Ijcp may 2015 by IJCP

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Volume 25, Number 12

May 2015, Pages 1101â&#x20AC;&#x201C;1200

Peer Reviewed Journal

American Family Physician

Cardiology

Community Medicine

Critical Care

Dermatology

Devices and Gadgets

Diabetology

ENT

Internal Medicine

Obstetrics and Gynecology

Pediatrics

Respiratory Infections

Surgery

Experts' View

an i c i ys ians

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

Dr KK Aggarwal Group Editor-in-Chief

Dr Veena Aggarwal MD, Group Executive Editor

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

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

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

Volume 25, Number 12, May 2015 FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

1106 Another Case of One Crore Compensation

KK Aggarwal

AMERICAN FAMILY PHYSICIAN

1111 Lung Cancer: Diagnosis, Treatment Principles, and Screening

Kelly M. Latimer, Timothy F. Mott

1118 Practice Guidelines 1119 Photo Quiz CARDIOLOGY

1122 Case of a Young Hypertensive with Recurrent

Cerebrovascular Disease due to a Rare Etiology

SM Rajendran, S Palaniandavar, Jamima Bhaskar, J Senthilnathan, Arun R, Jose Mathew

COMMUNITY MEDICINE

1125 Trends of Leptospirosis Cases and Mortality in Western India

Kedar G Mehta, Shikha Bansal, Ajay Sanghvi, Sudarshan Gupta

CRITICAL CARE

1129 Leukemoid Reaction Following Air Embolism in Kidney Transplant Recipient

Vishal V Ramteke, MM Bahadur, CL Chaudhary

DERMATOLOGY

1131 Impetigo Herpetiformis: A Dermatologist’s Headache and an Obstetrician’s Nightmare

Shaurya Rohatgi, Saurabh Jindal, HR Jerajani

DEVICES AND GADGETS

1135 Electronic Gadgets in Diabetes Management

Shriram V Kulkarni, Aditya Shriram Kulkarni

DIABETOLOGY

1140 Prevalence of Diabetic Retinopathy in Newly Diagnosed Type 2 Diabetes Mellitus Patients in South India

Dadapeer Karimsab, Prem Kumar D, Pratap VGM, Dileep HR

1143 A Study of Ankle Brachial Index in Type 2 Diabetes Mellitus

Prem Kumar D, Pratap GM, Dilip HR

1145 Pattern of HbA1C in Newly Detected Type 2 Diabetes Mellitus

Prem Kumar D, Krishnamurthy VR, Pratap VGM

ENT

1147 An Unusual Presentation of Adenoid Cystic Carcinoma at Nasal Septum: A Case Report

Kalpana Chandra, Aditi Mittal, Praveen Kumar

INTERNAL MEDICINE

1153 A Case Study on Chronic Suppurative Melioidosis in Kerala

Dinulal PP, Aleen Catharine, Manas Joshi, Thenu Jacob

OBSTETRICS AND GYNECOLOGY

1157 Shorten the Laborious Event with Valethamate Bromide

Vandana R Nimbargi, AS Mudholkar, SS Mehendale

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

1160 Posterior Reversible Encephalopathy Syndrome: A Pressing Enigma

Narayanan Palaniappan, Vembu Radha, Ram Prakash Thirugnanasambandam

1163 Study of Cytogenetic and Noncytogenetic Factors Amongst Congenitally Malformed Newborn/Fetuses and their Parents in Jammu

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

Indu Kaul, Amandeep K Anand, Bhawna Sharma

1170 Unilateral Atresia of Cervix Uteri and Uterus Didelphysis in a Girl with Operated Congenital Pouch Colon

Sangeeta Gupta, Taru Gupta, Akshay Sharma, Pushpa Bhatia, Nupur Gupta

PEDIATRICS

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.

1173 Stevens-Johnson Syndrome: A Case Report

Rajib Kumar Ray, Rishav Raj

1175 Intralesional Sclerotherapy Cures Unusual Presentation of Hemangioma in a Child

Editorial Policies

Bimal Kumar Mandal, Rina Das, Jayanta Bain

RESPIRATORY INFECTIONS

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.

1178 Isoniazid-induced Acute Psychosis

Praveen B Gautam, HN Chaudhary

SURGERY

1180 Bilateral Axillary Galactocele: A Case Report

KRK Prasad, A Sarath Chandra, G VijayaRamarao

EXPERTS' VIEW

1182 What are the Appropriate Secondary Prevention Strategies After MI?

Ashok K Kar, KK Aggarwal

ALGORITHM

1184 Management of Hyperkalemia MEDILAW

1185 Sexual Misconduct in Medical Practice

KK Aggarwal

INSPIRATIONAL STORY

1189 Words of Wisdom AROUND THE GLOBE

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.

1190 News and Views LIGHTER READING

1195 Lighter Side of Medicine

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FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

Prof. Dr KK Aggarwal

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

Another Case of One Crore Compensation NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION: CONSUMER CASE NO. 104 OF 2002 Dr (Mrs) Indu Sharma, Complainant(s) vs Indraprastha Apollo Hospital

Course of Events The patient was hospitalized in OP-1 hospital (Indraprastha Apollo Hospitals) after midnight due to rupture of membranes on 10.6.1999. On the same morning, Dr Sohini Verma (OP-3) advised IV fluid with 1 ampule of Syntocinon (Oxytocin) to speed up the delivery. According to the patient, she was administered the maximum dose of oxytocin and there was a fall in the fetal heart rate, which was 80/min during the midnight of 11/12-6-1999. She underwent emergency caesarean section (LSCS) and delivered a female baby at 3.36 am, birth weight 3.7 kg. The baby did not cry immediately after birth and it took almost 5 minutes. The baby was kept on ventilator in NICU. The condition of baby deteriorated further, till 29.6.1999. The baby was unable to suck milk. The patient was discharged on 16.6.1999, while the baby was discharged from OP-1, on 30.6.1999. The patient had taken treatment from OP-3 for infertility and thereafter, spontaneously she conceived after 4 ½ years. After 2 ½ months, from 23.08.1999, the baby was admitted to Holy Family Hospital with complaints of loose motions and strong clonic seizures from 23.8.1999. CT scan showed severe brain atrophy which could lead to severe mental retardation. The complainant observed that at age of 1 year 8 months, the baby’s milestones were delayed; episodes of seizures persisted. Also, the baby was unable to hold her neck and unable to suck milk. From 21.09.1999 to 03.12.2002, the child was treated at AIIMS. The Disability Board of AIIMS, New Delhi certified the baby as ‘95% disability’. The baby survived for 12 years with disabilities and with mental retardation and died on 15.1.2012. ALLEGATIONS ÂÂ No senior doctor available at the time of admission to the hospital; patient examined by resident doctor. ÂÂ Oxytocin administered in maximum dose, following which the fetal heart rate began to drop (80/min), but

none attended the patient immediately.

ÂÂ OP-3 failed to perform LSCS within 12-18 hours after membrane rupture and was abnormally delayed for

about 27 hours.

ÂÂ Excessive dose of oxytocin led to fetal distress and cerebral anoxia-palsy.

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Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF ÂÂ Further CT scan and x-ray reports of the baby were declared as normal by the OP; but, in the opinion of doctors

in the US and brother of the patient (a pediatric surgeon in USA) the severe atrophy of baby’s brain cortex was due to birth asphyxia and that the child might remain severally mentally retarded for as long as she lives.

ÂÂ OPs made number of corrections /interpolations on the case sheets; the neonatal record was also tempered

with.

ÂÂ The Complainant never received the CTG graphs from the OP. ÂÂ The OP-3 failed to take proper care during delivery, which resulted in birth of an asphyxiated baby.

The complainant filed a complaint in the NCDRC alleging medical negligence on the part of the treating doctors and the hospital where she delivered her baby. And sought a total compensation of Rs.2.5 crores plus Rs.5 lacs for the mental agony and Rs.25,000/- as costs of litigation. The commission examined three separate affidavits of evidence by Dr Sohini Verma, Senior Consultant and Gynaecologist, (OP-3), the Neonatologist, Dr Saroja Balan working at OP-hospital, and the Medical Superintendent, Mr. Singhal of OP-1 including that of the two witnesses from hospital, one of the sister In-charge Retnamma K. Nair and the other of Dr Poornima Dhar, the Anesthetist. OP-3 was allowed to argue and assist the counsel for OP. The counsel argued that as the complaint was filed after delay of 264 days, it was barred by limitation. According to OP-3, oxytocin was given only for 17 hours and not for more than 24 hours; total 66 units of oxytocin was given by controlled infusion pump with proper monitoring. The delay in LSCS was due to non-cooperative attitude of patient. The FHR was normal throughout. OP-3 denied that during the last two hours of the progress of the labour, in question, no uterine activity and FHR recording were mentioned in the nursing chart. The CTG records were handed over to the complainant at the time of discharge, along with other documents. The counsel asked for the complaint to be dismissed as there was no negligence on the part of OP-1 and/or OP. OBSERVATIONS OF THE COMMISSION ÂÂ On 03.03.2003, the Complainant filed an application for Condonation of 264 days delay in filing the complaint.

The Commission disregarded the defense of the OP that the complaint was time barred as the delay of 264 days in filing the complaint had been condoned on 16.12.2011. Also the cause of action remains continuous till the patient or the complainant comes to know about the real injury.

ÂÂ The Complainant has not produced any medical expert evidence, and has not produced any witnesses from

Holy Family Hospital and AIIMS where the baby was treated after discharge from OP-1. Initially on 27.03.2006 complainant filed one application for referring the case to the medical expert of AIIMS to take medical expert opinion but she withdrew the said application. The Complainant relied upon the medical textbooks, the research articles.

ÂÂ The OPs produced three expert opinions from doctors in own hospital, namely Prof (Dr.) Kamal Buckshee,

Senior Consultant with Department of Obstetrics & Gynaecology of OP-1 Hospital, Dr. (Mrs.) Urmil Sharma and Dr.(Mrs.) Harmeet Malhotra, all have examined the treatment papers, opined that the treatment given to the patient was correct, and that there was no deficiency or negligence on the part of the treating doctors.

ÂÂ ‘There was delay in performing LSCS by OP-3; waiting period should not have been more than 24 hours and

FHR should be carefully monitored.

ÂÂ The child was consulted at several hospitals like Holy Family Hospital, New Delhi from 29.091999 to 08.09.1999

and took treatment at AIIMS from 29.09.1999 to 2003 for cerebral palsy and brain atrophy.

ÂÂ The Commission did not accept the defense of OP-3 that it was induction failure and instead stated that OP-3

decided emergency LSCS because of fetal distress/non-reassuring fetal heart rate, and not induction failure. The Commission also did accept the contention of OP-3 that the baby was born with pre-existing (prenatal) neurological disability in the absence of any signs of foetal hypoxia or birth asphyxia

ÂÂ The medical records of the baby were produced after a decade i.e. on 20.11.2014. ÂÂ All investigations (blood and urine test, USG, colour Doppler, CTG) done in antenatal period were normal.

Triple marker test was not done as there was no previous family history of any genetic disorder.

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

1107

FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF ÂÂ Repeat USG was not done at the time of admission to recheck a loop of cord around neck seen in previous

USG done 12 days back. Pelvic adequacy by clinical pelvimetry was not checked for including adequacy of fluid even when the patient was leaking profusely. The FHS recorded was 146/minute, therefore the condition of foetus was good prior to delivery.

ÂÂ In the instant case, the resident and nurses failed to appreciate the signs of distress on the foetal heart monitor,

and they failed to inform the attending OP-3 of the non-reassuring heart tracings.

ÂÂ OP-3 did not follow the standard of care for a hospital to quickly deliver a baby by emergency C-section when

necessary. “Standard of care allow obstetricians two options to ensure that the continuation of labour is safe for the baby. One option is to perform a test to make sure that the baby is not acidotic. (If a baby is acidotic, it means inadequate gas exchange is taking place and the baby is being deprived of oxygen.) If that test is not performed, the Oxytocin must be stopped. However, if stopping the Oxytocin did not improve the heart tracing, the standard of care required C-section delivery since vaginal delivery was not imminent. Even if the foetal acidosis test is not familiar to some obstetricians, all obstetricians are familiar with the necessity of calling a stat C-section when a fetal heart tracing does not improve despite resuscitative measures. A good trial on fetal resuscitation would require randomization based on fetal distress diagnosed using the “gold standard” of fetal scalp blood pH < 7.2, testing the methods used for resuscitation, and accounting for the variables.”

ÂÂ In this case, the long labour process brought about by poor and negligent medical management caused the

birth of asphyxiated child with cerebral palsy and seizures. The birth record voluminously speaks about the asphyxia.

ÂÂ The medical records showed many cutting, erasing marks, pin holes; some handwritten insertions, over

writings and discrepancies in the doctor’s and sister’s chart, which showed that the records were apparently manipulated and fabricated.

ÂÂ The OPs were obliged to explain how the baby’s cerebral palsy occurred if the required treatment had been

given. In the absence of such exculpatory evidence, the invocation of the maxim res ipsa loquitur, is justifiable in this case.

ÂÂ The records of the patients should be maintained by doctors and hospitals. “It is wise to remember that “Poor

records mean poor defense, no records mean no defense”.

ÂÂ The Commission rejected the contention of the OP that the delay in cesarean section was due to the reluctance

on the part of the patient stating that “it was the bounden duty of the doctor to decide, the correct line of treatment; doctor wouldn’t just blindly obey the wishes of the patient…”

ÂÂ The Commission also rejected the expert opinions produced by OP-3 from the three experts of OP-1 hospital,

as they had given their opinion on the basis of tampered medical records, they were from same hospital and more chances of interested witnesses.

ÂÂ It is the responsibility of the medical team to closely monitor the heart tracings so that they know when the

baby becomes distressed.

ÂÂ The say of OP that the patient was informed about emergency LSCS which was rejected by the patient or

by her husband. The OP did not take written consent or signature of the complainant or her husband about refusal of C-section. The progress sheet clearly shows some insertion made by OP/staff to show that patient was informed. Thus, the entry was also tampered one.

CONCLUSIONS OF THE COMMISSION ÂÂ The patient had pregnancy after 4 ½ years of infertility making it a precious pregnancy. ÂÂ Corporate hospitals and Specialists must perform at a higher level than other hospitals/GPs as they represent

themselves as possessing highest standard facilities and care, superior skills and additional training.

ÂÂ The records clearly showed fetal distress indicated by hypertonic contractions and fall in FHR below 120/min

and OP-3 failed to take proper decision for emergency C-section making it an act of omission, thus negligence.

ÂÂ The medical records of the mother and baby are tampered at many places. ÂÂ The substandard care administered to the patient during labour resulted in poor outcome despite using modern

technology of CTG. Inability to interpret the CTG trace, i.e., poor pattern recognition, failure to correlate to

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Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF the pathophysiology that caused the CTG changes, not taking into consideration the clinical situation that may suggest fetal distress and delay in taking appropriate action due to poor communication and team work were reasons for the poor outcome. ÂÂ Taking into account the sufferings of mother and child for 12 years, treatment and other expenses, the metal

agony and trauma to the parents who suffered loss of their baby and thereon the quantum of interest on such amount, the Commission allowed a lump sum award of compensation of Rs. One crore by relying upon the judgments of Hon’ble Apex Court for award of compensation.

ÂÂ The Commission further imposed punitive costs of Rs.10 lacs on OP-1 as OP had not issued entire medical

record to the patient, indulged in the unethical medical practices and professional misconduct like tampering of medical records. It was the duty of the hospital to preserve the CTG tracings. Thus OP did not follow the standard of medical practice, not maintained medical records.

FINAL JUDGEMENT The commission found the OPs guilty of medical negligence and fixed total compensation of Rs. One Crore; out of which OP-1 will pay Rs. 80 lacs and OP-3 will pay Rs. 20 lacs to the patient/complaint within 90 days from the date of receipt of this order. The insurance company shall indemnify the respective OPs, as per law. Rs. 10 lacs was imposed as punitive cost which OP-1 shall deposit in the Consumer Legal Aid Account, NCDRC within 90 days from the date of receipt of this order. If the order is not compiled within 90 days, the OPs are liable to pay interest @ 9% per annum, till its realisation. ■■■■

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

1109

AMERICAN FAMILY PHYSICIAN

Lung Cancer: Diagnosis, Treatment Principles, and Screening KELLY M. LATIMER, TIMOTHY F. MOTT

ABSTRACT Lung cancer is classified histologically into small cell and non–small cell lung cancers. The most common symptoms of lung cancer are cough, dyspnea, hemoptysis, and systemic symptoms such as weight loss and anorexia. High-risk patients who present with symptoms should undergo chest radiography. If a likely alternative diagnosis is not identified, computed tomography and possibly positron emission tomography should be performed. If suspicion for lung cancer is high, a diagnostic evaluation is warranted. The diagnostic evaluation has three simultaneous steps (tissue diagnosis, staging, and functional evaluation), all of which affect treatment planning and determination of prognosis. The least invasive method possible should be used. The diagnostic evaluation and treatment of a patient with lung cancer require a team of specialists, including a pulmonologist, medical oncologist, radiation oncologist, pathologist, radiologist, and thoracic surgeon. Non–small cell lung cancer specimens are tested for various mutations, which, if present, can be treated with new targeted molecular therapies. The family physician should remain involved in the patient’s care to ensure that the values and wishes of the patient and family are considered and, if necessary, to coordinate end-of-life care. Early palliative care improves quality of life and may prolong survival. Family physicians should concentrate on early recognition of lung cancer, as well as prevention by encouraging tobacco cessation at every visit. The U.S. Preventive Services Task Force recommends lung cancer screening using low-dose computed tomography in high-risk patients. However, the American Academy of Family Physicians concludes that the evidence is insufficient to recommend for or against screening. Whether to screen high-risk patients should be a shared decision between the physician and patient.

Keywords: Lung cancer, chest radiography, computed tomography, positron emission tomography, targeted molecular therapies, early palliative care, tobacco cessation

n 2010, approximately 200,000 persons in the United States were diagnosed with lung cancer, and nearly 160,000 persons died of the disease.1,2 The average age at diagnosis is 68 to 70 years.3 Incidence and death rates vary widely among states and regions of the United States, commensurate with geographic disparities in tobacco use. Utah has the lowest incidence (28 per 100,000) and Kentucky has the highest (101 per 100,000).4 The overall incidence of lung cancer declined by 2% between 2005 and 2009.5

RISK FACTORS Tobacco use causes 80% to 90% of all lung cancers.6,7 Secondhand tobacco smoke exposure is also a significant

KELLY M. LATIMER, MD, MPH, FAAFP, is program director of the Family Medicine Residency Program at Naval Hospital Pensacola (Fla.) and is an assistant professor at the Uniformed Services University of the Health Sciences in Bethesda, Md. TIMOTHY F. MOTT, MD, is a staff physician in the Department of Family Medicine at Naval Hospital Pensacola and is an assistant professor at the Uniformed Services University of the Health Sciences. Source: Adapted from Am Fam Physician. 2015;91(4):250-256.

risk factor, with younger age at exposure associated with higher risk of lung cancer.8 Risk factors (Table 16-14) are typically dose- and duration-dependent, and many carcinogens act synergistically when combined with tobacco smoke.9 For example, arsenic in drinking water has been associated with lung cancer when combined with exposure to tobacco smoke.10,11 Radon, a naturally occurring radioactive gas found in some homes, is estimated to cause 21,000 cases of lung cancer per year.12 Any home can have elevated radon levels, but the highest levels are found in the Northern and Midwestern regions of the United States.13 A person’s risk of lung cancer can be calculated using a validated online tool available at http://www.disease riskindex. harvard.edu/update/index.htm. ETIOLOGY A combination of intrinsic factors and exposure to environmental carcinogens is involved in the pathogenesis of lung cancer.7 Preinvasive lesions such as adenocarcinoma in situ and minimally invasive

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

1111

AMERICAN FAMILY PHYSICIAN Table 1. Risk Factors for Lung Cancer Risk factors

Relative risk

Tobacco use or exposure Current smoking

Former smoking

Secondhand smoke exposure

1.3

Environmental exposures Asbestos

Radon

Other exposures

Air pollution Arsenic Beryllium Beta-carotene ingestion Chromium Nickel Soot Human immunodeficiency virus infection Idiopathic pulmonary fibrosis Chronic obstructive pulmonary disease Tuberculosis

2 to 11 7 2 to 3.1 -

Other History of chest radiotherapy

5.9

History of chemotherapy

4.2

Family history of lung cancer

Older age

squamous cell carcinoma, and large cell carcinoma; these are further subclassified.16 NSCLC is sometimes poorly differentiated and only distinguishable by immunohistochemical stains and molecular testing. This is problematic when only a small amount of tissue is available for testing. The optimal choice of treatment relies on a complete phenotypic and genotypic characterization of the tumor. CLINICAL PRESENTATION Patients with lung cancer are almost always symptomatic at diagnosis.17 Symptoms can be caused by the primary tumor (e.g., cough, hemoptysis); intrathoracic spread (e.g., Horner syndrome, superior vena cava obstruction); and distant metastases (e.g., bone pain). Tables 218 and 317 summarize these symptoms. Symptoms can also be caused by paraneoplastic syndromes (Table 417), such as the syndrome of inappropriate antidiuretic hormone. These symptoms are a result of ectopic production of hormones from the tumor or the bodyâ&#x20AC;&#x2122;s reaction to the tumor, and are not directly attributable to the tumor or metastasis. About 10% of patients with lung cancer present with a paraneoplastic syndrome, and this rate is higher in patients with SCLC.17 The best treatment for paraneoplastic syndromes is treatment of the underlying cancer.17 Digital clubbing is a common paraneoplastic syndrome finding that is poorly understood, and it is more common with NSCLC.

adenocarcinoma are well described and show that there is likely a stepwise progression from dysplasia to malignancy.7 Familial and genetic variations can predispose a person to lung cancer, even nonsmokers. Many genetic mutations within tumors have been identified. For example, mutations in the epidermal growth factor receptor (EGFR) gene are present in 20% of adenocarcinomas;15 patients with this mutation are candidates for targeted molecular therapy with a drug that inhibits EGFR (erlotinib or afatinib or with a monoclonal antibody against EGFR (cetuximab).15 Tumor mutations may also predict response to or toxicity from certain chemotherapies and are an important area for future investigation.15

Most data about symptoms at presentation of lung cancer are from referral centers, making extrapolation to the primary care setting difficult.19 Two individual symptoms that significantly increase the likelihood of lung cancer are digital clubbing and hemoptysis.18-21 Other independent predictors of lung cancer include loss of appetite, weight loss, fatigue, dyspnea, chest or rib pain, and an increasing number of visits to evaluate persistent cough.18 Patients rarely present with only one symptom, and the positive predictive value is higher when two or more symptoms are reported. For example, the combination of weight loss and hemoptysis has a positive predictive value of 9.2%.19 Lung cancer should be highly suspected in any patient older than 40 years with risk factors and symptoms. However, physicians must remember that lung cancer can occur in younger persons and in individuals without known risk factors.

PATHOLOGY

INITIAL EVALUATION

Lung cancer is classified by its histologic appearance into small cell lung cancer (SCLC) or nonâ&#x20AC;&#x201C;small cell lung cancer. NSCLC is divided into adenocarcinoma,

The initial evaluation of a patient with suspected lung cancer begins with a history and physical examination; complete blood count; measurement of alkaline

Information from references 6 through 14.

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Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

AMERICAN FAMILY PHYSICIAN Table 2. Signs and Symptoms of Lung Cancer due to Local Effects

Table 3. Signs and Symptoms of Lung Cancer due to Distant Metastases

Sign/symptom of the primary tumor*

LR+

LR–

Site

Digital clubbing

55.0

0.96

Hemoptysis

13.2

0.81

Weight loss

6.2

0.76

Loss of appetite

4.8

0.84

Dyspnea

3.6

0.68

Chest or rib pain

3.3

0.52

Fatigue

2.3

0.76

First visit for cough

2.2

0.50

Second visit for cough

3.2

0.66

Third visit for cough

4.2

0.77

Sign/symptom of intrathoracic spread

Clinical context

Decreased breath sounds and dyspnea

Malignant pleural effusion

Sign or symptom

Any site

Any sign or symptom

Liver

Weakness, weight loss, anorexia, hepatomegaly

Up to 60

Bone

Pain, fracture, elevated alkaline phosphatase

Up to 25

Lymphatics

Lymphadenopathy

15 to 20

Brain

Headaches, seizures, nausea and vomiting, mental status changes

Up to 10

Adrenals

Adrenal insufficiency

Rare

Skin

Subcutaneous nodules

Rare

Table 4. Paraneoplastic Syndromes Associated with Lung Cancer Syndrome

Dysphagia

Esophageal invasion

Elevated hemidiaphragm

Phrenic nerve paralysis

Systemic (anorexia, cachexia, weight loss, fatigue, fever)

Hoarseness, weak cough

Recurrent laryngeal nerve palsy

Pleuritic chest pain

Chest wall invasion

Ptosis, miosis, facial anhidrosis

Horner syndrome (sympathetic chain compression)

Shoulder pain and muscle wasting along the C8-T3 nerve root

Pancoast tumor (superior sulcus tumor)

LR+ = Positive likelihood ratio; LR– = Negative likelihood ratio. *Among patients presenting with lung symptoms, primarily cough. Information from reference 18.

phosphatase, hepatic transaminase, and calcium levels; chemistries (electrolytes, blood urea nitrogen, creatinine); and chest radiography.22 Normal findings on a chest radiograph do not rule out lung cancer because a small tumor can be hidden within the mediastinum or elsewhere in the chest. If suspicion remains high because a likely alternative diagnosis is not identified on the chest radiograph, contrast-enhanced computed tomography (CT) should be performed, followed by positron emission tomography if necessary.17,19,22 A multidisciplinary team consisting of a pulmonologist, medical oncologist, radiation oncologist, pathologist, radiologist, and thoracic surgeon then plans the

Information from reference 17.

Decreased heart sounds and Malignant pericardial effusion enlarged cardiac silhouette

Facial swelling, plethora, and Superior vena cava syndrome upper extremity edema

Frequency (%)

Frequency Comments (%) 0 to 68

May be readily apparent and striking

Digital clubbing

More common with non– small cell lung cancer

Hypercalcemia

10 to 20

Ectopic production of parathyroid hormone– related peptide; may be life-threatening

Hyponatremia

1 to 5

Syndrome of inappropriate antidiuretic hormone or ectopic production of atrial natriuretic peptide

Paraneoplastic encephalitis

0.2

Mental status changes

Cushing syndrome

Rare

Ectopic production of adrenocorticotropic hormone

Hypertrophic osteoarthropathy

Rare

Triad of clubbing, arthralgias, and ossifying periostitis

Muscular weakness

Rare

Lambert-Eaton myasthenic syndrome

Information from reference 17.

diagnostic evaluation, the results of which guide treatment and determine prognosis. The patient’s family physician should remain involved in the patient’s care to ensure that the values and wishes of the patient and

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AMERICAN FAMILY PHYSICIAN family are considered and, if necessary, to coordinate end-of-life care. DIAGNOSTIC EVALUATION The diagnostic evaluation includes three simultaneous steps: tissue diagnosis, staging, and functional evaluation.

for central lesions, whereas CT-guided transthoracic needle aspiration is typically the first-line method for peripheral lesions. Endobronchial ultrasound24 and electromagnetic navigation23 are some of the newer procedures that may increase the diagnostic yield of bronchoscopy for select patients with mediastinal or peripheral lesions.24

Staging

Tissue Diagnosis Although experienced physicians can often diagnose the type of lung cancer based on clinical presentation and radiographic appearance, an adequate tissue sample is imperative to optimize the diagnosis and plan treatment.22 Molecular testing requires a significant amount of tissue. Targeted therapies can increase treatment options for patients with advanced disease or poor functional status. Molecular testing is also standard in never smokers with squamous cell tumors, making ample tissue all the more essential in such patients.22 For small or peripherally located lung cancers, this can be challenging. A variety of diagnostic methods are available that yield cytology samples or small biopsies. The choice of procedure depends on the type, location, and size of the tumor; comorbidities; and accessibility of metastases (Table 5).22-24 In general, the least invasive method possible should be used.22 If the procedure fails to obtain tissue, a more invasive method is needed. Conventional bronchoscopy works best

Clinical staging is based on all information obtained before treatment, including findings from CT and positron emission tomography and invasive staging such as mediastinoscopy.25 Pathologic staging is performed after surgical resection and may upgrade or downgrade the clinical staging. NSCLC is staged according to the TNM (tumor size, nodes, metastasis) system. The 7th edition of this system, which is the most recent, is based on a retrospective analysis of more than 81,000 cases of lung cancer collected from around the world between 1990 and 2000.26,27 An online calculator available at http://staginglungcancer. org/calculator summarizes the TNM staging system and provides corresponding drawings, CT scans, and survival curves. For SCLC, American College of Chest Physicians (ACCP) guidelines recommend using the 7th edition TNM staging system for prognosis and placement into clinical trials.25,27 Many physicians use the simpler Veterans Administration Lung Study Group

Table 5. Methods for Tissue Diagnosis of Lung Cancer Method*

Comments

Biopsy or fine-needle aspiration of accessible metastasis or lymph node

Used in the presence of palpable lymph nodes

Conventional bronchoscopy brushings and washings

High sensitivity for central lesions, much lower sensitivity for peripheral lesions

Computed tomographyâ&#x20AC;&#x201C;guided transthoracic needle aspiration

Good for peripheral lesions seen on computed tomography, associated with pneumothorax, lower sensitivity for smaller lesions

Transbronchial needle aspiration

Indicated for central lesions

Electromagnetic navigation bronchoscopy23

Improved diagnostic yield for bronchoscopy of peripheral lesions, requires advanced training beyond skill of most bronchoscopists

Endobronchial ultrasoundâ&#x20AC;&#x201C;guided transbronchial needle aspiration24

Best for paratracheal, subcarinal, and perihilar nodes, lower sensitivity for peripheral lesions, requires advanced training beyond skill of most bronchoscopists

Pleural biopsy

Used with pleural effusion and if pleural fluid cytology findings are negative

Sputum cytology

Indicated for central lesions, noninvasive, follow-up testing required if findings are negative

Thoracentesis (pleural fluid cytology)

Easily accessible if present, ultrasound guidance improves yield and decreases risk of pneumothorax, second sample increases diagnostic yield

Video-assisted thoracic surgery

Used for a small single high-risk nodule

*Listed from least to most invasive. Information from references 22 through 24.

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AMERICAN FAMILY PHYSICIAN classification system to stage SCLC for treatment purposes.28 Limited disease is cancer confined within a single tolerable radiation field. Extensive disease is cancer that has extended outside of a single hemithorax.

Functional Capacity Patients with advanced age, poor nutritional status, or multiple comorbidities may not be able to tolerate lung resection, radiation, or chemotherapy and thus treatment must be individualized. The Eastern Cooperative Oncology Group Performance Status is an easy-to-use grading tool to predict how well patients will tolerate chemotherapy:29 ÂÂ 0: Fully active, able to carry on predisease activity

without restriction

ÂÂ 1: Restricted in physically strenuous activity but

ambulatory and able to perform light or sedentary work (e.g.,light housework, office work)

ÂÂ 2: Ambulatory and capable of all self-care but

unable to carry out any work activities, up and about more than 50% of waking hours

ÂÂ 3: Capable of only limited self-care, confined to a

bed or chair more than 50% of waking hours

ÂÂ 4: Completely disabled, incapable of any self-care,

totally confined to a bed or chair

ÂÂ 5: Dead

Candidates for lung resection need standard preoperative evaluation plus pulmonary function testing and carbon monoxide diffusion in the lung measurements to estimate postsurgical lung reserve.30 Brain magnetic resonance imaging is standard in the pretreatment evaluation, except in patients with stage IA NSCLC.30 TREATMENT

Non-small Cell Lung Cancer The treatment of NSCLC is well detailed in the 2013 ACCP evidence-based practice guidelines.31-33 The nuances of treatment are evolving, complex, and largely beyond the scope of this review, yet a few themes are significant. Morbidity and mortality outcomes may be improved for patients evaluated and treated by a surgical thoracic oncologist in conjunction with a multidisciplinary team at a lung cancer treatment center. Surgical resection is indicated in medically fit patients with resectable stage I or II NSCLC, preferably a minimally invasive approach such as video-assisted

thoracic surgery.31 The goal for stage III infiltrative NSCLC is eradicating known intrathoracic cancer while diminishing subsequent intrathoracic and systemic disease,32 usually through chemotherapy and radiation based on tumor histology and the patient’s functional status. In stage IV tumors, multidisciplinary management options are also largely dictated by histology and patient status. Palliative care should be initiated early in patients with stage IV NSCLC, or at any stage if underlying morbidity or patient choice prevents intent-to-cure therapy. Early palliative care significantly improves quality of life, decreases the incidence of depression in patients with newly diagnosed NSCLC, and may prolong survival.33 Additional management decisions may be influenced by a patient’s involvement in an approved clinical trial.

Small Cell Lung Cancer Limited stage SCLC is treated with an intent to cure; treatment results in a five-year survival rate of up to 25%.34 For early limited stage SCLC, surgery may be indicated. For both limited stage and extensive stage SCLC, concurrent chemotherapy and radiation therapy with a platinum-based agent and at least one other chemotherapeutic agent should be pursued. The five-year survival rate is virtually zero for extensive stage SCLC. As with more extensive NSCLC, a patient’s comorbidities, the extent of disease, and patient preferences are integral to making treatment decisions, and palliative care should be initiated early. PROGNOSIS Prognosis is better if presenting symptoms are caused by the primary tumor rather than by metastatic disease or paraneoplastic syndromes.17 It is also better in earlier stages of cancer. Survival rates at five years can be greater than 50% for those with localized disease, but decrease to less than 5% in those with distant disease.4 The online staging calculator at http://staginglung cancer.org/calculator can also be used for prognosis. SCREENING The U.S. Preventive Services Task Force (USPSTF) supports annual low-dose CT to screen for lung cancer in patients 55 to 80 years of age with at least a 30 packyear history who currently smoke or have quit within the past 15 years.35 The USPSTF cites the National Lung Screening Trial, which found a number needed to screen of 312 to prevent one lung cancer death in five years with three screening examinations.36 The

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AMERICAN FAMILY PHYSICIAN recommendation was also based on extensive modeling studies to refine estimates of benefit and harm.37 The American Academy of Family Physicians concludes that the evidence is insufficient to recommend for or against low-dose CT screening for lung cancer.38 This conclusion is based on the fact that the National Lung Screening Trial was performed at major centers with strict protocols (not community hospitals) and 40% of patients required some type of follow-up study or intervention because of positive results, and that the long-term hazards from cumulative radiation exposure with this screening are unknown. In light of differing guidelines, an approach of shared decision making and educating patients on the potential benefits and risks in relation to their personal health and health care setting is essential. PREVENTION Never smoking is the best way to prevent lung cancer, and smoking cessation is helpful. The USPSTF recommends screening every patient for tobacco use and encouraging smoking cessation for smokers at every appointment.39 Physician counseling techniques can be effective when tailored to a patient’s willingness to change.40 A variety of pharmacologic modalities are available that work best when combined with social and behavioral support. Legislation such as smoking bans in public buildings, prohibiting marketing of tobacco products to minors, and taxation of tobacco products likely play a role in decreasing tobacco use.41 PHYSICIAN AND PATIENT RESOURCES The National Cancer Institute website (http://www. cancer.gov/cancertopics/pdq/adulttreatment) is a helpful resource for physicians and patients. Clinical practice guidelines are summarized on the National Comprehensive Cancer Network website (http://www. nccn.org/professionals/physician_gls/f_guidelines. asp#site; free registration required). REFERENCES 1. Heron M. Deaths: leading causes for 2010. Natl Vital Stat Rep. 2013;62(6):1-96. 2. Centers for Disease Control and Prevention. Lung cancer statistics. http://www.cdc.gov/cancer/lung/statistics. Accessed July 5, 2014. 3. American Cancer Society. Lung cancer (non-small cell). http://www.cancer.org/cancer/lungcancer-non-smallcell/ detailedguide/non-small-cell-lung-cancer-key-statistics. Accessed July 5, 2014.

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4. Howlader N, Noone AM, Krapcho M, et al., eds. SEER Cancer Statistics Review (CSR) 1975-2011. Updated September 10, 2014. http://seer.cancer.gov/csr/1975_2011. Accessed July 5, 2014. 5. Henley SJ, Richards TB, Underwood JM, Eheman CR, Plescia M, McAfee TA; Centers for Disease Control and Prevention. Lung cancer incidence trends among men and women—United States, 2005-2009 [published correction appears in MMWR Morb Mortal Wkly Rep. 2014;63(2):45]. MMWR Morb Mortal Wkly Rep. 2014;63(1):1-5. 6. Jemal A, Thun MJ, Ries LA, et al. Annual report to the nation on the status of cancer, 1975-2005, featuring trends in lung cancer, tobacco use, and tobacco control. J Natl Cancer Inst. 2008;100(23):1672-1694. 7. Alberg AJ, Brock MV, Ford JG, Samet JM, Spivack SD. Epidemiology of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e1S-e29S. 8. Asomaning K, Miller DP, Liu G, et al. Second hand smoke, age of exposure and lung cancer risk. Lung Cancer. 2008;61(1):13-20. 9. National Cancer Institute. Lung cancer prevention. risk factors. http://www.cancer. Environmental gov/cancertopics/pdq/prevention/lung/Patient/ page3#Keypoint9. Accessed January 5, 2014. 10. Ferreccio C, Yuan Y, Calle J, et al. Arsenic, tobacco smoke, and occupation: associations of multiple agents with lung and bladder cancer. Epidemiology. 2013;24(6):898-905. 11. Hubaux R, Becker-Santos DD, Enfield KS, Lam S, Lam WL, Martinez VD. Arsenic, asbestos and radon: emerging players in lung tumorigenesis. Environ Health. 2012;11:89. 12. U.S. Environmental Protection Agency. A citizen’s guide to radon. http://www.epa.gov/radon/pubs/citguide.html. Accessed July 5, 2014. 13. U.S. Geological Society. Geologic radon potential of the United States. http://energy.cr.usgs.gov/radon/rnus.html. Accessed July 5, 2014. 14. Travis LB, Gospodarowicz M, Curtis RE, et al. Lung cancer following chemotherapy and radiotherapy for Hodgkin’s disease. J Natl Cancer Inst. 2002;94(3):182-192. 15. Amann J, Kalyankrishna S, Massion PP, et al. Aberrant epidermal growth factor receptor signaling and enhanced sensitivity to EGFR inhibitors in lung cancer. Cancer Res. 2005;65(1):226-235. 16. Travis WD, Brambilla E, Noguchi M, et al. International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011;6(2):244-285. 17. Beckles MA, Spiro SG, Colice GL, Rudd RM. Initial evaluation of the patient with lung cancer. Chest. 2003;123(1 suppl):97S-104S.

AMERICAN FAMILY PHYSICIAN 18. Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case control study. Thorax. 2005;60(12):1059-1065. 19. Hamilton W, Sharp D. Diagnosis of lung cancer in primary care: a structured review. Fam Pract. 2004;21(6):605-611. 20. Shim J, Brindle L, Simon M, George S. A systematic review of symptomatic diagnosis of lung cancer. Fam Pract. 2014;31(2):137-148. 21. Shapley M, Mansell G, Jordan JL, Jordan KP. Positive predictive values of 35% in primary care for cancer: systematic review. Br J Gen Pract. 2010;60(578): e366-e377. 22. Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: diagnosis and management of lung cancer, 3rd ed.: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e142-165S. 23. Lamprecht B, Porsch P, Pirich C, Studnicka M. Electromagnetic navigation bronchoscopy in combination with PET-CT and rapid on-site cytopathologic examination for diagnosis of peripheral lung lesions. Lung. 2009;187(1):55-59. 24. Herth FJ, Eberhardt R, Vilmann P, Krasnik M, Ernst A. Realtime endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax. 2006;61(9):795-798. 25. Detterbeck FC, Postmus PE, Tanoue LT. The stage classification of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e191S-e210S.

management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):7S-37S. 31. Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidencebased clinical practice guidelines. Chest. 2013;143(5 suppl):e278S-e313S. 32. Ramnath N, Dilling TJ, Harris LJ, et al. Treatment of stage III non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e314S-e340S. 33. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010; 363(8):733-742. 34. Jett JR, Schild SE, Kesler KA, Kalemkerian GP. Treatment of small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 suppl):e400S-e419S. Preventive 35. U.S. Services Task Force. Lung cancer: screening. December 2013. http://www. uspreventiveservicestaskforce.org/Page/Document/ RecommendationStatementFinal/lung-cancer-screening. Accessed March 24, 2014. 36. Aberle DR, Adams AM, Berg CD, et al.; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409.

26. Sobin LH, Gospodarowicz MK, Wittekind C; International Union Against Cancer. TNM Classification of Malignant Tumours. 7th ed. Oxford, United Kingdom: WileyBlackwell; 2009.

37. de Koning HJ, Meza R, Plevritis SK, et al. Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. Preventive Services Task Force. Ann Intern Med. 2014;160(5):311-320.

27. Mirsadraee S, Oswal D, Alizadeh Y, Caulo A, van Beek E Jr. The 7th lung cancer TNM classification and staging system: Review of the changes and implications. World J Radiol. 2012;4(4):128-134.

38. American Academy of Family Physicians. Clinical preventive service recommendation. Lung cancer. 2013. http://www. aafp.org/patient-care/clinical-recommendations/all/lungcancer.html. Accessed March 24,2014.

28. Stahel RA, Ginsberg R, Havemann K, et al. Staging and prognostic factors in small cell lung cancer: a consensus report. Lung Cancer. 1989;5(4-6): 119-326.

39. U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women. Ann Intern Med. 2009;150(8):551-555.

29. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5(6):649-655.

40. Larzelere MM, Williams DE. Promoting smoking cessation. Am Fam Physician. 2012;85(6):591-598.

30. Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris 41. Jha P, Peto R. Global effects of smoking, of quitting, and of D, Alberts WM. Executive summary: diagnosis and taxing tobacco. N Engl J Med. 2014;370(1):60-68. ■■■■

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AMERICAN FAMILY PHYSICIAN

Practice Guidelines ACIP RELEASES 2015 ADULT IMMUNIZATION SCHEDULE The 2015 adult immunization schedule from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has a few changes that are particularly relevant to family physicians. The schedule is available at http:// www.aafp.org/patient-care/immunizations/schedules. html. The most significant change involves the pneumococcal 13-valent conjugate vaccine (PCV13; Prevnar 13). You might recall that ACIP recommends that adults older than 18 years with certain high-risk conditions receive PCV13 and the pneumococcal polyvalent-23 vaccine (PPSV23; Pneumovax 23). In August 2014, ACIP extended that recommendation to older adults. The committee reviewed a large, randomized controlled trial that showed good protection against vaccine specific pneumococcal pneumonia using PCV13 in older patients (the CAPITA trial; http://www.cdc.gov/ mmwr/preview/mmwrhtml/mm6337a4.htm). Based on this study, ACIP now recommends that all adults 65 years and older receive both PCV13 and PPSV23 vaccines. Logistically, the recommendation is complicated, and vaccine timing depends on the patient’s age, medical condition, and if he or she has previously received PPSV23 or PCV13. If the patient is a healthy adult who has just turned 65 and has not received either vaccine, PCV13 should be given first and the PPSV23 six to 12 months later. If the patient has already received the PPSV23 vaccine after age 65, the PCV13 dose should be administered at least one year after the PPSV23 dose. The Centers for Medicare and Medicaid Services has updated its regulations to allow coverage of both

pneumococcal vaccines for adults 65 years and older as long as the two vaccines are spaced a year apart (http:// www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/ Downloads/MM9051.pdf). The key wording states that Medicare will cover a different, second pneumococcal vaccine one year after the first vaccine was administered. Although ACIP recommendations allow a second vaccine as early as six months in some circumstances, Medicare will not reimburse for both unless the two vaccines are given a year apart. There is no convincing evidence that anesthesia or surgery significantly affects the immunologic response to vaccines. Thus, ACIP concluded that recent, current, or upcoming surgery or anesthesia is not a contraindication or precaution to giving a vaccine. You should routinely offer appropriate vaccinations, such as influenza, PPSV23, and PCV13, unless there is a specific reason not to do so, such as moderate or severe illness. For pregnant patients, the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine is now recommended with each pregnancy between 27 and 36 weeks of gestation. Recent safety data on repeated doses of Tdap in subsequent pregnancies have been highly favorable. For patients hesitant to get vaccinated, the CDC recommends using the SHARE acronym: Share the reasons why the recommended vaccine is right for each patient; Highlight positive personal experiences with immunizations; Address patient questions and concerns in plain, understandable language; Remind patients that vaccinepreventable diseases still exist in the United States; and Explain the potential costs of getting the disease (e.g., health effects, time lost, financial costs).

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Source: Adapted from Am Fam Physician. 2015;91(4):264.

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AMERICAN FAMILY PHYSICIAN

Photo Quiz NEW-ONSET BULLOUS RASH A 63-year-old man presented with an asymptomatic rash that began four days earlier, one day after he was treated for an abscess on his right abdomen. The abscess was treated by incision and drainage, and he was prescribed trimethoprim/sulfamethoxazole because he had a history of methicillin-resistant Staphylococcus aureus infection. Physical examination revealed multiple large, erythematous, sharply demarcated circular plaques, some with tense bullae in the center, on his trunk and extremities (Figures 1 and 2). There was no mucosal involvement.

Figure 1.

Question Based on the patientâ&#x20AC;&#x2122;s history and physical examination, which one of the following is the most likely diagnosis? A. Bullous impetigo. B. Bullous pemphigoid. C. Erythema multiforme. D. Pemphigus vulgaris.

Figure 2.

SEE THE FOLLOWING PAGE FOR DISCUSSION.

Source: Adapted from Am Fam Physician. 2015;91(4):231-232.

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AMERICAN FAMILY PHYSICIAN DISCUSSION

Summary Table

The answer is C: erythema multiforme. Erythema multiforme minus is a self-limited hypersensitivity reaction. It most commonly occurs in response to an antecedent herpes simplex virus infection but may also be triggered by medications, including sulfonamides, barbiturates, penicillins, and phenytoin.1-3 Erythema multiforme majus is a more severe form of the condition also known as Stevens-Johnson syndrome. The diagnosis of erythema multiforme is clinical. Lesions may have a target appearance, and usually begin on the distal extremities and progress proximally.3 Vesicles and bullae sometimes form centrally.3

Condition

Characteristics

Bullous impetigo

Rapid onset of bullae containing clear or cloudy fluid, most common in infants and children; ruptured lesions may leave a collarette of moist scale and an erythematous base

Bullous pemphigoid

Tense bullae on an erythematous, urticarial, or noninflammatory base; commonly pruritic and may be preceded by a prodromal phase with eczematous, papular, or urticarial skin lesions

Erythema multiforme

Hypersensitivity reaction often to an infection or a medication; asymptomatic rash consisting of target-like lesions that commonly begin on the distal extremities and progress proximally

Erythema multiforme usually causes minimal symptoms and resolves over several weeks without treatment.2 Suspected causal medications should be withdrawn as soon as possible. Oral antihistamines or topical steroids may be used for itching.2 A short course of oral corticosteroids may be helpful in severe cases; however, this is controversial.3 Recurrent cases may be treated with antiviral agents or other immunosuppressant drugs.3

Pemphigus vulgaris

Autoimmune disease characterized by flaccid blisters on skin or mucosal surfaces; lesions may rupture easily, leaving painful erosions

surfaces that rupture easily, leaving painful erosions.7 Diagnosis is made through biopsy of the lesion and perilesional tissue. REFERENCES

Bullous impetigo is caused by toxinproducing staphylococcal strains and is most common in infants and children.2 Vesicles enlarge rapidly to form bullae containing clear or cloudy fluid. The lesions may expand and rupture, leaving a collarette of moist scale and an erythematous base.2 There is typically little to no surrounding erythema. Diagnosis is usually clinical but may require a culture of fluid from the lesion.4

1. Odom RB, James WD, Berger TG, eds. Andrews’ Diseases of the Skin: Clinical Dermatology. 9th ed. Philadelphia, Pa.: W.B. Saunders Co.; 2000.

Bullous pemphigoid is an autoimmune disease characterized by tense bullae on an erythematous, urticarial, or noninflammatory base.5 The bullae are commonly pruritic and may be preceded by a prodromal phase with eczematous, papular, or urticarial skin lesions lasting for weeks.6 Diagnosis is made through biopsy of the lesion and perilesional tissue, with subsequent microscopic evaluation using standard histology and direct immunofluorescent techniques.

4. Baddour LM. Impetigo. UpToDate. http://www.uptodate. com/contents/impetigo (subscription required). Accessed August 16, 2013.

Pemphigus vulgaris is an autoimmune disease characterized by flaccid blisters on the skin and mucosal

2. Habif TP, ed. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th ed. Edinburgh, Scotland: Mosby; 2010. 3. Lamoreux MR, Sternbach MR, Hsu WT. Erythema multiforme. Am Fam Physician. 2006;74(11):1883-1888.

5. DiZenzo G, Marazza G, Borradori L. Bullous pemphigoid: physiopathology, clinical features and management. Adv Dermatol. 2007;23:257-288. 6. Kasperkiewicz M, Zillikens D, Schmidt E. Pemphigoid diseases: pathogenesis, diagnosis, and treatment. Autoimmunity. 2012;45(1):55-70. 7. Hertl M, Sitaru C. UpToDate. http://www.uptodate. com/contents/pathogenesis-clinical-manifestations and-diagnosis-of-pemphigus (subscription required). Accessed August 16, 2013.

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CARDIOLOGY

Case of a Young Hypertensive with Recurrent Cerebrovascular Disease due to a Rare Etiology SM RAJENDRAN*, S PALANIANDAVAR†, JAMIMA BHASKAR‡, J SENTHILNATHAN#, ARUN R, JOSE MATHEW§

ABSTRACT A young individual presented as hypertensive emergency due to a rare cause, a tumor arising from autonomic nervous system. Screening test done in this patient revealed a case of extra-adrenal pheochromocytoma, which was confirmed by imaging studies. Pheochromocytoma usually manifests itself with paroxysmal symptoms and can be easily missed; therefore all young individuals with secondary hypertension must be screened for pheochromocytoma. This case presented clinically as recurrent cerebrovascular disease (CVD).

Keywords: Hypertensive emergency, pheochromocytoma, secondary hypertension, recurrent cerebrovascular disease

heochromocytoma is a tumor of the sympathetic or parasympathetic nervous system and is one of the causes of secondary hypertension, which is refractory to antihypertensive therapy. This is a curable cause of hypertension and its early detection and diagnosis is equally important.

CASE REPORT

Chief Complaints Mr. Suresh, a 22-year-old male was admitted to the hospital with chief complaints of: a) Inability to use both his left upper and lower limbs for 3 days; b) inability to speak; c) deviation of angle of mouth to the right side; d) double vision and e) recurrent episodes of headache, palpitation and sweating. There was history of similar episode 2 years ago. He also had history of one episode of seizure 7 years before. On examination, his blood pressure (BP) was 220/120 mmHg and pulse rate was 120/min. Cardiovascular system, respiratory rate and per abdomen examination revealed no abnormalities. On neurological examination, he had left-sided hemiplegia, horizontal nystagmus with lateral gaze, left-sided 3rd nerve palsy, right-sided 6th nerve palsy and right-sided

lower motor neuron type of facial palsy and cerebellar signs. INVESTIGATIONS

Blood Investigations ÂÂ Hemoglobin 13.2 g/dL, total leukocyte count 5,000 cells/mm3, differential leukocyte count P62L34E4, erythrocyte sedimentation rate 16 mm/hour. ÂÂ Urea 35 mg/dL, creatinine 1 mg/dL, Na+ 134.1 mEq/L Cl- 85.2 mEq/dL, K+ 3.1 mEq/dL. ÂÂ Total cholesterol 138 mg/dL, triglycerides 119 mg/dL, high-density lipoprotein 38 mg/dL, low-density lipoprotein 76 mg/dL, very low-density lipoprotein 24 mg/dL. Cholesterol ratio 3.6. ÂÂ Antiphospholipid antibody 6.67 U/mL. ÂÂ 24-hour urinary vanillylmandelic acid (VMA) 18.88 mg/24 hours (normal value <6-8 mg/dL in adults). ECG Sinus tachycardia, electrical left atrial enlargement/left ventricular hypertrophy.

Chest X-ray Normal

*Professor and Head †Professor ‡Associate Professor #Assistant Professor §Postgraduate Dept. of Medicine, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu

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MRI Abdomen Multiple relatively defined discrete lesions of varying sizes noted in the bilateral para-aortic region, extraadrenal pheochromocytoma, shrunken right kidney.

CARDIOLOGY Laparotomy was done and multiple tumors were excised from the bilateral para-aortic region. There was an intraoperative rise in the BP associated with handling of the tumors, which was brought to control by NTG infusion. A small portion of the tumor near the left renal vein was left behind because of difficulty in removing it without damaging the left renal artery. Postoperatively, the BP increased to 220/130 mmHg, which was managed by NTG infusion and magnesium sulfate regime. His BP was stabilized to 130/100 mmHg within a week and was discharged with methyldopa 250 mg b.i.d. and vitamins. During follow-up, his BP was found to be within normal limits.

Histopathological Examination Specimen: Extra-adrenal pheochromocytoma. Gross: Several fragmented dark brown masses in aggregates of size 7 × 4 × 3 cm. The cut surface showed a dark yellow to orange nodular lesion with a thin rim at the periphery. Microscopy: Revealed small nesting growth pattern (zellballen appearance). Tumor cells were fairly uniform with finely granular cytoplasm. Diagnosis: Extra-adrenal mass, excision-pheochromocytoma. DISCUSSION

Figure 1. MRI abdomen showing multiple relatively defined discrete bilateral lesions in para-aortic region and extraadrenal pheochromocytoma.

CT Brain Multiple infarcts. COURSE IN HOSPITAL He was admitted to the intensive care unit (ICU) with a BP of 220/120 mmHg and nitroglycerin (NTG) infusion was started to control his BP. There was a very irregular response. NTG infusion was gradually tapered and he was put on prazosin, calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors. Later, he was put on phenoxybenzamine, starting with 10 mg b.i.d. and increased to 20 mg t.i.d. After that, a b-blocker was added to control the tachycardia. He was advised low salt diet and adequate hydration. His BP was gradually reduced from 180/130-150/90 mmHg with episodes of wide fluctuations. After his BP was consistently below 160/90 mmHg for 2 weeks, he was taken up for surgery.

The patient was a young hypertensive who developed crossed hemiplegia due to brainstem lesion. Computed tomography (CT) brain showed multiple infarcts, which were secondary to hypertension. Urinary VMA was elevated and magnetic resonance imaging (MRI) abdomen showed multiple extra-adrenal masses. BP was refractory to antihypertensive therapy. Patient was put on a- and b-blockers, ACE inhibitor, methyldopa. Inspite of these drugs, his BP did not come under control. Metaiodobenzylguanidine (MIBG) scan could not be done because the patient could not afford it. Bilateral multiple extra-adrenal paraganglion masses were excised. In the postoperative period, BP started to come down and on follow-up, his BP was normal. ÂÂ About 10% pheochromocytomas are extra-adrenal and most of them are <10 cm in diameter. ÂÂ It manifests as hypertension, which responds paradoxically to antihypertensive therapy. ÂÂ Patients have paroxysms during which they develop headache, sweating and palpitations. ÂÂ Cardiac manifestations are supraventricular tachycardia, ventricular arrhythmias, angina and cardiomyopathy. ÂÂ Some patients present with acute respiratory distress syndrome.

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CARDIOLOGY ÂÂ

Patients should also be evaluated for other associated syndromes like multiple endocrine neoplasia 2A/2B, Von Hippel-Landau syndrome, neurofibromatosis, familial paraganglioma, familial pheochromocytoma with islet cell tumor, Sturge-Weber syndrome, ataxia telangiectasia, tuberous sclerosis and Carney’s triad.

CONCLUSION This case is being presented as a young hypertensive with recurrent cerebrovascular accident (CVA) and seizures who had resistant hypertension not amenable to antihypertensive therapy given in high dosage in different combinations. Urinary VMA was positive and further investigations confirmed pheochromocytoma. Surgical removal brought complete cure to the patient. Pheochromocytoma presenting as recurrent CVA is a very rare and unusual manifestation of the tumor. SUGGESTED READING 1. Stein PP, Black HR. A simplified diagnostic approach to pheochromocytoma. A review of the literature and report of one institution’s experience. Medicine (Baltimore). 1991;70(1):46-66. 2. Adler JT, Meyer-Rochow GY, Chen H, Benn DE, Robinson BG, Sippal RS, et al. Pheochromocytoma: current approaches and future directions. Oncologist. 2008;13(7):779-93. 3. Luo A, Guo X, Ren H, Huang Y, Ye T. Clinical features and anesthetic management of multiple endocrine neoplasia associated with pheochromocytoma. Chin Med J (Engl). 2003;116(2):208-11. 4. Pacak K, Linehan WM, Eisenhofer G, Walther MM, Goldstein DS. Recent advances in genetics, diagnosis, localization, and treatment of pheochromocytoma. Ann Intern Med. 2001;134(4):315-29. 5. Menger WM, Gifford RW Jr (Eds.). Clinical and Experimental Pheochromocytoma. 2nd Edition. Cambridge, MA: Blackwell Science; 1996. Figure 2. Histopathology showing small nesting growth pattern (zellballen appearance). ÂÂ

ÂÂ

There are reports of pheochromocytomas presenting as panic attacks, pre-eclampsia, impaired glucose tolerance and pulmonary edema. Biochemical assessment are done for urinary VMA, homovanillic acid, fractionated metanephrines and catecholamines. Plasma catecholamines, dopamine, free metanephrines (most sensitive) and chromogranin A may also be assayed. MRI/CT of the abdomen and MIBG scan help to localize the tumor.

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6. Sandur S, Dasgupta A, Shapiro JL, Arroliga AC, Mehta AC. Thoracic involvement with pheochromocytoma: a review. Chest. 1999;115(2):511-21. 7. Whalen RK, Althausen AF, Daniels GH. Extra-adrenal pheochromocytoma. J Urol. 1992;147(1):1-10. 8. Plouin PF, Chatellier G, Fofol I, Corvol P. Tumor recurrence and hypertension persistence after successful pheochromocytoma operation. Hypertension. 1997;29(5):1133-9. 9. Scott HW Jr, Halter SA. Oncologic aspects of pheochromocytoma: the importance of follow-up. Surgery. 1984;96(6):1061-6.

10. d’Herbomez M, Gouze V, Huglo D, Nocaudie M, Pattou F, Proye C, et al. Chromogranin A assay and (131) I-MIBG scintigraphy for diagnosis and follow-up of pheochromocytoma. J Nucl Med. 2001;42(7):993-7. ■■■■

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COMMUNITY MEDICINE

Trends of Leptospirosis Cases and Mortality in Western India KEDAR G MEHTA*, SHIKHA BANSAL†, AJAY SANGHVI‡, SUDARSHAN GUPTA#

ABSTRACT Background: Leptospirosis is common worldwide even in developing countries like India. It has been endemic in Gujarat, Western India since 1994, but there is a paucity of data regarding its cases and mortality. So, the current study is carried out with an aim to look over the trend of leptospirosis cases in Western India. Material and methods: The records of leptospirosis cases and deaths were collected from District Health Office, Valsad after taking necessary permissions. The last 5-year records of leptospirosis cases and mortality from January 2007 to December 2012 was analyzed using MedCalc software. Results: Initially, rising trend of leptospirosis cases were observed till 2010, then after a decline was seen in the trend. Case fatality rate (CFR) was nearly 25% in 2007, which reduced to almost 15% in 2011. CFR was nearly 22% in males and 15% in females, which was not statistically significant. Conclusion: Knowledge of such changing epidemiology of leptospirosis is essential for successful prevention, early diagnosis and treatment.

Keywords: Leptospirosis, trend, case fatality rate, India

eptospirosis is a worldwide zoonotic disease which is associated with many complications including death, since it was first reported in India.1 It is common in almost all parts of India, especially where heavy monsoon, animal rearing practices, unplanned urbanization and agrarian way of life is observed.2-7 Leptospirosis has long been recognized as one of the important causes of acute febrile illness in many parts of India.2,5 Though similar conditions exist in the West, reports of this disease from Western India are very few. Lack of awareness, clinical suspicion and active surveillance could be the probable reason. Leptospirosis has been a neglected

*Assistant Professor Dept. of Community Medicine GMERS Medical College, Vadodara, Gujarat †Officer-NTSU Ministry of Health and Family Welfare (MOHFW) Family Planning Division, MOHFW, New Delhi ‡Chief District Health Officer Valsad District Health Office, Valsad, Gujarat #Assistant Professor Dept. of Anatomy GMERS Medical College, Vadodara, Gujarat Address for correspondence Dr Kedar G Mehta Assistant Professor B/104, Amber Heights, Behind Yash Complex, Near Gotri Police Station, Gotri, Vadodara - 390 021, Gujarat E-mail: kedar_mehta20@yahoo.co.in

disease even in developed countries like USA.8 Leptospirosis has been under-diagnosed and underreported from India due to a lack of awareness of the disease, a lack of appropriate laboratory diagnostic facilities in most parts of the country, and a reliance on indigenous remedies to treat jaundice. It mainly occurs in farmers and individuals involved in water-related occupations and it can be 100 times more frequent in tropical areas. While most patients with Leptospira infection present only with mild fever and recover without complications, but still some proportion develops various complications due to involvement of multiple organ systems. Currently, there has been a paucity of data regarding the leptospirosis cases although being endemic in Gujarat since 1994.7,9,10 So, the current study was conducted with an objective to look over the trend of leptospirosis cases over last few years in Valsad district of South Gujarat. MATERIAL AND METHODS The current study was carried out by collecting retrospective records of diagnosed leptospirosis cases. The study was conducted after taking clearance from Institutional Ethics Committee and health officials. The records of leptospirosis cases and deaths were collected from District Health Office, Valsad after taking necessary permissions. The records regarding leptospirosis cases and deaths in Valsad district was obtained from January

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COMMUNITY MEDICINE

Table 1 shows the year wise comparison of leptospirosis case fatality rates (CFRs) from January 2007 to December 2012. As shown in Table 1, the trend of leptospirosis cases does not show significant difference in the last 6 years (χ2 : 2.82, p = 0.09). Figure 1 shows month-wise distribution of leptospirosis cases from 2010 to 2012 in which maximum 50-60 cases were seen in the month of September followed by 30-40 cases in the month of August. Figure 2 shows month-wise distribution of leptospirosis deaths from 2010 to 2012 in which around 13 deaths were observed in September followed by nine deaths in August during 2011, whereas no deaths were recorded in 2012. A total of 182 males and 61 females were recorded as leptospirosis cases from 2010 to 2012 as Table 1. Trend of Leptospirosis Cases and Deaths in Valsad District Year

Cases

Death

CFR (%)

χ2 for trend (p value)

2007

102

26.4

2.82 (0.09)

2008

25.6

2009

12.9

2010

106

23.5

2011

119

18.4

2012

2010

2011

2012 13

12 10

6 5

6 4

2 0

July

June

August

September

October

Figure 2. Month-wise distribution of leptospirosis reported deaths.

Males 100 90 80 70 60 50 40 30 20 10 0

Females 94

25 13

2010

2011

2012

Figure 3. Gender-wise distribution of leptospirosis cases.

Males 2010

2011

No. of cases

RESULTS

shown in Figure 3. As high as 40 males and nine females is gender-wise distribution of leptospirosis recorded deaths from 2010 to 2012 as clearly seen in Figure 4. Out of 182 males, 40 died while out of 61 female, nine died so making CFR 21.9% and 14.7% in males and females, respectively but is not statistically significant (χ2: 1.06, p = 0.06).

No. of cases

2007 to December 2012. Whereas, month-wise and gender-wise records of leptospirosis cases and deaths were obtained for 3 years only, which includes from January 2010 to December 2012. Data were entered in Microsoft Excel worksheet and analysis was carried out using MedCalc software Version 11.5.0.11

Females

2012 25

20 No. of cases

No. of cases

50 40

30 20 10 0

18 1 0 0 June

5 35 July

6 August

3 September

16 4

October

Figure 1. Month-wise distribution of leptospirosis cases.

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Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

15 10 5 0

2010

2011

0 0 2012

Figure 4. Gender-wise distribution of leptospirosis reported deaths.

COMMUNITY MEDICINE DISCUSSION Leptospirosis, an infectious disease caused by spirochetes known as leptospira, of which more than 20 serogroups and more than 200 serovars are known. Leptospirosis had long been considered a rare zoonotic disease in India, with only sporadic cases being recorded and with very wide geographical distribution. There has been large proportion of cases still underreported and under-diagnosed in India, but combining clinical expertise and awareness with confirmatory laboratory backup can definitely increase the recognition of patients with leptospirosis. Everard point out that where leptospires are widespread in the environment, and where the disease is endemic, infection will be related to a way of life as well as to specific occupations.12 Leptospirosis is endemic in South Gujarat since 1994 and the endemic districts are Valsad, Navsari and Surat.7,9,10 As shown in Table 1, no specific trends of leptospirosis cases were observed from January 2007 to December 2012. Although, initially rising trends were seen but thereafter, it remained steady and it showed drastic decline in the year 2012. The initial increase in number of leptospirosis cases during the last few years could be possibly due to greater awareness of this disease in South Gujarat. This alarming prevalence of leptospirosis in the society would have reflected the health officials for early necessary steps to prevent further outbreaks. The reasons for the decline in severe leptospirosis in 2012 may be greater awareness of disease, availability of better diagnostic facilities and widespread use of antibiotics as chemoprophylaxis. A study conducted by Sethi et al also observed similar rising trends and a decline afterward in leptospirosis cases in North India.13 CFRs were as high as 26% in 2007, which has been reduced to nearly 18% by 2011 and 0% by 2012. The number of cases and mortality rates often fluctuates from year to year due to various factors such as rainfall, flooding and animal infections. A study done by Antony et al concluded that CFR of leptospirosis was as low as 4.13% in Kerala.14 It is clearly seen in Figures 1 and 2, that the peak of leptospirosis cases and deaths was seen in the months of August, September and October. Since, it is the period after maximum rains in Gujarat and more water stagnation during the monsoon may be reasons for such peak. Intimate contact with animals, unprotected entry into waterlogged fields and bathing in contaminated

community ponds are a part of rural life in India. These are precisely the conditions most suitable for the survival and transmission of Leptospira.2 Moreover, agroclimatic conditions including heavy rainfall, clay soil and high water table for South Gujarat favor endemicity and more CFR of leptospirosis.9 Thus, the stupendous rise in the number of cases seen in this study during this period should not come as a surprise. Persons of all ages and races are susceptible. But as shown in Figures 3 and 4, cases and deaths recorded were more among males as compared to females. Moreover, CFR was also high among males (21.9%) as compared to females (14.7%). Similar findings of high CFR in males were also obtained in a study done by Antony et al. This may be because men are more frequently working outside in high-risk jobs like farming, paddy fields and other water-related outside activities. Contradictory to our study, high prevalence of leptospirosis was seen among females as compared to males in a study done by Swapna et al in Calicut.4 CONCLUSION A significant rise in the number of leptospirosis cases and mortality in South Gujarat has been documented till 2010 and thereafter a considerable decline in the same has been noted. But, still further effective leptospirosis control in these areas needs a multifactorial approach. However, knowledge of such changing epidemiological parameters of leptospirosis is essential for successful prevention, early diagnosis and treatment. REFERENCES 1. Sambasiva RR, Naveen G, Bhalla P, Agarwal SK. Leptospirosis in India and the rest of the world. Braz J Infect Dis. 2003;7:178-93. 2. Sehgal SC. Epidemiological patterns in leptospirosis. Indian J Med Microbiol. 2006;24:310-1. 3. Anagnani R, Pathak AA, Mishra M. Prevalence of leptospirosis in various risk groups. Indian J Med Microbiol. 2003;21:271-3. 4. Swapna RN, Tuteja U, Nair L, Sudarsana J. Seroprevalence of leptospirosis of high risk groups in Calicut, North Kerala, India. Indian J Med Microbiol. 2006;24:349-52. 5. Sumathi G, Narayanan R, Shivakumar S. Leptospirosis Laboratory, Madras Medical College: review of our experience. Indian J Med Microbiol. 2008;26:206-7. 6. Basu D, Sarkar P, Chakraborty N, Chanda PR, Biswas S, Bera AB, et al. Leptospirosis and Weilâ&#x20AC;&#x2122;s disease in eastern India. J Indian Med Assoc. 2003;101:532,534,536. 7. Clerke AM, Leuva AC, Joshi C, Trivedi SV. Clinical profile of leptospirosis in south Gujarat. J Postgrad Med. 2002;48:117-8.

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COMMUNITY MEDICINE 8. Shivakumar S, Shareek PS. Diagnosis of leptospirosis using modified Faine’s Criteria. J Assoc Physicians India. 2004;52:678-9. 9. Report of the Brainstorming meeting on leptospirosis prevention and control. Joint Publication by Office of WHO, Representative to India, New Delhi and Regional Medical Research Centre (ICMR), WHO Collaborating Centre for Diagnosis, Research, Reference and Training in Leptospirosis; 2006.

11. MedCalc for Windows, Version 11.5.0 MedCalc Software, Ostend, Belgium. 12. Everard JD, Everard COR. Leptospirosis in the Caribbean. Reviews in Medical Microbiology. 1993;4:114-22. 13. Sethi S, Sharma N, Kakkar N, Taneja J, Chatterjee SS, Banga SS, et al. Increasing trends of leptospirosis in Northern India: a clinico-epidemiological study. PLoS Negl Trop Dis. 2010;4(1):e579.

14. Antony J, Celine M, Chacko M. Case fatality rate of 10. Patel BK, Gandhi SJ, Desai DC. Clinico-epidemiological leptospirosis in a tertiary care hospital in Kerala, India. aspects of leptospirosis in south Gujarat. Indian J Med Microbiol. 2006;24(4):322-6. Ann Trop Med Public Health. 2012;5(3):236-9. ■■■■

ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ

ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ

ÂÂ ÂÂ ÂÂ

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Zoonosis: Dog Hygiene Risk of transmission from contact with dogs is low and may be further reduced by simple precautions. Dogs should be seen by a veterinarian on a regular basis. Dogs should be treated promptly for diarrhea. Dogs should be vaccinated for rabies. Dogs should be treated to prevent heartworm disease (Dirofilaria immitis). Effective flea control requires treatment of affected dogs, their environment and other animals they contact. Dogs should be fed high quality commercial food. Dogs should not eat raw meat or eggs. Raw meat may have higher rates of Campylobacter and Salmonella in their stools. Dogs should not be allowed to eat garbage, feces, or hunt. Dogs should not be allowed to drink non-potable water (e.g., surface water or toilet water). Dogs should be inspected for ticks regularly. Dog owners should wash their hands following contact with or cleaning up dog feces. Groups at high risk for serious infection from pets include: Persons with waning immunity (e.g., older adults); children less than five years old; pregnant women and immunocompromised patients with AIDS, those without a functioning spleen or taking immunosuppressive therapy. To avoid infections, people at higher risk should take particular precautions with any animal contact. They should do thorough and frequent hand wash. They should avoid contact with animals and their environment (e.g., pens, bedding and manure).

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

CRITICAL CARE

Leukemoid Reaction Following Air Embolism in Kidney Transplant Recipient VISHAL V RAMTEKE*, MM BAHADURâ&#x20AC; , CL CHAUDHARY*

ABSTRACT Air embolism in nephrology practice is infrequently noted following accidental air entry from the hemodialysis catheter. Leukemoid reaction due to air embolism is rare. We report a case of air embolism in a kidney transplant recipient following hemodialysis catheter removal manifesting as acute respiratory distress and leukocytosis. We stress on the need of its prompt diagnosis and utility of hyperbaric oxygen therapy (HBOT) as an effective treatment modality.

Keywords: Air embolism, kidney transplant, hyperbaric oxygen therapy

atrogenic entry of air in circulation during hemodialysis catheter insertion or removal can be fatal and require a high index of suspicion for diagnosis. We present a case of air embolism following hemodialysis catheter removal presenting as leukemoid response which was diagnosed and managed successfully with hyperbaric oxygen therapy (HBOT). CASE REPORT A 28-year-old male patient underwent pre-emptive live related kidney transplantation after getting dialyzed from right internal jugular triple lumen straight hemodialysis catheter inserted under sonology guidance. The catheter was left in situ for fluid infusion and central venous pressure monitoring. The patient was observed in kidney transplant room postoperatively. On 7th postoperative day, removal of dialysis catheter was done in supine position. The patient was extremely anxious and coughed during catheter removal. He had sudden dyspnea followed by bradycardia (heart rate-50/min),

*Resident â&#x20AC; Consultant Nephrologist Dept. of Nephrology Jaslok Hospital and Research Centre, Mumbai, Maharashtra Address for correspondence Dr Vishal V Ramteke Resident Dept. of Nephrology Jaslok Hospital and Research Centre 15-G, Deshmukh Marg - 400 026, Mumbai, Maharashtra E-mail: vvramteke@gmail.com

hypotension (blood pressure-90/54 mmHg) and syncope, which responded to injection atropine 1 mg. This was followed by sinus tachycardia (heart rate >160/min), desaturation (SPO2-70%) and hypoxemia (PaO2- 47%) on arterial blood gas (ABG). He complained of severe body ache. Patient was put on noninvasive ventilation (NIV) and shifted to medical intensive care unit where ionotropes were started. Chest radiograph was unremarkable and ECG showed sinus tachycardia without S1Q3T3. D-dimer was normal and 2D Echo did not show right ventricular strain or thrombus in pulmonary vessels. Sudden leukocytosis (TLC of 68,000/mm3 from 14,600/mm3; 4 hours earlier) increasing further the next day (1,05,000/mm3) without toxic granulation on peripheral smear was noted. Possibility of air embolism following catheter removal was considered due to the stormy course and deterioration from absolute stable condition. Sepsis was ruled out by sterile blood, sputum cultures and normal procalcitonin levels. Pulmonary thromboembolism was unlikely as D-dimer and lower limb venous Doppler was normal. Considering the temporal association of acute presentation following catheter removal, the patient was subjected to HBOT with a clinical diagnosis of air embolism. He received 3 hours session at 2.5 Atm at 100% oxygen on Day 1 with short interruptions as no ionotrope infusions and monitors were allowed in HBOT chamber. On 2nd day, he received two sessions of 4 hours each. Injection heparin 1,000 U/hour was given for anticoagulation. Injection meropenem 1 g t.d.s. was started in view of the severe leukocytosis and

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CRITICAL CARE shock. Patient dyspnea and body ache subsided and the requirement of ionotropes, bilevel positive airway pressure (BiPAP) support decreased over next 48 hours. The leukocytosis subsided with counts normalizing to 10,800/mm3 on 4th day. Patient was shifted to ward and was asymptomatic on room air from 5th day. Patient was discharged in health with normal renal allograft function and is doing well on follow-up. DISCUSSION Air embolism due to hemodialysis catheters is seen with 1 in 47 to 1 in 3,000 catheters noted during catheter insertion, removal, manipulation or disconnection.1 Risk increases during deep inspiration and patient in the upright position during catheter removal or immediately postremoval causing a pressure gradient for passage of air into the blood vessel.3 Amount of air, the speed of entry and body position at the time of embolism determine the mortality, which can be as high as 30%.4 Fatal dose is 300-500 mL at a rate of 100 mL/sec but even 15 mL of air can be fatal in hemodynamically unstable patients.1,2,5 Rapid entry of large volume of air causes right ventricular outflow obstruction and death. In our patient, hyperventilation and cough might have led to air embolism during the catheter removal. Air embolism presents with sudden hypotension, dysrhythmia, chest pain, dyspnea most of which were noted in our patient.1,2 Headache, syncope and seizures seen with arterial air embolization can occur in venous embolization following ‘paradoxical embolism’. Hypoxemia (due to alveolar shunting) and hypercarbia (due to increased dead space) may be seen on ABG. Nonspecific ST/T wave changes and right ventricular strain may be seen on ECG. Transesophageal Echo is the most sensitive investigation detecting as little as 0.02 mL/kg of air and accurately locating air bubbles as small as 5-10 microns. Leukemoid reaction following systemic inflammatory response (SIRS) is an inconsistent finding.6 Air forms microscopic bubbles disrupting the microvascular flow triggering platelet aggregation, release of plasminogen activator inhibitor, interleukin-1 and tumor necrosis factor leading to SIRS and leukocytosis. Identification of the source and stopping of the further entry is crucial. About 50% of air can be aspirated from the right heart with catheter in situ. Head low in left lateral decubitus position allows passage of air out of the outflow tract by placing it below the right ventricular cavity. Volume replacement to increase venous return, inotropes and mechanical ventilation may be required. HBOT is advocated by some (more

in arterial air embolism than venous) as treatment of choice. It delivers 100% oxygen improving hemoglobin saturation, peripheral tissue oxygenation and reduces air bubble size by reducing the nitrogen content.2 Though promising even with delayed initiation, efficacy of HBOT in air embolism is not a validated option considering the logistic difficulties involved and the critical condition of patients.4,7 Intravenous lignocaine, corticosteroids and heparin have not found to be effective. Prevention strategies include catheter removal in supine or Trendelenburg position, breath held in at the end of inspiration or during a Valsalva maneuver.8 In mechanically ventilated patient, it should be removed at end-inspiration. Direct pressure should be applied on the catheter site for several minutes after bleeding has stopped and an occlusive dressing should be placed over the exit site.9 In conclusion, though air embolism is uncommon, a prompt diagnosis and aggressive management as done in our case can prove life saving. Though HBOT is not a validated treatment modality, its use considering the benefit versus risk involved can have good impact on the final outcome. REFERENCES 1. Orebaugh SL. Venous air embolism: clinical and experimental considerations. Crit Care Med. 1992;20(8):1169-77. 2. Palmon SC, Moore LE, Lundberg J, Toung T. Venous air embolism: a review. J Clin Anesth. 1997;9(3):251-7. 3. Ely EW, Hite RD, Baker AM, Johnson MM, Bowton DL, Haponik EF. Venous air embolism from central venous catheterization: A need for increased physician awareness. Crit Care Med. 1999;27(10):2113-6. 4. Durant TM, Long J, Oppenheimer MJ. Pulmonary (venous) air embolism Am Heart J. 1947;33(3):269-81. 5. Shaikh N, Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock. 2009;2(3):180-5. 6. Tanus-Santos JE, Gordo WM, Udelsmann A, Cittadin MH, Moreno H Jr. Nonselective endothelin receptor antagonism attenuates hemodynamic changes after massive pulmonary air embolism in dogs. Chest. 2000;118(1):175-9. 7. Sheridan RL, Shank ES. Hyperbaric oxygen treatment: a brief overview of a controversial topic. J Trauma. 1999;47(2):426-35. 8. Wysoli MG, Covey A, Pollak J, Rosenblatt M, Aruny J, Denbow N. Evaluation of various maneuvers for prevention of air embolism during central venous catheter placement. J Vasc Interv Radiol. 2001;12(6):764-6.

9. Sing RF, Thomason MH, Heniford BT, Miles WS, Huyna TT, Jacobs DG, et al. Venous air embolism from central venous catheterization: under-recognized or overdiagnosed? Crit Care Med. 2000;28(9):3377-8. ■■■■

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DERMATOLOGY

Impetigo Herpetiformis: A Dermatologistâ&#x20AC;&#x2122;s Headache and an Obstetricianâ&#x20AC;&#x2122;s Nightmare SHAURYA ROHATGI*, SAURABH JINDAL*, HR JERAJANI*

ABSTRACT Impetigo herpetiformis (IH) is a rare, pustular dermatosis of pregnancy and often presents a therapeutic challenge due to the additional risk to maternal and fetal well-being. It is now generally regarded as a variant of pustular psoriasis during pregnancy. A 27-year-old female during the 6th month of pregnancy presented with intermittent fever and multiple tiny pustules all over the body. Histopathology was consistent with IH. In view of second episode of the disease during successive pregnancies, patient was started on oral prednisolone and cyclosporine simultaneously, which led to rapid resolution of the lesions in two and a half months. Steroids were tapered over the next one and a half months, but cyclosporine was continued until 1 month postpartum. The rest of the pregnancy, labor and peurperium were uneventful. An increased incidence of congenital anomalies and placental insufficiency resulting in increased risk of intrauterine growth retardation, stillbirth and neonatal deaths necessitates an early diagnosis and aggressive treatment. Although systemic steroids form the first-line of management, but factors such as steroid unresponsiveness, flare on withdrawal and metabolic decompensation associated with IH or due to adverse effect of steroids can result in fetomaternal morbidity and mortality. Therefore, instead of waiting for steroids to take effect, we also started the patient on cyclosporine. In addition, cyclosporine may be particularly relevant in cases of IH starting in the first trimester, where steroids are known to cause fetal malformations.

Keywords: Impetigo herpetiformis, pregnancy, pustular psoriasis, prednisolone, cyclosporine

mpetigo herpetiformis (IH) is a rare, pustular dermatosis of pregnancy and often presents a therapeutic challenge due to the additional risk to maternal and fetal well-being. In contrast to the given name, it is not a bacterial infection per se. It is now generally regarded as a variant of pustular psoriasis during pregnancy;1 however, some authors maintain that it is a distinct clinical entity.2 We report a case of IH in a 27-year-old presenting during the 6th month of amenorrhea.

surrounding skin. Similar lesions gradually appeared on legs, arms, chest, abdomen, back, buttocks, face and neck over the next few days.

CASE REPORT

We elicited a positive history of similar lesions 4 years back, during the previous pregnancy at about 6th month of gestation. The previous episode responded well to treatment with systemic steroids, but used to flare-up on steroid withdrawal. Hence, steroids were continued till term and no adverse effects were seen on the pregnancy outcome. No recurrence of similar pustular lesions was seen during the interim period.

A 27-year-old female in the 26th week of pregnancy (G2P2L1) presented with multiple tiny pus-filled lesions all over the body of 12-day duration. The lesions first appeared on the thighs associated with redness of the

*Dept. of Dermatology, Venereology and Leprosy MGM Medical College, Kamothe, New Mumbai, Maharashtra Address for correspondence Dr Shaurya Rohatgi 502, Sai Prasad Residency Sector 10, Kharghar, Navi Mumbai - 410 210, Maharashtra E-mail: shaurya023@gmail.com

The lesions used to dry up in the center with development of fresh lesions over adjacent areas. Patient also gave history of intermittent fever with nausea of 12-day duration. There was no history of any preceding infections, drug intake and irritant applications. There was history of a few itchy lesions on elbows on and off with winter exacerbation.

Clinical examination revealed fever (100â °F) with elevated pulse and respiratory rate. Palor, bilateral pedal and periorbital edema were also present. Cutaneous examination showed multiple tiny pustules on erythematous base over the chest,

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DERMATOLOGY abdomen, neck, back, thighs and face (Fig. 1) coalescing to form a ‘sheet of pus’ appearance (Fig. 2). Scalp showed localized scaly plaques. The pustules showed centrifugal extension to involve about 60-70% of body surface area. Oral cavity, genitals and hair were normal. Multiple superficial irregular pits were seen on the nails. Obstetric examination revealed a single live fetus with no anomalies on scanning. Histopathology revealed parakeratosis, acanthosis and subcorneal neutrophilic pustules consistent with IH (Fig. 3). Hemogram showed hemoglobin of 10.5 g/dL and leukocytosis (18.4 × 109/L) with neutrophilia (85%). Fasting and postprandial blood sugar, serum calcium, electrolytes, liver enzymes, thyroid function tests and urine routine/microscopy were within normal limits. Total proteins, serum albumin and globulin were low. Pus for culture showed no microbial growth. Patient was started on oral prednisolone 60 mg/day (1 mg/kg/day). In view of second episode of the disease during successive pregnancies, and to avoid flare on steroid withdrawal, as well as metabolic and obstetric

Figure 1. Multiple tiny pustules and erythema with few areas showing exfoliation on the face and trunk.

Figure 2. Multiple tiny pustules coalescing to form 'lake of pus' appearance on the anterior aspect of right leg.

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complications, oral cyclosporine 150 mg (2.5 mg/kg/day) was also started simultaneously. Strict monitoring of vitals, sugars, calcium and electrolytes was carried out. There was rapid resolution of the pustules with generalized exfoliation and then complete subsidence of lesions in one and a half month (Figs. 4 and 5). In addition, systemic antibiotics, intravenous fluids, protein and calcium supplements were given. There

Figure 3. (a) Psoriasiform dermatitis with elongated parakeratotic scale-crust overlying small collection of neutrophils in the upper spinous layers (H & E, 10x). (b) High power view of scale-crust overlying collection of neutrophils in the upper spinous layers, also called as 'spongiform pustule of Kogoj' (H & E, 40x).

Figure 4. Resolution of the lesions on face and trunk one and a half month post-treatment.

Figure 5. Few pustules and exfoliation seen over the anterior aspect of left leg one and a half month post-treatment.

DERMATOLOGY was no flare after gradual tapering of steroids over the next one and a half month. Cyclosporine was continued until 1 month postpartum as IH is known to exacerbate following delivery. The rest of the pregnancy, labor and peurperium were uneventful and the patient delivered a healthy 1.9 kg baby girl at term. The patient was advised not to breastfeed, while she was on oral cyclosporine. DISCUSSION Hebra is credited with the first description of IH in 1872.3 It is controversial, whether IH is a form of generalized pustular psoriasis based on the identical histopathology, or a distinct entity. It is known to occur in patients with no personal or family history of psoriasis.4 Interestingly, our patient had history of itchy lesions on the elbow with probable winter exacerbations. Most common reported time of onset during pregnancy is third trimester, but it may occur earlier.5 IH is not thought to have a genetic background, but there are some familial case reports in literature.6 Although primarily seen during pregnancy, Chaidemenos reported monthly exacerbations during menstruation, which lasted for 7 years in a 26-year-old primigravida.7 Recurrence during subsequent conceptions, as was the case in our patient, is not an uncommon occurrence,8,9 and it may also persist or exacerbate during peurperium,10 hence treatment may have to be continued until after delivery. Possible triggers include decrease of serum calcium and vitamin D during pregnancy and peurperium.10 The primary lesion is a pustular eruption that begins symmetrically in the flexural and intertriginous areas with centrifugal extension. Gradually, erythematous patches with sterile pustules at their margins giving a â&#x20AC;&#x2DC;lake of pusâ&#x20AC;&#x2122; appearance are seen. Generalized eruption and even exfoliation of the whole body with impending erythroderma can also occur. Mucous membranes may be affected. Systemic features such as fever, sweating, tachycardia, nausea, diarrhea, vomiting, lymphadenopathy, splenomegaly and tetany; in severe cases renal or cardiac failure, may occur. Moreover, IH is associated with increased incidence of congenital anomalies and placental insufficiency resulting in increased risk of intrauterine growth retardation, stillbirth and neonatal deaths.10,11 Therefore, an early diagnosis is of utmost importance as fetomaternal morbidity and even mortality may

ensue. Although systemic steroids are widely used for the treatment of IH and may be well-designated as the drug of choice, certain cases flare on withdrawal or are unresponsive.9 Recent publications report the successful use of cyclosporine in the treatment of IH with the additional benefit of a good perinatal outcome.9,12,13 Antibiotics may be indicated for secondary bacterial infection. Fluid and electrolytes, especially calcium should be monitored and normalized. Cyclosporine is a selective immunosuppressive agent that attenuates T cell-mediated responses by preventing the formation of interleukin (IL)-2. According to the drug insert obtained from the US Food and Drug Administration (FDA) website, cyclosporine is classified as pregnancy Category C14, i.e. animal studies have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women. It is recommended that such drugs should be given only if the potential benefit justifies the potential risk to the fetus. The dose for cyclosporine is 2.5-5 mg/kg/day and it is noteworthy to point out that fetal toxicity in animal studies was noted only when the dose exceeded 6 mg/kg/day.14 Bar et al15 reported a malformation prevalence rate of 4.1% with use of cyclosporine, but this figure failed to achieve a statistical significance when compared to the prevalence of congenital malformation in general population (3%). The only catch while using this drug during pregnancy is high-risk of preterm birth and low birth weight.14,15 Interestingly, even systemic prednisolone is classified as pregnancy Category C drug as it is associated with a three fold rise in malformations, especially if prescribed during the first trimester16,17 and risk of low birth weight in later trimesters.17,18 Systemic steroids form the first-line of management, but there is high-risk of fetomaternal morbidity and mortality not only from steroid unresponsiveness, but also due to the associated metabolic decompensation seen due to IH itself or due to adverse effect of steroids. While managing our case, instead of waiting for steroids to take effect, we also started the patient on cyclosporine. With this report, we emphasize the use of cyclosporine side by side with steroids in the management of IH to prevent the impending complications of steroid flare on withdrawal. It might be particularly relevant in cases of IH starting in the first trimester where steroids are known to cause fetal malformations.

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DERMATOLOGY REFERENCES 1. Karen JK, Pomeranz MK. Skin changes and diseases during pregnancy. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ (Eds). Fitzpatrick’s Dermatology in General Medicine. New York: McGraw Hill Companies; 2008. pp. 955-62. 2. Heymann WR. Dermatoses of pregnancy update. J Am Acad Dermatol. 2005;52(5):888-29. 3. Hebra F. Ueber einzlne wahrend S chaft, dens wacherbette unde bei uterinal, Krankheiten der Frauen zu beobachtende Hautkrank-heiten. Wieb Med Wochenschr. 1872;48:1197-202. 4. Katsambas A1, Stavropoulos PG, Katsiboulas V, Kostakis P, Panayiotopoulos A, Christofidou E, et al. Impetigo herpetiformis during the peurperium. Dermatology. 1999;198(4):400-2. 5. Winton GB, Lewis CW. Dermatoses of pregnancy. J Am Acad Dermatol. 1982;6(6):977-98. 6. Erbagci Z, Erkiliç S. A case of recurrent impetigo herpetiformis with a positive family history. Int J Clin Pract. 2000;54(9):619-20. 7. Chaidemenos G, Lefaki I, Tsakiri A, Mourellou O. Impetigo herpetiformis: menstrual exacerbations for 7 years postpartum. J Eur Acad Dermatol Venereol. 2005;19(4):466-9. 8. Sahin HG, Sahin HA, Metin A, Zeteroglu S, Ugras S. Recurrent impetigo herpetiformis in a pregnant adolescent: case report. Eur J Obstetr and Gynecol Reprod Biol. 2002;101(2):201-3.

10. Fouda UM, Fouda RM, Ammar HM, Salem M, Darouti ME. Impetigo herpetiformis during the peurperium triggered by secondary hypoparathyroidism: a case report. Cases J. 2009;2:9338. 11. Oumeish OY, Parish JL. Impetigo herpetiformis. Clin Dermatol. 2006;24(2):101-4. 12. Imai N, Watanabe R, Fujiwara H, Ito M, Nakamura A. Successful treatment of impetigo herpetiformis with oral cyclosporine during pregnancy. Arch Dermatol. 2002;138(1):128-9. 13. Valdés E1, Núñez T, Pedraza D, Muñoz H. Recurrent Impetigo herpetiformis: successful management with cyclosporine. Rev Med Chile. 2005;133(9):1070-4. 14. Novartis. Neoral: prescribing information. [online] Available from http://www accessdata.fda.gov/ drugsatfda_docs/label/2012/050715s029,050716s030lbl. pdf [Accessed May 4, 2015]. 15. Bar Oz B, Hackman R, Einarson T, Koren G. Pregnancy outcome after cyclosporine therapy during pregnancy: a meta-analysis. Transplantation. 2001;71(8):1051-5. 16. Park-Wyllie L, Mazzotta P, Pastuszak A, Moretti ME, Beique L, Hunnisett L, et al. Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Teratology. 2000;62(6):385-92. 17. Bae YS, Van Voorhees AS, Hsu S, Korman NJ, Lebwohl MG, Young M, et al. Review of treatment options for psoriasis in pregnant or lactating women: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol. 2012;67(3):459-77.

9. Lakshmi C, Srinivas CR, Paul S. Recurrent impetigo 18. herpetiformis with diabetes and hypoalbuminemia successfully treated with cyclosporine, albumin, insulin and metformin. Indian J Dermatol. 2010;55(2):181-4. ■■■■

Crowther CA, Doyle LW, Haslam RR, Hiller JE, Harding JE, Robinson JS, et al. Outcomes at 2 years of age and repeated doses of antenatal corticosteroids. N Engl J Med. 2007;357(12):1179-89.

Sodium Nitrite and Citric Acid Creams Helpful for Anogenital Warts ÂÂ

Twice-daily application of sodium nitrite and citric acid creams cleared anogenital warts more effectively than placebo, suggests new research published in JAMA Dermatology.

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Hematopoietic Cell Transplant may Increase Skin Cancer Risk Hematopoietic cell transplant (HCT) recipients appear to be at an increased risk of developing skin cancer, suggests a systematic review published online in JAMA Dermatology.

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New Optical Device to Diagnose Basal Cell Carcinoma A new optical technology called multiphoton microscopy (MPM) could allow for noninvasive, painless and rapid diagnosis of basal cell carcinomas (BCCs) in the clinic, suggests a small pilot study published online April 24 in JAMA Dermatology.

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DEVICES AND GADGETS

Electronic Gadgets in Diabetes Management SHRIRAM V KULKARNI*, ADITYA SHRIRAM KULKARNI†

ABSTRACT Over the last few years, diabetes management has been improving but there is still a huge gap of unmet needs in this sector of healthcare and a proactive approach will surely make a lot of impact on majority of our patients attaining standard care targets. Diabetes management can be very significantly improved by using the modern technology of smart phones, simple electronic devices, which are affordable and make a change in patient care outcome.

Keywords: Diabetes management, electronic gadgets, patient care outcome

iabetes management can be very significantly improved by using the modern technology of smart phones, simple electronic devices, which are affordable and make a change in patient care outcome. There is a huge gap of unmet needs in this sector of healthcare and a proactive approach will surely make a lot of impact on majority of our patients attaining standard care targets. This has been stressed by all organizations like International Diabetes Federation (IDF).1

In this article, we will discuss the types of gadgets: ÂÂ

Apps which are built-in in any basic smartphone

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Addons: Wearables over wrist, over clothes

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Addons: Wearable-attached to the skin for vital signs sensing

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Gadgets of a specification can be attached to any internet-based instrument

The main needs of a diabetic patient are: ÂÂ

Glycemic control-monitoring—invasive as well noninvasive

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Adherence to the treatment

*Dept. of Internal Medicine Kulkarni Nursing Home, Khopoli, Raigad Diabetes-Heart and Child Care Center, Kharghar, Navi Mumbai, Maharashtra †3rd Year (Biotechnology Student) Pillai College of Arts, Commerce and Science Dr KM Vasudevan Pillai Campus, New Panvel, Maharashtra Address for correspondence Dr Shriram V Kulkarni Kulkarni Nursing Home, Khopoli, Raigad Diabetes-Heart and Child Care Center, Kharghar - 410 210, Navi Mumbai, Maharashtra E-mail: drsvk@yahoo.com

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Follow-up with regularity

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Maintaining: Preserving medical records

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Detecting conditions like arrhythmias, diabetic autonomic neuropathy, silent myocardial ischemia, hypoglycemia, falls, convulsions, etc.

The insulin pumps and the various add-ons are not discussed in details here. Diabetes management is a very fast changing subject with a lot of add-ons practically every day. Lack of a validating and controlling authority is an obstacle in using the gadgets right now in our country. Many standards are for the Caucasian populations and we need to adopt them to our settings. GLUCOMETERS Many glucometers can be attached to a smartphone and the results can be simultaneously relayed to the caregivers (nurse, dietician, exercise trainer and doctor). Various new biosensors, pailred or cell-based hybrid biosensors can be incorporated. The glucometer paired with the smartphone which have built in personalized insulin calculators which depend upon the caloric intake and physical-exercise activity will indirectly suggest the approximate dose if the caloric count is provided. The prototype of this is iBGStar blood glucose monitoring device. It, uses dynamic electrochemistry. This technology is created by a complex mathematical method that automatically adjusts for factors that can lead to inaccuracies in blood glucose readings such as temperature, humidity and hematocrit levels. Ninteen studies have shown the device to be 99.5% accurate and to meet the International Organization for Standardization’s standards for glucose monitors (ISO 15197). The iBGStar app was created from the

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DEVICES AND GADGETS WaveSense Diabetes app. The features of the WaveSense Diabetes app are nearly identical to the iBGStar app. Subtle differences in the iBGstar app include improved interface resolution, crisp, clear and visually appealing. There are many similar utilities in the use, we have to select according to its needs and features. GLUCOSE TATTOOS A Cambridge laboratory has developed a special ink for glucose tattoos that changes color-based on glucose levels in the blood. The ink is made-up of a bunch of tiny spheres, about 120 nm across that contain: “The glucose detecting molecule, a color-changing dye and another molecule that mimics glucose.” These molecules are moving around in spheres, and when they near the surface, they grab onto either glucose or the molecule that mimics glucose. If they mostly latch onto real glucose, the ink (and consequently the tattoo) will look yellow, but if they grab the fake glucose, the tattoo will look purple, indicating a low level of glucose in the bloodstream. Apparently, the tattoo itself doesn’t need to be a design or anything; it can be only a few millimeters across and get the job done. The technique is still a couple years off, but it’s a much more immediate and constant monitor of the blood than having to prick and swab a few times a day. EYESENSE The advanced version on the horizon is EyeSense, which uses the eye as a preferred glucose monitoring site. We are able to eliminate problems associated with other technologies in this field. The blood glucose is measured in the tissue fluid under the conjunctiva of the eye. This site is particularly well-suited because: ÂÂ

The transparency of the conjunctiva, which makes optical monitoring ideal

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The site is normally covered by the eyelid

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Compared to other body sites

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The conjunctiva shows an excellent acceptance of implants

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Implanting the sensor is simple and pain free

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The conjunctiva has a particularly good blood supply.

A biochemical sensor is used to monitor blood glucose. It reacts reversibly to the glucose concentration and correspondingly emits differing fluorescence intensity, correlating to the monitored glucose concentration. The sensor is placed at the eye rim by an ophthalmologist. The implantation is painless and takes only 3 minutes.

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The size, site and material of the mini sensor are specially chosen to firstly avoid a feeling of a ‘foreign body’ in the eye and secondly to leave the functioning areas, essential for sight, untouched. The sensor is not visible and can be worn for up to 1 year before being replaced. In this time, a small monitoring hand device is used for blood and touch-free monitoring. Its emitted light falls on the eye sensor and reads out the returned optical signal sent from the sensor. Once, the device is calibrated, the results are expressed in the usual blood glucose measuring units. An added advantage, along with the painlessness, of this completely new measuring technique, is that one can measure as often as wished without additionally incurred costs. A measurement lasts only a few seconds. HYPOGLYCEMIA THE DEADLIEST BARRIER IN GLYCEMIC CONTROL-HYPOBAND Hypoband is an intelligent Bluetooth interface; a smartphone device that measures cold sweat. It works on android and triggers for help via a phone call or short message service (SMS) when the threshold limits are met or when the panic button is activated. It also has a standalone alarm mode. Whether your loved ones are near or far, hypoband is the only remote connectivity cold sweat device that gives you a peace of mind. ‘Cold sweats’ refers to sudden sweating that doesn’t come from heat or exertion. Hypoband works by pairing it with via bluetooth to an android smartphone. The smartphone calls out, SMS or alarms when the hypoband detects cold sweat or a panic button is triggered., it measures and detects sweat levels and skin temperature. The SMS/call/alarm sequence will come into play and would initiate the smartphone to trigger the caregivers. As an added advantage, it can detect conditions like acute myocardial infarction, gastrointestinal bleeding, early septicemia of which all are characterized by cold sweating. NONINVASIVE GLUCOSE MONITORING GlucoTrack is battery-operated system to monitor glucose noninvasively. This innovation uses ultrasonic, electromagnetic and thermal technologies to noninvasively measure glucose levels in the blood. The hardware includes a main unit (MU), which contains display and control features, as well as transmitter, receiver and processor, and a personal ear clip (PEC), which is clipped to the earlobe and contains sensors and calibration electronics. The device is small, light and easy to use and handle. The MU can be shared by

DEVICES AND GADGETS

PATIENT RECORDS EHR INTERACTIVE mylife Diabass is an easy and flexible data management, software, for people with diabetes. It has advantages like that it replaces conventional ‘paper diabetes diaries’, records all the relevant therapy data easily and quickly, supports the analysis and monitoring of all data and generates a large number of useful reports. This special edition readout software provides you with an easy and convenient data management system for all other mylife devices, such as mylife OmniPod, mylife Unio, mylife Pura, Pura X and GM300. The option for manual data entry enables a complete replacement of paper-based diabetes diaries. Different graphics and tables support you in analyzing trends and monitoring blood glucose levels. To get the most out of the mylife Diabass data management software, set the therapy control with your individual goals and use it to improve the quality of your therapy. TUBE LESS INSULIN PUMP mylife OmniPod- The insulin patch pump: This insulin pump functions without tubing. It comprises two components: A ‘Pod’ that is adhered to the skin and acts as the actual insulin pump (with an insulin reservoir, cannula and insulin administration system). A ‘Personal Diabetes Manager’ (PDM) that controls the functions of the insulin patch pump. Compared with multiple daily injections (MDIs) insulin pump therapy has the following advantages, including: Smoother control, less hypoglycemic episodes and ease of functioning of device, no blockages.

Insulin pens that remember your last dose come in handy during moments when you can’t quite remember how much insulin you took—or how long ago: Novo Nordisk’s NovoPen Echo reusable insulin pen features half-unit dosing and a memory function that records your last insulin dose and how much time has passed since your injection. AMBULATORY GLUCOSE PROFILE Glucose monitoring is an integral and valuable part of diabetes management. It provides insight to clinicians, so they can take action and achieve better glucose control. Ambulatory glucose profile (AGP) provides a comprehensive view of the patient’s changing glucose levels over time, thus allowing the clinician to see patterns and adjust therapy accordingly. Based on the concept of the Modal Day, glucose data, collected over several days or weeks, are analyzed as if they occurred within a single 24-hour period and plotted in a series of bands around the median. While Modal Day analysis can sometimes be time-consuming and problematic, AGP is designed to be quick to generate and easy to interpret.

350 300 Glucose (mg/dL)

GlucoTrack model DF-F main features: Uses three different technologies simultaneously to increase accuracy; reliable results; complete set of data for each reading (user’s name/date/time/glucose level); long-term of calibration validity; provides spot measurements; visual and verbal glucose readings; MU supports up to three users; comparable to a smart phone in size and weight. Up to 1,000 recent readings per user; readings history data in tabular and graphic formats; USB communication for easy data downloading for back-up storage and analysis; user friendly: easy to operate, easy to read data, large color touch screen; repeatable audible result; reduced life cycle cost (less expensive than finger prick device in long-term) are the major advantages.

SMART INSULIN PEN

250 200 150 100 50 0 12 am

Target range Glucose (mg/dL)

up to three users (in model DF-F), although each user requires his/her own (individually calibrated) PEC. The device includes a USB port for data downloading (enables off-line analysis), as well as battery recharging.

4 am

350

9 am

0.0 pm

4 pm

9 pm

12 pm

Median 25th to 75th percentile

300

10th to 90th percentile

250

200 180 150 100 60 50 0

12 14 Time

0.0

AGP enables a rapid assessment of glucose stability and variability for the instant recognition by the clinician of patterns that require therapeutic adjustment.

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DEVICES AND GADGETS EXERCISE PROMOTION WITH VARIOUS ELECTRONIC COMMUNICATING GADGETS

PATIENT ALARM SYSTEMS: HOME MEDICAL ALARM, MEDICAL ALARM MONITORING

New fitness gadgets that can be clipped onto your belt or worn around your wrist, socks measure physical activity and they upload your heart rate or steps to social media sites like Facebook. This can keep you motivated if you have an exercise or weight loss goal. Wearable fitness trackers monitor everything from calories burned to heart rate to signs you’ve been still too long.

Patient safety becomes convenient and hassle-free with a selection of safety alarms and fall prevention products. A wide variety of door alarms and bed alarms are avaliable to enhance the care of patients.

Sync yours with a phone or tablet to keep up with the info–and to set and meet health goals. Need some friendly competition? Look for a fitness app that lets you join a group and compete against other users. Exercise promotion can be easily achieved with apps of pedometers, runtastic. It can help a PVD patient to assess improvement in claudication distance and effects on nonsmoking. SMART DRUG DISPENSERS TO IMPROVE THE COMPLIANCE Smart pillbox could help seniors live at home longer with help of a visiting nurse, responsible relative or a social worker—e-pill automatic pill dispenser gives you a warning about last few doses remaining as well as orders an online refill to the concerned agency. It sends a SMS to the caregiver about the medicines consumed CARDIAC ARRHYTHMIAS, AUTONOMIC NEUROPATHY AND SIMILAR CONDITIONS VITALITI Medical Monitor is a portable vital signs monitor and system that will be able to help diagnose the 15 different conditions specified by the Qualcomm Tricorder XPrize as targets. It continuously records ECG, measures the heart rate, heart rate variability, oxygen saturation, blood pressure, core body temperature, as well as parameters like respiration, movement, steps taken and calories spent. The main sensor is worn over the shoulders, with pads touching the chest doing much of the important sensing and a ear lobe sensor that is in charge of monitoring the heart rate and oxygen saturation. The whole system can stay on for up to 3 full days, streaming the various health parameters continuously that can be retrieved at any time using a smartphone or tablet. This can be an wonderful tool to diagnose earlyautonomic neuropathy, silent cardiac ischemia.

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A door alarm monitors motion through doorways. Once motion is detected by a sensor, the door alarm will immediately notify a caregiver that a patient or loved one is wandering out of a room. A bed alarm is a personal alarm that allows a caregiver to monitor the activity of a patient in bed. Generally, this type of alarm connects to a bed sensor or bed pad, and functions through detecting a lack of pressure. A bed pad, essentially, alerts the alarm unit when pressure is removed from the sensor. Truly, fall prevention has never been this easily accessible. FALLGUARD ECONOMY ALARM WITH BED ALARM SENSOR PAD Fall alarm and bed alarm sensor pad are available separately. The sensor pad is 10 × 30 inches, allowing caretakers to place the pad on the bed. When the sensor pad is connected to a fall/mobility monitor, the pressure pad will trigger the monitor when weight is removed from the pressure pad. The volume and alarm tone are adjustable. The alarm itself is also functional with other pressure pads such as the FallGuard floor mat sensor, chair or wheelchair sensor pad, and seat belt sensor. It can detect falls or deviation in position at any time or patients orientation in space. FallGuard economy alarm with bed alarm sensor pad include alarm gives audio and visual alert, has an test on/off switch on alarm, adjustable volume on alarm, three different alarm tones, silver-lining on bed alarm sensor pad, great fall alarm for beds of all sizes, breakaway cord for sensor pad, a long 72 inch cable for sensor pad and pad is water proof. DIAB-SPOT, A NONINVASIVE DIABETES SCREENING AN TEST Diab spot is a noninvasive test to identify people at risk for diabetes or prediabetes without overnight fasting, a blood draw or waiting for a lab result. DiagnOptics was the first to introduce a technology to noninvasively measure the tissue accumulation of advance glycation end-products (AGEs) by means of fluorescence techniques (AGE reader). Diab-spot features the AGE measurement and combines this with a small number of patient characteristics to calculate the Diab-spot test

DEVICES AND GADGETS result. These simple characteristics include questions about other well-known diabetes risk factors, which can be easily answered on the touch screen. Diabspot yields an immediate screening result on the spot. Diab-spot offers a noninvasive and convenient method for diabetes screening with an immediate screening result on the spot. Furthermore, the detection of (pre-) diabetes patients by Diab-spot is superior to FPG and glycosylated hemoglobin (HbA1C). In a multicenter clinical study in the Netherlands, both sensitivity and specificity of Diab-spot were significantly better than fasting plasma glucose and at least as good as HbA1C. The Diab-spot has a light source which illuminates the skin of the forearm. This light will excite fluorescent moieties in the tissue, which will emit light with another wavelength. In the used wavelength band, the major contribution in fluorescence comes from fluorescent AGEs linked mostly to collagen, but also to other proteins and lipids. The emitted light is detected using a spectrometer. By using specific technical adaptations including selection of specific wavelength, modulated or pulsed light sources, a more selective discrimination of specific AGEs can be obtained. SUGGESTED READING 1. International Diabetes Federation. Diabetes voice. In: Sir Hurst M (Ed.). A Technological Leap for Improved Diabetes Awareness and Education; 2015.

approach for using continuous glucose data to guide therapeutic decision making. J Diabetes Sci Technol. 2014;8(4):720-30. 3. Hoss U, Budiman ES, Liu H, Christiansen MP. Feasibility of factory calibration for subcutaneous glucose sensors in subjects with diabetes. J Diabetes Sci Technol. 2014;8(1):89-94. 4. Hoss U, Budiman ES, Liu H, Christiansen MP. Continuous glucose monitoring in the subcutaneous tissue over a 14-day sensor wear period. J Diabetes Sci Technol. 2013;7(5):1210-9. 5. Lutgers HL, Gerrits EG, Graaff R, Links TP, Sluiter WJ, Gans RO, et al. Skin autofluorescence provides additional information to the UK Prospective Diabetes Study (UKPDS) risk score for the estimation of cardiovascular prognosis in type 2 diabetes mellitus. Diabetologia. 2009;52(5):789-97. 6. Meerwaldt R, Graaff R, Oomen PH, Links TP, Jager JJ, Alderson NL, et al. Simple non-invasive assessment of advanced glycation end product accumulation. Diabetologia. 2004;47(7):1324-30. 7. Furuya F, Shimura H, Takahashi K, Akiyama D, Motosugi A, Ikegishi Y, et al. Skin autofluorescence is a predictor of cardiovascular disease in chronic kidney disease patients. Ther Apher Dial. 2015;19(1):40-4. 8. Hofmann B, Jacobs K, Navarrete Santos A, Wienke A, Silber RE, Simm A. Relationship between cardiac tissue glycation and skin autofluorescence in patients with coronary artery disease. Diabetes Metab. 2014;S12623636(14):00196-7.

9. Rigalleau V, Cougnard-Gregoire A, Nov S, Gonzalez C, Maury E, Lorrain S, et al. Association of advanced 2. Dunn TC, Hayter GA, Doniger KJ, Wolpert HA. glycation end products and chronic kidney disease Development of the Likelihood of Low Glucose (LLG) with macroangiopathy in type 2 diabetes. J Diabetes Complications. 2015;29(2):270-4. algorithm for evaluating risk of hypoglycemia: a new ■■■■

Screen Type 2 Diabetes for NAFLD People with type 2 diabetes who are obese and have dyslipidemia should be considered for screening for nonalcoholic fatty liver disease (NAFLD), suggests new research published online in Gut.

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DIABETOLOGY

Prevalence of Diabetic Retinopathy in Newly Diagnosed Type 2 Diabetes Mellitus Patients in South India DADAPEER KARIMSAB*, PREM KUMAR D†, PRATAP VGM‡, DILEEP HR#

ABSTRACT Background: Retinopathy is one of the serious and blinding complications frequently associated with diabetes mellitus. This study was done to determine the prevalence of diabetic retinopathy in newly diagnosed type 2 diabetes mellitus (T2DM) in South India. Material and methods: This was a cross-sectional study conducted from January 2014 to January 2015 on 100 newly diagnosed T2DM patients at Hassan Diabetes Centre at Hassan, Karnataka, India. Complete ocular examination was done by consultant ophthalmologist which included measurement of visual acuity, slit lamp examination and dilated fundoscopic examination by indirect ophthalmoscopy and slit lamp biomicroscopy. Diabetic retinopathy was diagnosed and graded according to Early Treatment of Diabetic Retinopathy Study Group. Results: Of the 100 newly diagnosed T2DM patients, 15% showed the presence of diabetic retinopathy. Nonproliferative diabetic retinopathy without diabetic maculopathy was seen in 9% and nonproliferative diabetic retinopathy with diabetic maculopathy was seen in 6% of newly diagnosed T2DM patients. Conclusion: Screening for diabetic retinopathy by dilated fundus examination should be advised compulsorily in newly diagnosed T2DM patients to prevent sight threatening complications of diabetic retinopathy.

Keywords: Type 2 diabetes mellitus, diabetic retinopathy

iabetes is a major public health problem that is approaching epidemic proportions globally. The number of diabetics worldwide in the year 2000, among adults more than 20 years of age, was estimated to be about 171 millions. Type 2 diabetes mellitus (T2DM) is the most common form of diabetes constituting 90% of the diabetic population. The number of patients with diabetes in India is currently around 40.9 million and is expected to rise to 101 million by 2030.1 Retinopathy is one of the most frequent and serious complication of diabetes mellitus. It is a major cause of blindness throughout the world in age group 20-60 years. The prevalence of retinopathy in newly diagnosed type 2 diabetic patients ranges from 5% to 35%. Blindness from diabetic retinopathy can be delayed with timely detection and appropriate therapy.2

*Associate Professor, Dept. of Ophthalmology †Professor and Registrar Dept. of Medicine Hassan Institute of Medical Sciences, Hassan and Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka ‡Consultant Primary Care Physician in Diabetes Hassan Obesity and Diabetes Wellness Centre, Hassan, Karnataka #Junior Resident

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This study was conducted to find the prevalence of diabetic retinopathy in newly diagnosed T2DM patients. MATERIAL AND METHODS The study was conducted from January 2014 to January 2015 on 100 newly diagnosed T2DM patients at Hassan Diabetes Centre at Hassan, Karnataka, India and the study type was cross-sectional study. Patients with type 1 diabetes mellitus (T1DM) and patients who were already on treatment were excluded from the study. All patients underwent general examination with measurement of body mass index, blood pressure by a physician and a diabetologist. Laboratory work-up of the patients included fasting and postprandial blood sugar levels, glycosylated hemoglobin, lipid profile, serum creatinine and urine examination for proteinuria. Complete ocular examination was done by consultant ophthalmologist which included measurement of visual acuity, slit lamp examination and dilated fundoscopic examination by indirect ophthalmoscopy and slit lamp biomicroscopy. Diabetic retinopathy was diagnosed by the presence of microaneurysms, dot blot hemorrhages, superficial retinal hemorrhages, cotton wool spots, hard exudates,

DIABETOLOGY venous beading, intraretinal microvascular retinal abnormalities and graded according to Early Treatment of Diabetic Retinopathy Study Group.3 Data was analyzed by using SPSS-10. The demographic and clinical characteristics of newly diagnosed patients with T2DM with retinopathy were compared with those of newly diagnosed patients with T2DM without retinopathy using chi-square test and student t-test. RESULTS Of the total study group of 100 patients, 15 patients (15%) showed presence of diabetic retinopathy. These results are shown in Table 1. Sixty percent of the patients with diabetic retinopathy showed nonproliferative diabetic retinopathy without diabetic maculopathy, 40% showed nonproliferative diabetic retinopathy with diabetic maculopathy requiring treatment and none of them showed proliferative diabetic retinopathy. These results are shown in Table 2. Sixty-five were females and 35 were males. Of the 15 patients who showed diabetic retinopathy, 12 were females and three were males. These results are shown in Table 3. The age of the study group ranged from 35-75 years. Ten patients who showed diabetic retinopathy were aged between 65 and 75 years. These results are shown in Table 4. All patients underwent general examination with measurement of body mass index, blood pressure by a physician and a diabetologist. Laboratory workup of the patients included fasting and postprandial blood sugar levels, glycosylated hemoglobin, blood cholesterol, serum creatinine. The analysis of the various Table 1. Prevalence of Diabetic Retinopathy in Patients Newly Diagnosed with T2DM Total number of patients newly diagnosed with T2DM 100

Patients with diabetic retinopathy

Patients without diabetic retinopathy

15 (15%)

85 (85%)

Table 2. Different Stages of Diabetic Retinopathy Seen in Patients with Diabetic Retinopathy, Classified According to Early Treatment of Diabetic Retinopathy Study Group Nonproliferative diabetic retinopathy without diabetic maculopathy 9 (60%)

Nonproliferative diabetic retinopathy with diabetic maculopathy 6 (40%)

Proliferative diabetic retinopathy

0 (0%)

clinical parameters showed that diabetic retinopathy at the time of diagnosis of diabetes was associated with high body mass index, high blood pressure, high blood sugar levels, increased blood cholesterol and elevated serum creatinine. The results are described in Table 5. The p value was calculated and a p value of <0.005 was taken as significant. Significant p value was associated with age, body mass index, blood sugar and glycosylated hemoglobin. Table 3. Sex-wise Distribution of the Study Total study population (n = 100)

Males 35 (55%)

Females 65 (65%)

Number of people with diabetic retinopathy 15 (15%)

3 (20%)

12 (80%)

Table 4. Age-wise Distribution of the Study Age group (years)

Number in the study population

Number of those with diabetic retinopathy

35-45

20 (20%)

1 (6.6%)

45-55

25 (25%)

1 (6.6%)

55-65

25 (25%)

3 (20%)

65-75

30 (30%)

10 (66.6%)

Table 5. Comparison of Clinical Parameters in Newly Diagnosed Diabetes Mellitus Patients with Diabetic Retinopathy Compared to those without Diabetic Retinopathy Clinical parameter

Newly diagnosed diabetes mellitus patients with diabetic retinopathy

Newly diagnosed diabetes mellitus patients without diabetic retinopathy

Body mass index

34.1 ± 5.5

30.1 ± 2.5

134/92 ± 12/6

124/80 ± 8/6

Blood sugar fasting/postprandial

201/270 ± 45/62

124/170 ± 15/32

Blood cholesterol

221 ± 42

174 ± 24

Serum creatinine

1.1 ± 0.2

0.9 ± 0.1

Glycosylated hemoglobin

9.5 ± 2.5

6.5 ± 1.5

Blood pressure

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DIABETOLOGY DISCUSSION

CONCLUSION

Noninsulin dependent diabetes mellitus (NIDDM) or type 2 diabetes constitutes, nearly 95-97% of all diabetic patients in most population groups. The prevalence of NIDDM varies considerably from <1% in some countries to 50% in certain populations and developing countries like Pima Indians and Micronesians.4 The number of patients with diabetes in India is currently around 40.9 million and is expected to rise to 101 million by 2030.5

The study tells the importance of screening for diabetic retinopathy at the time of diagnosis of T2DM, which will help in timely intervention and prevention of blindness. Along with this identification of the risk factors like high body mass index, high blood pressure, high blood sugar levels, increased blood cholesterol, elevated serum creatinine and controlling them will help in preventing the development and progression of diabetic retinopathy.

The course leading to complications related to diabetes starts with lingering dysglycemia. Chronic complications of diabetes, the major cause of morbidity and mortality, are often present at the time of diagnosis. The problem is further worsened as the diagnosis of diabetes is often delayed from months to years due to lack of symptoms, lack of awareness and the fear of unknown in spite of awareness.6

REFERENCES

Diabetes is a common cause of acquired blindness in developed and developing countries. In fact it is second only to cataract as a cause of blindness in India. This is indeed pathetic as it is a treatable cause and as more recent research has shown, to a certain extent, a preventable one also. There are an incredibly large number of undiagnosed diabetic patients who are unaware of their disease, depriving them of appropriate diabetes care and placing them at a greater risk of complications with untreated diabetes. Recent advances in screening and treatment have not resulted in a significant reduction in sight-threatening retinopathy.7

3. Diabetic Retinopathy Study Research Group. Design methods and baseline results. DRS report no. 6. Invest Ophthalmol. 1991;21:149-209.

In our study, the incidence of diabetic retinopathy in newly diagnosed patients with T2DM was found to be 15%. The similar results were obtained in various studies. A study by Wahab et al showed the incidence of diabetic retinopathy to be 15%.8 Similar studies by Abdollahi9 reported 13.8%, Agarwal10 reported 11.7% and Nathan11 has reported 12.6% prevalence of retinopathy in newly diagnosed T2DM. The analysis of the various clinical parameters in our study showed diabetic retinopathy at the time of diagnosis of diabetes was associated with high body mass index, high blood pressure, high blood sugar levels, increased blood cholesterol, elevated serum creatinine. The similar association was seen in a study by Wahab et al.8

1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projection for 2030. Diabetes Care. 2004;27:1047-53. 2. Hayat AS, Khan AH, Baloch GH, Shaikh N. Frequency and pattern of Retinopathy in newly diagnosed type 2 Diabetic patients in tertiary care centre settings in Abbottabad. J Ayub Med Coll Abbottabad. 2012;24(2):87-9.

4. Zimmet P. Type II (non insulin dependent diabetes) – an epidemiological overview. Diabetologia. 1982;22(6): 399-411. 5. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047-53. 6. Sosale A, Prasanna Kumar KM, Sadikot SM, Nigam A, Bajaj S, Zargar AH, et al. Chronic complications in newly diagnosed patients with Type 2 diabetes mellitus in India. Indian J Endocr Metab. 2014;18:355-60. 7. Sprafka JM, Fritsche TL, Baker R, Kurth D, Whipple D. Prevalence of undiagnosed eye disease in high-risk diabetic individuals. Arch Intern Med. 1990;150:857-61. 8. Wahab S, Mehmood N, Shaikh Z, Kazmi H. Frequency of retinopathy in newly diagnosed type 2 diabetes patient. J Pak Med Assoc. 2008;58:557-61. 9. Abdollahi A, Malekmadani MH, Mansoori MR, Bostak A, Abbaszadeh MR, Mirshahi A. Prevalence of diabetic retinopathy in patients with newly diagnosed type II diabetes mellitus. Acta Medica Iranica. 2006;44:415–9. 10. Agarwal S, Raman R, Kumari RP, Deshmukh H, Paul PG, Gnanamoorthy P. Diabetic retinopathy in type II diabetics detected by targeted screening versus newly diagnosed in general practice. Ann Acad Med Singapore. 2006;35:531-5.

11. Diabetes Prevention Program Research Group. The prevalence of retinopathy in impaired glucose tolerance and recent-onset diabetes in the Diabetes Prevention Program. Diabetic Med. 2007;24:137-44. ■■■■

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DIABETOLOGY

A Study of Ankle Brachial Index in Type 2 Diabetes Mellitus PREM KUMAR D*, PRATAP GM†, DILIP HR‡

ABSTRACT Peripheral arterial disease (PAD) is common in type 2 diabetes, which may lead to decreased blood flow to the limbs which is determined by lot of factors like duration of diabetes, dyslipidemia and hypertension. Ankle brachial index is a simple efficient tool for objectively documenting the presence of lower extremity PAD, which also determines the events of coronary artery disease. It is a simple, reproducible and cost effective tool for assessing lower extremity arterial stenosis in primary care treatment facilities. Early detection and prevention with adequate attention to risk factors will decrease the incidences of comorbid complication of diabetes mellitus.

Keywords: Peripheral artery disease, ankle brachial index, vascular Doppler

ecently, diabetes is considered as coronary vascular disease (CVD) equivalent, the morbidity and mortality of the disease is increasing every day. As disease may be complicated by presence of hypertension and dyslipidemia, the risk of microvascular complications is high. Limb amputations due to diabetes and its complications are very high compared to any other causes. There is lot of contributory factors that might play a role in the development of the disease, which might cause obstruction to the blood flow in the limbs causing ischemia and gangrene, which ultimately lead to amputation. A thorough examination along with biochemical markers such as high-sensitive C-reactive protein which is considered as marker of atherosclerosis and urine microalbumin estimation will determine the progression of microvascular and macrovascular complications of the disease. Ankle

*Professor and Registrar Dept. of Medicine Hassan Institute of Medical Sciences, Hassan and Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka †Consultant Primary Care Physician in Diabetes, Hassan Obesity and Diabetes Wellness Centre, Hassan, Karnataka ‡Junior Resident Address for correspondence Dr Prem Kumar D Professor and Registrar Dept. of Medicine Hassan Institute of Medical Sciences, Hassan and Rajiv Gandhi University of Health Sciences, Bangalore - 560 041, Karnataka E-mail: premdkumar@yahoo.com

brachial index (ABI) measurement will provide a lot of analytical details, which will help to determine the early complications. It is very simple to perform with the help of ultrasound probes which are available as automatic and manual models. ABI <0.90 has been shown to have sensitivity of 90% and specificity of 98% for detecting lower extremity stenosis of >50%. Periodical measurement of ABI will decrease the complications by early initiation of treatment. MATERIAL AND METHODS The study group consisted of 30 patients. Criteria such as age, duration of diabetes, associated conditions such as hypertension and dyslipidemia were standardized. Patients in the age group between 45 and 50 years with controlled blood glucose, blood pressure and lipid parameters were selected. The body mass index (BMI) of the selected group fell into normal between 18 and 24 kg/m2. Urine microalbumin, 24-hour excretion sample were below 30 mg/dL, which is an early marker of nephropathy and is also considered as independent marker of complications. Blood pressure was maintained below 130/80 mmHg and low-density lipoprotein (LDL) cholesterol was maintained below 100 mg/dL. ABI was estimated using smartdop 30EX for all patients; values are tabulated and analyzed. OBSERVATIONS Observations, based on the measured values were subsequently analyzed and tabulated. Thirty patients

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DIABETOLOGY Table 1. Ankle Brachial Index of the Patients Included in the Study No. of patients 30

Severe

Moderate

Mild

Borderline

Normal

Incompressible vessel wall

<0.5 0

0.5-0.79 0

0.81-0.89 1

0.91-0.99 4

1.0-1.4 23

>1.4 2

treatment. Three percent of the patients had lower ABI indicating mild stenosis. Six percent of the patient had increased ABI indicating incompressible arteries due to vessel wall calcification.

Percentage (%)

70 60 50 40

CONCLUSION

30 20 10 0

Mild

Borderline

Normal

Incompressible vessel wall

Figure 1. Percentage-wise of mild, borderline, normal and incompressible vessel wall.

were recruited for the study with the mean age groups between 45 and 50 years. These patients had a strong family history of CVD in the family. Twenty-three patients measured normal ABI between 1.0 and 1.4. Four patients measured borderline between 0.91 and 0.99. One patient had mild stenosis measuring between 0.81 and 0.89. Two patients measured >1.4, which indicates incompressible vessels due to calcification and stenosis (Table 1). Percentage of patinets having mild, borderline, normal brachial index and those with incompressible vessel wall is shown in Figure 1. DISCUSSION Decreased blood flow to the limbs might cause delayed wound healing and sometimes nonhealing ulcers which can result in severe infections and end up in limb amputations. Early detection and protection of vasculature will delay the progression into plaque formation and obstruction. Seventy-six percent of the patients in the study group had normal ABI indicating normal vessel wall. Thirteen percent of the patients had borderline ABI which indicates the onset of complications and needs further investigations and

Ankle brachial index is a wonderful tool in assessing peripheral artery disease (PAD) and complications of diabetes. With regular screening we can detect complications at very early stages which enables us to prevent and treat at early stages. This study has shown that approximately 25% of the patients with type 2 diabetes will have abnormal ABI which will have consequences of coronary artery disease, peripheral vascular disease and gangrene. Early detection and intervention will not only prevent the complications, but also improve the cardiovascular outcome and decrease the risks. SUGGESTED READING 1. Holt RIG, Cockram C, Flyvbjerg A, Goldstein BJ (Eds.). Textbook of Diabetes, 4th Edition. USA: Wiley-Blackwell; 2010. 2. Tentolouris N, Katsilim N, Dounis E, Makrilakis K, Tsapogas P. Atlas of Diabetic Foot, 2nd Edition. USA: Wiley-Blackwell; 2010. 3. Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, et al. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58(19):2020-45.

4. Potier L, Abi Khalil C, Mohammedi K, Roussel R. Use and utility of ankle brachial index in patients with diabetes. Eur J Vasc Endovasc Surg. 2011;41(1):110-6. ■■■■

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DIABETOLOGY

Pattern of HbA 1C in Newly Detected Type 2 Diabetes Mellitus PREM KUMAR D*, KRISHNAMURTHY VR†, PRATAP VGM‡

ABSTRACT The incidence of type 2 diabetes mellitus is increasing day by day. The disease is now becoming a global burden. According to the latest American Diabetes Association (ADA) guidelines, glycosylated hemoglobin (HbA1C) should be maintained below 7 to avoid microvascular as well as macrovascular complications; however, higher values may be acceptable depending on comorbidities and age. But during the initial stages, it is recommended to control below 7. HbA1C above 6.5 can be taken as diagnostic criteria for diagnosis of diabetes. First visit HbA1C was measured to know the common HbA1C visit pattern in type 2 diabetes patients.

Keywords: Glycosylated hemoglobin, type 2 diabetes mellitus, ADA guidelines

ype 2 diabetes mellitus is one of the most common forms of noncommunicable disease globally and few societies are ethnic groups are spared. It accounts for about 85% of cases of diabetes in the Caucasians and virtually all in certain nonCaucasian ethnic groups, 80% of the type 2 diabetes is developed in the developed countries and areas. Type 2 diabetes mellitus is a major component of metabolic syndrome characterized by dyslipidemia, hypertension and hyperglycemia with central obesity.

There are several criteria recommended for diagnosis of diabetes such as oral glucose tolerance test, measurement of fasting and postprandial blood glucose and according to latest American Diabetes Association (ADA) guidelines, glycosylated hemoglobin (HbA1C) above 6.5 is diagnosed as diabetes. It is recommended

*Professor and Registrar Dept. of Medicine Hassan Institute of Medical Sciences, Hassan and Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka †Assistant Professor Dept. of Surgery Hassan Institute of Medical Sciences, Hassan, Karnataka ‡Consultant Primary Care Physician in Diabetes Hassan Obesity and Diabetes Wellness Centre, Hassan, Karnataka Address for correspondence Dr Prem Kumar D Professor and Registrar Dept. of Medicine Hassan Institute of Medical Sciences, Hassan and Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka E-mail: premdkumar@yahoo.com

to control HbA1C below 7 to minimize the progression of microvascular and macrovascular complications. The present study involved the measurement of glycemic control in the form of HbA1C during their first visit to their outpatient department. MATERIAL AND METHODS One hundred cases of freshly detected type 2 diabetes patients were screened and HbA1C was measured irrespective of patient age, sex and occupation. HbA1C was measured using chromatography-based highperformance liquid chromatography (HPLL) assay. All the records were tabulated and analyzed. RESULTS HbA1C of all the 100 patients over a period of 3 months was measured and analyzed as shown in Table 1 and Figure 1. Table 1. HbA1C of the Patients HbA1C

No. of patients

5.0-5.9

6.0-6.9

7.0-7.9

8.0-8.9

9.0-9.9

>10

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DIABETOLOGY

>10

during their outpatient visits. These patient could be taken as potentially untreated, since they were freshly detected or they had not been screened previously. Most of the patients are frankly diabetic at the time of screening.

9 10

9.0-9.9

8.0-8.9 7.0-7.9

6.0-6.9

5.0-5.9

3 0

HbA1C

Figure 1. Analysis of HbA1C of the patients.

As HbA1C is a reliable test for diagnosis as well as assessing the control of diabetes, there is an increased need for the implementation of proper screening techniques and to detect the disease at an earlier stage. SUGGESTED READING 1. American Diabetes Association. Diabetes care: clinical practice recommendations (revised), 2014.

DISCUSSION

2. DeFronzo RA, Ferrannini E, Zimmet P, Alberti G (Eds.). Epidemiology of type 2 diabetes. International After analyzing the tabulated results, it was seen that Textbook of Diabetes, 4th Edition. USA: Wiley-Blackwell; more than 50 patients had HbA1C between 7.0 and 9.0 2015. ■■■■

Two Diabetes Drugs may Ease Fatty Liver Disease Two diabetes drugs, one approved and one investigational, show promise in treating fatty liver disease, according to new research presented here at the European Association for the Study of the Liver (EASL) International Liver Congress 2015. The glucagon-like peptide-1 analog liraglutide (Victoza, Novo Nordisk) resolved nonalcoholic steatohepatitis in more than a third of patients in a phase 2 study. Post hoc findings from another phase 2 study of the investigational sodium-glucose cotransporter-2 inhibitor remogliflozin etabonate suggest benefit in nonalcoholic fatty liver disease.

Endo Guidelines Keep Cholesterol Targets in T2D Cholesterol targets stay, according to new, more comprehensive American Association of Clinical Endocrinologists (AACE) guidelines for type 2 diabetes management that address both glycemic control and risk factors. The group did not endorse the American Heart Association/American College of Cardiology (AHA/ACC)’s lipid and obesity guidelines in 2013 that eliminated LDL goals and had called for its members to use AACE guidelines instead.

Doubling of Mortality Post-CABG in Type 1 Diabetic Patients Patients with type 1 diabetes undergoing CABG surgery have a more than twofold increased risk of death at 6 years compared with the general population undergoing CABG, according to the results of a new study. In contrast, individuals with type 2 diabetes have only a slightly worse prognosis 6 years after CABG compared with those without diabetes who underwent surgery.

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ENT

An Unusual Presentation of Adenoid Cystic Carcinoma at Nasal Septum: A Case Report KALPANA CHANDRA*, ADITI MITTAL†, PRAVEEN KUMAR‡

ABSTRACT Adenoid cystic carcinoma is a rare and slow growing salivary gland neoplasm with aggressive behavior and high recurrence rate. It originates from minor salivary glands commonly around the mouth, rare in parotids and uncommon in the nasal cavity and paranasal sinuses. It is extremely rare at nasal septum with only few reports available in the literature. We are presenting a case of adenoid cystic carcinoma of nasal septum who presented to ENT OPD for correction of nasal deformity caused by trauma resulting in swelling over the root of nose for 4 years.

Keywords: Adenoid cystic carcinoma, nasal septum

denoid cystic carcinoma (ACC) is one of the commonest malignant salivary gland tumors affecting major and minor salivary glands, constituting 10% of salivary neoplasm but uncommon in sinonasal tract.1,2 It arises both from paranasal sinuses and nasal cavity comprising approximately 3% of all the upper aerodigestive tract malignancies.3 Within the nasal cavity, the tumor usually involves the lateral wall rather than the nasal septum.3 The incidence of malignant tumors of nasal septum is rare and ranges from 2.7% to 8.4% of nasal and paranasal malignant tumors.4 We here present a case of ACC of nasal septum who presented to clinics only because of cosmetic deformity. CASE REPORT

with pain, tenderness and deformity following a history of trauma 4 years back. The swelling was 0.5 × 0.5 cm and firm to hard. All hematological and biochemical investigations were within normal limits. Anterior rhinoscopy was done, which showed a mild spur on right side with right deviated nasal septum. She was posted for septorhinoplasty for correction of deformity. A mass was found during the procedure and the same was sent for histopathology. On gross, multiple tan white tissue pieces were received and all were embedded. On microscopy, tumors were arranged predominantly in cribriform pattern and also in sheets, cords and confluent glands at occasional places (Figs. 1 and 2). These tumor cells were small to angulated with hyperchromatic nuclei and scanty to moderate amount of cytoplasm with indistinct cell borders. Few tubules

A 50-year-old female presented to the ENT OPD with chief complaints of swelling over root of nose associated

*Associate Professor †Junior Resident Dept. of Pathology Shri Ram Murti Smarak Institute of Medical Sciences (SRMS-IMS) Bhojipura, Bareilly, Uttar Pradesh ‡Associate Professor Dept. of Medicine Indira Gandhi Institute of Medical Sciences, Patna, Bihar Address for correspondence Dr Kalpana Chandra Associate Professor Dept. of Pathology SRMS-IMS, Bhojipura, Bareilly - 243 202, Uttar Pradesh E-mail: kalpana_chandra_14@yahoo.co.in

Figure 1. Cribriform pattern (H&E-10X).

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ENT

Figure 2. Cells arranged in cords (right) and showing hyalinization (on left) (H&E-10X).

Figure 3. Ductules lined by many layer of basaloid cells having angulated and hyperchromatic nuclei. Cells are haphazardly arranged around the extracellular spaces (H&E-10X).

contained eosinophilic and mucinous material in lumen (Fig. 3). Scanty stroma showed fibrosis, mucin and foci of sclerosis. Focally, the nasal mucosa was lined by pseudostratified respiratory epithelium (Fig. 4). Perineural infiltration was not identified in the submitted biopsy. On immunohistochemistry, tumor showed focal positivity for S-100 (Fig. 5) supporting the above finding and excluding the close differential of polymorphous low-grade adenocarcinoma (PLGA). The patient was discharged on request and was referred to a higher center. At All India Institute of Medical Sciences (AIIMS), New Delhi, CT scan was done, which revealed involvement of eyeball with intracranial extension. DISCUSSION Adenoid cystic carcinoma is a basaloid tumor consisting of epithelial and myoepithelial cells. The peak incidence

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Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

Figure 4. Normal respiratory epithelium (H&E-10X).

Figure 5. Focal positivity for S-100.

of occurrence is fourth to sixth decades of life with slight predominance in females.3 Most common site is maxillary sinus followed by nasal cavity,5 where it commonly involves the lateral wall of the nose. However, ACC limited to nasal septum is very rare with few reported cases in literature.5 Clinically, the patients with tumor in the nasal cavity usually present with nonspecific symptoms like nasal obstruction, epistaxis and pain but with same biological behavior as ACC of minor salivary glands being characterized by slow growth rate, high tendency of local recurrence and perineural spread. Histologically, tumors are composed of infiltrating cytologically bland, basaloid epithelial cells arranged in nests and cords and associated with abundant mucoid material forming pseudocysts. Three histologic patterns have been described - cribriform, tubular and solid. Out of these, cribriform pattern is most commonly encountered, which was also present in our case.3 Perineural invasion is invariably present, which was

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

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

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

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

Who is Eligible?

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

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

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

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

To promote and train hands-only CPR.

Activities of the Fund Financial Assistance

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

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

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

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

Drug Subsidy

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

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

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

BPL Card (If Card holder)

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

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

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

Free Diagnostic Facility

Free Education and Employment Facility

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

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

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

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

About Heart Care Foundation of India

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

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

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

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

Committee Members

Chief Patron

President

Raghu Kataria

Dr KK Aggarwal

Entrepreneur

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

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

Advisors Mukul Rohtagi Ashok Chakradhar

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

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

Rishab Soni

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

http://heartcarefoundationfund.heartcarefoundation.org

ENT not seen in our case. Adenoid cystic carcinoma has the tendency to spread hematogenously and perineurally but not lymphatically4 causing higher incidence of metastases to lung and rarely to neck lymph nodes. The less common sites of metastasis include bone, liver, brain and kidney. The closest differential diagnosis includes pleomorphic adenoma, PLGA and basal cell adenocarcinoma, which is a diagnostic challenge especially in small biopsy. Pleomorphic adenoma can be identified by the presence of mesenchymal elements, especially cartilaginous differentiation. Pleomorphic adenoma of minor salivary glands though is not a well-encapsulated tumor, but is well-circumscribed and lacks infiltrative pattern. PLGA contains overlapping histopathologic features with ACC but lacks a dual population of ductal and myoepithelial cells and tubular structures are lined by a single cell line. Perineural invasion is also commonly seen in PLGA. However, the key features in differentiating ACC from PLGA is the constant uniform cytological appearance of later, despite a variety of similar growth pattern. Role of immunohistochemistry is valuable more in unclear cases particularly in small biopsies where distinction between ACC and other malignant neoplasm may be challenging. Expression of c-KIT is negative or low not only in PLGA, but also in many other tumors of head and neck region as compared with the high c-KIT expression in ACC.6 ACC shows focal positivity for S-100, while PLGA is strongly positive for it. Our case also showed focal positivity for S-100. We could not apply immunohistochemistry for proliferation index which is commonly high in ACC as the patient had financial constraint. This tumor needs thorough sampling and definite histological evaluation since it has worse long-term prognosis and also limited clinical treatment options.

CONCLUSION Adenoid cystic carcinoma of nasal septum is an extremely rare and aggressive tumor commonly presenting with nonspecific symptoms, necessitating the need to keep this entity in differential diagnosis of any nasal septal masses for early diagnosis and satisfactory outcome.

Acknowledgment I take this opportunity to extend my gratitude and sincere thanks to all those who helped me to complete this study. I am highly thankful to Dept. of Pathology and ENT for providing me adequate facility, which helped me to carry out this study. I owe great sense of indebtedness to Dean, SRMS-IMS, Bhojipura, Bareilly for permitting me to carry out this study.

REFERENCES 1. Fordice J, Kershaw C, El-Naggar A, Goepfert H. Adenoid cystic carcinoma of the head and neck: predictors of morbidity and mortality. Arch Otolaryngol Head Neck Surg. 1999;125(2):149-52. 2. Gondivkar SM, Gadbail AR, Chole R, Parikh RV. Adenoid cystic carcinoma: a rare clinical entity and literature review. Oral Oncol. 2011;47(4):231-6. 3. Sivaji N, Basavaraj S, Stewart W, Dempster J. Adenoid cystic carcinoma of the nasal septum. Rhinology. 2003;41(4):253-4. 4. Belaldavar BP, Batra R. Adenoid cystic carcinoma of nasal septum: a rare case report. J Sci Soc. 2013;40(1):39-40. 5. Dulguerev P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra T. Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review. Cancer. 2001;92(12):3012-29.

6. Mino M, Pilch BZ, Faquin WC. Expression of KIT (CD 117) in neoplasm of the head and neck: an ancillary marker for adenoid cystic carcinoma. Mod Pathol. 2003;16(12):1224-31. ■■■■

Probiotic Nose Drops may Protect Against Meningitis Probiotic nose drops reduced the likelihood of students being colonized with the bacteria that cause meningitis, according to a study published online March 25 in Clinical Infectious Diseases. The nose drops contained Neisseria lactamica, a nondisease-causing relative of the bacterium that causes meningitis, Neisseria meningitidis. Epidemiological studies had previously shown that people who carry N. lactamica in their nose and throat are both less likely to be colonized with N. meningitidis and less likely to contract meningitis than people who do not, possibly because colonization with one species prevents colonization with the other.

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INTERNAL MEDICINE

A Case Study on Chronic Suppurative Melioidosis in Kerala DINULAL PP*, ALEEN CATHARINE†, MANAS JOSHI†, THENU JACOB†

ABSTRACT Melioidosis is an endemic to several South Asian countries. Now, it is a treatable emerging infection in India. In our case, a 50-year-old man presented with intermittent fever and left-sided chest pain for 3 months. He was a pet lover, had 10 cats and 8 dogs at home. He is an ex-smoker and alcoholic. He has been a diabetic for past 7 years. From the radiological and clinical findings, he was diagnosed to have melioidosis of left lung and treated. About 1½ year later, he had relapse of the disease with liver and spleen abscesses.

Keywords: Burkholderia pseudomallei, melioidosis, liver abscess, spleen abscess

elioidosis is a disease caused by Gramnegative organism, Burkholderia pseudomallei. It was considered as a glanders like disease. The etiological agent was first described by Whitmore and Krishnaswami. Later on, Stanton and Flecther named the disease as ‘melioidosis’.

chills and left-sided chest pain for 3 months. He is an ex-smoker and chronic alcoholic having diabetes for 7 years. He had 10 cats and 8 dogs at home and had close contact with his pets. He doesn’t remember any experiences of outdoor injury. He had no relevant history of travel.

The organism is found in contaminated soil and water. It can resist nutrient deficiency, acid and alkali pH, disinfectant, antiseptic solution, extreme temperatures and can adapt to host defensive enzymes. This disease is seen in both humans and animals. Diabetes mellitus, alcoholism, male gender are the predisposing factors of the infection. The disease can affect any organ, and can mimic many diseases.

On 1st May 2013, patient experienced high-grade fever with chills, generalized weakness, fatigue and weight loss. The erythrocyte sedimentation rate was 70 mm in 1st hour. White blood cell count was 8,000/mm3 with neutrophil (51%), lymphocytes (45%) and eosinophil (4%). C-reactive protein level was elevated to 26.6 µg/dL. On 3rd May 2013, computed tomography (CT) of thorax revealed loculated left pleural effusion with passive collapse of underlying lung fields and necrotic posterior mediastinal lymph nodes.

The classical symptoms of the disease are fever, chest pain and osteomyelitis. This disease is categorized as acute localized, acute pulmonary, disseminated and chronic suppurative infection. Ceftazidime, carbapenems, amoxicillin + clavulanic acid antibiotics are commonly used in the management of melioidosis. CASE REPORT A 50-year-old male living in Tirur, Kerala, India, presented with intermittent high-grade fever with

*Junior Resident Dept. of General Surgery Government Medical College, Calicut, Kerala †5th Year Pharm D National College of Pharmacy, Calicut, Kerala Address for correspondence Dr Aleen Catharine E-mail: aleencatharine07@gmail.com

The above features are likely of infective etiology possibly Koch’s. The multiple peripherally enhancing hypodense lesions in spleen likely represented microabscesses or granulomas. On 5th May, pleural fluid analysis showed adenosine deaminase (10 IU/L), protein (6 g/dL), sugar 232 (mg%), neutrophil (6%), lymphocyte (95%), white blood cell count (62/µL). From discrepancies of spiked fever and other clinical, radiological findings the patient was suspected to have pleural effusion and pulmonary tuberculosis. He was started with empirical antitubercular therapy and discharged on 6th May 2013. On 12th July 2013, he developed swelling on left chest wall and pleuritic chest pain. CT guide aspiration of pus from chest wall showed heavy growth of Burkholderia species sensitive to chloramphenicol, imipenem, tetracycline, co-trimoxazole, ceftazidime. On 18th July,

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INTERNAL MEDICINE CT-guided aspiration of pus from liver abscess had moderate growth of B. pseudomallei. The chest X-ray showed decreased rib space on left lower ribs and diaphragm pulled up on left side (Fig. 1). On 19th July, bronchial wash with cytology-isolated Pseudomonas aeruginosa resistant to co-trimoxazole, sensitive to amikacin, cefepime, ceftazidime, ciprofloxacin, gentamycin, imipenem, meropenem, ofloxacin, piperacillin. On 20th July, CT revealed multiple areas of left subsegmental atelectasis in basal segments of left lower lobe. Minimally displaced fracture in lateral aspect of 8th rib with adjacent collection; osteomyelitis to be excluded. Multiple nonenhancing hypodense areas with features of splenic cysts were present. On comparing with previous CT, pleural effusion was seen to resolve completely. From the clinical evidence, final diagnosis of pleuropulmonary melioidosis with osteomyelitis 8th left rib was made. Patient was responsive to imipenem and cilastatin combination. He was on his antituberculosis therapy (ATT) combination phase. Fever subsided and patient was discharged on 23rd July 2013.

not controlled with plain insulin, but injection, human mixtard and metformin combination could control it. Patient was put on ciprofloxacin and metronidazole, but when fever spiked despite the treatment, piperacillintazobactam combination was tried. After isolation of Burkholderia species, patient was given injection ceftazidime. The 28 days treatment could reduce fever

On 24th November 2014, patient was again admitted with spiked fever and generalized tiredness. The previous history of melioidosis went unnoticed. The clinical condition was suspected of malaria and treated with antimalarials. On 11th February 2015, patient was admitted with high-grade fever with chills, generalized weakness and fatigue. Routine laboratory investigations revealed erythrocyte sedimentation rate of 110 mm in 1st hour, white blood cell count was 6,600 cells/mm3, high blood sugar of (randomized blood sugar) 160 mg%, serum alkaline phosphate of 169 IU/dL, total protein to albumin ratio of 7.6/3.1. Peripheral smear showed microcytic hypochromic red blood cell, preterm neutrophils with toxic granules and mild thrombocytopenia.

Figure 1. Decreased rib space on left lower ribs and diaphragm pulled up on left side (18th July 2013).

On 12th February, ultrasonogram showed liver mildly enlarged, right lobe (15.3 × 6.3 × 5.8 × 5.6 mm) with solid cystic irregular and ill-defined mass in left lobe. Spleen was irregular in size with multiple small cystic linear avascular structures scattered in parenchyma. On 13th February, high dose contrast-enhanced CT (CECT) of abdomen showed multiple nonenhancing hypodense areas in left lobe of liver, the largest measuring of 6 × 4.3 × 7 mm extending to subcapsular location and spleen with multiple nonenhancing lesions (Fig. 2). On 15th February, pus drained from liver abscess was positive for B. pseudomallei by culture. Blood sugar was

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Figure 2. Multiple nonenhancing hypodense areas in left lobe of liver and multiple nonenhancing lesions in spleen (13th February 2015).

INTERNAL MEDICINE and have good diabetic control. Patient was discharged on 11th March 2015 with better health status.

can reduce the significant mortality and morbidity associated with this disease.

DISCUSSION

SUGGESTED READING

Melioidosis is a rare endemic caused by B. pseudomallei found in soil and water. It mimics many diseases and can cause multiple organ dysfunctions. Animals and humans usually acquire this disease from contaminated environment. Transmission of the disease is by ingestion, inhalation or by wounds and abrasions. Infected animals shed the organism through wound exudates, nasal secretions, milk, feces and urine which can survive the divesting temperature and pH of soil for several months. A human with exposed wound in contact with this soil gets infected. Unless the predisposing factors like diabetes mellitus, liver dysfunction, alcoholism and general physical wellbeing are controlled the patient will have relapses of the disease. Early detection and prevention of the disease

1. Whitmore A, Krishnaswami CS. An account of the discovery of a hitherto undescribed infective disease occurring among the population of Rangoon. Indian Med. Gaz. 1912;47:262-7. 2. Stanton AT, Fletcher W. Melioidosis, a new disease of the tropics. Trans 4th Congress Far East. Assoc Trop Med 1921;2:196-8. 3. Jamkhandi DM, Alex R, Geroge K. Melioidosis: a report of two cases. Natl Med J India. 2014;27(4):202-3. 4. Mukhopadhya A, Balaji V, Jesudason MV, Amte A, Jeyamani R, Kurian G. Isolated liver abscess in melioidosis. Indian J Med Microbiol. 2007;25(2):150-1.

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

Guidelines Not Followed in Testing for Acid Reflux Nearly 38% of the upper endoscopies performed in outpatients with gastroesophageal reflux disease and lowrisk dyspepsia do not adhere to current best-practice guidelines, according to new research presented at the Society of General Internal Medicine 2015 Annual Meeting in Toronto. According to the American College of Physicians (ACP), “inappropriate use of endoscopy generates unnecessary costs and exposes patients to harms without improving outcomes.”

Zoledronic Acid Ups BMD in Seniors without Cutting Fractures A single 5-mg infusion of the bisphosphonate zoledronic acid can improve bone mineral density (BMD) over the course of 2 years in frail institutionalized elderly women with osteoporosis, according to a study published online April 13 in JAMA Internal Medicine. However, this improvement does not translate to better outcomes, reports the randomized, double-blind, placebo-controlled trial. The study found a slight fracture increase and higher mortality in the zoledronic acid group. “The clinical importance of nonsignificant increases in fracture and mortality rates in the treatment group needs further study,” Susan L Greenspan, MD, from the University of Pittsburgh’s Division of Geriatric Medicine in Pennsylvania, and colleagues write.

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Shorten the Laborious Event with Valethamate Bromide VANDANA R NIMBARGI*, AS MUDHOLKAR†, SS MEHENDALE*

ABSTRACT A randomized prospective study was carried out to know the efficacy of intravenous valethamate bromide on cervical dilatation during first stage of labor. Patients with singleton term pregnancy, vertex presentation with spontaneous onset of labor and no risk factors were selected for study and control group, 100 in each group. Group A (100 cases) patients received intravenous injection valethamate bromide 3 doses at interval of 30 minutes after 3 cm cervical dilatation. Group B (100 cases) patients were not given any antispasmodics. All patients were monitored for pulse and blood pressure. Progress of labor was assessed by per abdominal, per vaginal examination and side-effects were observed. Patients who required augmentation and cesarean section before full dilatation were dropped from study. Primigravida patients in valethamate bromide group dilated in 4.13 hours (248 minutes) as compared to Group B primigravida who dilated in 6.0 hours (360 minutes) and multigravida in valethamate group dilated in 2.96 hours (178 minutes) as compared to Group B multigravida who needed 3.66 hours (220 minutes) for full dilatation. In short, duration of first stage was shorter with valethamate bromide injection. Transient tachycardia was seen in 7.31% patients and vomiting in 3.6% patients. Our findings are similar to previous studies. From this randomized prospective study, we conclude that valethamate bromide is effective for smooth cervical dilatation and helps in reducing the duration of first stage of labor with few side-effects.

Keywords: Valethamate bromide, cervical dilatation, first stage of labor

very woman dreams of a normal labor with smooth progress and a short duration of time. First stage of normal labor takes about 10-12 hours in primigravida and 5-6 hours in multigravida. The progress of labor is assessed by number of contractions in 10 minutes, descent of head by per abdominal examination and cervical dilatation, effacement and station of presenting part by per vaginal examination.1 Driscoll introduced the concept of active management of labor to shorten the duration of labor.2 Sometimes, cervix fails to dilate due to inadequate uterine contractions, which can be treated by oxytocin. In spite of good contractions cervix may not dilate due to fibrosis of previous surgery or this could be cervical smooth muscle spasm. Use of antispasmodics was introduced by Von Kries and his assistants in 1923 to relieve cervical spasm.3 Several drugs like drotaverine

*Professor †Assistant Professor Dept. of Obstetrics and Gynecology Bharati Hospital, BVDUMC, Pune, Maharashtra Address for correspondence Dr Vandana R Nimbargi Professor, Dept. of Obstetrics and Gynecology Bharathi University Medical College, Satara Road Dhankawasi, Pune - 411 043, Maharashtra E-mail: nimbargivandana@gmail.com

hydrochloride, valethamate bromide, hyoscine-N-butyl bromide, camylofin dihydrochloride, valium, relaxin are being used to facilitate cervical dilatation. Valethamate bromide is a quaternary ammonium antimuscarinic agent, which acts by blocking the cholinergic receptors, ganglia and by direct musculotropic action. A randomized prospective study was carried out for a period of 13 months from October 2013 to October 2014 in Bharati Vidyapeeth’s Deemed University Medical College and Research Centre, Pune in order to know utility of injection valethamate bromide for cervical dilatation in active phase of labor. MATERIAL AND METHODS Randomly, 100 cases including primigravida and multigravida with singleton pregnancy, vertex presentation without any risk factors at term with spontaneous onset of labor were selected for study group. During same period, 100 same cases were selected randomly with same criteria to serve as control group. Group A was study group (100 cases) who received injection valethamate bromide and Group B was control group (100 cases) who did not receive any antispasmodics and they followed the natural course of labor. On admission, detailed history was obtained and thorough general and obstetrical examination was carried out.

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OBSTETRICS AND GYNECOLOGY After 3 cm cervical dilatation, patients in Group A received intravenous injection valethamate bromide 8 mg (1 mL) every half an hour 3 doses. The patients in control group were allowed to progress naturally. Progress of labor was assessed by: (1) Maternal pulse and blood pressure; (2) number of uterine contractions in 10 minutes and fetal heart sounds monitored every 30 minutes; (3) assessment of cervical dilatation, effacement and station of vertex was done by per vaginal examination every 2 hours and (4) side-effects noted were tachycardia, headache, dryness of mouth. Total duration of first stage was calculated in minutes and hours. Augmentation with oxytocin was considered if contraction were 2 or <2 and lasting <20 seconds in 10 minutes, which was required in 18 patients in Group A and 22 in Group B. Cesarean section was considered for obstetrical indications if needed. RESULTS Group A and Group B were comparable in respect to parity and gestational age as seen in Table 1. From Table 1, it is seen that in both the groups primigravida were more in number (Group A [56%] and Group B [51%]). Similarly, in both the groups more number of patients were between 38 weeks and 40 weeks of gestation. Augmentation of labor was required in 15 patients in Group A and 18 patients in Group B. Out of these 15 patients, 10 delivered vaginally and 5 required lower segment cesarean section (LSCS) in Group A. In Group B, out of 18 patients, 12 had normal delivery and 6 required LSCS. From Tables 2 and 3, it is seen that from Group A, 15 patients who were augmented, which included 5 sections before full dilatation and another three patients who delivered by LSCS that is total 18 patients were dropped from study. So, Group A had 82 patients. Similarly from Group B, 18 patients who were augmented and another two patients who delivered by section before full dilatation, i.e.,

total 20 patients were dropped from study, so Group B had 80 patients (Table 4). Table 5 shows that time taken for cervical dilatation was less in Group A patients, as compared to Group B for both primigravida and multigravida. Table 6 shows that tachycardia was seen in 7.31% patients, Table 2. Number of Patients Needed Augmentation and Mode of Delivery in Both Groups Group A

Group B

Number of patients who delivered normally after augmentation

Number of patients who delivered by LSCS after augmentation

Total

Table 3. Total Number of Cesarean Sections in Each Group and their Distribution in Respect to Cervical Dilatation Group A

Group B

LSCS before full dilatation patients with augmentation

LSCS before full dilatation patients without augmentation

After full dilatation

Total

Table 4. Number of Patients Dropped from Study Group A

Group B

Normal delivery

LSCS before full dilatation

Patients with augmentation

LSCS without augmentation

Total

Table 1. Distribution of Patients by Parity and Gestational Age

Table 5. Time Taken for Cervical Dilatation from 3 to 10 cm

Factor

Group

Group A (valethamate bromide) 100 case (%)

Group B (control) 100 case (%)

Parity

Mean time (minutes/hours)

Rate of dilatation (cm/minutes)

Primi

248/4.4

1/35.4

Multi

178/2.96

1/25.4

Group A

Primi

56 (56)

51 (51)

Multi

44 (44)

49 (49)

Gestational age

Group B

37-38

37 (37)

31 (31)

Primi

360/6

1/51.4

38-40

63 (63)

69 (69)

Multi

220/3.6

1/31.4

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OBSTETRICS AND GYNECOLOGY 35% cases and vomiting was not seen. In our study, tachycardia was seen in 7.31% and vomiting in 3.6% which were short lasting and dryness of mouth was present in 2.4% subjects; these findings are comparable with previous studies.

Table 6. Side-effects Effect

No. of patients Group A (82) (%)

No. of patients Group B (80) (%)

Tachycardia

6 (7.31)

3 (3.75)

Vomiting

3 (3.6)

2 (2.5)

Dryness of mouth

2 (2.4)

vomiting in 3.6% patients and dryness of mouth in 2.4% patients in valethamate bromide Group A as compared to Group B in 5 which tachycardia was seen in patients 3.75%, vomiting in 2.5% patient, not a single patient had dryness of mouth. DISCUSSION It has been observed that in spite of good uterine contractions, sometimes cervical dilatation is not satisfactory due to smooth muscle spasm. In this modern era, active management of labor is done with the help of drugs for safe confinement with short duration, which gives a pleasant experience to mother. In a study conducted by Jayashree and Umadevi,4 the authors found out that subjects in study group who received injection valethamate bromide intravenously, primigravida required 146.43 minutes for full dilatation (control, 219.66 minutes) and multigravida required 76.19 minutes (control, 106.25 minutes) for full dilatation; which was considerably less than control group. Dash and Patnaik5 in their study using injection valethamate bromide intramuscularly have stated that the duration of first stage of labor was shortened. Our findings are also similar, primigravida in injection valethamate group dilated in 248 minutes (4.13 hours) as compared to Group B primigravida who dilated in 6 hours (360 minutes), and multigravida in valethamate group dilated in 178 minutes as compared to Group B multigravida who needed 220 minutes for full dilatation. In a study conducted by Jayashree et al,3 duration of active phase was 160 minutes for primigravida and 147.12 minutes for multigravida.3 In our study, patients in valethamate bromide group had active phase of 248 minutes for primigravida and 178 minutes for multigravida, which are similar to previous studies by different authors.4-6 Jayashree et al4 in their study have documented that tachycardia was seen in 5.6% and 2.4% patients had vomiting; these effects were transient. Dash and Patnaik5 have stated that transient tachycardia was noted in

Purwar and Balsara6 have done study for injection valethamate bromide by intravenous and intramuscular route. Authors have stated that for intravenous route, the induction delivery interval was 3.05 ± 1.33 hours and with intramuscular route, induction delivery interval was 3.53 ± 1.40 hours, which proved intravenous route had edge over intramuscular route. In our study group, first stage was 4.4 hours for primigravida and 2.96 hours for multigravida, which is comparable with intravenous injection valethamate group of authors. In our study, 10 patients in study group and nine in control group were delivered by cesarean section, these findings are comparable with previous authors (Jayashree and Umadevi). In the trial conducted by Purwar and Balsara, 18 patients in intravenous group and 11 in intramuscular group required augmentation, which is similar to our findings. CONCLUSION From our study, we conclude that injection valethamate bromide is safe and effective. Valethamate helps to accelerate cervical dilatation and reduces time of first stage of labor and in short total duration of labor. REFERENCES 1. MacDonald PC. Parturition: biomolecular and physiologic process. In: Williams Obstetrics, Cunningham FG, MacDonald, PC, Gant, NF, Leveno, KJ, Gilstrap, LC III (Eds.), 19th Edition, Appleton & Lange, Connecticut; 1993. p. 298. 2. Aziz M. Effect of rectal hyoscine butyl bromide suppositories on first stage of labor. Int J Adv Res. 2014;2(4):128-35. 3. Jayashree S, Ajjammanavar V, Sujatha MS. Comparison of drotaverine and valethamate bromide in first stage of labor. Int J Biol Med Res. 2013;4(2):3215-8. 4. Jayasree S, Umadevi N, Rajani M. Efficacy of valethamate bromide in cervical dilatation during labor. Indian J Clin Pract. 2011;22(4):169-72. 5. Dash MK, Patnaik P, Singh AK, Tripathy PR. Study of the effect of valethamate bromide on cervical dilatation during labour. Indian J Clin Pract. 1994;104(Pt 4):1095-103.

6. Purwar M, Balsara R. Acceleration of labour by intravenous epidosin in primigravidae: a randomized controlled trial. Indian J Clin Pract. 1996;6:71-2. ■■■■

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Posterior Reversible Encephalopathy Syndrome: A Pressing Enigma NARAYANAN PALANIAPPAN*, VEMBU RADHA†, RAM PRAKASH THIRUGNANASAMBANDAM‡

ABSTRACT Three patients with PRES syndrome are described here for their variegated way of presentation. A 27-year-old primi at 39 weeks + 3 days came in labor and underwent LSCS for fetal distress. On the third day, patient had episode of GTCS and was given injection magnesium sulfate, which was subsequently changed to phenytoin and later changed to levetiracetam. The other two patients delivered outside, both by LSCS and were referred to our institution on POD 0 and 6, respectively with GTCS. Both had high BP on admission. Both were started magnesium sulfate, labetalol and levetiracetam and stabilized in the ICU. All three patients underwent MRI + MRV which showed features of hyperintensities involving predominantly subcortical deep white matter of bilateral parieto-occipital lobes with few areas showing involvement of gray matter. A neurologist and an ophthalmologist were opined with. All of them were in the ICU with ventilatory support.

Keywords: PRES, eclampsia, seizures, antihypertensives, ICU

osterior reversible encephalopathy syndrome (PRES) is a clinically and radiologically defined syndrome which is associated with a widespectrum of symptoms and causes. As with any other disease, it is early diagnosis and treatment which is the mainstay for patients. The importance of the prompt recognition of symptoms cannot be overstated since the condition may result in permanent neurological damage and death. It is interesting to note that many of the patients with PRES have comorbidities such as bone marrow or solid organ transplantation and chronic renal failure. It has now been agreed that the confirmation of this syndrome is by a clinico-radiological study and hence it would benefit us to have an understanding about this particular entity. Here, we would like to report three cases of PRES which have occurred in our patients at a tertiary care hospital.

*Professor †Associate Professor ‡Intern Dept. of Obstetrics and Gynecology Sri Ramachandra Medical College, Porur, Chennai, Tamil Nadu Address for correspondence Dr Ram Prakash Thirugnanasambandam Intern Dept. of Obstetrics and Gynecology Sri Ramachandra Medical College, Porur, Chennai - 600 116, Tamil Nadu E-mail: ramcancer12@gmail.com

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CASE REPORTS Three patients with PRES syndrome are described here for their variegated way of presentation. A 27-year-old primi at 39 weeks + 3 days came in labor and allowed for spontaneous progression. But in view of variable decelerations and Grade 1, multiple symmetric lipomatosis (MSL) patient was taken up for emergency lower segment cesarean section (LSCS) and delivered a baby boy weighing 3.6 kg. Postoperative period was uneventful. However, 3 days later mother had generalized tonic-clonic seizures (GTCSs) for which injection magnesium sulfate was started. She had another episode and was switched over to injection phenytoin 150 mg t.d.s. The neurologist opined and a magnetic resonance imaging (MRI) + magnetic resonance venography (MRV) was done, which showed features of PRES. Fundus examination was normal. Her blood pressure (BP) was controlled with labetalol and patient was put on injection levetiracetam and injection mannitol. There were no further episodes of seizures after 48 hours of admission and observation in the intensive care unit (ICU). The patient was discharged with tablet levetiracetam 500 mg t.d.s. Both the mother and the child are being followed up. A 41-year-old P1LIA1 with emergency LSCS done outside, postoperative day (POD) 0 referred to our hospital with severe eclampsia for further management.

OBSTETRICS AND GYNECOLOGY The obstetric history revealed an in vitro fertilization (IVF) conception and emergency LSCS done outside in view of severe eclampsia (180/100 mmHg). She is a known case of hypothyroidism on thyroxine 50 mg o.d. Following the surgery, she had four episodes of seizures. Her BP on admission was 140/90 mmHg. MRI done at our hospital showed features of intracranial hemorrhage with reversible encephalopathy. Patient admitted in the ICU and neurologist opinion obtained. Patient was put on injection levetiracetam and injection mannitol. Her BP was controlled with labetalol and she was monitored for 5 days. After recovery, she was discharged with tablet levetiracetam. A 26-year-old P1L1A1 with LSCS done, POD 6 came to our hospital with complaints of GTCS of five episodes with two more episodes in our emergency room (ER). She complained of headache since the day of discharge and visual disturbance since morning. She gave history of loss of consciousness in between episodes. She was admitted and put on tablet a-methyldopa, tablet levetiracetam and tablet phenytoin. Her cerebral spinal fluid analysis showed no abnormality except high proteins. MRI done showed features of PRES. Her BP was monitored and patient symptomatically improved. She was discharged with tablet levetiracetam and tablet phenytoin. DISCUSSION Posterior reversible encephalopathy syndrome (PRES) is an entity, which is widely acknowledged as a clinicoradiological syndrome and is seen to be associated with a wide array of medical conditions and has numerous presenting symptoms.1 Though, we have numerous cases reported in medical literature, its presentation and onset in an obstetric patient still remains an enigma to obstetricians, which in turn hampers the provision of appropriate healthcare to patients. In our case report, the women presenting to our tertiary care hospital had a medical history of eclampsia, which was subsequently followed by the onset of seizures in their immediate postpartum period. The numerous instances of reports in literature have confirmed that the most common cause of PRES in a pregnant woman is the onset of severe eclampsia.2 The commonly seen symptoms of PRES include headaches, seizures, altered mental status and visual impairment.3 PRES can also occur due to other causes which include severe hypertension, transplantation or autoimmune disease, metabolic disturbances like hyponatremia, high-dose chemotherapy for various malignant

conditions or in combination with immunosuppressive therapy.1 The presence of these causes in the thought process of the obstetrician may lead to a better prognosis in case the patient is a nonobstetric case of PRES. The pathophysiology postulates that increased BP is not the only causative factor in the onset but the presence of endothelial dysfunction, which is the cause of preeclampsia. Pregnancy itself decreases the threshold at which a rise in BP could lead to hyperperfusion and brain edema.4 The importance of neuroimaging in the diagnosis of this condition has reportedly been stressed since it gives a clear cut diagnosis to the obstetrician. In the three cases reported by us, the patients all underwent an MRI as advised by a neurologist. The findings were consistent with the diagnosis of PRES since all of them had edema involving the white matter of cerebral posterior regions, especially parietooccipital lobes.5 But, the second patient had intracranial hemorrhage possibly caused by the increase in BP along with cerebral edema. The important question in the minds of obstetricians, today is whether all patients with eclampsia be subjected to neuroimaging despite the fact that the result may or may not influence their treatment. As of today, we still follow the protocol of controlling the BP of an eclamptic patient with drugs and a speedy delivery in case of signs suggestive of eclampsia. We do not rely on neuroimaging on a routine basis unless we suspect other causes, which may mimic eclampsia as described above. A study conducted at the Mayo Clinic in Rochester concludes that the use of imaging can be justified in patients with an uncertain diagnosis and for those presenting with typical symptoms of the syndrome with a high BP and seizures.3 Admission in an ICU and life-supporting treatments may be required.6 Patients with PRES syndrome usually require the symptomatic measures usually taken in the ICU, including the need for endotracheal intubation and use of intravenous benzodiazepines in case of persistent epileptic activity at the time of admission. Once they are stabilized the main aim of treatment should be the aggressive reduction of BP in hypertension, treatment of seizures and status epilepticus and elimination of the causative agent. The use of a lumbar puncture in such patients still poses a dilemma for obstetricians. The cerebral spinal fluid may be examined in patients when deemed appropriate by the physician in case of presence of fever or when meningitis is suspected.7 As described above the main stay of treatment in a tertiary care hospital involved

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OBSTETRICS AND GYNECOLOGY the immediate control of BP with the help of labetalol while the seizure activity was treated with phenytoin. All three patients had imaging studies done in the form of an MRI, which confirmed the diagnosis while a neurologist and an ophthalmologist were called in for an opinion to rule out nonobstetric causes and to advise on the appropriate line of management for our patients. The importance of a thorough physical examination should not be ruled out in this syndrome since patients may present with isolated signs or atypical signs, which could easily mislead us clinicians. The need for opining with the ophthalmologist and a neurologist is stressed since papilledema or seizures may give definite clue despite the fact that imaging clears any doubt of the diagnosis.8 The presence of a neurocritical care unit, which ensures close consultation with other specialties according to the underlying systemic condition, is considered the best setting for management of PRES. With all this care, the prognosis is good with the patient recovering well though the MRI findings take a few months to resolve.9 The long-term follow-up of these patients is mandatory and the duration of continuation of the drugs is always a question in our minds. The answer varies if the cause is an obstetric or a nonobstetric entity. In case of an obstetric cause like eclampsia then the solution for seizure activity is to discharge the patient with antiepileptic drugs and to withdraw them after duration of 3 months and with a neurology opinion since the presence of seizure activity at the time of presentation does not mean that the patient is an epileptic for life.9 PRES is caused by various etiologies and may present with various symptoms to clinicians. Its diagnosis is incomplete without the presence of neuroimaging. Obstetricians should strongly suspect PRES if mental

status disorders and seizure activity is seen in the prepartum, during the delivery or in the postpartum period in the presence or absence of pre-eclampsia/ eclampsia. With good critical care and presence of a multidisciplinary team, the outcome is excellent. REFERENCES 1. Jeon JS, Park SP, Seo JG. Posterior reversible encephalopathy syndrome due to hyponatremia. J Epilepsy Res. 2014;30(4):31-3. 2. Wagner SJ, Acquah LA, Lindell EP, Craici IM, Wingo MT, Rose CH, et al. Posterior reversible encephalopathy syndrome and eclampsia: pressing the case for more aggressive blood pressure control. Mayo Clin Proc. 2011;86(9):851-6. 3. Postma IR, Slager S, Kremer HP, de Groot JC, Zeeman GG. Long-term consequences of the posterior reversible encephalopathy syndrome in eclampsia and pre-eclampsia: a review of the obstetric and nonobstetric literature. Obstet Gynecol Surv. 2014;69(5):287-300. 4. Cipolla MJ. Cerebrovascular function in pregnancy and eclampsia. Hypertension. 2007;50(1):14-24. 5. Petrović B, Kostić V, Sternić N, Kolar J, Tasić N. Posterior reversible encephalopathy syndrome. Srp Arh Celok Lek. 2003;131(11-12):461-6. 6. Servillo G, Striano P, Striano S, Tortora F, Boccella P, De Robertis E, et al. Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients. Intensive Care Med. 2003;29(12):2323-6. 7. Legriel S, Schraub O, Azoulay E, Hantson P, Magalhaes E, Coquet I, et al; Critically Ill Posterior Reversible Encephalopathy Syndrome Study Group (CYPRESS). Determinants of recovery from severe posterior reversible encephalopathy syndrome. PLoS One. 2012;7(9):e44534. 8. Caputo ND, Fraser RM, Abdulkarim J. Posterior reversible encephalopathy syndrome presenting as papilledema. Am J Emerg Med. 2012;30(5):835-7.

9. Roth C, Ferbert A. The posterior reversible encephalopathy syndrome: what’s certain, what’s new? Pract Neurol. 2011;11(3):136-44. ■■■■

Uterine Cooling Reduces Bleeding in Cesareans Icing the uterus might halve the rate of postpartum hemorrhage during cesarean delivery, a new study shows. “This could be a good preventive measure for postpartum hemorrhage, and potentially for uterine atony,” Janice Mitchell, MD, from the Baylor College of Medicine in Dallas, told Medscape Medical News. Postpartum hemorrhage is the leading cause of worldwide maternal mortality.

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OBSTETRICS AND GYNECOLOGY

Study of Cytogenetic and Noncytogenetic Factors Amongst Congenitally Malformed Newborn/ Fetuses and their Parents in Jammu INDU KAUL*, AMANDEEP K ANAND†, BHAWNA SHARMA‡

ABSTRACT The birth of congenital malformed newborn is a global problem as it affects the welfare of individuals and their families. An increased awareness of the occurrence of cytogenetic abnormalities in individuals reporting infertility, mental retardation and/or dysmorphism has increased the demand for chromosomal analysis. Chromosome and gene mutation abnormalities take effect during all phases of pre- and postnatal life and can cause isolated or multiple congenital anomalies. The present study aimed to determine the chromosomal abnormalities and their possible relationship with congenital malformations among fetuses (from 8th week of conception until birth), newborns (up to 28th day following birth) and also their parents. Also, an attempt was made to study the association of noncytogenetic factors with congenital malformations.

Keywords: Congenital malformations, cytogenetics, chromosomal anomalies

he birth of congenital malformed newborn is a global problem as it affects the welfare of individuals and their families. Attempts have been made from time to time to establish the relationship between various environmental factors and chromosomal aberrations in relation to congenital anomalies. Recent interest has focused on the interplay between genetic and environmental factors acting during the period of embryogenesis.1 Evidence says that around 20-25% of anomalies are found to have multifactorial origin because of complex interaction between multiple genetic anomalies and environmental risk factors. Another 10-13% of anomalies have a purely environmental cause (e.g., infections, illness or drug abuse in mother). The cause of 40-60% of congenital anomalies in humans remains

*Professor Dept. of Obstetrics and Gynecology SMGS Hospital, Jammu (J&K) †Consultant Gynecologist J&K Health Services, Jammu (J&K) ‡Senior Resident Jolly Grant Hospital, Dehradun, Uttrakhand Address for correspondence Dr Amandeep K Anand Consultant Gynecologist Dept. of Health, Govt. of J&K E-mail: amandeepkanand@gmail.com

unknown. Only 12-25% of anomalies has a purely genetic cause and are mainly chromosomal in nature.1 An increased awareness of the occurrence of cytogenetic abnormalities in individuals reporting infertility, mental retardation and/or dysmorphism has increased the demand for chromosomal analysis.2 Studies on selected populations of newborns have been reported.3-5 However, these studies show a considerable variation in the frequencies of chromosomal abnormalities. In addition to this, the epidemiological studies have shown other significant risk factors for the occurrence of fetal malformations like consanguineous marriage (risk increases twofold), elderly age of mother, positive family history of malformations, alteration of volume of amniotic fluid. Intrauterine growth retardation, presence of multiple pregnancies and pregnancies that occur following infertility treatment.6 Approximately, 2% of newborn infants in USA have major congenital malformations making this the leading cause of infant mortality in USA.7 In India, the incidence of fetal congenital malformations varies from 3% to 5%.6 Chromosome and gene mutation abnormalities take effect during all phases of preand postnatal life and can cause isolated or multiple congenital anomalies.8 It is performed on a sample of blood, bone marrow, amniotic fluid or the tissue from the placenta.

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OBSTETRICS AND GYNECOLOGY The present study aimed to determine the chromosomal abnormalities and their possible relationship with congenital malformations among fetuses (from 8th week of conception until birth), newborns (up to 28th day following birth) and also their parents. Also, an attempt was made to study the association of noncytogenetic factors with congenital malformations.

spreads were taken. The karyotypes were prepared by using automatic karyotyping software installed in the automated cytogenetic workstation (Olympus Bx-61). The prepared slides were referred to Dept. of Genetics, University of Jammu for interpretation.

MATERIAL AND METHODS

Noncytogentic Findings

The present study was conducted in the Dept. of Obstetrics and Gynecology of SMGS Hospital affiliated to Govt. Medical College, Jammu and Institute of Human Genetics, University of Jammu after taking clearance from ethical committee of respective institutions. A total of 50 cases of congenital malformed fetuses/newborns and their parents were subjected to the chromosomal studies. A standard questionnaire was prepared, which covered various factors associated with the risk of congenital malformations such as maternal age, rural/ urban distribution, ethnic background, consanguinity, previous history of congenital anomalies, gravidity, sex of the fetus and folic acid intake.

Majority of the mothers of newborns or fetuses with congenital malformations in the present study, 24 (48%) were in the age group of 26-30 years. A total of 34 (68%) cases belonged to rural areas and 16 (32%) belonged to urban area. Congenital malformations in the present study were found to be commonest in Muslims 30 (60%) as compared to Hindus 18 (36%) and Sikhs 2 (4%). Consanguinity, i.e., the marriage between close relations was seen in 8 (16%) cases with congenital malformations. In our study, only 3 (6%) of mothers had previous history

Live newborn and dead fetus was thoroughly examined after delivery as per criteria documented in the proforma and type of congenital malformation was noted and confirmed. Heparinized blood sample (0.3 mL blood in 0.1 mL of heparin) collected from peripheral vein in case of newborn and parents and from heart in case of dead fetus constituted the material for the chromosomal study. For cytogenetic analysis, heparinized blood was incubated in complete lymphocyte culture medium (10% fetal bovine serum in RPMI 1640, with 0.15% phytohemagglutinin) and 1% pentstrept (HiMedia, Mumbai) in 5% carbon dioxide incubator at 37Â°C for 72 hours). Metaphases were harvested by adding 10 mg/mL colchicine solution (HiMedia, Mumbai) for 2 hours followed by hypotonic KCl (0.0075 MKCl) treatment for 30-35 minutes and fixation using standard 3:1 methanol acetic acid fixative. The slides were then prepared by splashing technique and prepared slides were stained with 2% Giemsa stain.9 G-banding of the prepared slides was done using standard trypsin-Wright G-banding. G-banded slides were scanned for metaphase spread under 10 times magnification using Carl Zeiss AXIO imager metaphase analyzer. The chromosomes were paired following International Seminar on Chromosome Nomenclature (1995).10 Well-spread banded prometaphase and metaphase plates were photographed under oil immersion objective and photographic prints of metaphase

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RESULTS

Table 1. Summary of Demographic Parameters of Participants and their Association with Congenital Malformations Parameters

No. of participants (n = 50)

Maternal age group (years) 20-25

18 (36%)

26-30

24 (48%)

31-35

07 (14%)

36-40

01 (02%)

Gravidity Primigravida

19 (38%)

Second gravida

14 (28%)

Multigravida (â&#x2030;Ľ3)

17 (34%)

Urban/rural distribution Urban

16 (32%)

Rural

34 (68%)

Religion Muslim

30 (60%)

Hindu

18 (36%)

Sikh

02 (04%)

Consanguinity Consanguineous

08 (16%)

Nonconsanguineous

42 (84%)

Previous history of congenital anomalies Present

03 (06%)

Absent

47 (94%)

OBSTETRICS AND GYNECOLOGY of delivering a congenital malformed newborn/fetus. Regarding parity, in the present study, primigravida 19 (38%) were the commonest followed by multigravida with birth order of more than or equal to 3, 17 (34%). In our study, all the mothers gave a positive history of folic acid intake (Table 1). As per sex of the fetus/newborn with congenital malformations, out of 50 fetuses, 31 (62%) were males and 19 (38%) were females and the ratio of males:females was 1.6:1. Regarding distribution of Table 2. Distribution of Congenital Anomalies Parameters

No. of fetuses/ newborns (n = 50)

Sex Male

31 (62%)

Female

19 (38%)

Organ system involvement CNS

30 (60%)

Musculoskeletal

07 (14%)

GIT

09 (18%)

CVS

02 (04%)

Genitourinary

02 (04%)

Details of anomalies in CNS Anencephaly

13 (26%)

Hydrocephalus

08 (16%)

Meningocele

03 (06%)

Spinabifida

03 (06%)

Others

03 (06%)

Details of anomalies in GIT

congenital malformations, central nervous system (CNS) was the most commonly involved organ system (60%) followed by gastrointestinal tract (GIT) (18%) (Table 2). Out of anomalies in CNS, anencephaly was the commonest (26%) followed by hydrocephalus (16%). (Table 2).

Cytogenetic Findings During the present study, attempt has been made to obtain a possible correlation of the detected chromosomal anomalies in newborn/fetuses and their parents with the congenital malformations. The results were peculiar because the chromosomal aberrations were found in two dead fetuses and no live newborn was found to have any chromosomal aberration. Both the fetuses with chromosomal aberrations were suffering from neural tube defects (NTDs) and their parents had normal karyotypes. Out of all the studied parents, two had chromosomal aberrations and in these two cases, the fetuses did not show any chromosomal aberration although the fetuses were also suffering from NTD. Another important finding was that in both cases, the chromosomal aberrations were seen in mothers only, i.e., among the parents no paternal chromosomal aberrations were noted (Table 3). In the present study, among two fetuses with abnormal karyotype, trisomy 13 was seen in one fetus with holoprosencephaly (a type of NTD) (Fig. 1) and deletion of short arm of chromosome 16 was seen in other fetus (Fig. 2) who

Omphalcele

05 (10%)

Table 3. Distribution of Chromosomal Anomalies

Cleft-lip

02 (04%)

Parameters

Gastroschisis

01 (02%)

Others

01 (02%)

Details of anomalies in musculoskeletal system Achondroplasia

01 (02%)

CTEV

02 (04%)

Absent neck

02 (04%)

Deformed spine

02 (04%)

Details of anomalies in CVS Dextrocardia

02 (04%)

Details of anomalies in genitourinary Multidysplastic kidneys

01 (02%)

Infantile kidneys

01 (02%)

CNS = Central nervous system; GIT = Gastrointestinal tract; CVS = Congenital varicella syndrome; CTEV = Congenital talipes equinovarus.

No. of participants (n = 50)

Chromosomal anomalies in fetus Present

02 (04%)

Absent

48 (96%)

Chromosomal anomalies in parents of congenitally malformed fetuses Present

02 (04%)

Absent

48 (96%)

Type of chromosomal anomalies Fetus Trisomy 13

01 (02%)

16p deletion

01 (02%)

Mother 13p deletion

01 (02%)

18p deletion

01 (02%)

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OBSTETRICS AND GYNECOLOGY

Figure 1. Karyotype of a fetus with NTD showing trisomy 13.

Figure 3. Karyotype of mother of fetus with NTD (anencephaly) showing deletion of short arm of chromosome 13.

Figure 2. Karyotype of a female fetus with NTD (anencephaly) showing deletion of short arm of chromosome 16.

Figure 4. Karyotype of mother of fetus with NTD (anencephaly) showing deletion of short arm of chromosome 18.

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OBSTETRICS AND GYNECOLOGY had CNS involvement (NTD). In case of parents with abnormal karyotype, one mother had deletion of short arm of chromosome 13 (Fig. 3) and other had deletion of short arm of chromosome 18 (Fig. 4). DISCUSSION Literature available on human congenital anomalies show that environmental factors like maternal age, consanguinity, birth order, religion, sex of the fetus/ newborn have a strong association with human congenital anomalies.11 These probable risk factors were detected and analyzed in all the 50 cases in the present study. Present findings on the maternal age factor, i.e., majority between 26 years and 30 years (Table 1) are akin to the earlier reports.12,13 But in their study, Singh and Gupta14 reported that congenital anomalies were more common at either 20 or more than 35 years of age. Females from the rural background have been found to have a higher incidence of delivering congenital malformed fetuses/ newborns. In the present study, 68% of mothers were from rural background (Table 1). Similar observations have been made earlier.15 The primary reason for this could be the lack of awareness and access to screening at 20 weeks of gestation by ultrasonography for early detection of malformations in rural areas. Religion has been associated with congenital malformations. In our study, congenital malformations were more common in Muslims as compared to Hindus (60% vs 36%) (Table 1). This is in accordance with findings by Singh and Gupta.14 The reason can be attributed to the consanguineous marriages, which are more commonly seen in Muslim population. The deleterious effects associated with consanguinity may be caused by the expression of rare recessive genes inherited from common ancestors. During the present study consanguinity was seen in 8 (16%) of cases (Table 1) which is comparable with a report by Amudha et al, where consanguinity was seen in 17% cases.16 Regarding the relation with previous outcome, only 6% females had previous history of congenital malformed fetuses/newborns (Table 1), which is comparable to study by Bosso.17 The frequency of congenital malformations (Table 2) was more in males (62%) as compared to females (38%) in the present study and the ratio of males:females was 1.6:1. Similar observations have been made by others.14,18 In our study, CNS was the most commonly affected organ system in case of congenital

malformations (60%) followed by GIT (Table 2). This is in consonance with other studies, where CNS was found to be most commonly involved.19-21 Whereas Singh and Gupta14 in their study observed musculoskeletal disorders to be commonest (30.6%) followed by CNS involvement (20.5%). The frequency of various chromosomal abnormalities is quite different in neonates (0.7%) as compared to abortuses (50%) because some chromosomal anomalies are lethal in utero.22 In our study, all the 50 cases of congenital malformed newborns/fetuses and their parents were subjected to karyotyping. Chromosomal aberrations were found in two dead fetuses but not in any live newborn (Figs. 1 and 2). Thus, 4% of fetuses/newborns had abnormal karyotype. Our findings on the incidence of chromosomal aberrations are by and large similar to those of earlier reports.23-26 But Yashwanth et al documented 17% of chromosomal aberrations. All these 17% cases had multisystemic involvement.27 Out of 27 cases of NTD, two fetuses (7.4%) had chromosomal aberrations which is in concordance with study by Oâ&#x20AC;&#x2122;Reilly et al.28 Out of all parents, two mothers had chromosomal aberrations with their fetuses suffering from NTD with normal karyotype. Similar observations were made in other studies.24,29,30 Such studies signify the importance of parental karyotyping and their role as carriers in case of congenital malformations. Regarding types of chromosomal aberrations, trisomy 13 was seen in one fetus (Fig. 1), which was a case of holoprosencephaly (a type of NTD). Trisomy 13 also known as Patau syndrome has a prevalence of 1:12,000.31 Most embryos with trisomy 13 are spontaneously aborted. Of those surviving to term, approximately 80-85% does not survive past 1 month of age. In addition to holoprosencephaly, trisomy 13 has other features also like microcephaly, cleft lip, cleft palate, which were absent in this case. Earlier studies have similar reports of trisomy of chromosomes in case of congenital malformations. Various trisomies reported are of trisomy 8p,29 trisomy 21 and trisomy 1832 and trisomy 22 in various congenital malformed newborns/fetuses. Deletion (16p) of short arm of chromosome 16 was reported in another fetus with NTD (Fig. 2). Also in case of parents, one mother had deletion (13p) of short arm of chromosome 13 (Fig. 3) and other had deletion (18p) of short arm of chromosome 18 (Fig. 4). Deletion of parts of chromosomes has also been found to be a common chromosomal aberration in congenital malformations.33-36

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OBSTETRICS AND GYNECOLOGY CONCLUSION Present work is an addition to the existing literature on congenital malformations. This study has shown that the distribution of environmental risk factors and cytogenetic abnormalities in our population is comparable to that reported worldwide in literature. Also, chromosomal abnormalities are an important cause of congenital malformations emphasizing the need for cytogenetic evaluation. To determine the exact role of chromosomal aberrations in congenital malformations, more extensive and detailed cytogenetic work needs to be carried out.

Acknowledgments We are thankful to Prof Subhash Gupta and his team from Institute of Human Genetics, University of Jammu, for providing resources and facilities in the study.

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12. Puri RK, Khanna KK, Bhargava I, Balakrishnan S. Role of consanguinity in chromosomal syndromes. Indian J Med Res. 1977;65:859-64. 13. Hume RF Jr, Drugan A, Reichler A, Lampinen J, Martin LS, Johnson MP, et al. Aneuploidy among prenatally detected neural tube defects. Am J Med Genet. 1996;61(2):171-3. 14. Singh A, Gupta RK. Pattern of congenital anomalies in newborn: a hospital based prospective study. JK Science. 2009;2:34-6. 15. Xiao KZ, Zhang ZY, Su YM, Liu FQ, Yan ZZ, Jiang ZQ, et al. Central nervous system congenital malformations, especially neural tube defects in 29 provinces, metropolitan cities and autonomous regions of China: Chinese Birth Defects Monitoring Program. Int J Epidemiol. 1990;19: 978-82. 16. Amudha S, Aruna N, Rajangam S. Consanguinity and chromosomal abnormality. Indian J Hum Genet. 2005;11;108-10. 17. Basso O, Olsen J, Christensen K. Recurrence risk of congenital anomalies—the impact of paternal, social and environmental factors: a population-based study in Denmark. Am J Epidemiol. 1999;150(6):598-604. 18. Navsaria D, Mathews T, Conte RA, Verma RS. Chromosomal anomalies in 1000 children referred with suspected genetic disorders. Hum Hered. 1993;43:137-40. 19. Parmar DA, Rathod DSP, Patel DSV, Patel DS. A study of congenital anomalies in newborn. NJIRM. 2010;1(1):13-7. 20. Grover N. Congenital malformations in Shimla. Indian J Pediatr. 2000;67(4):249-51. 21. Swain S, Agrawal A, Bhatia BD. Congenital malformations at birth. Indian Pediatr. 1994;31(10):1187-91. 22. Thompson WM, McInnes RR, Willard HF. (Eds). Genetics in medicine, 5th Edition. Philadelphia: WB Saunders; 1991. pp. 201-28. 23. Stewartab AL, Keayab AJ, Jacobsab PA, Melville MM. A chromosome survey of unselected live-born children with congenital abnormalities. The Journal of Pediatrics. 1969;74(3):449-58. 24. Centeno Malfaz F, Beltrán Pérez A, Ruiz Labarga C, Centeno Robles T, Macías Pardal J, Martín Bermejo M. Chromosome aberrations in malformed newborns. An Esp Pediatr. 2001;54(6):582-7. 25. Azumi JI, Kohama GI, Sasaki M. Cytogenetic studies in patients with cleft lip and/or cleft palate (IV). Japanese Journal of Human Genetics. 1978;23(2):161-6.

9. Mitelman F, Karger BS. (Eds). An International System for Human Cytogenetic Nomenclature (ISCN); 1995.

26. Hamerton JL, Canning N, Ray M, Smith S. A cytogenetic survey of 14,069 newborn infants. I. Incidence of chromosome abnormalities. Clin Genet. 1975;8(4):223-43.

10. Atkin NB, Baker MC, Fox MF. Chromosome changes in 43 carcinomas of the cervix uteri. Cancer Genet Cytogenet.1995;44:229-41.

27. Yashwanth RK, Chandra N, Gopinath PM. Chromosomal abnormalities among children with congenital malformations. Int J Hum Genet. 2010;10(1-3):57-63.

11. Kumari Kusuma C, Sujatha M, Chandra M, et al. Clinicogenetic study in Trisomy 21. Bulletin on Down syndrome. 1988;1:12-4.

28. O’Reilly GC, Shields LE. Karyotyping for isolated neural tube defects. A report of two cases. J Reprod Med. 2000;45(11):950-2.

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OBSTETRICS AND GYNECOLOGY 29. Mahjoubi F, Totian S, Kareeme S, Shafegatee Y. Trisomy 8p (p11.2-pter) due to maternal translocation t(8;13)(p11;p12) in a child with dysmorphic features. Indian J Hum Genet. 2005;11:111-3.

33. Luo J, Balkin N, Stewart JF, Sarwark JF, Charrow J, Nye JS. Neural tube defects and the 13q deletion syndrome: evidence for a critical region in 13q33-34. Am J Med Genet. 2000;91(3):227-30.

30. Singer N, Gersen S, Warburton D. The value of chromosome analysis in cases of neural tube defects: a case of anencephaly associated with fetal DUP(2) (p24→pter). Prenatal Diagnosis. 1987;7(8):567-71.

34. Hernando C, Plaja A, Rigola MA, Pérez MM, Vendrell T, Egocue J, et al. Comparative genomic hybridisation shows a partial de novo deletion 16p11.2 in a neonate with multiple congenital malformations. Med Genet. 2002;39:e24.

31. Hook EB. Rates of 47, + 13 and 46 translocation D/13 Patau syndrome in live births and comparison with rates in fetal deaths and at amniocentesis. Am J Hum Genet. 1980;32(6):849-58.

35. Genesio R, De Brasi D, Conti A, Borghese A, Di Micco P, Di Costanzo P, et al. Inverted duplication of 15q with terminal deletion in a multiple malformed newborn with intrauterine growth failure and lethal phenotype. Am J Med Genet. 2004;128A(4):422-8.

32. Zhang Y, Zhuang Y. Study on the karyotype and recurrence risk of malformed newborns. Zhongua Fu 36. Genesio R. Neural tube defects and deletions of 22q11. Chan Ke Za Zhi. 1998;33(8):472-4. Am J Med Genet. 2004;66(1):25-7. ■■■■

Age of IVF Culture Medium may Affect Birth Weight The age of the medium used to culture fertilized embryos may affect eventual birth weight, a new study shows. “Age of a specific in vitro fertilization (IVF) culture medium was found to be inversely associated with birth weight of human newborns,” Dr John CM Dumoulin, of the Department of Obstetrics and Gynecology at Maastricht University Medical Center, the Netherlands, told Reuters Health by email.

New Guidelines Focus on Diagnosis and Management of Fetal Anemia The primary technique for detecting fetal anemia should be middle cerebral artery peak systolic velocity (MCAPSV) measured by Doppler interrogation, according to a new Clinical Guideline from the Society for MaternalFetal Medicine (SMFM). The new guideline, detailed in a March 27 online article in the American Journal of Obstetrics and Gynecology, includes six other recommendations for the diagnosis and management of fetal anemia, based on a systematic literature review.

Risk for Preterm Delivery Higher among Mothers Born Preterm Women who were themselves born prematurely are more likely to give birth prematurely than women born full-term, a study published online April 3 in Obstetrics and Gynecology suggests. “The present study indicates that the risk of preterm delivery is significantly higher in women who were preterm themselves,” the authors write. “Moreover, this risk presents a dose-response relationship with more preterm women being at a greater risk of preterm delivery.”

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Unilateral Atresia of Cervix Uteri and Uterus Didelphysis in a Girl with Operated Congenital Pouch Colon SANGEETA GUPTA*, TARU GUPTA†, AKSHAY SHARMA‡, PUSHPA BHATIA#, NUPUR GUPTA$

ABSTRACT This case report describes a girl with uterus didelphys with unilateral hematometra and hematosalpinx with congenital pouch colon (CPC), a condition where all or part of the colon is replaced by a pouch-like dilatation (5-15 cm in diameter), which communicates distally with the urogenital tract through a large fistula and is associated with anorectal agenesis (supralevator anorectal malformation). CPC is seen in Asia and more specifically in northern India, Pakistan and Nepal. The management summary of this condition is creation of diverting colostomy at birth with or without the excision of pouch followed by pull through (abdominoposterior sagittal anorectoplasty) later on. The girl underwent similar procedure at birth and subsequent definitive surgery (pull through), to create a neoanus at 15 months of age. Subsequently since menarche, the child had severe cyclical abdominal pain, which on investigation was found due to hematometra and hematosalpinx in right-sided uterus. Laparotomy with removal of right-sided uterus and right fallopian tube was performed. Right-sided uterus had atresia of cervix uteri. This report emphasizes the need for comprehensive evaluation and a long-term management strategy for associated gynecologic anomalies in girls with CPC, especially with regard to patency of the outflow tract.

Keywords: Anorectal malformation, congenital pouch colon, cervical atresia, hematometra, uterus didelphys

terus didelphys with unilateral cervical atresia is an unusual müllerian duct anomaly with defect of vertical-lateral fusion. A wellknown clinical association of congenital pouch colon (CPC) with genital anomalies exists.1 At puberty, they present with incapacitating dysmenorrhea shortly after menarche. Similar findings in a girl with CPC have not been reported earlier in the literature. CASE REPORT A 10.5-year-old girl attended gynecology out patient department (OPD) with complaint of severe colicky abdominal pain since attainment of menarche. Pain was cyclical in nature occurring at monthly intervals.

*Senior Consultant †Associate Professor ‡Specialist #Professor $Assistant Professor Dept. of Gynecology and Pediatric Surgery ESI-PGIMSR, New Delhi Address for correspondence Dr Taru Gupta Dept. of Gynecology and Pediatric Surgery ESI-PGIMSR, Basaidarapur, New Delhi - 110 015 E-mail: tarugupta1971@yahoo.com

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Periods were regular. There was history of multiple surgeries for associated CPC. On examination, there were three scars on abdomen. Available old records of child revealed that she was a diagnosed case of CPC, for which an emergency laparotomy with ileostomy was done at age of 15 days, followed by pull through to create a neoanus operation at age of 18 months and intraoperative findings suggested a type III CPC. Closure of colostomy was done at 2 years of age. Menarche was attained at the age of 10 years and she started having cyclical pain lower abdomen, unrelieved with medications. She was subsequently imaged in the private sector. Ultrasound (whole abdomen and pelvis) showed both kidneys, uterus as normal and cystic mass in midline and toward right, 7.7 × 4.3 cm with internal echoes with a volume of 75 cc. Left ovary was normal. Contrast enhanced computed tomography (CECT) abdomen showed a normal uterus with tubo-ovarian mass in right adnexa probably of infective etiology. CT urography and micturating cystourethrogram showed normal urethra and urinary bladder. Local examination showed normal perineum with patulous vaginal and normally placed neoanus with visible rim of anal mucosa. Magnetic resonance imaging (MRI) at our institute showed uterus didelphys with obstructing hemivaginal septum with right hematometra and

OBSTETRICS AND GYNECOLOGY hematosalpinx (Fig. 1). Left uterine, cervix was identified while cervix could not be identified in right uterus. Right ovary was not visualized separately. Clinical diagnosis of müllerian duct anomaly, Class IV American Fertility Society (AFS) classification of uterovaginal anomalies, unusual configuration of vertical-lateral fusion was made. Lateral fusion defect of müllerian ducts may be the cause of uterus didelphys and vertical fusion disorder might have resulted in right cervical agenesis.

Right uterus with hematometra

Left uterus

Examination under anesthesia showed a normal urethral orifice, patulous vagina and normally placed patulous neoanus. Per speculum examination showed normal vagina except a partial vaginal septum in the upper third of vagina. Normal well-developed cervix was present on left side. Menstrual blood was coming through the os. Per vaginum examination showed smallsized uterus in continuation with cervix on left side. On right side, no cervix could be felt, firm mass of 5 × 4 cm was felt. Uterine sound was put through left cervical os into uterine cavity. Left uterocervical length was 6 cm. Laparotomy was done, which revealed uterus didelphys with right uterus distended with blood and a large right hematosalpinx. Right-sided ovary could not be visualized. Left-sided uterus, fallopian tube and ovary were normal. Removal of right-sided uterus and right hematosalpinx was done (Fig. 2). There was complete cervical atresia on right side. The postoperative period was uneventful. The histopathological examination confirmed rightsided hematosalpinx and right-sided uterus with no cervix. DISCUSSION

Pull through colon

Figure 1. MRI pelvis showing uterus didelphys with obstructing hemivaginal septum with right hematometra and hematosalpinx.

Right uterine cavity with collected blood

■■■■

Right hematosalpinx

Figure 2. Cut section of removed right uterus with hematometra and hematosalpinx.

Müllerian ducts represent the primordial components of the female reproductive system. They differentiate into fallopian tubes, uterus, cervix and superior aspect of vagina. Overall published data suggest the prevalence of uterovaginal anomalies of 1-6%.2 Complete failure of medial fusion of two müllerian ducts can result in complete duplication, partial failure of fusion can result in a single vagina with a single or duplicate cervix and complete or partial duplication of the uterine corpus. If uterine anomaly is associated with obstruction of menstrual flow, then it causes symptoms that will come to the attention of the gynecologist shortly after menarche.3 Early diagnosis offers significant advantages in patient care. Incapacitating dysmenorrhea shortly after menarche with regular menstrual periods in young girls can be due to unicornuate uterus with a noncommunicating rudimentary anlagen containing functional endometrium, unilateral obstruction of a cavity of a double uterus (complete septum), a clinical syndrome consisting of a double uterus, obstruction of vagina and ipsilateral renal agenesis or unusual configuration of vertical-lateral fusion defects Class IV AFS, as in our case where there was uterus didelphys with unilateral cervical atresia.

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OBSTETRICS AND GYNECOLOGY It is important to make diagnosis as soon as possible, because if lumen of tube communicates with functional endometrial cavity and is patent at fimbrial end, then retrograde menstruation and pelvic endometriosis can develop, destroying reproductive potential. Removal of associated fallopian tube is strongly recommended to minimize risk of an ectopic pregnancy.3 There are very few reports of uterus didelphys, a finding that appears to be invariable in girls with types I-III CPC.4 Chadha et al described a girl with CPC, uterus didelphys with bilateral cervical atresia. At puberty, child had primary amenorrhea with severe cyclic abdominal pain due to hematometra, hematosalpinx and endometriosis. Laparotomy with removal of both uteri was done. Both uteri had atresia of cervix uteri.5 In a recent review on the subject of gynecologic concerns in girls with anorectal malformation (ARM), Breech6 emphasized the role of vaginoscopy before puberty, preferably at the time of definitive repair of the ARM. Vaginoscopy allows evaluation of the vaginal anatomy and can also document the appearance, development and position of the cervices in vagina and the presence or absence of mucus at the ectocervix (to infer patency). Any underdevelopment of the müllerian structures can be detected by serial US starting soon after the onset of breast development.6 If neglected, onset of menarche in the presence of obstruction to the outflow tract may result in hematometra and/or hematocolpos, hematosalpinx, adnexal cysts, endometriosis and chronic abdominal pain. CONCLUSION In conclusion, our report emphasizes the need for a comprehensive evaluation and long-term management strategy for associated gynecologic anomalies in girls with CPC, especially with regard to the patency of the outflow tract. Uterus didelphys with a septate vagina

appears to be invariable in girls with types I-III CPC4 and needs to be assessed and managed appropriately with awareness of the possibility of obstetric complications in later life.7,8 Therefore, it is strongly recommended that the parents of such patients are duly counseled and the entire case record with operative findings are to be preserved. It is also advocated that treating pediatric surgeon should team up with the gynecologist for ideal long-term management. REFERENCES 1. Gupta DK, Sharma S. Congenital pouch colon. In: Holschneider AM, Hutson J (Eds.). Anorectal Malformations in Children, Heidelberg: Springer; 2006. pp. 211-21. 2. Rock JA, Zacur HA, Dlugi AM, Jones HW Jr, Telinde RW. Pregnancy success following surgical correction of imperforate hymen and complete transverse vaginal septum. Obstet Gynecol. 1982;59(4):448-51. 3. Rock JA, Breech LL. Surgery for anomalies of the mullerian ducts. In: Rock JA, Jones HW (Eds.). Telinde’s Operative Gynecology, 10th Edition. Philadelphia: Kluwer/Lippincott Williams & Wilkins; 2008. pp. 539-84. 4. Chadha R, Choudhury SR, Pant N, Jain V, Puri A, Acharya H, et al. The anomalous clinical anatomy of congenital pouch colon in girls. J Pediatr Surg. 2011;46(8):1593-602. 5. Chadha R, Puri M, Saxena R, Agarwala S, Puri A, Choudhury SR. Congenital pouch colon in a girl associated with bilateral atresia of cervix uteri and uterus didelphys. J Indian Assoc Pediatr Surg. 2013;18(2):81-3. 6. Breech L. Gynecologic concerns in patients with anorectal malformations. Semin Pediatr Surg. 2010;19(2):139-45. 7. Levitt MA, Bischoff A, Breech L, Peña A. Rectovestibular fistula-rarely recognized associated gynecologic anomalies. J Pediatr Surg. 2009;44(6):1261-7; discussion 1276.

8. Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN, Devroey P. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod Update. 2001;7(2):161-74. ■■■■

Cesarean without Labor Safest for Breech Delivery In cases of breech presentation, planned cesarean delivery is associated with fewer adverse outcomes than vaginal delivery or cesarean delivery during labor, according to a study of 52,671 breech births. Moreover, a new review of several studies, including the current study, shows the accumulated evidence supports planned cesarean delivery as the best option for breech presentation. The two articles are the latest evidence in the see-sawing opinion on breech deliveries, beginning with the 2000 Term Breech Trial. That trial led to recommendations by the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynaecologists advising cesarean delivery for breech presentation.

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PEDIATRICS

Stevens-Johnson Syndrome: A Case Report RAJIB KUMAR RAY*, RISHAV RAJ†

ABSTRACT Stevens-Johnson syndrome (SJS) is a rare drug-induced reaction, which is life-threatening. It is a medical emergency that requires hospitalization. Identification and removal of the causative medication administered in the treatment of the patient is of paramount importance to prevent its recurrence. SJS is characterized by high fever, headache, widespread-blistering exanthema of macules and atypical target like lesions accompanied by mucosal involvement. We report a case of a 2-year-old patient who presented with symptoms suggestive of SJS.

Keywords: Stevens-Johnson syndrome, drug-induced reaction, skin eruptions, life-threatening

tevens-Johnson syndrome (SJS) is a rare druginduced reaction, which is life-threatening. It is important to recognize SJS and toxic epidermal necrolysis (TEN) and manage them properly at the earliest. As a matter of fact, the identification and removal of the causative medication administered in the treatment of the patient is of paramount importance to prevent its recurrence.

hemorrhagic crusting of the lid margins, watery eyes due to fibrosis of the lacrimal puncta. Dry eyes occur due to fibrosis of the lacrimal gland ductules and conjuctival metaplasia with loss of goblet cells. More than 80% have conjuctival involvement leading to corneal ulceration, anterior uveitis and synechiae.

SJS and TEN can be recognized earlier if we are familiar with clinical features. Patients with SJS/TEN are characterized by high fever, headache, widespreadblistering exanthema of macules and atypical target like lesions accompanied by mucosal involvement. SJS advances to TEN, which is characterized by widespread epidermal detachment. In SJS/TEN, skin eruptions first appears as erythematous then dusky or purpuric macules. Some lesions are atypical targets with only two concentric rings. Rash first appears on the face and upper part of the trunk and proximal part of the extremities. These lesions develop into flaccid blisters. Nikolsky sign (separation of epidermis from dermis with lateral pressure) can be demonstrated. Ocular features present with flu-like symptoms which last for 14 days before appearance of mucocutaneous lesions,

A 2-year-old patient weighing 10 kg reported with complaints of fever for 25 days, multiple skin eruptions all over the body, mouth ulcers and purulent eye discharge for 3 days. The fever was continuous in nature without chills and rigor. The patient was being treated for pneumonia elsewhere. He developed generalized tonic-clonic type of convulsions on 3rd day of admission and was treated with epsolin followed by oral valproate.

*Associate Professor †2nd Year Resident Dept. of Pediatrics Hi-Tech Medical College and Hospital (Utkal University), Bhubaneswar, Odisha Address for correspondence Dr Rishav Raj 2nd Year Resident, Dept. of Pediatrics Hi-Tech Medical College and Hospital (Utkal University), Bhubaneswar - 751 025, Odisha E-mail: drrishavraj@gmail.com

CASE REPORT

After 7th day, the child developed pruritic, multiple maculopapular eruptions, oral ulceration, lips and eyelid swelling, itching and redness of eye. The medication given in SUM Hospital was combimist nebulization and maximum dose of ceftriaxone. Then the child was treated with meropenem and ranitidine, but the child didn’t improve and was then sent to Hi-Tech Hospital for further management. The parents of the child informed about prolonged drug intake, hospitalization and drug allergy. The medications taken were gardenal syrup, nobel plus, cefotaxime, gentamycin, racigyl, oflomac, frisium, ceftriaxone and bacigyl. On examination, the patient was conscious, irritable and he had pulse (110/min), temperature (98.2°F), respiratory rate (32/min) and SpO2 (97%). Patient had bilateral matting of the eyelashes, redness of

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PEDIATRICS eyes and swelling of the eyelid, angioedema with mucous membrane lesions in the mouth and lips (Fig. 1). Multiple ulcers accompanied by reddish-purple maculopapular vesicular lesions were noted on the face, chest, abdomen, trunk back, forearm, legs and genital area (Figs. 2 and 3). All these features favored the diagnosis of SJS. He was immediately asked to stop the medication and then managed by following medications: Intravenous immunoglobulin (IVIG), linezolid, vancomycin,

gentamycin, ranitidine, avil, fevastin, glycerin mouth paint for local application. Medicines prescribed by the ophthalmologist included moxicip eye ointment, softdrop (lubricant) and fusidic acid cream (2%). Patient was nil per oral and was given oral nutrition by nasogastric tube to minimize the protein loss, promote healing and decrease the risk of stress-induced ulcers. The patient was examined by a team of specialists including an ophthalmologist and a dermatologist. Routine blood investigations revealed that the patient was anemic and had acute infection while urine analysis showed pus cells of 6-8/hpf, urine culture showed significant number of Escherichia coli growth, Mantoux test showed negative interpretation with 4 mm size, widal test was negative and quantitative buffy coat (QBC) test for malaria was also negative. The patient’s condition was reviewed on daily basis and at the end of 1 week, there was significant healing of oral, cutaneous and eye lesions. The patient was recommended iron supplements and antibiotic eye ointment and was discharged from hospital. CONCLUSION

Figure 1. Patient suffering from SJS with purpuric macules on face, crusting of lid margin, eyelid swelling, eye discharge and ulceration of lips.

Medication is considered as one of the most common cause of SJS. Early diagnosis is essential for better outcome. There are approximately 100 drugs that cause SJS. Few of the drugs are oxicam, sulfa drugs, diclofenac, maximum dose of ceftriaxone, allopurinol, antiepileptic drugs like phenytoin, carbamazepine, etc. It was presumed that SJS was due to higher dose of ceftriaxone and phenytoin. The patient’s first-degree relative should be informed about the causative drug. SUGGESTED READING 1. Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333(24):1600-7.

Figure 2. Appearance of cutaneous lesions at the back.

2. Walva R, Garg A, Sharma S. Short-rooted premolars and Steven-Johnson syndrome. Int J Pharm Pharm Sci. 2011;3(5):1-4. 3. Kakourou T, Klontza D, Soteropoulou F, Kattamis C. Corticosteroid treatment of erythema multiforme major (Stevens-Johnson syndrome) in children. Eur J Pediatr. 1997;156(2):90-3. 4. Patterson R, Grammer LC, Greenberger PA, Lawrence ID, Zeiss CR, Detjen PF, et al. Stevens-Johnson syndrome (SJS): effectiveness of corticosteroids in management and recurrent SJS. Allergy Proc. 1992;13(2):89-95.

Figure 3. Reddish-purple maculopapular rash.

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5. Bastuji-Garin S, Rzany B, Stern RS, Shear NH, Naldi L, Roujeau JC. A clinical classification of cases of toxic epidermal necrolysis, Stevens-Johnson syndrome and erythema multiforme. Arch Dermatol. 1993;129(1):92-6. ■■■■

PEDIATRICS

Intralesional Sclerotherapy Cures Unusual Presentation of Hemangioma in a Child BIMAL KUMAR MANDAL*, RINA DAS†, JAYANTA BAIN‡

ABSTRACT Hemangiomas are benign tumors made up of blood vessels. They usually regress spontaneously within 9 years of age. Hemangioma of retropharyngeal space is a rare entity. History, digital palpation, computed tomography (CT) and fine-needle aspiration cytology (FNAC) clinches the diagnosis. We want to report a case of retropharyngeal hemangioma in a 33-month-old female child who presented with respiratory distress. She was diagnosed and treated successfully in our department.

Keywords: Retropharyngeal hemangioma, CT scan, aspiration, sclerotherapy

CASE REPORT NK, a 33-month-old Muslim female child from Jharkhand, presented in early August 2010 to the local doctor with fever, cough and cold, who treated her symptomatically (Fig. 1). She used to have frequent episodes of upper respiratory tract infection (URTI) until last week of January 2011, when she got first attack of breathing difficulty during sleep. Her parents took her to Dept. of ENT, Ranchi Medical College, where she was admitted and stayed for 2 days. X-ray and computed tomography (CT) scan of nasopharynx revealed a retropharyngeal space occupying lesion (SOL) (Fig. 2) and they referred the case to a higher center.

unknowingly during sleep when her posture changed to supine she again felt the distress. On examination, her general condition was poor, her cry sounded a bit hoarse and she was very much apprehensive. She was admitted on 22nd February 2011 and planned for examination of the SOL under general anesthesia. In the operation theater (OT), digital palpation was done under general anesthesia. A cystic retropharyngeal mass was diagnosed. About 15 mL of altered blood

Subsequently, they came to Dept. of ENT, Calcutta National Medical College and Hospital (CNMCH), Kolkata. Her parents complained that the child had sleepless nights for a fortnight because of the breathing difficulty she felt each time she desired to sleep. Only in prone position she got some relief from the distress, but

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

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

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PEDIATRICS

Figure 2. Shows retropharyngeal space occupying lesion.

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

from the cystic mass was aspirated (Fig. 3). Cytologic examination of that fluid showed RBC - 5.5 million/dL, WBC - 6,400/dL, platelets - 1,50,000/mL and no pus cells. She was kept under observation for 5-6 days and was discharged. In late March 2011, she was readmitted in our department with the same complaints. Digital palpation and aspiration was done under general anesthesia. At this time 10 mL of fluid was aspirated followed by injection of sclerosing agent sodium tetradecyl sulfate (2 mL of the sclerosing agent was mixed with 4 mL of distilled water). She was asked to come for follow-up 2-3 weeks later. For approximately 3 months she did well. On 6th June 2011, again she got admitted but there was mild breathing problem and examination under general anesthesia was done. This time no fluid came out of the aspiration but 2 mL of the same diluted sclerosing agent was injected into the site. Follow-up CT scan of neck was found normal. The patient is under regular follow-up and leading a normal life. DISCUSSION The retropharyngeal space lies between the buccopharyngeal fascia covering posterior pharyngeal wall anteriorly and cervical vertebra with prevertebral muscles covered by prevertebral fascia posteriorly. This space is divided into two compartments (right and left) by its attachment with the median raphe. Types of

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retropharyngeal SOL: 1) Congenital (brachial cleft cyst, ectopic thyroid); 2) inflammatory (retropharyngeal abscess and retropharyngeal cellulitis); 3) neoplastic (cystic hygroma, neurofibroma, neuroblastoma, hemangioma); 4) traumatic (foreign body, hematoma) and 5) metabolic (hypothyroidism). Of them, the hemangioma is a rare cystic mass in this space, a benign tumor that grows within the blood vessels. Hemangiomas are the most common childhood tumors. A hemangioma (comes from the Latin words hemangio meaning blood vessel and oma meaning tumor with active cell dividing activity) is a benign self-involuting tumor of endothelial cells. This tumor is most often found on the head or neck. However, they may occur anywhere on the skin or internal organs. It is usually found at 2-4 months of age. In most cases, hemangioma appears during the first days or weeks of life and resolves at the latest by age 10. Hemangiomas never develop in an adult. There is no reason now-a-days to accept that the only option available is to ‘leave it alone’ and wait for the hemangioma to ‘go away’ or allow it to attain mega size. Secondly, the most appropriate treatment plan needs to be individualized for each patient and each lesion. Therefore, similar lesions in different patients may be treated differently.1,2 Sclerotherapy is a procedure used to treat blood vessels or blood vessel malformations (vascular malformations) and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults, sclerotherapy is often used to treat varicose veins and hemorrhoids. Sclerosant is diluted with blood as it diffuses away from the site of injection, thus if a strong sclerosant is injected there will be three zones of action. In zone 1, vascular endothelium is irreversibly injured: The vessel will be fully sclerosed and eventually will be completely replaced by a fibrous tissue. In zone 2, vascular endothelium is injured, and the vessel will be partially or completely thrombosed but will eventually recanalize. In zone 3, the sclerosant will be diluted below its injurious concentration, and there will be no endothelial injury. Sclerosants are polidocanol, 5% phenol, absolute alcohol, hot water, hypertonic saline and sodium teradecyl sulfate.3 In our case, we unanimously thought that sclerotherapy would be the best treatment option and accordingly we did it. We used sodium tetradecyl sulfate as sclerosant. Being a detergent-based chemical, its action is on the lipid molecules in the cells of the vein wall, causing destruction of the internal

PEDIATRICS lining of the vein and causing them to shed, leading to thrombosis, fibrosis and obliteration (sclerosis). It is used in concentrations ranging from 0.1% to 3% for this purpose. Till now, the patient is relieved of the distress with this treatment (one and half years follow-up) and we expect no recurrence in future. There are various types of treatment protocol like sclerotherapy, laser, interferon a2, intralesional corticosteroid therapy,3-6 but we used sclerotherapy with successful result without any complication. CONCLUSION Hemangioma of retropharyngeal space is a rare entity. CT scan followed by digital palpation and fine-needle aspiration cytology (FNAC) can clinch the diagnosis in case of retropharyngeal hemangiomas, which present with respiratory distress. Repeated aspiration of collected fluid and sclerotherapy in hemangiomas is a preferable treatment option.

REFERENCES 1. Fishman SJ, Mulliken JB. Hemangiomas and vascular malformations of infancy and childhood. Pediatr Clin North Am. 1993;40(6):1177-200. 2. McCook TA, Felman AH. Retropharyngeal masses in infants and young children. Am J Dis Child. 1979;133(1): 41-3. 3. Woods JE. Extended use of sodium tetradecyl sulfate in treatment of hemangiomas and other related conditions. Plast Reconstr Surg. 1987;79(4):542-9. 4. Landthaler M, Hohenleutner U, el-Raheem TA. Laser therapy of childhood haemangiomas. Br J Dermatol. 1995;133(2):275-81. 5. Gawrych E, Walecka A, Rajewska J, Juszkiewicz P. Intralesional corticosteroid therapy in infantile hemangiomas. Ann Acad Med Stetin. 2009;55(1):15-21.

6. Ezekowitz RA, Mulliken JB, Folkman J. Interferon alfa- 2a therapy for life-threatening hemangiomas of infancy. N Engl J Med. 1992;326(22):1456-63. ■■■■

Survival, Outcomes Similar for Bioprosthetic vs Mechanical MVR in Middle-aged Patients The answer to whether bioprosthetic mitral-valve replacement (MVR) is preferable to mechanical for nonelderly patients is “it depends,” suggests new research. A retrospective cohort study of patients between the ages of 50 and 69 years who underwent primary, isolated MVR showed no difference 15 years later in survival rates between the two types of valves. Although the patients who received mechanical mitral valves had significantly higher incidents of both stroke and bleeding events, those who received bioprosthetic valves had higher incidents of reoperation.

Growth Hormone Therapy in Children does not Increase Risk of Malignancy For children who do not have any known risk factors for cancer, growth hormone therapy does not increase future risk of developing a malignancy, according to a recent clinical review. The report, published online April 4 in the Journal of Clinical Endocrinology and Metabolism, also found that growth hormone can be used to treat survivors of childhood cancer who are in remission and have a growth hormone deficiency. However, appropriate surveillance for cancer should be undertaken in these patients, as growth hormone therapy may increase the chance of secondary malignancy.

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RESPIRATORY INFECTIONS

Isoniazid-induced Acute Psychosis PRAVEEN B GAUTAM*, HN CHAUDHARY†

ABSTRACT Isoniazid-induced psychosis, a rare entity was diagnosed and being presented. The time of onset in relation to dose and duration of isoniazid intake and its mode of presentation are being discussed. Here we present a case report of a patient who developed acute psychosis after 2nd dose of isoniazid therapy under DOTS regimen that resolved after withdrawal of the offending drug.

Keywords: Antitubercular therapy, isonicotinic acid hydrazide, DOTS

sonicotinic acid hydrazide (INH) is an antitubercular drug used mainly in prevention and treatment of tuberculosis (TB), because of its potency, safety and low cost. The common side-effects of INH are peripheral neuropathy, hepatitis and rashes. Rarely psychosis, convulsion and even death have reported with conventional dose of this drug.1,2 The less frequent but serious neurological adverse effect which have been reported with INH are toxic psychosis, optic neuritis, optic atrophy, toxic encephalopathy, cerebellar ataxia and death. It produces acute toxic effect by competing with pyridoxal 5-phosphate, resulting in lowered brain gamma-aminobutyric acid (GABA) levels. Acute ingestion of as little as 1.5-2.0 g can cause toxicity; severe poisoning is likely occur to after ingestion of >80-100 mg/kg. No definite data is available on potential toxicity, especially neurotoxicity, when the drug is used in high doses of 15 mg/kg under directly observed-treatment, short-course (DOTS).

past history. On examination, the patient was hemodynamically stable. In the chest, crackles present on left infraclavicular region, his blood examination revealed hemoglobin-10.5 gm%, total leukocyte count (TLC)-5,300/mm3, differential leukocyte count (DLC)-P90, L08, E01, M01, platelet count-4.4 lac/mm3, RBS-103.4 mg%, serum urea-28.1 mg%, serum creatinine-0.91 mg%, total bilirubin-0.8 mg%, serum glutamic-oxaloacetic transaminase (SGOT)-26.3 U/L, serum glutamic-pyruvic transaminase (SGPT)-54.3 U/L, serum sodium-135 mEq/L, serum potassium-3.4 mEq/L, serum calcium-8.8 mg%, sputum smear for acid-fast bacilli (AFB) was positive and chest X-ray revealed infiltration on left upper zone.

A 24-year-old male was admitted in TB and Chest Department with complaints of cough with expectoration and low-grade fever for 2 months and breathlessness for 1 month, hemoptysis for 1 week. No history of orthopnea or paroxysmal nocturnal dyspnea was present. There was no significant

Patient was put on antitubercular treatment (ATT) as per the DOTS category 1 regimen and given symptomatic treatment for hemoptysis. While on ATT, on the 5th day (i.e., 2nd dose of ATT) of admission, the patient suddenly became restless, agitated and irritable, with aimless incongruous acts and irrelevant talking. He had no past history of any mental illness. There was no neck rigidity and Kerning’s sign was absent. An initial diagnosis of acute drug-induced psychosis was made after a psychiatric consultation with isoniazid being identified as the likely culprit. His hemogram, kidney function tests, liver function tests and serum electrolyte tests were all repeated, but were within normal limits.

*Senior Resident †Professor and Head Dept. of TB and Chest, BRD Medical College, Gorakhpur, Uttar Pradesh Address for correspondence Dr Praveen B Gautam H. No.: 727, Anand Vihar Colony, Rapti Nagar, Arogya Mandir Gorakhpur - 273 003, Uttar Pradesh E-mail: pravingautom12@gmail.com

Patient was given antipsychotic drug and withdrawn all antitubercular drugs. Patient became free of psychiatric symptoms over next 3 days. Antitubercular drug restarted with ethambutol, rifampicin and pyrazinamide being added one by one, without any antipsychotic drug. After 1 week, isoniazid restarted in low dose (300 mg) after consent. After few hours, patient became restless, irritable and started irrelevant talking. After that isoniazid stopped and patient became free of

CASE REPORT

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RESPIRATORY INFECTIONS psychotic symptoms after 3 days. He was discharged on rifampicin, ethambutol and pyrazinamide (without INH) and had no further psychotic symptoms. DISCUSSION Isoniazid is one of the primary drugs of the ATT regimen because of its low cost, high safety and potency. However, it is known to have side-effects such as peripheral neuropathy, hepatitis, psychosis, etc.1,2 In 1953, the Committee on Therapy of American Trudeau Society estimated that toxic reactions due to INH occurred in 5% of patients, with 1% having serious reaction.3 The first description of psychotic symptoms due to isoniazid was by Mandel et al. who reported three such cases in 1956.4 The mechanism of production of isoniazid related psychiatric disorder is not clearly known but isoniazid is known to interfere with several metabolic processes essential for the normal functioning of the neuron.5 Isoniazid causes deficiency of vitamin B6 by causing excessive excretion of the vitamin, which in turn leads to disturbance of normal tryptophan metabolism. Isoniazid also inhibits the activity of brain pyridoxal 5-phosphate, which leads to decrease in brain GABA and other synaptic transmitters, resulting in neurological ill effects.6 Other predisposing factors for the occurrence of psychotic illness are diabetes mellitus, hepatic insufficiency, old age, alcoholism and family and personal history of mental illness. Incidentally, no such risk factors were seen in our patient. The diagnostic criteria for substance-induced psychosis, as per as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification, are given below: ÂÂ

Prominent hallucinations or delusions.

ÂÂ

There is evidence from the history, physical examination or laboratory findings of either (1) or (2): 1.

The symptoms in criterion A develop during, or within a month of, substance intoxication or withdrawal.

OR 2.

Medication use is etiologically related to the disturbance C. The symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent nonsubstance-induced

psychotic disorder (e.g., a history of recurrent nonsubstance-related episodes). There is great variability in the clinical features of isoniazid-induced psychosis in the various reported cases. Jackson, in 1957, reported five cases of isoniazidinduced psychosis between 7 and 45 days after INH therapy that presented with excessive argumentation, mental depression, euphoria, grandiose ideas and complex delusions; none of these patients had any previous history of mental illness.7 Agarwala, in 1974, reported symptoms of restlessness, irritability, emotional instability, agitation, apprehension and fluctuation in behavior after 7 days of isoniazid therapy8 (as was seen in our patient). Bedi, in 1994, reported a case of isoniazid psychosis in a 74-year-old, who developed restlessness, irritability, aimless activity and incongruous actions 10 days after starting isoniazid therapy (similar to the present case).9 In 1996, Tiwari reported a case of isoniazid-induced psychosis with disturbed sleep, restlessness and abnormal behavior.10 CONCLUSION Acute psychosis-induced by isoniazid, especially when given as part of the DOTS regimen, has a variable presentation and should always be kept in mind in the differential diagnosis. In the present case, following discontinuation of all antitubercular drugs, the psychiatric symptoms subsided. When patient was challenged with isoniazid, the same psychiatric symptoms recurred but resolved after withdrawal of the offending drug. It is important to be aware that, isoniazid can induce psychosis in a patients when antitubercular drugs are prescribed. REFERENCES 1. Dixon GJ, Robert GB, Tyrrell WF. Scot Med J. 1956;1(11):350-4. 2. Janssen G, Boke W. Klin Wochenschr. 1955;33 (19-20):477-9. 3. Am Rev Tuberc. 1953;68(2):302-5. 4. Cohn ML, Mandel W, Middlebrook G, Russell WF Jr. Am J Med Sci. 1957;233(1):66-8. 5. Holtz P, Palm D. Pharmacol Rev. 1964;16:113-78. 6. Girling DJ. Bull Int Union Tub. 1984;53:152. 7. Jackson SL. Br Med J. 1957;2(5047):743-6. 8. Agarwala MC, Kansal HM, Gupta RK, Gupta DK, Kumar S. Indian J Tuberculosis. 1975;3:119-20. 9. Bedi RS. Indian J Tuberculosis. 1994;41:269-70.

10. Tiwari VK, Verma SM. Indian J Tuberculosis. 1997;44:95-6. ■■■■

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SURGERY

Bilateral Axillary Galactocele: A Case Report KRK PRASAD*, A SARATH CHANDRA†, G VIJAYARAMARAO‡

ABSTRACT Ectopic breast is rare to occur but is more common in axilla. Ectopic breast occurs along the milk line from axilla to pubic symphysis. Ectopic breast is distinguished from axillary tail of the breast by its discontinuity from the normal breast in the former. Such ectopic breasts can be a seat of different lesions similar to breast tissue. Bilateral galactocele is not common, and such galactocele presenting as bilateral axillary swellings in a 30-year-old lactating woman is reported here for its rarity.

Keywords: Breast mass, galactocele, benign breast lesion, axillary mass

and pressure on both breasts led to small droplets of white greasy fluid (milk) exuding from the nipple. No masses were found in both breasts.

CASE REPORT

Laboratory investigations like X-ray, blood cell counts, erythrocyte sedimentation rate, serologic tests for contagious diseases were within normal limits. Fine needle aspiration cytology (FNAC) of both axillary swellings resulted in 30 mL of milky fluid from right axillary mass and 18 mL milky fluid from left axillary mass. Both axillary masses drastically diminished in

reast is the natural habitat for structural and functional lactiferous ducts and lobules. Sometimes such lactiferous ducts and sinuses are anatomically present in unnatural sites as accessory breast tissue in axilla, etc.1 A symptomless accessory breast will be noticed when complaints of swelling, pain during pregnancy or lactation in the ectopic breast appear.1 Accessory breast presenting in both axillae is uncommon. Galactocele occurring in both axillae is very rare2 and our case appears to be 2nd case on review of available literature.

A 30-year-old female complained of slowly growing painless axillary swellings on both sides since 3 months. The swellings started 10 days of postpartum period. There was no discharge from the swellings, no other swellings in the body and no fever. General examination revealed that respiratory, cardiovascular, renal, genital tract, central nervous system were normal. Local examination showed pendulous breasts

*Professor Dept. of Pathology Mallareddy Medical College for Women, Suraram, Ranga Reddy, Telangana †Associate Professor Dept. of Surgery and Cardiothoracic Surgeon Mallareddy Institute of Medical Sciences, Suraram, Ranga Reddy, Telangana ‡Pathologist and Director Dept. of Pathology Sigma Hospital, Shapur, Ranga Reddy, Telangana Address for correspondence Dr KRK Prasad Professor Dept. of Pathology Mallareddy Medical College for Women, Surarm, Ranga Reddy - 500 055, Telangana

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Anterior portions of both the axillae showed welldefined swellings of 4 × 3 cm in right axilla and 3.5 × 3 cm in left axilla, soft in consistency and not attached to the surface skin. No other masses were palpable in the body (Figs. 1 and 2).

Figure 1. Bilateral axillary swellings.

SURGERY Accessory breast tissue should be differentiated from ‘axillary tail of Spence’, which is defined as the extension of the breast tissue to the axilla. Ectopic breast tissue is subject to the same physiological and pathological changes as in the normal breast tissue, including lactational changes, benign and malignant conditions.1,2 When a female patient is diagnosed with a mass in axilla, a metastatic lymphadenopathy from breast cancer should be excluded first; lymph node involvement of lymphoma and granulomatous diseases (tuberculosis and sarcoidosis) should also be ruled out. Lesions like lipoma, sebaceous cyst, hidradenitis, cavernous hemangioma, venous malformation, lymphangioma are to be considered in the differential diagnosis.2,6

Figure 2. Well-circumscribed nature of axillary swelling. size after aspiration. FNAC material when stained with Leishman, hematoxylin and eosin stains showed proteinaceous and fatty background with occasional benign cuboidal epithelial cell and lymphocytes. No malignant cells were found. The cytological features, prompted us to make a diagnosis of galacotocele of the ectopic breasts in right and left axillae. The patient was on follow-up and after 6 months, when she discontinued breastfeeding completely, both axillary swellings markedly diminished in size. DISCUSSION In an analysis of 176 breast lesions Sangeeta et al3 found only a single case of galactocele, while Desai et al4 found 1.76 cases among 212 cases indicating rarity of the lesion. During embryogenesis, the galactic band extends from the axillae to the groin. Breast tissue continues to form only in the pectoral region. Failure of regression of the remainder of this galactic band gives rise to ectopic breast tissue. Although, they can be located anywhere along the embryonic milk line extending from the axilla to the inguinal line, 60-70% of the accessory breast tissue occur in axilla.5

Galactocele in axillae is differentiated from all other lesions by the finding of milk in the aspirated material in the axillary swelling, as in our case. The lesions usually regress in postlactational period and surgical excision brings cure to the disease. CONCLUSION A galactocele is to be considered as differential diagnosis of axillary masses in lactating women and a simple laboratory test of FNAC helps in the diagnosis. REFERENCES 1. Dilli A, Tatar İG, Kızılgöz V, Koç ER, Hekimoğlu B, MRI appearance of ectopic axillary breast tissue during lactational period. Journal of Ankara University Faculty of Medicine. 2013;66(2):75-77. 2. Whang IY, Lee J, Kim KT. Galactocele as a changing axillary lump in a pregnant woman. Arch Gynecol Obstet. 2007;276(4):379-82. 3. Kulkarni S, Vora IM, Ghorpade KG, Srivastava S. Histopathological spectrum of breast lesions with reference to uncommon cases. J Obstet Gynecol India. 2009;59(5):444-52. 4. Desai M. Role of obstetrician and gynecologist in management of breast lump. J Obstet Gynaecol India. 2003;53:389-91. 5. Burdick A, Thomas KA, Welsh E, Powell J, Elgart GW. Axillary polmastia. J Am Acad Dermatol. 2003;49:1154-6. 6. Bertschinger K, Caduff R, Kubik-Huch RA. Benign intramammary and axillary lesions mimicking malignancy. Eur Radiol. 2000;10:1029-30.

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EXPERTS’ VIEW

What are the Appropriate Secondary Prevention Strategies After MI? ASHOK K KAR, KK AGGARWAL*

ersons with coronary artery disease (CAD) can reduce their risk of subsequent cardiovascular events through effective secondary prevention, which reduces mortality and improves quality-of-life.1 All patients with clinical atherosclerotic cardiovascular disease (CVD) should receive secondary preventive interventions. Other indications of secondary prevention include patients with high-risk due to the presence of multiple risk factors (metabolic syndrome) and most patients with diabetes, or those with chronic kidney disease (CKD) with estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2. Options for secondary prevention include medical therapy and surgical revascularization (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]). Medical therapy focuses on comprehensive risk factor modification with therapeutic lifestyle changes viz. dietary modification, physical activity, tobacco cessation and weight management.1 In 2013, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force released updated guidelines on lifestyle management2 and treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults.3 In 2013, AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk emphasize Mediterranean-style dietary patterns over a ‘low-fat dietary pattern,’ although ‘low-fat dairy products’ are part of the dietary pattern advice. The major recommendations are summarized as below:2 In a major change from Adult Treatment Panel III (ATP III) guidelines, the new 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults do not recommend treating to target. Instead, the new guidelines have identified four groups for primary- and secondary-prevention

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

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2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk2 Advise adults who would benefit from low-density Diet lipoprotein cholesterol (LDL-C) and blood pressure (BP) lowering to:

Physical activity

yy Consume a dietary pattern that emphasizes intake of vegetables, fruits and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts consistent with Mediterranean or DASH-type diet. yy Limit intake of sweets, sugar-sweetened beverages and red meats. yy Aim for a dietary pattern that achieves 5-6% of calories from saturated fat. yy Reduce percent of calories from saturated and trans fat. yy Lower sodium intake ♦♦ Consume no more than 2,400 mg of sodium/day ♦♦ Further reduction of sodium intake to 1,500 mg/ day is desirable since it is associated with even greater reduction in BP ♦♦ Reduce intake by at least 1,000 mg/day since that will lower BP, even if the desired daily sodium intake is not yet achieved. Advise adults to engage in aerobic physical activity to reduce LDL-C and non–HDL-C (high-density lipoprotein cholesterol) BP: 3-4 sessions a week, lasting on average 40 minutes/session and involving moderate-to-vigorous intensity physical activity.

where physicians should focus their efforts to reduce CVD events and make recommendations regarding the appropriate ‘intensity’ of statin therapy to achieve relative reductions in LDL-C.3 The four treatment groups include: ÂÂ

Individuals with clinical atherosclerotic CVD (ASCVD)

ÂÂ

Individuals with primary elevations of LDL-C ≥190 mg/dL

ÂÂ

Individuals 40-75 years of age with diabetes with LDL-C 70-189 mg/dL

ÂÂ

Individuals without clinical ASCVD or diabetes, who are 40-75 years of age with LDL-C 70- 89 mg/dL and an estimated 10-year ASCVD risk of 7.5% or higher.

EXPERTS’ VIEW Secondary Prevention of Atherosclerotic CVD: 2013 ACC/AHA Recommendations3 yy High-intensity statin therapy should be initiated or continued as first-line therapy in women and men ≤75 years of age who have clinical ASCVD*, unless contraindicated. yy In individuals with clinical ASCVD* in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderateintensity statin should be used as the second option if tolerated yy In individuals with clinical ASCVD >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects, drug-drug interactions and to consider patient preferences, when initiating a moderate- or high-intensity statin. It is reasonable to continue statin therapy in those who are tolerating it. *Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA or peripheral arterial disease presumed to be of atherosclerotic origin.

PHARMACOLOGICAL INTERVENTION ÂÂ

Antiplatelet: Aspirin 75-162 mg; if aspirin allergy, clopidogrel 75 mg or warfarin (international normalized ratio [INR] 2.5-3.5) per day.

ÂÂ

Renin-angiotensin-aldosterone system (RAAS) inhibitors: Angiotensin-converting enzyme (ACE) inhibitor for all; aldosterone antagonist to be added in those with left ventricular ejection fraction (LVEF) <40%, symptomatic heart failure or diabetes mellitus (DM) and without renal dysfunction (creatinine <2.5 mg/dL in males; <2.0 mg/dL in females) or hyperkalemia (K+ <5 mEq/L); angiotensin receptor blocker (ARB) in those intolerant to ACE.

ÂÂ

b-blockers: In all; gradual dose titration in moderate or severe failure.

ÂÂ

Warfarin: In those with aspirin allergy with indications for anticoagulation - as alternative to clopidogrel (INR 2.5-3.5); post-stenting regimen with clopidogrel (75 mg/day) (INR 2-3). Paroxysmal atrial fibrillation (INR 2-3) LV thrombus (INR 2.53.5) (continue at least for 3 months).

ÂÂ

Hormone replacement therapy: Should not be given.

ÂÂ

Antioxidants: No evidence for any significant benefit.

OTHER SECONDARY PREVENTION INTERVENTIONS Weight management: Achieve and maintain a healthy weight. The new 2013 AHA/ACC/TOS recommendations retain the body mass index (BMI) as a quick and first easy screening step to help identify who should be counseled to lose weight and also advise use of waist circumference as an indicator of risk for type 2 diabetes, CVD and all-cause mortality. Weight loss should be encouraged at a BMI of 25 with just one comorbidity, and elevated waist circumference can be one of those comorbidities Overweight and obese adults with cardiovascular risk factors such as hypertension, hyperglycemia and hyperlipidemia should be counseled that even modest, sustained weight loss of 3-5% leads to clinically meaningful health improvements.4 Smoking cessation: Tobacco cessation has been shown to reduce all-cause mortality in patients with established CAD.1 Control of diabetes: The 2014 American Diabetes Association (ADA) standards of medical care recommend A1C goal <7%. Lowering A1C to below or around 7% has been shown to reduce microvascular complications of diabetes and, if implemented soon after the diagnosis of diabetes, is associated with longterm reduction in macrovascular disease. Less stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications and extensive comorbid conditions and in those with long-standing diabetes in whom the general goal is difficult to attain.5

REFERENCES 1. Hall SL, Lorenc T. Secondary prevention of coronary artery disease. Am Fam Physician. 2010;81(3):289-96. 2. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013 Nov 12. 3. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/ AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013 Nov 12. 4. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 2013 Nov 12. 5. American Diabetes Association. Standards of medical care in diabetes - 2014. Diabetes Care 2014;37 Suppl 1:S14-80.

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

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ALGORITHM

Management of Hyperkalemia Is potassium elevated?

Yes

Is elevation real*

Stop

Yes

No Stop

Is potassium level more than 6.0 mEq per L (6.0 mmol per L) or are electrocardiograph(ECG) changes present?

Yes Patient requires emergency potassium reduction

ECG abnormal?

Yes

No Give insulin with glucose and/or albuterol by nebulizer (10 to 20 mg over 10 minutes [use concentrated form, 5 mg per mL])

Give calcium gluconate intravenously (10 to 20 mL of 10 percent solution over two to three minutes)

Order tests: spot urine potassium, osmolality, creatinine

Proceed with evaluation

Is potassium <6.0 mEq per L?

No Repeat insulin and glucose; consider hemodialysis

Yes Give sodium polystyrene sulfonate or furosemide

Further evaluation and long-term therapy

*Causes of actual potassium values that are lower than laboratory values yy yy yy yy yy yy

Drawing blood samples from a vein or line into which potassium is being infused Laboratory error Pseudohyperkalemia: Hemolysis, leukocytosis and thrombocytosis Repeated clenching of the fist during phlebotomy Traumatic venipuncture Uncommon genetic syndromes: Familial pseudohyperkalemia and hereditary spherocytosis

Adapted from Am Fam Physician 2006;73(2):283-90.

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MEDILAW

Sexual Misconduct in Medical Practice KK AGGARWAL

What is sexual misconduct in the practice of medicine? The American Medical Association (AMA) has defined sexual misconduct as below. AMA Opinion 8.14: Sexual Misconduct in the Practice of Medicine 1. Sexual contact that occurs concurrent with the physician-patient relationship constitutes sexual misconduct. 2. Sexual or romantic interactions between physicians and patients detract from the goals of the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the physician’s objective judgement concerning the patient’s healthcare, and ultimately may be detrimental to the patient’s well-being. 3. If a physician has reason to believe that nonsexual contact with a patient may be perceived as or may lead to sexual contact, then he or she should avoid the nonsexual contact. 4. At a minimum, a physician’s ethical duties include terminating the physician-patient relationship before initiating a dating, romantic or sexual relationship with a patient. 5. Sexual or romantic relationships between a physician and a former patient may be unduly influenced by the previous physician-patient relationship. Sexual or romantic relationships with former patients are unethical if the physician uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship. 6. Sexual relationships between supervisors and trainees are unethical. Such relationships would include residents and interns or attending physicians and residents or fellows.

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

7. Physicians and patients may be genuinely attracted to each other. However, any relationship in which a physician might take advantage of the patient’s emotional or psychological vulnerability is unethical. 8. “Sexual exploitation”: “A pattern, practice or scheme of conduct, which may include sexual contact, that can reasonably be construed as being for the purposes of sexual arousal or gratification or sexual abuse of any person. The term does not include obtaining information about a patient’s sexual history within standard accepted practice while treating a sexual or marital dysfunction.”

How does the MCI deal with this issue? MCI guidelines to deal with this issue are as under: 7.4: Adultery or Improper Conduct: Abuse of professional position by committing adultery or improper conduct with a patient or by maintaining an improper association with a patient will render a physician liable for disciplinary action as provided under the Indian Medical Council Act, 1956 or the concerned State Medical Council Act.

What are the AMA guidelines on sexual relationship with patients? As per the American Medical Association’s Council on Ethical and Judicial Affairs ÂÂ

Sexual contact or a romantic relationship concurrent with the physician-patient relationship is unethical.

ÂÂ

Sexual contact or a romantic relationship with a former patient may be unethical under certain circumstances. Sexual or romantic relationships with former patients are unethical if the physician uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship.

ÂÂ

Education on the ethical issues involved in sexual misconduct should be included throughout all levels of medical training.

ÂÂ

In the case of sexual misconduct, reporting offending colleagues is especially important.

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MEDILAW A State Medical Council seeks to discipline a physician for having an affair with a patient, but both the patient and the physician insist that the patient consented to the relationship. Should the Council dismiss the proceeding? If the patient is a minor: The answer is No. Consent is not a defence to a charge of statutory rape or sexual imposition on a minor. If the patient is a competent adult: According to AMA “sexual contact that occurs concurrent with the physician-patient relationship constitutes sexual misconduct (Opinion 8.14).” In an article in JAMA announcing the policy, the AMA Ethics Council rejected the position that sexual relationships should be permitted with the patient’s consent on the ground that the relative position of the patient within the professional relationship is such that it is difficult for the patient to give meaningful consent to such behaviour. AMA categorically condemns sexual relationships to which patients allegedly consent. However, the US courts have indicated that, despite the physician’s greater power within the relationship, they are willing to consider on a case-by-case basis whether to uphold agreements between patients and physicians, in which the patient agrees not to sue the physician for malpractice.

to have strong feelings about psychotherapists for 5-10 years after the therapeutic relationship ends. SUGGESTIONS ÂÂ

Physicians should be alert to feelings of sexual attraction to a patient, and may wish to discuss such feelings with a colleague. To maintain the boundaries of the professional relationship, a physician should transfer the care of a patient to whom the physician is attracted to another physician and should seek help in understanding and resolving feelings of sexual attraction without acting on them.

ÂÂ

Physicians must be alert to signs indicating that a patient may be encouraging a sexual relationship, and must take all steps necessary to maintain the boundaries of the professional relationship including doing nothing to encourage this behavior and transferring the patient.

ÂÂ

Physicians must respect a patient’s dignity at all times and should provide appropriate gowns and private facilities for dressing, undressing and examination.

ÂÂ

To minimize misunderstandings and misperceptions between a physician and patient, the physician should explain the need for each of the various components of an examination and for all procedures and tests.

ÂÂ

Physicians should choose their words carefully, so that their communications with a patient are clear, appropriate and professional.

ÂÂ

Physicians should seek out information and formal education in the area of sexual attraction to patients and sexual misconduct, and should in turn educate other healthcare providers and students.

ÂÂ

Physicians should not discuss their intimate personal problems with patients.

ÂÂ

Physicians should remember that treatment boundaries tend to erode gradually, and that once a sexual relationship begins, it may be impossible to terminate without serious consequences for both parties.

What about sexual relationships after the patientphysician relationship has ended? One would think that these would be acceptable, provided the physician did not abuse the relationship. But, the AMA takes the position that ending the professional relationship may not be enough; a relationship still may violate professional ethics “if the sexual contact occurred as a result of the use or exploitation of trust, knowledge, influence, or emotions derived from the former professional relationship.” Some commentators have suggested that the way to deal with sexual relationships with former patients is to impose a minimum waiting period following the termination of the patient-physician relationship. Some have proposed 3-6 months but AMA rejects this idea, citing research, which shows that patients continue

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INSPIRATIONAL STORY

Words of Wisdom Words of great wisdom, The Native American Code of Ethics:

ÂÂ Nature is not FOR us, it is a PART of us. They are

ÂÂ Rise with the sun to pray. Pray alone. Pray often.

ÂÂ Children are the seeds of our future. Plant love in

The Great Spirit will listen, if you only speak.

part of your worldly family.

their hearts and water them with wisdom and life’s lessons. When they are grown, give them space to grow.

ÂÂ Be tolerant of those who are lost on their path.

Ignorance, conceit, anger, jealousy and greed stem from a lost soul. Pray that they will find guidance.

ÂÂ Search for yourself, by yourself. Do not allow

others to make your path for you. It is your road and yours alone. Others may walk it with you, but no one can walk it for you.

ÂÂ Treat the guests in your home with much

ÂÂ Avoid hurting the hearts of others. The poison of

your pain will return to you.

ÂÂ Be truthful at all times. Honesty is the test of ones

will within this universe.

ÂÂ Keep yourself balanced. Your Mental self, Spiritual

self, Emotional self and Physical self—all need to be strong, pure and healthy. Work out the body to strengthen the mind. Grow rich in spirit to cure emotional ails.

consideration. Serve them the best food, give them the best bed and treat them with respect and honor.

ÂÂ Do not take what is not yours whether from a

person, a community, the wilderness or from a culture. If it was not earned or given, it is not yours.

ÂÂ Make conscious decisions as to who you will be

and how you will react. Be responsible for your own actions.

ÂÂ Respect all things that are placed upon this earth—

whether it be people or plant.

ÂÂ Honor other people’s thoughts, wishes and words.

Never interrupt another or mock or rudely mimic them. Allow each person the right to personal expression.

ÂÂ Respect the privacy and personal space of others.

Do not touch the personal property of others— especially sacred and religious objects. This is forbidden.

ÂÂ Never speak of others in a bad way. The negative

ÂÂ Be true to yourself first. You cannot nurture and

energy that you put out into the universe will multiply when it returns to you.

help others if you cannot nurture and help yourself first.

ÂÂ All persons make mistakes. And all mistakes can

ÂÂ Respect others religious beliefs. Do not force your

ÂÂ Bad thoughts cause illness of the mind, body and

ÂÂ Share your good fortune with others. Participate in

belief on others.

be forgiven.

spirit. Practice optimism.

charity.

“The greatest gift you can give another is the purity of your attention.” ― Richard Moss “If we wait until our lives are free from sorrow or difficulty, then we wait forever. And miss the entire point.” ― Dirk Benedict ■■■■

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AROUND THE GLOBE

News and Views ÂÂ A new study has stated that being male is

associated with worse memory and lower hippocampal volume throughout middle and old age in cognitively normal individuals. The findings are published online in JAMA Neurology.

an updated clinical practice guideline on adult sinusitis, with a greater focus on patient education and patient preference. The guidelines are published April 1 in Otolaryngology–Head and Neck Surgery.

ÂÂ Screening for prostate cancer using MRI and a

ÂÂ An

ÂÂ Among patients with symptomatic intracranial

ÂÂ Antidepressants,

ÂÂ Most patients with lumbosacral radiculopathy have

ÂÂ Basophil activation testing (BAT) may assist in

lower prostate-specific antigen (PSA) threshold could result in fewer men needing biopsies with no compromise to cancer detection rates, suggests a pilot study presented at the European Association of Urology 30th Annual Congress. arterial stenosis, the use of a balloon-expandable stent was associated with worse outcomes than medical therapy alone, reported the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT) study. The study results were published in JAMA. gluteal trigger points (GTrP), suggests a new study. The findings suggest that treating these trigger points could help ease pain in these patients. The findings are published in the American Journal of Physical Medicine and Rehabilitation.

ÂÂ Natamycin treatment of mycotic corneal ulcers

improves vision-related quality-of-life, compared with voriconazole treatment, suggests the mycotic ulcer treatment trial I (MUTT I). The data are published online in JAMA Ophthalmology.

ÂÂ Consuming herring, mackerel and certain fish oils

may heighten the risk of cancer patients becoming resistant to chemotherapy, suggests a new study published in JAMA Oncology.

ÂÂ Alcohol-dependent hospital patients die from

multiple morbidities 7.6 years earlier than patients without a history of alcohol addiction, suggests new research published in European Psychiatry.

ÂÂ In a study of the sleeping habits and metabolism,

investigational, first-in-class antipsychotic has shown promise as an effective agent in the treatment of schizophrenia, with an improved side effect profile, suggests a phase 2 study presented at the 15th International Congress on Schizophrenia Research (ICOSR). including selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) have been linked to an increased risk for first-time seizures in patients being treated for depression, suggests new research presented at the European Psychiatric Association (EPA) 23rd Congress. the prediction of food allergy reaction severity, suggests new research published online April 1 in the Annals of Allergy, Asthma and Immunology.

ÂÂ Pooled data do not prove the safety of finasteride

for androgenic alopecia (AGA), with sexual side effects in particular not sufficiently analyzed, suggests a new meta-analysis published online in JAMA Dermatology.

ÂÂ Obese people are better at detecting the scent of

chocolate and find it more pleasant than nonobese people, suggests a small study from the UK published online in Chemical Senses.

ÂÂ Once-daily

dolutegravir maintains its higher virological response rates over those of ritonavirboosted darunavir in treatment-naïve adults with HIV-1 infection, suggest the 96-week results from the FLAMINGO study published online in Lancet HIV.

ÂÂ Eating two large, fiber-rich meals a day as part of a

people who stayed up late, regardless of lifestyle factors, had a higher risk of diabetes or reduced muscle mass than those who were early risers. The findings are published in the Journal of Clinical Endocrinology and Metabolism.

calorie-restricted diet, rather than six smaller meals spread throughout the day, helps people with type 2 diabetes feel less hungry and less depressed, suggests a secondary analysis of a crossover trial published in the European Journal of Clinical Nutrition.

ÂÂ The American Academy of Otolaryngology–Head

ÂÂ A reduced abundance of the Prevotellaceae bacteria

and Neck Surgery Foundation has presented

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Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

family has been noted in the gut microbiome of

AROUND THE GLOBE Parkinson’s disease (PD) patients compared with healthy control persons in a new study. This could be an important clue to what drives PD. The findings are published in Movement Disorders.

harmful, report long-term results of the Radiation Therapy Oncology Group (RTOG) 9903. The findings are published in the International Journal of Radiation Oncology Biology and Physics.

ÂÂ Patients with lumbar spinal stenosis (LSS) who

ÂÂ Compared with proton pump inhibitor (PPI)

receive physical therapy (PT) seem to have similar symptom relief and functional improvements during the first 2 years as those who undergo surgical decompression, suggests new research published online April 6 in the Annals of Internal Medicine.

ÂÂ Certain types of mutation in specific parts of the

BRCA1 and BRCA2 genes can alter the risk for breast or ovarian cancer, suggests a study published in the April 7 issue of JAMA.

ÂÂ Tofacitinib impairs responses to pneumococcal

vaccine, but not influenza vaccine, in patients with rheumatoid arthritis (RA), suggests new research published online in Annals of the Rheumatic Diseases.

ÂÂ Topical gel combinations of adapalene and benzoyl

peroxide appear to be safe and effective in the long-term management of patients with moderate to severe inflammatory acne, suggest two new studies presented at the American Academy of Dermatology 73rd Annual Meeting.

ÂÂ The transition from extensive use of intravenous

(IV) sedation for interventional pain procedures to almost exclusive use of oral anxiolysis at an outpatient pain center led to significant improvements in patient satisfaction and recovery times in a new study presented at the American Academy of Pain Medicine (AAPM) 31st Annual Meeting.

ÂÂ Noisy operating rooms, especially during closure,

were associated with a higher risk of surgical-site infections (SSIs) after hernia repair in a recent small study published online in Surgery.

ÂÂ A landmark study that traces the evolutionary

history of genetic mutations in lethal prostate cancer has found that some metastases are actually seeded by cancer cells from other metastases, and not from the original primary tumor. The findings are published online in Nature.

ÂÂ Women who were themselves born prematurely are

more likely to give birth prematurely than women born full-term, suggested a study published online in Obstetrics and Gynecology.

ÂÂ Adding erythropoietin (EPO) to radiation therapy

(RT) in patients with head and neck squamous cell carcinoma (HNSCC) is not helpful and may be

treatment for gastroesophageal reflux disease (GERD), transoral incisionless fundoplication (TIF) brings on improvements in quality-of-life and reflux, but normalization of pH does not persist at 12 months, suggests a new trial published online in the American Journal of Gastroenterology.

ÂÂ A new study suggests that any amount of

leisure-time physical activity is associated with a significantly lower risk of death when compared with no physical activity at all. The findings are published online in the Journal of the American Medical Association: Internal Medicine.

ÂÂ Engaging in arts and crafts and social activities in

mid-life and late life and using a computer in late life were associated with a reduced risk for mild cognitive impairment (MCI) in elderly patients, suggested a new study published online April 8 in Neurology.

ÂÂ A 15-year study of more than 1,300 men and

women who were initially free of early or late age-related macular degeneration (AMD) has shown that overall, 13.9% of the participants developed medium drusen, and older people and those with risk alleles in the CFH and ARM2 genes had a greater risk of developing medium drusen. The findings are published online in JAMA Ophthalmology.

ÂÂ The first recommendations to help clinicians make

the best use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA) were published online by an expert task force assembled by the European League Against Rheumatism (EULAR). The task force developed 10 recommendations that addressed all currently available imaging modalities. The guidelines are published in the Annals of Rheumatic Disease.

ÂÂ The beneficial effects of subthalamic nucleus (STN)

deep brain stimulation (DBS) on pain in patients with Parkinson’s disease (PD) persist long-term, suggests a new study published online in JAMA Neurology.

ÂÂ Aerobic exercise reduces liver fat and visceral

adipose tissue (VAT) by a small amount even in individuals who do not experience clinically significant weight loss, suggests a randomized placebo-controlled study published online April 7 in the Journal of Hepatology.

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

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AROUND THE GLOBE ÂÂ The

American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) have issued new, more comprehensive guidelines outlining optimal care for patients with type 2 diabetes. The guidelines include an algorithm to help guide clinicians and the updated information also briefly addresses the use of insulin in type 1 diabetes. The guidelines are published in the April issue of Endocrine Practice.

ÂÂ Individuals who take more than 800 mg of calcium

daily are almost twice as likely to be diagnosed with age-related macular degeneration (AMD) as those who do not, suggests a new study published online April 9 in JAMA Ophthalmology.

ÂÂ The 5-alpha-reductase inhibitors (5-ARIs) used to

treat benign prostatic hyperplasia (BPH) do not increase the risk of prostate cancer-specific or allcause mortality in men newly diagnosed with prostate cancer, suggests a study published online in JAMA Oncology.

ÂÂ A single dose of a broadly neutralizing HIV-1

antibody (bNAb) significantly decreased viral load up to 8 weeks, reported a small phase 1 clinical trial published online April 8 in Nature.

ÂÂ New research shows that it is possible to kill drug-

resistant bacteria by alternating two antibiotics at doses that would ordinarily boost bacterial resistance and survival when used alone or combined. The findings are published in the journal PLOS Biology.

ÂÂ A new study suggests that obesity could be a

protective factor against dementia, while people who are underweight may be at increased risk. Being underweight was linked with a 34% increased dementia risk, while being severely obese reduced dementia risk by 29%. The study is published in the Lancet Diabetes and Endocrinology.

ÂÂ Hematopoietic stem cell transplant recipients

should receive influenza vaccine beforehand, if possible, suggests new research published in Bone Marrow Transplantation.

ÂÂ Screening asymptomatic people for type 2 diabetes

does not improve mortality after 10 years of followup, but detection and treatment of impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) possibly delay progression to diabetes, suggests a systematic literature review published online in the Annals of Internal Medicine.

ÂÂ Almost 1 in 6 women with bipolar disorder develop

hypothyroidism while being treated with lithium,

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Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

suggests new research presented at the European Psychiatric Association (EPA) 23rd Congress. ÂÂ Subdissociative ketamine is as safe and effective as

morphine for short-term treatment of acute pain in the emergency department, suggests new research published online in Annals of Emergency Medicine.

ÂÂ An all-oral, interferon-free regimen consisting of

ombitasvir, paritaprevir and ritonavir is effective at treating patients with genotype-4 chronic hepatitis C virus (HCV), suggests new research published online in the Lancet.

ÂÂ A quantitative fecal immunochemical test (FIT)

predicts mucosal healing in ulcerative colitis at least as well as the more expensive fecal calprotectin (Fcal), suggests new research published online in the American Journal of Gastroenterology.

ÂÂ The

use of aspirin after newly diagnosed nonmetastatic prostate cancer does not lower disease-specific or overall mortality, suggests a large population-based study published in the April issue of the Journal of Urology.

ÂÂ Women have a significantly greater risk of

developing posttraumatic stress disorder (PTSD) than men, regardless of the severity of the traumatic event, suggests a new prospective study presented at the Anxiety and Depression Association of America (ADAA) Conference 2015.

ÂÂ An intensified hospital-based program providing

physical rehabilitation and information to patients coming out of the intensive care unit (ICU) did not appear to improve most outcomes in the RECOVER trial. The findings are published online April 13 in JAMA Internal Medicine.

ÂÂ The

Royal College of Obstetricians and Gynaecologists (RCOG) released updated guidelines on preventing and treating thromboembolic disease in pregnancy, during childbirth, and after delivery. The guidelines were published online April 13.

ÂÂ Gene

therapy is superior to haploidentical hematopoietic stem cell transplantation (HSCT) to treat X-linked severe combined immunodeficiency (SCID-X1), suggests a report published online April 13 in Blood.

ÂÂ Men who use muscle-building supplements (MBSs)

that contain creatine or androstenedione may have up to 65% increased risk of developing testicular cancer, suggests a case-control study published online in the British Journal of Cancer.

ÂÂ Noninvasive prenatal testing (NIPT), which relies

AROUND THE GLOBE on cell-free fetal DNA in the mother’s blood, is increasingly common. However, two studies published online in the New England Journal of Medicine highlight the risk for false-positives, particularly in low-risk women. ÂÂ Sleep-disordered

breathing (SDB) speeds up cognitive decline—in some cases by almost 10 years—and treating this condition may delay this decline, reported a new study published online April 15 in Neurology.

Annual Meeting of the American Academy of Orthopedic Surgeons. ÂÂ In cases of breech presentation, planned cesarean

delivery is associated with fewer adverse outcomes than vaginal delivery or cesarean delivery during labor, reported a new study published online in Obstetrics and Gynecology.

ÂÂ Heroin users who do not benefit from conventional

than half of medicare beneficiaries undergoing cataract surgery undergo at least one preoperative test, despite robust evidence showing that preoperative tests are not associated with any improvement in outcomes, suggests new research published online April 15 in the New England Journal of Medicine.

ÂÂ A single 5 mg infusion of the bisphosphonate

ÂÂ The beneficial effects of subthalamic nucleus

addiction treatments should receive heroin-assisted therapy, suggests new research published in the BMJ. zoledronic acid can improve bone mineral density (BMD) over the course of 2 years in frail institutionalized elderly women with osteoporosis, suggests a study published online April 13 in JAMA Internal Medicine.

ÂÂ New research has suggested that patients with

optic neuritis (often the first symptom of multiple sclerosis) who were given the monoclonal antibody BIIB033 had improved conduction of electrical impulses along the optic nerve between the retina and the brain. The findings will be presented at the American Association of Neurology (AAN) 67th Annual Meeting.

ÂÂ Losing weight in middle age may be associated

with losing precious bone density, at least for women, suggests a new study published online in the Journal of Clinical Endocrinology and Metabolism.

ÂÂ An aerosolized measles vaccine appeared to provide

significantly less protection than a traditional shot in a noninferiority trial from India. Ninety one days after vaccination, 85.4% in the aerosol group and 94.6% in the subcutaneous injection group were seropositive, reported the study published April 16 in the New England Journal of Medicine.

ÂÂ Limited use of radioactive iodine (RAI) should be

the strategy of choice in the treatment of low-risk differentiated thyroid cancer (DTC), as survival outcomes are excellent even without use of RAI, suggests new research published in the April issue of Thyroid.

ÂÂ Patients over 70 years of age with end-stage

ankle arthritis experience improvements in gait parameters after total ankle arthroplasty that are comparable with those seen in patients in their 50s, suggests new research presented at the 2015

ÂÂ More

deep brain stimulation on pain in patients with Parkinson’s disease persist long-term, suggests a new study published online in JAMA Neurology.

ÂÂ New research suggests that women with doctor-

diagnosed celiac disease are more likely to miscarry or deliver preterm than women with no history of the condition. The findings are published online April 15 in Annals of Gastroenterology.

ÂÂ Depression and diabetes each independently raise

the risk of developing dementia, and having both conditions poses the greatest risk, especially in those younger than 65 years, reported a Danish population-based study published recently in JAMA Psychiatry.

ÂÂ Older patients taking proton pump inhibitors for

heartburn and acid reflux are twice more likely to be hospitalized with kidney failure than peers who do not take the pills, reports a study published online April 16 in CMAJ Open.

ÂÂ Patients with enterovirus D68 (EV-D68) infection

may develop acute flaccid myelitis, suggests new research published online in the Lancet Infectious Diseases.

ÂÂ The US Food and Drug Administration US (FDA)

has approved a new intraocular lens (IOL) for patients having cataract surgery who choose to correct their vision problems at the same time.

ÂÂ QT intervals may be prolonged after hematopoietic

stem cell transplantation (HSCT), suggests new research published online in Bone Marrow Transplantation.

ÂÂ A new study suggests that a Western lifestyle may

have a negative impact on the diversity of the crucial gut bacteria. The findings are published in the journal Cell.

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

1193

AROUND THE GLOBE ÂÂ Review

of data from two Women’s Health Initiative clinical trials reveals the varying effects of menopausal hormone therapy on the incidence of breast cancer over time. Researchers noted that while combined hormone therapy was associated with increased breast cancer risk, the use of estrogen alone was not. The results are published in the journal JAMA Oncology.

individual decisions about screening in association with their doctors. ÂÂ Omega-3 fatty acid supplementation improves

the signs and symptoms of meibomian gland dysfunction, suggests a new study presented at the World Cornea Congress (WCC) VII.

ÂÂ The American Academy of Neurology (AAN) and

the American Epilepsy Society (AES) have released a new guideline on the prognosis and treatment of first unprovoked seizures. The guidelines are published online April 20 in Neurology.

ÂÂ Breathing problems during sleep, such as heavy

snoring and sleep apnea, may be associated with earlier decline in memory and thinking skills, suggests a new study published in the journal Neurology.

ÂÂ Mechanical thrombectomy after thrombolysis is

better than thrombolysis alone when initiated within 5 hours of stroke onset in patients with moderate to severe strokes due to large artery occlusion, suggest intermediate results of the THRACE study presented at the European Stroke Organisation Conference (ESOC) 2015 meeting.

ÂÂ New research suggests that the presence of

ultrasound-detected bone erosions is not specific for RA, but erosions of RA are generally more extensive than for other diseases.

ÂÂ Glucose tolerance is lower in the evening than in

the morning, and the body’s internal clock and misalignment of that clock with behavior can affect the level of tolerance, suggests a new study published in Proceedings of the National Academy of Sciences of the USA.

ÂÂ A study from UK has identified six types of obese

people: young males who were heavy drinkers, middle-aged individuals who were unhappy and anxious, older people who despite living with physical health conditions were happy, younger healthy females, older affluent healthy adults and individuals with very poor health. According to the study, those who have a body mass index (BMI) of 30 or over fit into one of the six groups and treatment approaches should be tailored according to which group they fall into.

ÂÂ New findings published online in the European

Journal of Clinical Nutrition suggest that the body metabolizes glucose from foods with more slowly digestible starch (SDS) comparatively more slowly and steadily than from foods with less SDS.

ÂÂ Of the more than 2.5 million emergency department

visits related to drug abuse in the US in 2011, more than half resulted from illicit drug use. Approximately 40% of these visits were related to cocaine use, which indicates that cocaine is perhaps one of the most commonly used illicit drugs in the US In 2012, 2.2% of the US population aged 12 years and older used cocaine.

ÂÂ The US FDA has approved the first short-distance

ÂÂ The updated draft guidelines for breast cancer

screening issued by the US Preventive Services Task Force (USPSTF) remain unchanged from the 2009 revision. The update restated that mammography screening is most beneficial for women 50–74 years of age and that women 40–49 years should make ■■■■

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Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

vision implant for certain patients with presbyopia who have had no cataract surgery. Besides this, the implant is intended for use in patients 45–60 years old who are unable to focus clearly on near objects or small print and need reading glasses with +1.00 – +2.50 diopters of power but do not need glasses or contacts for clear distance vision.

LIGHTER READING

The wife put down her drink and said, “Let the old man dig. I had him buried upside down.”

OVERLOADED My wife, a flight attendant for a major airline, watched one day as a passenger overloaded with bags tried to stuff his belongings in the overhead bin of the plane. Finally, she informed him that he would have to check the oversized luggage.

THE ANESTHESIOLOGIST Jill received a bill from the hospital for her recent surgery, and was astonished to see a $900 fee for the anesthesiologist. She called his office to demand an explanation.

“When I fly other airlines,” he said irritably, “I don’t have this problem.”

“Is this some kind of mistake?” Jill asked when she got the doctor on the phone. “No, not at all,” the doctor said calmly.

My wife smiled, “When you fly other airlines, I don’t have this problem either.” THREATENING LETTERS

“Well,” said Jill, “that’s awfully costly for knocking someone out.”

The fellow stormed into the postmaster’s office in a fury. “I’ve been getting threatening letters in the mail for months and I want them stopped.”

“Not at all,” replied the doctor. “I knock you out for free. The 900 dollars is for bringing you back around.”

“Of course,” said the postmaster. “Sending threatening letters through the mail is a federal offence. Do you know who’s sending them?” “Yes,” shouted the man. “It’s those idiots down at the Internal Revenue Service.” AN OLD WOMAN An old man and woman were married for years, even though they hated each other. When they had a confrontation, screaming and yelling could be heard deep into the night. The old man would shout, “When I die, I will dig my way up and out of the grave and come back and haunt you for the rest of your life!”

QUOTE

“The secret of a good sermon is to have a good beginning and a good ending; and to have the two as close together as possible.” —George Burns

Dr. Good and Dr. Bad SITUATION: A patient came with tubercular pericarditis.

No steroids are needed

Start steroids

Neighbors feared him because of the many strange occurrences that took place in their neighborhood. The old man liked the fact he was feared. To everyone’s relief, he died of a heart attack when he was 68. His wife had a closed casket at the wake. After the burial, she went straight home and began to party as if there was no tomorrow. Her neighbors, concerned for her safety, asked, “Aren’t you afraid that he may indeed be able to dig his way up and out of the grave and come back and haunt you for the rest of your life?”

©IJCP Academy

LAUGH-A-WHILE

Lighter Side of Medicine

LESSON: The current recommendation is to use corticosteroids for patients with constrictive tuberculous pericarditis and for those felt to be at high risk of developing the condition (i.e., large effusion, high level of pericardial fluid inflammatory cells, or early signs of constriction). KK Aggarwal

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

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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,

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

Confidence intervals for the measurements should be provided wherever appropriate.

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

Discussion –

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

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

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

Do not use clips/staples on photographs and artwork.

–

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

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

Books

5. Special requests _____________________________

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

Indian 1.____________Foreign 1.________________

Articles in Books

2.____________ 2.________________

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

3.____________ 3.________________

4.____________ 4.________________

Tables –

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

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

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

6. Suggestions for reviewers (name and postal address)

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

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

Dr KK Aggarwal

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

Indian Journal of Clinical Practice, Vol. 25, No. 12, May 2015

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Other Facilities

PFT (Pulmonary Function Test)

Corporate Office ADDRESS Sanghi Medical Centre Pvt. Ltd. S-51, Greater Kailash – I, New Delhi – 110048 Tel.: +91 11 29232010, +91 11 29234400

Audiometry

Cardiology Facilities Laboratory

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)-01/3200/2015-2017 Posted in N.D. PSO New Delhi

One Stop for All Diagnostics

MRI

Latest MRI by Siemens

CT Scan

16- Multislice Spiral CT

Health Packages

Executive Health Check Up

Ultra Short Magnet = No Claustrophobia

Safest Scanner

Risk Categories

1st MRI in India on VC 15 Platform

Least Radiation Dose

Age Based Health Packages

Fully Automated Digital Pathology Laboratory - NABL Accredited

Immunology

Biochemistry

S-63 Greater Kailash Part 1 Opposite M Block Market, New Delhi 110048 Tel.: 011- 41234567

Haematology

Special Tests