementation have been noted to reduce the incidence of severe diarrhea.5-7 Bacteria in the fermented products can compete with microorganisms capable of causing illness. Lactic acid bacteria including Lactobacilli species and Bifidobacteria species constitute the commonest beneficial microbes that reside in the human gastrointestinal tract.8 Investigations into the molecular biology and genomics of probiotics have dealt with the interactions of these agents with the immune system, and have put forward their therapeutic potential in the management of varying diarrheal illnesses like antibiotic-associated diarrhea, travelers’ diarrhea, infectious diarrhea, inflammatory bowel disease and irritable bowel syndrome.9

Pediatrics Probiotics are live microbial feed supplements that beneficially affect the host by improving its microbial balance.9 They are commonly used in the treatment and prevention of acute diarrhea. The rationale for using probiotics in acute infectious diarrhea is based on the assumption that they act against intestinal pathogens.

The possible mechanisms include the synthesis of antimicrobial substances, competing for nutrients required for growth of pathogens, competitive inhibition of adhesion of pathogens, modification of toxins or toxin receptors, and stimulation of nonspecific and specific immune responses to pathogens.9,10 Scientific literature on synbiotics (combination of prebiotic and probiotic) for the management of diarrhea has increased dramatically during the last decade.11,12 Therapy using prebiotics and probiotics as bacteriotherapy has enhanced potential in the coming years to combat various gastrointestinal disorders.

Methods This randomized, double-blind, clinical trial included 113 children with diarrhea. The study was approved by the Institutional Ethics Committee of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) and was conducted as per the International Conference on Harmonization-Good Clinical Practice (ICH-GCP). Children, both male and female, aged 6 months to 10 years, having acute diarrhea, presenting to the Dept. of Pediatrics, were evaluated for eligibility to be included in the study.

Children were enrolled only after obtaining informed consent from their parents/guardians.

The children were included if they fulfilled the following inclusion criteria: ÂÂ

Children aged 6 months to 10 years, having acute diarrhea for a duration of <3 days.

The exclusion criteria included the following: ÂÂ

Severe dehydration

ÂÂ

Presence of respiratory/systemic infection

ÂÂ

Children with known probiotics/synbiotics

ÂÂ

Children with chronic or severe respiratory, cardiovascular, central nervous system, endocrine and other gastrointestinal disorders

ÂÂ

History of probiotic or synbiotic administration over the last 1 month.

hypersensitivity

for

After fulfilling the inclusion criteria, 113 children were randomized to two groups, Group A and Group B.

Group A received oral placebo dry syrup at a dose of 5 mL twice-daily for 7 days along with standard treatment. Group B received Bifilac dry syrup at a dose of 5 mL twice-daily for 7 days along with standard treatment.

Standard treatment comprised of ORS (oral rehydration salts) along with zinc (Elemental zinc: Children <1 year 10 mg o.d. for 7 days; >1 year 20 mg o.d. for 7 days).

Bifilac dry syrup composition: Each 5 mL of reconstituted Bifilac dry syrup contains ÂÂ

Streptococcus faecalis T-110

30 million

ÂÂ

Clostridium butyricum TO-A

2 million

ÂÂ

Bacillus mesentericus TO-A

1 million

ÂÂ

Lactobacillus sporogenes

50 million

Clinical examination including vital signs and physical examination were done for all children and investigations like complete blood count (CBC) and serum electrolytes were done when required. Any concomitant medication or adverse events reported by the subjects where also recorded. At the end of the treatment period (1 week), children were re-evaluated.

Results Ninety-four percent of the children recruited were <5 years of age with the average age being 15.89 and 16.82 months in the placebo and the Bifilac group, respectively. At the screening visit, 78.8% (n = 89) children had watery stools while 21.2% (n = 24) had semisolid stools.

The mean number of stools per day after 24 hours of treatment was 2.84 in Bifilac group and 3.59 in placebo group. The mean number of stools per day after 48 hours of treatment was 1.26 in Bifilac group and 2.46 in placebo group (Table 1).

The mean duration of diarrhea in the Bifilac group was 5.52 days while it was 7.67 days in placebo group (Table 1); the difference was statistically significant in favor of Bifilac group.

Discussion Acute diarrhea is a significant public health concern, especially in children in tropical countries like India.

Sociodemographic characteristics, as noted in this study, constitute the major reasons for the clinical findings in the settings of acute diarrhea. Most significant of these characteristics include lack of proper sanitation facilities like use of good potable water, lack of awareness about ORS and improper defecation habits.

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Pediatrics Table 1. Efficacy Findings on Number of Stools in 24 and 48 Hours and Duration of Diarrhea Efficacy parameters

Groups

N

Mean

No. of stools per day after 24 hrs

Placebo

55

3.59

Standard deviation 2.399

Bifilac

58

2.84

1.167

Placebo

55

2.46

2.143

Bifilac

58

1.26

.983

Placebo

55

7.67

4.769

Bifilac

58

5.52

1.985

No. of stools per day after 48 hrs Duration of diarrhea (in days)

The current study has been done in children, who were suffering from acute diarrhea, which is a lifethreatening disease in this age group. It appears from the study results that early initiation of a probiotic such as Bifilac dry syrup for 7 days has the potential to bring about successful reduction in the episodes of acute diarrhea.

Patients in the placebo arm had a significantly higher number of diarrhea episodes over the 24 and 48 hours periods and also had higher total number of days with the acute illness, as compared to Bifilac arm. Additional support with ORS and oral zinc during the entire duration of treatment is equally important to justify the beneficial findings. It was thus deduced that Bifilac dry syrup along with ORS given for a period of 7 days is an effective treatment option for the management of acute diarrhea in children.

P value <0.01 <0.001 <0.05

Conclusion Children treated with synbiotic (Bifilac dry syrup) along with ORS and zinc for 7 days did better than children with only ORS and zinc in the management of acute diarrhea. Moreover, it was noticed that the children tolerated the synbiotic (Bifilac dry syrup) well and no adverse events were reported.

Acknowledgment The authors thank Jhaver Research Foundation, No. 72, Marshalls Road, IV Floor, Jhaver Center, Egmore, Chennai 600 008 for sponsoring the study.

Conflict of Interest The authors have no conflict of interest with the sponsor.

Key Points ÂÂ

Diarrheal disease is the second leading cause of death in children <5 years of age.

ÂÂ

In developing countries, children under 5 years of age experience on average three episodes of diarrhea every year.

ÂÂ

One out of every five children who die of diarrhea worldwide is an Indian.

ÂÂ

Rotavirus constitutes the predominant cause for diarrhea in children.

ÂÂ

Oral rehydration and zinc supplementation reduce the incidence of severe diarrhea.

ÂÂ

Probiotics are live microbial feed supplements that beneficially affect the host by improving its microbial balance.

ÂÂ

The mean number of stools per day after 24 hours of treatment with Bifilac dry syrup and placebo was 2.84 and 3.59, respectively in this study.

ÂÂ

The mean number of stools per day after 48 hours of treatment was 1.26 in Bifilac group and 2.46 in placebo group.

ÂÂ

The mean duration of diarrhea in the Bifilac group was 5.52 days while it was 7.67 days in placebo group.

ÂÂ

Treatment of acute diarrhea in children with a synbiotic (Bifilac dry syrup) along with ORS and zinc for 7 days is better than treatment with only ORS and zinc.

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Pediatrics References 1. WHO – Fact sheets on Diarrheal Disease. Available from: http://www.who.int/mediacentre/factsheets/fs330/en/ 2. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361(9376):2226-34.

3. Kosek M, Bern C, Guerrant RL. The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ 2003;81(3):197-204.

4. Bajait C, Thawani V. Role of zinc in pediatric diarrhea.

Indian J Pharmacol 2011;43(3):232-5.

5. Trivedi SS, Chudasama RK, Patel N. Effect of zinc supplementation in children with acute diarrhea: randomized double blind controlled trial. Gastroenterol Res 2009;2(3):168-74.

6. WHO/UNICEF Joint Statement - Clinical management of acute diarrhea. WHO/FCH/ CAH/04.7. 2004 May.

7. Bhatnagar S, Alam S, Gupta P. Management of acute diarrhea: from evidence to policy. Indian Pediatr 2010;47(3):215-7.

8. Soccol CR, Vandenberghe LP, Spier MR, Medeiras AB, Yamaguishi CT, De Dea Linder J, et al. The potential of probiotics: a review. Food Technol Biotechnol 2010;48(4):413-34.

9. World Gastroenterology Organisation Practice Guideline : Probiotics and Prebiotics. May 2008.

10. Fuller R. Probiotics in man and animals. J Appl Bacteriol 1989;66(5):365-78.

11. Schrezenmeir J, de Vrese M. Probiotics, prebiotics, and synbiotics - approaching a definition. Am J Clin Nutr 2001;73(2 Suppl):361S-364S. 12. Narayanappa D. Randomized double blinded controlled trial to evaluate the efficacy and safety of Bifilac in patients with acute viral diarrhea. Indian J Pediatr 2008;75(7): 709-13.

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1181

Preventive Medicine

Pharmaceuticals in the Environment: An Unforeseen Disaster Manoj Goyal*, Monika Bansal†, Shailesh Yadav‡, Shinu P#, Jasbir Singh§, Kamlesh Garg¶

Abstract The literature suggests that pharmaceuticals are widespread contaminants, entering the environment from a myriad of scattered points. Patients, in case of drugs for human use, or animals for veterinary drugs, are the main sources of contamination.

Pharmaceuticals in the environment are becoming a subject of global concern, with potential environmental consequences. Further knowledge of the causes, occurrence and effects of drugs as environmental pollutants is necessary for a better understanding of this ecological issue, as well as to improve abatement strategies and to mitigate subtle environmental consequences.

Keywords: Pharmaceuticals, contaminants, environmental pollutants, ecological issue

P

harmaceutical chemicals once manufactured, for human, veterinary and agriculture use or disposal after expiry of a drug, reach the aquatic, terrestrial and atmospheric environment.

They can persist in the environment at one time or the other and ultimately can reach the humans again and impact the human health, animals and environment negatively. The literature suggests that pharmaceuticals are widespread contaminants, entering the environment from a myriad of scattered points. Patients, in case of drugs for human use, or animals for veterinary drugs, are the main sources of contamination. This article is to highlight the very important aspect of the overall issue of pharmaceuticals and drugs as environmental pollutants.

*Associate Professor Dept. of Pharmacology †Assistant Professor Dept. of Physiology ‡Professor Department of Pharmacology #Professor Deptt. of Microbiology Maharishi Markandeshwar Institute of Medical Sciences & Research, Mullana, India §Lecturer Department of Pharmacology Govt. Medical College & Rajindra Hospital, Patiala, India ¶Assistant Professor Dept. of Microbiology 6VMMC & Safdarjung Hospital, New Delhi Address for correspondence Dr Manoj Goyal, Associate Professor Dept. of Pharmacology Maharishi Markandeshwar Institute of Medical Sciences & Research, Mullana, India E-mail: dr_manojgoyal@yahoo.co.in

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Sources of contamination During the development of a new medicine, it’s pharmacological and toxicological profile is established before being accepted for marketing. However, clinical test procedures are not entirely sufficient to completely guarantee that a new pharmaceutical is devoid of unacceptable side effects when used in large cohorts of patients for a long time.

Consumed drugs make a significant contribution towards environmental pollution. These drugs pass out of the system either as metabolites or unchanged through excretion. Drugs are usually water-soluble and therefore find their way into the sewage. Ineffective sewage treatment plants and the use of this water for irrigation purpose is also a very big source of contamination of the soil; environment. In many parts of the world, the sewage plant water is reused as drinking water, not always after cleaning treatment.

To add a step for cleaning sewage water from pharmaceuticals means more energy, more chemicals and higher costs. Alternatively, the sewage is directly let out into various surface waters like rivers, lakes, streams or the open sea.

Industrial waste of the pharmaceutical companies contributes significantly towards the entry of drugs into the environment. Though such industries adopt the sewage treatment process before disposal but because of their obsolete processes the contamination of environment by drugs continues. Few drugs are not entirely removed by treatment process leaving their traces to go into water in environment.1 Leftover medicines constitute another dominating

Preventive Medicine cause of environmental contamination with drugs.

Improper disposal of leftover medication usually contaminates the environment to a great extent. In a study of 445 interviews, 59% of respondents reported disposing medications in the household garbage and 31% flushed them down the toilet or sink. Drug residuals from the formulations like transdermal patches also leave significant amount of drug in environment.2 Transdermal patches containing fentanyl are reported to retain 28-84% of the loaded drug after removal from skin.3 Such pollution of environment by the drugs or their metabolites is creating an alarming situation.4 Examples A study by the US Geological Survey report published in 20025 found detectable quantities of pharmaceuticals in 80% of a sampling of 139 susceptible streams in 30 states. Cocaine has been detected in Po River in Italy.4 Antidepressant drugs, antiepileptics and lipid-regulating agents (statins) were detected in Niagara River.4 Fluoxetine has been found in the river Thames.6 In a study done on effluent samples collected from Patancheru, Hyderabad more than 11 drugs were detected at the highest level ever on the planet.

Ciprofloxacin, was detected at 28-31 mg/L (generally detected at µg/L in the west), followed by losartan (2.4-2.5 mg/L), cetirizine (1.3-1.4 mg/L) and other drugs like metoprolol, citalopram, norfloxacin, ofloxacin were also detected in higher amounts. The discharge load of ciprofloxacin has been estimated to be greater than 45 kg/day. The antibiotics were detected at levels that are toxic even to plants and algae. It was estimated that if the drugs extracted from the effluents were sold as tablets, it would fetch approximately `65 lac per day. This had a negative effect on tadpole growth and yield of paddy.7 One more study found detectable concentrations of 28 pharmaceutical compounds in sewage treatment plant effluents, surface water, and sediment. The therapeutic classes included antibiotics, analgesics and anti-inflammatories, lipid regulators, b-blockers, anti-epileptics and steroid hormones.8 Impact of pharmaceuticals on the environment and on living beings Researchers have found that a class of antidepressants may be found in frogs and can significantly slow their development. The increased presence of estrogen and other synthetic hormones in waste water due to birth control and hormonal therapies has been linked

to increased feminization of exposed fish and other aquatic organisms. The chemicals within these products could either affect the feminization or masculinization of different fishes; therefore, impacting their reproductive rates. In addition to being found only in waterways, the ingredients of some pharmaceuticals can also be found in the soil. Since ,some of these substances take a long time or cannot be degraded biologically, they make their way up the food chain. There are various concerns about the effects of pharmaceuticals found in surface waters and specifically the threats against rainbow trout exposed to treated sewage effluents. In a study by Dr Jerker Fick9 rainbow trout were exposed to undiluted, treated sewage water at three different sits in Sweden. The progestin levonorgestrel was detected in fish blood plasma at concentrations between 8.5 and 12 ng/mL, which exceed the human therapeutic plasma level.

Studies show that the measured effluent level of levonorgestrel in the three areas was shown to reduce the fertility of the rainbow trout.

The ‘Diclofenac Saga’ Diclofenac, a nonsteroidal anti-inflammatory drug (NSAID) is used in human beings and in veterinary for its analgesic and antirheumatic properties. Unforeseen effects on the population of Asian vultures were seen in the form of decrease in the population of vultures in India. It has been linked to the caracasses of animals treated with diclofenac upon which the vultures fed, which led to renal toxicity, increased serum uric acid concentrations, visceral gout and ultimately death of these birds.10-12 Consequently there is an increase in the feral dog population for the fact that they feed on the caracasses of dead animals in the absence of natural scavangers, leading to an increased incidence of human bites and consequently rabies.13 The development of resistant bacteria in sewage plants is stimulated by high concentration of antibiotics (e.g., in plant sewage), large amounts of bacteria (e.g., from human sewage water that is added in plant sewage), and selection of information that can be used to assess the nominated issue have been observed. Chronic effects are known to occur to the nontargeted population. The diffuse exposure might contribute to extinction of species and imbalance of sensible ecosystems, as many pharmaceuticals affect the reproductive systems of frogs, fish, mussels etc. genetic, developmental, immune and hormonal health effects to humans and other species occur in the same way as development of microbes resistant to antibiotics.

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Preventive Medicine Assessment, Laws and regulations Detection and monitoring at global scale of pharmaceuticals in drinking and surface water as in animals and plants is necessary to understand the magnitude of the problem.

Though a number of regulatory bodies like the Food and Drug Administration (FDA) and the European Union have set some cut-off limit for environmental concentration of drugs, no actual testing is conducted after a drug is marketed to see if the environmental concentration was estimated correctly.14 When a new drug is proposed for market, FDA requires the manufacturer to conduct a risk assessment that estimates the concentrations that will be found in the environment. If the risk assessment concludes that the concentration will be less than one part per billion, the drug is assumed to pose acceptable risks. FDA has never turned down a proposed new drug based on estimated environmental concentrations, and no actual testing is conducted after a drug is marketed to see if the environmental concentration was estimated correctly.

Apart from that there is little concern and research to find the adverse effects on environment, of particular drugs given at therapeutic doses. Even in clinical trials, where many limitations like that of limited size, narrow population, narrow indications and short duration are observed, we also found that evaluation of drugs on environment is practiced very minimally.

In the European Union, the new directive for human pharmaceuticals explicitly requires that all member states should establish collection systems for unused or expired medicines. Such systems were already in use in several member countries at the time the new legislation went into action in 2004. Nevertheless, the extent to which such systems have been established and made publicly known, varies between regions.

Furthermore, the directive does not regulate how the collected pharmaceuticals should be handled.

Disposal into the sewage system is still a legally accepted route of elimination. However, incineration at high temperature (1200°C) is a preferred alternative to avoid environmental pollution.

According to John P Sumpter, these recent European Medicines Agency guidelines covering the environmental risk assessment of human pharmaceuticals are a step in the right direction, but a more sophisticated approach, rather than a â&#x20AC;&#x153;one-size-fits-allâ&#x20AC;? solution, is probably needed.14 As a part of a Good Clinical Trial, studies on

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impact of particular drugs on the environment should too be incorporated. Some concerns that need to be taken up under pharmacoenvironmentology are that of drugs and their exact concentration in different components of the environment. Over 80% of respondents stated that they had never received information about proper medication disposal. For pharmaceuticals approved for marketing in European Union before 1995, there are no requirements for documentation of environmental effects. Hence, pharmaceuticals which have been on the market for decades may have serious environmental effects that have not been detected.

In Sweden, the industry together with universities and healthcare sector has developed a method for environmental risk assessment and environmental classification of drugs.15 Environmental risk refers to the risk of toxicity to the aquatic environment. It is based on the ratio between predicted environmental concentration of the substance (PEC) and the highest concentration of the substance that does not have a harmful effect in the environment (PNEC). Environmental hazard expresses the inherent environmentally damaging characteristics of the substance in terms of persistence, bioaccumulation and toxicity. The toxicity tests used are acute toxicity of fish, acute toxicity of Daphnia spp. and growth inhibition test of algae. Most medications on the Swedish market are now classified. This gives the healthcare possibilities to make better choices when prescribing medicines.

Possible Solutions Effective environmental detection methods have to be developed and global detection strategy applied to map the current global situation. There are currently no test methods to assess whether negative effects may occur after long-term environmental diffuse exposure in humans, during the vulnerable periods of development, on aquatic microorganism or how it may affect other animals. Therefore, the precautionary principle must be guiding. Consideration must be taken to bio-accumulation in fish and other aquatic food used by humans, as well as to additive and synergetic effects between pharmaceutical and other chemicals in the contaminated water. The industry must be invited to actively work on reducing pharmaceuticals in the environment. Emission of pharmaceuticals should be included in good manufacturing practices (GMP).

Some Proposals from the Authors Regulatory bodies of the respective countries should make it mandatory for the pharmaceuticals to supply

Preventive Medicine the information of proper disposal of the unused medicines in the package inserts. They will also have to ensure the strict compliance to the regulations by the pharmaceutical companies. The prescribers, dispensers and consumers should be educated and informed about the ill effects of the drugs on the environment with the help of mass campaigns in print and mass media and the initiative should come from the government. Advertisements and awareness campaigns on the lines similar to water conservation and electricity saving can be promoted. Biomedical waste disposal (includes medicines also) in the hospitals and other healthcare set ups is mandated by the Pollution Control Board in India; consumers can be motivated to deposit the expired and left over medicines at the nearest dispensary or the hospital for their proper disposal.

Prescribers should clearly indicate the number of doses to be dispensed in the prescription order by the pharmacist. Moreover prescribers can display the relevant information regarding the safe disposal of the medicines in their cabins or in the waiting area meant for the patients. In addition, they can also motivate the patients to deposit the left over medicines to them conveying the ill effects of their inadvertent disposal.

Dispensers and chemists should not dispense the medicine without a valid prescription and should dispense as many doses as indicated. Apart from this, they should avoid refilling of the prescription orders until unless indicated by the prescriber. They can also act as an important link to educate the consumers about the safe disposal of expired and left over medicines. Apart from this pharmaceutical companies and manufacturers should thrive to devise new ecocompatible ways and materials which ensure high biodegradability of medicines in the environment (‘green pharmaceuticals’).

References

CONCLUSIONS

12. Atula. Six reasons why vultures may be dying in India. (Cited 2014 March 10) Available from http:// indiasendangered.com/six-reasons-why-vultures-maybe-dying-in-india/.

Pharmaceuticals in the environment are a subject of global concern, with potential environmental consequences. We must realize this and should be able to foresee the impending disaster before it’s too late.

Reducing, minimizing or eliminating leftover drugs via an active pharmEcovigilance program represents a very significant opportunity to improve both ecological and human health. To say the least, every individual must take the moral and ethical responsibility for ensuring his well-being along with the mother Earth’s!

1. Kümmerer K. Pharmaceuticals in the Environment – A Brief Summary. In: Kümmerer, Klaus (Ed.). Pharmaceuticals in the Environment 3rd Edition: Springer Berlin Heidelberg, 2008: 3-21 2. Daughton CG “Pharmaceuticals as Environmental Pollutants: the Ramifications for Human Exposure,” In: International Encyclopedia of Public Health, Kris Heggenhougen and Stella Quah (Eds.), Vol. 5, Oxford: Academic Press; 2008, pp 66-102 3. Pharmaceuticals and personal care products. (Cited 2014 March 10) Available from http://www.nethelper.com.au/ article/Pharmaceuticals_and_personal_care_products 4. Medhi B, Sewal RK. Ecopharmacovigilance: an issue urgently to be addressed. Indian journal of pharmacology.

2012 october; Vol. 44 issue5:547-9 5. Kolpin DW, Furlong ET, Meyer MT et al. Pharmaceuticals, Hormones, and Other Organic waste water contaminants in U.S. Streams, 1999-2000: A National Reconnaissance.

Environmental science & technology. 2002; Vol. 36 no.

6:1201-11 6. Velo G. Pharmacovigilance and ecopharmacology. (ppt) Ist international conference of sustainable pharmacy. 2008 April 24-25 Osnabruck Germany.

7. Larsson DG, de Pedro C, Paxeus N. J Hazard Mater. 2007 Sep 30;148(3):751-5.

8. Hernando MD, Mezcua M., Fernandez-Alba AR, Barcelo D. Environmental Risk Assessment of Pharmaceutical Residues in Wastewater Effluents, Surface Waters and Sediments. Talanta 2006; 69: 334–342.

9. Environmental impact of pharmaceuticals and personal care products. (Cited 2014 March 08) Available from http:// www.ireme.com/pharmaceuticals-care-products98764.htm.

10. Green, RE, NewtonI, Shultz S et al. Diclofenac poisoning as a cause of vulture population decline across the Indian subcontinent. J. Appl. Ecol. 2004; 41:793–800 11. Shultz S. Diclofenac poisoning is widespread in declining vulture populations across the Indian subcontinent. Proc.

R. Soc. B 2004; 271: S458–S460.

13. Chatterjee S, Riah H. Rabies-beware of the dog. BMJ 2013; 347: f5912 14. Rahman SZ, Khan RA, Gupta V and Uddin M. Pharmacoenvironmentology – a component of pharmacovigilance. Environmental Health 2007; 6:20 15. Tong, A.Y.; Peake, B., & Braund, R. Disposal practices for unused medications around the world. Environment International 2011; 37: 292–298.

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respiratory diseases

Masked Large Subpulmonic Effusion: An Atypical Presentation MONIKA MAHESHWARI*, TARACHAND SAINI†, RAJESH JAIN‡

Abstract Most commonly used investigative modality for diagnosing pleural effusion is chest skiagram. On a routine posteroanterior/frontal X-ray film, small amount of pleural fluid may be masked and as much as 300-600 mL of pleural fluid collection is mandatory to become radiologically evident. We report here an atypical case of large subpulmonic effusion (3000 mL) masked on frontal X-ray film.

Keywords: Pleural effusion, chest skiagram, frontal X-ray, subpulmonic effusion, lateral decubitus view

M

ost commonly used investigative modality for diagnosing pleural effusion is chest skiagram. Many factors may influence the radiographic findings of pleural effusion, including the nature of the fluid (free vs loculated), the amount of fluid, the patient’s position, the radiographic projection and the presence of underlying lung abnormalities. It is reported in literature that lateral decubitus X-ray film is the most sensitive view to detect even small amount of fluid collected in pleural space.1 On the contrary, on a routine postero-anterior/frontal X-ray film, small amount of pleural fluid may be masked and as much as 300-600 mL of pleural fluid collection is mandatory to become radiologically evident.2 We recently encountered an atypical case of subpulmonic effusion where even large amount of pleural fluid (3000 mL) was masked on a frontal X-ray film and was detected only after taking lateral decubitus view.

aching in character, localized to right hypochondrium and aggravated on coughing. Physical examination revealed pulse 78/min, blood pressure - 112/80 mmHg, temperature 98.6° F with shallow rapid respiration at rate of 28/min. There was mild pallor but no icterus or pedal edema. On systemic examination, abdomen was slightly distended. Tender liver was palpable 2 cm below subcostal margin in midclavicular line.

On respiratory system examination, there was dull note on percussion with diminished breath sounds in right hemithorax involving 8th, 9th and 10th intercostal spaces infrascapularly.

CASE REPORT A 34-year-old male, alcoholic and smoker, presented in outdoor with complaints of abdominal pain and anorexia since 10 days. Abdominal pain was dull-

*Assistant Professor †Senior Resident ‡Professor and Unit Head Dept. of Cardiology Jawaharlal Nehru Medical College, Ajmer, Rajasthan Address for correspondence Dr Monika Maheshwari Navin Niwas, 434/10, Bapu Nagar, Ajmer, Rajasthan - 305 001 E-mail: opm11@rediffmail.com

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Figure 1. Frontal view of chest skiagram showing raised right he midiap hgram w ith late rization of th e diaphragmatic apex.

respiratory diseases the lung from the parietal pleural and chest wall and the parietal pleura-chest wall margin can be identified as a line connecting the inner apices of the curvature of the ribs.

Lateral chest radiograph in upright position may also show blunting of the posterior costophrenic recess at an early stage, since the posterior costophrenic sulcus is inferior to the lateral costophrenic sulcus. Therefore, fluid accumulating in dependent areas may be seen early on the lateral view as blunting of the posterior costophrenic angle before it becomes visible on the frontal view as blunting of lateral costophrenic angle.

Figure 2. Lateral decubitus view of chest skiagram confirming right pleural effusion by demonstrating dependent layering of fluid.

Routine laboratory investigations including blood biochemistry, renal and liver function tests were within normal limits. Chest skiagram (PA) view revealed raised right dome of diaphragm with both costophrenic angles clear (Fig. 1). Since, the patient was alcoholic, keeping possibility of subphrenic abscess, ultrasonography of abdomen was done.

However, to our surprise, it revealed congestive hepatomegaly. Finally, right lateral decubitus chest skiagram was planned, which revealed large subpulmonic pleural effusion with dependent layering of fluid (Fig. 2). Immediately thoracocentesis was done and approximately 3,000 mL of fluid could be drained.

Pleural fluid showed transudate picture with 50 cells, predominant lymphocytes. Patient was started diuretics (furosemide and spironolactone).

He improved gradually and on 7th day, he was completely asymptomatic and was discharged.

DISCUSSION A lateral decubitus view obtained with a horizontal X-ray beam is the most sensitive radiographic projection for detecting an effusion.1 A small amount of fluid (10-25 mL) can be depicted on this projection.

The layering fluid can easily be detected as a dependent, sharply defined, linear opacity separating

On a frontal X-ray film, small amount of pleural fluid may be masked and as much as 300-600 mL of pleural fluid collection is mandatory to become radiologically evident.2 Therefore, minimal to moderate subpulmonic effusions can be missed on frontal view of chest skiagram unless carefully kept in mind. Many signs have been described in literature to diagnose this condition on a plain frontal chest skiagram as follows: ÂÂ

Raised dome of diaphragm, with a difference of two intercostal spaces, higher on right side.

ÂÂ

The pseudodiaphragm (visceral pleural interface) appears flattened specially at medial margins, with blunting of the cardiophrenic angle.

ÂÂ

The pseudodiaphragm shows a more lateral peak ‘lateralization of diaphragmatic apex.’

ÂÂ

In contrast to the normal diaphragmatic opacity, the pulmonary vessels are poorly visualized through the pseudodiaphragmatic contour.3

ÂÂ

Crowding of lung markings at lower zones in cases of moderate-to-large subpulmonic effusions.

ÂÂ

In some cases parietal pleural calcifications may help to delineate and diagnose the effusion.

REFERENCES 1. Lynch KC, Oliveira CR, Matheson JS, Mitchell MA, O’Brien RT. Detection of pneumothorax and pleural effusion with horizontal beam radiography. Vet Radiol Ultrasound 2012;53(1):38-43.

2. Burgener FA, Kormano M, Pudas T. Differential diagnosis in conventional radiology. Stuttgart and New York: Georg Thieme Verlag, 2008. 1-869. 2008.

3. Husen YA, Khalid TR, Khan ZA, Sheikh MY. Nonvisualization of lung markings below hemidiaphragm in subtle subpulmonic effusion: an old sign resuscitated.

J Pak Med Assoc 1997;47:284-86.

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Respiratory diseases

Round Pneumonia: An Unusual Presentation of Lung Infection Sanjivani J Keny*, Uday C Kakodkar†, Durga J Lawande‡

Abstract Round pneumonia is an unusual presentation of lung parenchymal infection. It is uncommon in adults. However, presence of symptoms of respiratory infection and a recent normal chest radiograph may help in diagnosis. Here we present a case of a round pneumonia in an adult female

Keywords: Round pneumonia, pores of Kohn, canals of Lambert

R

ound pneumonia is a lung parenchymal infection, which presents as a round opacity on chest radiograph. The recognition of round pneumonia in adults prompts timely institution of appropriate antimicrobial therapy and unnecessary diagnostic tests and the associated complications of infection can therefore be avoided.1

CASE REPORT A 30-year-old female presented with fever, dry cough, breathlessness of acute onset and left-sided dull-aching chest pain for days. Positive findings on examination were tachycardia, tachypnea, raised temperature and increased vocal resonance in left suprascapular area.

On investigations only positive finding was mild leukocytosis with 2% stabs.

Figure 1. Chest radiograph showing a round homogenous opacity in left lung.

Chest radiograph showed a homogenous round opacity measuring 5 × 5.5 cm in diameter in left upper zone (Fig. 1). Chest ultrasonography ruled out pleural effusion. She was started on injectable antibiotics.

Four days later as fever continued, antibiotics were

*Lecturer †Assistant Professor ‡Associate Professor Dept. of Pulmonary Medicine Goa Medical College, Goa Address for correspondence Dr Sanjivani J Keny Dept. of Pulmonary Medicine Goa Medical College, St. Inez, Caranzalem, Goa 403 002 E-mail: sanjukeny@dataone.in

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Figure 2. CT thorax shows nonhomogenous opacity with areas of breakdown suggestive of resolving consolidation in left upper lobe.

Respiratory diseases changed. With change in antibiotics fever subsided.

CECT thorax done at this stage showed signs of resolving pneumonia in left upper lobe (Fig. 2) thus confirming diagnosis of round pneumonia.

DISCUSSION Round pneumonia is an unusual presentation of lung parenchymal infection. It is uncommon in adults.1 Patients with round pneumonia generally present with acute to sub-acute symptoms of community acquired pneumonia.2 Radiological features of round pneumonia in adults vary. The overall appearance can vary from a small dense mass to a large, ill-defined rounded opacity.

Round pneumonia is thought by some to be an early manifestation of disease resulting from an infectious focus that has spread centrifugally either by travelling through pores of Kohn and canals of Lambert or by destroying walls of surrounding acini.

Alternate theory is that it is common in children because of under developed pores of Kohn and canals of Lambert, thus limiting spread of organisms and resulting in focal round mass like lesion. This theory would also explain why it is uncommon in adults who have fully developed canals of Lambert. It may also represent incomplete resolution of lobar pneumonia.3

Acknowledgment We wish to thank Dr VN Jindal, Dean, Goa Medical College, for granting us permission to publish this pictorial CME.

REFERENCES 1. Fox LA, Hunsaker AR. Localized organizing (round) pneumonia. [cited 1997 Feb 13].Available at: brighamrad. harvard.edu/cases/bwh/hcache/210/full.html.

2. Durning SJ, Sweet JM, Chambers SL. Pulmonary mass in tachypneic, febrile adult. Chest 2003;124:372-5.

3. Garland J, Liebeman G. Round Pneumonia in Adults.

Available at http://radiology.bidmc.harvard.edu/ LearningLab/respiratory/Garlandpdf.

■■■■

Test to Detect ESBL Bacteria Shows Promise A biochemical test that can rapidly identify extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in a blood culture is 100% accurate on all fronts, new research shows. It could soon be ready for clinical use.

“The reasons we developed this test were, first, to identify ESBL-producing bacteria — mostly Klebsiella pneumoniae — that could be the source of an outbreak,” said Patrice Nordmann, MD, PhD, professor and chair of microbiology at University of Fribourg in Switzerland. “Second, we developed the test to treat patients with carbapenem when they need it.”

“Of all the research we’ve done over the past 25 years, this is the most important,” he told Medscape Medical News.

Dr. Nordmann presented the results here at 16th International Congress on Infectious Diseases.

The 13-valent pneumococcal conjugate vaccine (PCV-13) may offer moderate protection against the most common forms of pneumococcal community-acquired pneumonia in healthy elderly people, reports the large prospective “CommunityAcquired Pneumonia Immunization Trial in Adults (CAPiTA)” study, presented at the 16th International Congress on Infectious Diseases.

The vaccine was 45.5% effective at preventing a first episode of vaccine-type pneumococcal pneumonia, compared with placebo. Additionally, it was 45.0% effective at preventing a first episode of nonbacteremic/noninvasive vaccine-type pneumococcal pneumonia and 75.0% effective at preventing vaccine-type invasive pneumococcal pneumonia.

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Around the Globe

News and Views ÂÂ

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The Centers for Disease Control and Prevention (CDC) has reported in an analysis published in the May 2 issue of the Morbidity and Mortality Weekly Report that up to 39% of annual premature deaths from the 5 leading causes of death, including heart disease, cancer, chronic lower respiratory diseases, stroke and unintentional injuries, could be prevented.

The European Commission has approved marketing authorization for delamanid for the treatment of adults with pulmonary multidrug– resistant tuberculosis (TB). The drug is approved for use as part of a combination regimen when an effective treatment regimen is unavailable.

Recommended dosing is 100 mg twice-daily for 24 weeks.

A study presented recently at the American Academy of Neurology (AAN) 66th Annual Meeting has revealed an association between vitamin C depletion and increased risk for intracerebral hemorrhage (ICH). Low plasma vitamin C is a risk factor for spontaneous ICH, reported the researchers.

A novel study conducted in Brazil has noted a 50% improvement in balance and considerably lesser falls among elderly subjects who participated in a half hour of ballroom dancing three days a week for three months. The practice gave the individuals a better sense of balance. The study is published online in the Archives of Gerontology and Geriatrics.

A small observational study has shown that hypoglycemia increases the risk of serious arrhythmias in high cardiovascular – risk patients with type 2 diabetes, possibly because the condition modifies cardiac autonomic tone and promotes abnormal repolarizations. The study appears in the May 2014 issue of Diabetes.

A study of three London hospitals has found that despite European guideline recommendations that cases of patients with severe coronary artery disease (CAD) should be discussed by a ‘heart team’, the step is not being followed and is often ignored. Elective PCI or percutaneous coronary intervention is still performed in a large number of patients with severe CAD without discussion by the heart team or with a cardiac surgeon.

Babies whose skulls are deformed due to lying in the same position for prolonged periods appear

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to have no apparent benefit from the use of corrective helmets, reports a new randomized study. Researchers noted that about 26% of babies using helmets fully recovered their skull shape compared with about 23% who had not used them. ÂÂ

Results from the Pediatric Eye Disease Investigator Group (PEDIG) trial have stated that patching or atropine eye drops both have the potential to improve visual acuity in children with amblyopia.

The findings are published online May 1 in JAMA Ophthalmology.

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Three analyses from the phase 3 ADVANCE trial have established the efficacy and safety of pegylated interferon β-1a in the treatment of relapsingremitting multiple sclerosis (MS). The efficacy was better with dosing every 2 weeks (Q2W) compared with once every 4 weeks (Q4W) and the safety and immunogenicity were good after 2 years.

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Chronic stress in women whose diet contains high-fat and high-sugar foods could increase the metabolic health risks, including abdominal fat and insulin resistance, to a greater extent as compared to low–stressed women who eat the same foods, reports a recent study published in the journal Psychoneuroendocrinology.

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The routine induction of pregnant obese women at 39 weeks of gestation has the potential to minimize stillbirths, cesarean deliveries and delivery–related healthcare costs, reported a study presented at the American Congress of Obstetricians and Gynecologists (ACOG) 2014 Annual Clinical Meeting.

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Treatment of subclinical hypothyroidism, a condition associated with increased cardiovascular risk, with levothyroxine does not reduce mortality, reported a new study presented at the European Congress of Endocrinology (ECE) 2014.

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A 2-week-long restrictive diet has been noted to shrink obese patients’ livers, thereby making gall bladder laparoscopic surgery quicker and easier, reported a study presented at the annual Digestive Disease Week. There was a 20% reduction in surgical time.

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A new study has shown that an HDL mimetic used in the treatment of patients with ACS could not reduce the burden of atherosclerotic disease. The findings are published online in the European Heart Journal.

Around the Globe ÂÂ

The INTERSTROKE study, presented at the World Congress of Cardiology 2014 Scientific Sessions, has identified the following risk factors that explain approximately 90% of the population–attributable risk of stroke: hypertension, lipid levels, physical inactivity, smoking, diet, larger waist–to–hip ratios, history of diabetes, alcohol intake, psychosocial stress or depression, and cardiac causes.

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The risk for congenital heart malformations in fetuses of women exposed to lithium during pregnancy is higher than that has already been reported in prospective studies, suggests a new study. The study was published online in the American Journal of Psychiatry.

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An analysis of more than 2 million families has found genetics to contribute 50% of the risk for an autism spectrum disorder (ASD), with environmental influences contributing to the remaining 50%. The findings are published in the May 7 issue of JAMA.

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A study presented at the Digestive Disease Week (DDW) 2014 has revealed that bariatric surgery may improve nonalcoholic fatty liver disease (NAFLD) besides leading to weight loss and better metabolic profiles. The surgery has been noted to reduce fat deposits in the liver, resolve liver inflammation and reverse early–stage liver fibrosis and scarring.

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Repetitive transcranial magnetic stimulation (rTMS) could be a promising treatment for generalized anxiety disorder (GAD), reports a study presented at the American Psychiatric Association’s 2014 Annual Meeting. Study authors noted that the efficacy of rTMS was superior to sham and about 70% of patients who completed treatment had a significant clinical response to rTMS vs. 25% in the sham condition.

Salivary gland ultrasonography (SGUS) improves American College of Rheumatology (ACR) classification of patients with Sjögren’s syndrome (SS) and should be included in evaluations, reports a new study conducted in France.

Healthy People 2020, a health initiative by the U.S. Department of Health & Human Services, is failing to achieve the targets, reported a study presented at the National Kidney Foundation’s 2014 Spring Clinical Meeting. Less than 8% of patients with kidney disease are aware of their condition.

Additionally, percentage of those with CKD and hypercholesterolemia has risen, while the goal is to move in the other direction.

Patients with leukemic cutaneous T–cell lymphoma (CTCL) with diffuse erythema are more likely to experience complete response to alemtuzumab

therapy, reports a new study published online in JAMA Dermatology. The study reported that none of the patients with discrete patches, plaques, or tumors with or without background diffuse erythema experienced full remission after alemtuzumab. ÂÂ

According to two studies presented at the American Association for Thoracic Surgery 2014 Annual Meeting, using the right internal mammary artery (RIMA) rather than the radial artery (RA) as the second conduit improves survival when performing CABG for multivessel disease; and that total arterial revascularization provides better long–term survival than a single arterial graft.

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According to the 25×25 World Health Assembly (WHA) roadmap, adopting a comprehensive plan aimed at reducing tobacco use, alcohol use, salt intake, limiting physical inactivity, and reducing elevated blood pressure and glucose levels, can remarkably reduce the risk of premature mortality from noncommunicable diseases (NCDs), including CVD. The article is published May 3 in the Lancet.

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A new study presented at the American Psychiatric Association’s 2014 Annual Meeting has suggested that high school students who frequent the tanning salon (40 times or more in 12 months) may have 2–fold increased odds of depressive symptoms and suicidal thoughts and a greater than 4–fold likelihood of suicide attempt.

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The Committee on the Fetus and Newborn (COFN) has changed their guidelines on the basis of new findings, and has recommended that antibiotic therapy for neonates with abnormal laboratory findings and those born to mothers with chorioamnionitis (CAM) should not be extended for longer than 72 hours. The previous guidelines led to prolonged antibiotic therapy, longer length of stay, and more interventions.

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Despite past reports suggesting a link between marijuana use and increased stroke risk, a recent study presented at the American Academy of Neurology (AAN) 66th Annual Meeting has shown a statistically significant inverse relationship between marijuana use more than a year ago and ischemic stroke risk in young people.

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In another new revelation from the 66th AAN Annual Meeting, researchers have found both pro– and anti–inflammatory epigenetic factors in the intestinal microbiota of patients with multiple sclerosis (MS) that may be implicated in the disease pathogenesis.

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Around the Globe ÂÂ

The US FDA’s Nonprescription Drugs Advisory Committee has voted against recommending montelukast to be approved as an over–the– counter (OTC) drug for the treatment of allergic rhinitis (AR).

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A study presented at the American Pain Society (APS) 33rd Annual Scientific Meeting has stated that a novel extended–release formulation of hydrocodone having antiabuse properties provides safe and long–lasting pain relief to patients with chronic pain, including those who have used opioids before and those who are opioid–naive.

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A study presented at the American Congress of Obstetricians and Gynecologists (ACOG) 2014 Annual Clinical Meeting has pointed that women who require reoperation for recurrent prolapse could possibly benefit from vaginal mesh repair.

Mesh erosion was more common in women who had not previously undergone vaginal prolapse surgery as compared to those who had (10.6% vs 2.8%).

In a new study presented at the American Association for Thoracic Surgery 2014 Annual Meeting, performing mitral valve–in–valve or valve–in–ring implantations in extremely high– risk patients with degenerated prosthetic mitral valves leads to one-year clinical outcomes that are comparable to those obtained with transcathetervalve implantations in native aortic–valve disease.

However, valve–in–valve procedures can result in high postprocedural gradients, device malposition, and coronary obstruction.

A study published online in the Journal of the American College of Cardiology has revealed that thromboembolic risk increases similarly in either preexisting or incident atrial fibrillation (AF) in patients with ischemic heart failure, and that treatment with a vitamin–K antagonist (VKA) alone, compared with an antiplatelet agent alone, can cut that thromboembolic risk, though with increased associated bleeding risk.

A urine dipstick test alone could be the best initial screen to test for urinary tract infections (UTIs) in febrile infants, reports a study published online in Pediatrics. While the test is known to work well for children aged > 2 years, this new study has shown its utility in infants aged 1 to 90 days too.

muscular dystrophy (DMD) that continued with more than 2 years of treatment. Boys aged 7 to 13 years who were able to walk at least 200 meters in 6 minutes had the mean 6–minute walk distance (6MWD) completely preserved for 120 weeks with eteplirsen therapy. ÂÂ

Long–term results from the Study of Heart and Renal Protection (SHARP) have shown that for patients with chronic kidney disease (CKD), lowering LDL cholesterol with a combination of simvastatin and ezetimibe may not curb the progression of kidney disease to end–stage renal disease (ESRD). The findings are published May 1 in the Journal of the American Society of Nephrology.

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The American Heart Association/American Stroke Association (AHA/ASA) has issued new guidelines on the secondary prevention of stroke. While the guidelines stress upon the importance of blood pressure, cholesterol, weight, and exercise, they also include some important new recommendations like screening stroke and transient ischemic attack (TIA) survivors for diabetes and obesity, monitoring for atrial fibrillation (AF) among patients with a stroke of unknown cause, use of new oral anticoagulants in specific situations, etc.

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An international team of researchers has developed a blood test that will assist doctors in quickly identifying most active tuberculosis infections in children. Based on a genome–wide analysis of RNA transcripts in the children’s blood, researchers found a 51–transcript signature that distinguished TB from other diseases, and 42 transcripts that could differentiate it from latent infection.

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A study published online April 3 in the Journal of the Pediatric Infectious Diseases Society has reported that treatment of cutaneous leishmaniasis with systemic meglumine antimoniate is well tolerated in children and the rate of adverse events is similar to that seen in adults.

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The US Food and Drug Administration (FDA) has recently approved the anticholinergic umeclidinium 62.5 μg delivered through an inhaler as a once– daily maintenance treatment for patients with chronic obstructive pulmonary disease, including chronic bronchitis and emphysema.

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The World Health Organization’s extensively used Fracture Risk Assessment Tool (FRAX) significantly underestimates the risk for fragility fractures, reports a study published online April 29 in the Journal of Clinical Endocrinology and Metabolism.

A study presented at the American Academy of Neurology’s 66th Annual Meeting has reported favorable results with eteplirsen for Duchenne ■■■■

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mediLAW

Is there a Violation of Guidelines for Preparation of Medicolegal Report?

The important guidelines as given in the “Hospital Manual” published in 2002 by the Directorate General of Health Services, MOHFW, GOI, in Appendix 5 titled “The guidelines for medico-legal work—Pages 192-193” are given below along with their serial no. given therein: ÂÂ All the cases coming to the casualty shall be entered

in the concerned casualty register.

ÂÂ Cases of suspected accident, poisoning, burns,

comatosed or brought dead persons should invariably be made a medico-legal case. In a case where the condition is not serious and the CMO does not suspect any foul play the fact should be recorded in the casualty register with reasons under (patient’s) signature. However, detailed findings and treatment administered should always be recorded in the casualty register.

ÂÂ All MLC cases should be entertained after they are

either registered with the police post of the hospital or after the police is informed.

ÂÂ All medico-legal papers must be stamped MLC.

ÂÂ In case of death of an admitted MLC case, police is

to be informed and the body handed over to them.

Whether the MLC examination and report preparation be done without the person’s consent is a matter to be examined as per the following legal and general principles: ÂÂ When a physician approaches a person in the

course of his medical duty, the approach basically remains the same whether he is a medico-legal or non-medico-legal case. The medical principles or the code of professional ethics does not vary depending upon the legal status. The only difference is that documentation has to be as per strict standards in a legal case.

ÂÂ In accordance with the above, a doctor cannot

forcibly examine or treat a patient whether he be a medicolegal case or not. The only exception is when a physician does so under orders of the court or under provisions of law.

ÂÂ If a person refuses to get medically examined

(three in cases of suspected poisoning). Original copy will be handed over to the concerned police officer and duplicate will be kept in safe custody.

in connection with a crime, this fact should be noted in the MLC and that part of the MLC should be completed which is permissible without consent. Let us not forget that a good part of such examination can be done by inspection alone which should be possible without applying force. It is for the court to draw any adverse inference as per law in the event of such refusal.

ÂÂ CMO who examines the case first is responsible

ÂÂ In case of a person who has been arrested by the

ÂÂ All the columns in the MLC form must be properly

Examination of accused by medical practitioner at the request of police officer.

ÂÂ In emergency, first aid treatment should promptly

be given before documentation or other medicolegal formalities.

ÂÂ Two copies of the MLC report shall be prepared

for completion and handing over the MLC report within 48 hours to the police. Preliminary or interim report should not be given to anyone. filled in and mention must be made about proper identification marks, consent, brief history, general physical examination, specific comments like nature and age of injuries, type of weapon used or nature of poisoning suspected, investigations advised and material preserved and handed over to the police.

ÂÂ Before discharge of MLC cases the police must be

informed about the same.

police, sections 53 and 54 the Criminal Procedure Code, apply:

ÂÂ When a person is arrested on a charge of committing

an offence of such a nature and alleged to have been committed under such circumstances that there are reasonable grounds for believing that an examination of his person will afford evidence its to the commission of an offence, it shall be lawful for a registered medical practitioner, acting, at the request of a police officer not below the rank of sub-inspector, and for- any person acting in good

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

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mediLAW faith in his aid and -under his direction, to make such all examination of the person arrested as is reasonable necessary in order to ascertain the facts which may afford such evidence, and to use such force as is reasonably necessary for that purpose. ÂÂ Whenever the pet-son of a female is to be examined

under this section, the examination shall be made only by, or under the supervision of, a female registered medical practitioner.

Explanation: In this section and in section 54, “registered medical practitioner” means a medical practitioner who possesses any recognized medical qualification as defined in clause (l) of section 2 of the Indian Medical Council Act, 1956 (102 of 1956), and whose name has been entered in a State Medical Register.

Examination of arrested person by medical practitioner at the request of the arrested person.

When a person who is arrested, whether on a charge or otherwise, alleges, at the time when he is produced before a Magistrate or at any time during, the period of his detention in custody that the examination of his body will afford evidence which will disprove the commission by him of any offence or which Magistrate shall, if requested by the arrested person so to do direct the examination of’ the body of such person by a registered medical practitioner unless the Magistrate considers that the request is made for the purpose of vexation or delay or for defeating the ends of Justice.

As mentioned above, the MLC report should be completed and given to the police within 48 hours.

Preliminary or interim report should not be given to anyone.

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Source: Dr M C Gupta, Practicing Advocate (Personal Communication)

eMedi Quiz

Quiz Time 1.

Do women have more headaches than men?

4.

A. No, they get equal numbers.

Lipodystrophy is most characteristically seen with

B.

Yes, but not that many more.

A. Zidovudine

C.

Yes, and the headaches are more severe.

B.

Nevirapine

C.

Indinavir

D. Yes, but men tend to get more painful kinds that last longer.

E.

None of the above.

2.

Prevalence of skin infections in HIV infection is approximately:

A. 50–60% B. 70–80% C. 90–100%

D. Tenovir 5.

Which of the following is present intracellularly in muscle cells:

A. Insulin.

B.

Corticosteroid.

C.

Epinephrine.

D. Glucagon.

D.

Extremely rare

3.

An early systolic murmur may be caused by all of the following except:

6. Which of the following is not a post transcriptional modification of RNA?

A.

Small ventricular septal defect.

A. Splicing.

B.

Papillary muscle dysfunction.

B.

5’ Capping.

C.

Tricuspid regurgitation.

C.

3’ polyadenylation.

D.

Aortic stenosis.

D. Glycosylation.

Answers to eMedi Quiz Published in April 2014 Issue Q1. (c) Leaves extension at elbow joint intact.

Q2. (a) Transitional Q3. (d) Vertebral venous plexus Q4. (b) Propionyl CoA Q5. (c) Leaves extension at elbow joint intact.

Q6. (a) Transitional Send your answers to the Editor-Indian Journal of Clinical Practice.

E-mail: editorial@ijcp.com The correct answers will be published in the next issue of IJCP.

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

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lighter reading

A few months back while sitting in a boat fishing with a couple of friends, I noticed a field mouse on the river bank. He emerged out of his hole, darted in a couple of directions, and then scurried back.

I thought of the existence of this little creature.

His life is spent running around, frightened and frantic, following his nose. He darts here, scurries there, turns in circles, but never really sees much beyond his nose. He is trying to sniff his way to successful living, which defined, by a mouse’s existence, is finding some daily morsel to consume, to sustain him, so that he can carry on for the rest of his life, frightened and frantic. Sound familiar.

A few minutes later I glanced up and noticed soaring high above was an Osprey. Rather than a picture of a frightened and frantic existence, I saw a wide winged creature using the air currents to maneuver majestically in the unlimited heights.

Rather than sniffing out a meagre existence, this keen eyed hunter with a panoramic view of the river and lake beneath was simply waiting for the appropriate time to swoop and capture his prey. The amazing creature, rather than return to some tiny hole in the river bank, glides toward a nest fashioned at the top of the tallest of trees The strength in his wings, the power in his talons, the amazing capacity of his vision, the effortless capacity to soar, It is the osprey, not the field mouse that models our human potential.

I don’t know about you, but it is easy for me to decide which creature I want to exemplify my life. I want to soar. I want to explore. I want to see the big picture. I want to conquer. I want to climb higher, go farther, dive deeper, and experience more. I want my soul enlarged, my mind expanded, my heart enlivened and my spirit energized. I want the scurrying to stop. I want the frantic darting about following my nose, to end.

I want new strength, fresh thinking, clear vision and resolved courage. I want to be more and more like the osprey and less like the field mouse, for to live like this field mouse is to insult my creator and deny my true destiny.

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Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

Visiting a barber A man enters a barber shop for a shave. While the barber is foaming him up, he mentions the problems he has getting a close shave around the cheeks.

“I have just the thing,” says the barber taking a small wooden ball from a nearby drawer.

“Just place this between your cheek and gum.”

The client places the ball in his mouth and the barber proceeds with the closest shave the man has ever experienced. After a few strokes the client asks in garbled speech.

“And what if I swallow it?”

“No problem,” says the barber. “Just bring it back tomorrow like everyone else does.”

“Happy is the man who can do only one thing; in doing it, he fulfills his destiny.” −Joseph Joubert

Dr. Good & Dr. Bad Situation : A heart patient died after drinking 200 mL of drink in one go.

It cannot be a cause of death

Binge drinking can cause sudden death

© IJCP GROUP

Life offers two choices: We can live scurrying for survival or soaring to the unlimited heights. The choices are modeled by these two creatures.

LAUGH A WHILE

A Field Mouse or an Osprey

Quote

Inspirational Story

Lighter Side of Medicine

Lesson : Binge drinking means 5 or more drinks in one session. One US

drink is 40 mL; therefore, 200 mL of whiskey in one session can precipitate sudden cardiac death.

KK Aggarwal

Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767).

Indian Journal of Clinical Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.

The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript.

Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper.

Covering letter –

– –

The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper.

Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors.

Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript – Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures).

–

The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

–

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

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

Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed,

name of the corresponding authors, acknowledgment of financial support and abbreviations used.

– The title should be of no more than 80 characters and should represent the major theme of the manuscript.

A subtitle can be added if necessary.

– A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

– The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page.

– A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary – The summary of not more than 200 words. It must convey the essential features of the paper.

– It should not contain abbreviations, footnotes or references.

Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives.

Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others.

– Ethical guidelines followed by the investigations should be described.

Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected.

– Method of selecting the sample (cases, subjects, etc. from the statistical universe).

– Method of allocating the subjects into different groups.

– Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

–

Confidence intervals for the measurements should be provided wherever appropriate.

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

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

1197

Discussion –

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

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses).

At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution.

Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes.

Q. J. Expt. Physiol. 1955;40:89-111.

Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat.

– All photomicrographs should indicate the magnification of the print.

– Special features should be indicated by arrows or letters which contrast with the background.

– The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen.

– Color illustrations will be accepted if they make a contribution to the understanding of the article.

–

Do not use clips/staples on photographs and artwork.

–

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

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

Books

5. Special requests _____________________________

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

6. Suggestions for reviewers (name and postal address)

Articles in Books

2.____________ 2.________________

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

3.____________ 3.________________

4.____________ 4.________________

Tables –

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

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

–

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

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

Indian 1.____________Foreign 1.________________

7. All authors’ signatures________________________ 8.

Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

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

Dr KK Aggarwal

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

Indian Journal of Clinical Practice, Vol. 24, No. 12, May 2014

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R.N.I. No. 50798/90 Date of Publication 13th of Same Month Date of Posting 13-14 Same Month

POSTAL REGISTRATION NO. DL (S)-01/3200/2012-2014 Posted in N.D. PSO New Delhi