Ijcp november 2016

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Volume 27, Number 6

November 2016, Pages 501–600

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yy American Family Physician yy Alternative Medicine yy Community Medicine yy ENT yy Internal Medicine yy Obstetrics and Gynecology yy Ophthalmology

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Fademy of F n ica Aca

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yy Around the Globe

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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

Dr KK Aggarwal Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus 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, Dr Vijay Viswanathan, Dr V Mohan, Dr V Seshiah, Dr Vijayakumar ENT Dr Jasveer Singh, Dr Chanchal Pal Dentistry Dr KMK Masthan, Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar, Dr Rajiv Khosla, Dr JS Rajkumar Dermatology Dr Hasmukh J Shroff, Dr Pasricha, Dr Koushik Lahiri, Dr Jayakar Thomas Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan, Dr Vineet Suri, Dr AV Srinivasan Oncology Dr V Shanta Orthopedics Dr J Maheshwari

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

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Volume 27, Number 6, November 2016 FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

505 All About Pollution

KK Aggarwal

AMERICAN FAMILY PHYSICIAN

507 Diet and Physical Activity for Cardiovascular Disease Prevention

Jeffrey B. Lanier, David C. Bury, Sean W. Richardson

514 Practice Guidelines 515 Photo Quiz ALTERNATIVE MEDICINE

519 A Comparative Clinical Study on Efficacy of Leech Therapy in the Management of Osteoarthritis

K Mohammad Nasar, Arifuddin, Yasmin

COMMUNITY MEDICINE

525 Prevalence of Sexually Transmitted Infections and Condom Use Among Female Sex Workers of Urban Vadodara, Gujarat

Preeti P Panchal, JR Damor, VS Mazumdar, K Shringarpure, K Mehta

ENT

531 Globus Hystericus Not Only Headache to Doctor But Also Lump Problem in Throat for Patient: A Study in 100 Patients

Shamendra Kumar Meena

INTERNAL MEDICINE

534 Dengue Fever Complicated with Pleural Effusion: A Case Report and Review of Literature

Monika Maheshwari

538 Tuberculous Meningitis: A Case Report

Mohammad Rashid Farooqui, Abdul Salam Ghulam Shah

OBSTETRICS AND GYNECOLOGY

540 Conservative Surgical Techniques in Management of Morbidly Adherent Placenta: A 5-year Study

Rekha Rani, Surendra Kumar, Shikha Singh, Ruchika Garg, Urvashi Verma, Rachana Agrawal, Saroj Singh, Himani

547 Analysis of Cesarean Section in a Tertiary Care Center: A Retrospective Study

Gurdip Kaur, Parmjit Kaur, Ruby Bhatia, Satinder Kaur, Ramiti Gupta, Aman Dev

555 A Comparative Study Between Oral Iron, Intravenous Iron Sucrose and Ferric Carboxymaltose in the Management of Postpartum Anemia

Divya Yadav Sharma, Saroj Singh, Abhilasha Yadav, Asha Nigam, Deepti Tandon, Alok Sharma

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

559 Fundus Changes and Fetomaternal Outcomes in Pregnancy-induced Hypertension

Urmila Karya, Muquaddas Aafreen, Anupam, Ganesh Singh, Charu Mitthal, Abha Gupta

564 Intrapartum HELLP Syndrome Associated with Mild Pre-eclampsia: A Case Report

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

Jaya Kundan Gedam, Minal Bhalerao, Utkarsh

568 Endometriosis and the Role of Resveratrol

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Anita Kant

OPHTHALMOLOGY

572 To Study the Effect of Steroid Eye Drops on Intraocular Pressure After Cataract Surgery

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

Jitender Phogat, Sumit Sachdeva, Sumeet Khanduja, CS Dhull, Himani Anchal

CONFERENCE PROCEEDINGS

575 71st Annual Conference of The Association of Physicians of India (APICON 2016) 578 69th Indian Dental Conference (IDC 2016) 581 India’s Premier Interventional Experience (TCT India Next 2016) EXPERT'S VIEW

584 What are the Salient Features of the Updated NICE Guidelines for Hypertension Management?

Manish Bansal

MEDILAW

586 Time Limitation of Filing a Complaint 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.

591 News and Views LIGHTER READING

596 Lighter Side of Medicine

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FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF

Dr KK Aggarwal

Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus

All About Pollution AIR POLLUTION IN THE CAPITAL INCREASED TO DANGEROUSLY HIGH LEVELS POST-DIWALI ‘One Health’ initiative is human health, animal health and environmental health together. It recognizes that the health of humans, animals and environment are all interrelated. Vedic science clearly says "As is the microcosm, so is the macrocosm".

This topic is especially relevant today as diseases like Dengue, Chikungunya, Zika, Japanese encephalitis are a cause of much concern today. With regard to animals, Bird flu has been in the news lately. And, environmental health is the rising pollution levels.

Pollution has become a major threat to the health of society today. While earlier, one took note of the weather forecast, it is now time that one also take note of pollution levels in the area that you will be traveling to and accordingly plan your activities.

POLLUTION IN DELHI DURING DIWALI WORST IN 3 YEARS PTI reported on October 31, 2016 that “Diwali fireworks pushed pollution in Delhi to a dangerous level, the worst in 3 years, as it turned the air highly toxic due to a deadly cocktail of harmful respirable pollutants and gases, engulfing the city with a cover of thick smog triggering health alarms. As per Delhi Pollution Control Committee (DPCC's) real time monitoring mechanism, the ultra-pollutant PM2.5 breached the safe standard by over 14 times at Anand Vihar, Delhi's most polluted area, at 2:30 AM. Many other areas including densely populated RK Puram had nearly similar readings when pollution peaked past mid night. Noise pollution, which was monitored at five locations in the city, was marginally higher than last year as it ranged between 66.1 dB(A) and 75.8 dB(A), while last year, it had varied from 65.9 dB(A) to 74.8 dB(A). The volume of sulfur dioxide (SO2), which can aggravate asthma, also breached the safe standards, indicating that the crackers contained a high level of sulfur. It averaged between 20-131 ug/m3, while it was between 26-64 ug/m3 last year. On Diwali night, PM10 ranged from 448 (micrograms per cubic meter) g/m3 to 939 g/m3 in Delhi as against the national safe standard of 100 g/m3, DPCC said”.

SOME KEY ASPECTS OF AIR POLLUTION ÂÂ

SO2, oxides of nitrogen (as NO2), suspended particulate matter (SPM) and respirable suspended particulate matter (RSPM/PM10) are measured as part of air quality monitoring.

ÂÂ

Particulate matter or suspended particles <10 µm in diameter are called PM10.

ÂÂ

PM10 will remain in the lungs and can damage the lung alveoli causing asthma and chronic obstructive pulmonary disease (COPD) and may later on permanently damage the lungs.

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FROM THE DESK OF THE GROUP EDITOR-IN-CHIEF ÂÂ

For India, the PM10 levels should be <100 and PM2.5 levels should be <60. As per international recommendations, both PM10 and PM2.5 should be <40.

ÂÂ

Particulate matter or suspended particles <2.5 µm in diameter are called PM2.5.

ÂÂ

PM2.5 is absorbed in lung and enters circulation. It increases free radicals, cholesterol deposition and precipitates heart attack, stroke and hypertension.

ÂÂ

Short-term exposure to PM2.5 pollutants is associated with acute coronary ischemic (insufficient blood flow in the coronary arteries of the heart) events.

ÂÂ

Exposure to CO2, NO2, SO2, PM10, PM2.5 is associated with increased risk of heart attack (1.25%).

ÂÂ

PM2.5 exposure can increase the resting blood pressure due to sympathetic overactivity.

ÂÂ

PM2.5 exposure causes endothelial dysfunction.

ÂÂ

PM2.5 exposure causes thickening of the blood.

ÂÂ

PM2.5 exposure is linked with blockages in the heart.

ÂÂ

High SO2 and NO2 levels may precipitate asthma attacks, or acute exacerbations of COPD.

ÂÂ ÂÂ

High levels of NO2 and PM2.5 can trigger atrial fibrillation with 2 hours of exposure.

The chances of irregular heart rhythm jumps by 26% for each 6 µg/mm3 increase in PM2.5 levels.

■■■■

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AMERICAN FAMILY PHYSICIAN

Diet and Physical Activity for Cardiovascular Disease Prevention JEFFREY B. LANIER, DAVID C. BURY, SEAN W. RICHARDSON

ABSTRACT Cardiovascular disease (CVD) is the leading cause of death in the United States. One-third of these deaths may be preventable through healthy lifestyle choices including diet and physical activity. The Mediterranean diet is associated with reduced cardiovascular mortality, whereas the Dietary Approaches to Stop Hypertension (DASH) eating plan is associated with a reduced risk of coronary artery disease. Substituting dietary saturated fat with polyunsaturated fatty acids is associated with improved cardiovascular outcomes, although exogenous supple­mentation with omega-3 fatty acids does not improve cardiovascular outcomes. There is an association between increased sodium intake and cardiovascular risk, but reducing dietary sodium has not consistently shown a reduc­tion in cardiovascular risk. Physical activity recommendations for adults are at least 150 minutes of moderate-intensity aerobic activ­ity per week, 75 minutes of vigorous-intensity aerobic activity per week, or an equivalent combination. Increases in physical activity by any level are associated with reduced cardiovascular risk. Intro­ducing muscle-strengthening activities at least twice per week in previously inactive adults is associated with improved cardiovas­cular outcomes. Inactive adults without known CVD can gradually increase activity to a moderate-intensity level without consulting a physician. The U.S. Preventive Services Task Force recommends behavioral counseling to promote healthy diet and physical activ­ity in adults at high risk of CVD. Evidence of benefit for counsel­ing patients at average risk is less established.

Keywords: Cardiovascular disease prevention, U.S. Preventive Services Task Force, behavioral counseling, healthy diet, physical activ­ity

C

ardiovascular disease (CVD) is the leading cause of death in the United States.1 From 2008 to 2010, CVD accounted for 272,668 deaths annually in persons younger than 80 years. Nearly onethird of deaths from CVD are considered potentially preventable.1 The American Heart Association (AHA) has published recommendations defining ideal cardiovascular health. Recommendations for physical activity in adults are at least 150 minutes of moderateintensity aerobic activity or at least 75 minutes of vigorous-intensity aerobic activity per week.2 Ideal cardiovascu­lar health also includes adhering to at least

four of five components of a diet consistent with the Dietary Approaches to Stop Hyper­tension (DASH) eating plan (Table 1).2 Adherence to these recommendations is low. Only 5% of adults achieve the recom­mended amount of moderate-intensity phys­ical activity when objectively measured,3 and only 18% meet the AHA goals for daily fruit and vegetable consumption.4 Additionally, nearly 35% of adults in the United States were obese in 2011 and 2012.5 Family physi­ cians can make an important contribution by counseling patients on the Table 1. Dietary Approaches to Stop Hypertension (DASH) Eating Plan

JEFFREY B. LANIER, MD, FAAFP, is a physician recruiter for the United States Army Recruiting Command and a staff family physician at Ireland Army Community Hospital, Fort Knox, Ky. At the time the article was writ­ten, he was the associate residency director at Martin Army Community Hospital Family Medicine Residency Program, Fort Benning, Ga. DAVID C. BURY, DO, is a staff family physician at U.S. Army Health Clinic, Camp Casey, South Korea. At the time the article was written, he was a third-year family medicine resident at Martin Army Community Hospital Family Medicine Residency Program.

SEAN W. RICHARDSON, DO, is a third-year family medicine resident at Martin Army Community Hospital Family Medicine Residency Program.

Source: Adapted from Am Fam Physician. 2016;93(11):919-924.

yy ≥ 4.5 cups of fruits and vegetables per day yy ≥ 2 3.5-oz servings of fish, preferably oily fish, per week yy ≥ 3 1-oz-equivalent servings of fiber-rich whole grains per day (defined as at least 1.1 g of fiber per 10 g of carbohydrate) yy < 1,500 mg of sodium per day yy < 450 calories (36 oz) of sugar-sweetened beverages per week Information from reference 2.

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AMERICAN FAMILY PHYSICIAN health benefits of adhering to healthy diet and physical activity recommendations.

DIET It is difficult to isolate the effects of individual nutrients on health benefits. Current research suggests the greater importance of viewing diet as a whole rather than focusing on specific nutrients.6,7 Several dietary approaches have been studied for their effects on CVD. Low-fat diets and high-fat, low-carbohydrate diets are popular and effective for weight loss, but there is insufficient evidence to recommend them for primary CVD prevention.8,9 There are several dietary strategies that have been evaluated for patient-oriented outcomes, such as cardiovascular events, cardiovascular mortality, and all-cause mortality. A summary of differ­ent dietary strategies is shown in Table 2.7,10-14

Mediterranean Diet Mediterranean diets emphasize diversity and seasonality, fruits and vegetables, whole grains, and olive oil, with moderate intake of fish, seafood, dairy, and wine.12 A 2010 meta-analysis of prospective cohort studies showed that increased adherence to a Mediterranean diet reduced cardiovascular events such as myocardial infarction (MI) and stroke, and tive risk [RR] lowered cardiovascular mortality (rela­ = 0.90; 95% confidence interval [CI], 0.87 to 0.93) and all-cause mortality (RR = 0.92; 95% CI, 0.90 to 0.94).13 A 2013 randomized controlled trial (RCT) of 7,447

patients in Spain with type 2 diabetes mellitus or three other cardiovascular risk factors showed that a Mediterranean diet was associated with a five-year reduc­tion in a composite end point of MI, stroke, and cardio­vascular mortality. The diet was supplemented with extra virgin olive oil (absolute risk reduction = 0.6%; number needed to treat = 167) or nuts (absolute risk reduction = 1%; number needed to treat = 100).14

Swedish Diet A population-based prospective cohort study of 17,216 men in Sweden evaluated diet quality as measured by adherence to the 2005 Swedish dietary guidelines, emphasizing low intake of saturated fat and sugar, and higher intake of dietary fiber, fish, and fruits and vegeta­bles. The primary composite outcome after 16 years was cardiovascular events including MI, ischemic stroke, or death from ischemic heart disease.

Participants with a high-quality diet had a lower risk of cardiovascular events (hazard ratio [HR] = 0.68; 95% CI, 0.49 to 0.73 for men; HR = 0.73; 95% CI, 0.59 to 0.91 for women).7

DASH Eating Plan The DASH eating plan emphasizes a diet with high intake of fruits and vegetables, low-fat dairy products, whole grains, poultry, fish, and nuts, and low intake of total and saturated fat and cholesterol.10 A 2013 metaanalysis of six cohort studies evaluated the association of adherence to the DASH diet and the incidence of car­diovascular outcomes. Adherence decreased the risk

Table 2. Diet and Effects on Cardiovascular Outcomes Diet

Description

Study type

Outcomes studies11

21% reduced risk of coronary artery disease and 21% reduced risk of stroke11

10% reduction in cardiovascular events and 8% reduction in mortality13

DASH eating plan

High intake of fruits and vegetables, low-fat dairy products, whole grains, poultry, fish, and nuts; low intake of total and saturated fat and cholesterol10

Meta-analysis of cohort

Mediterranean diet

Fruits and vegetables; whole grains; olive oil; moderate intake of fish, seafood, dairy, wine12

Meta-analysis of cohort studies13 Spanish randomized controlled

trial14

Reduction in cardiovascular events over 4.8 years14 Swedish diet (based on national standards)

Low intake of saturated fat and sugar; higher intake of dietary fiber, fish, and fruits and vegetables7

Swedish prospective cohort7

DASH = Dietary Approaches to Stop Hypertension.

Information from references 7, and 10 through 14.

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Reduced risk of cardiovascular events (32% in men, 27% in women)7

AMERICAN FAMILY PHYSICIAN of coronary artery disease (RR = 0.79; 95% CI, 0.71 to 0.88) and stroke (RR = 0.81; 95% CI, 0.72 to 0.92).11

Polyunsaturated Fatty Acids There is significant debate about polyunsaturated fatty acids (PUFAs) and their role in the primary prevention of cardiovascular events. Several meta-analyses of RCTs have shown varying degrees of benefit for omega-3 fatty acids.15 Several of these analyses, however, pooled the effect of increased dietary intake and exogenous supplementation of omega-3 fatty acids.

A 2012 meta-analysis of 21 prospective cohort studies involving more than 675,000 participants evaluated fish consumption and cerebrovascular disease over a mean of 15.1 years. The authors found that eating two to four servings of fish weekly was associated with a reduced risk of cerebro­vascular disease (RR = 0.94; 95% CI, 0.90 to 0.98). An increase of two servings of any fish per week was asso­ciated with a 4% risk reduction of cerebrovascular dis­ease.16 However, a 2014 RCT of more than 4,200 patients 50 to 85 years of age taking omega-3 fatty acids for mac­ular degeneration showed that supplementation did not decrease the risk of cardiovascular events.17 A 2010 meta-analysis of eight RCTs with more than 13,000 patients evaluated an increase in total or omega-6 PUFA intake as a substitute for saturated fat intake. The primary outcome was a composite of cardiovascular events including MI, cardiovascular mortality, or sudden death. In aggregate, participants in the intervention group consumed 15% of daily calories from PUFAs vs. 5% in the control group. Increased PUFA consumption was associated with an RR of 0.81 (95% CI, 0.70 to 0.95) for the primary outcome.18 The U.S. Food and Drug Administration recommends that saturated fats account for no more than 5% to 6% of daily caloric intake.10 Evidence shows that a diet high in PUFAs is associated with a reduction in cardiovascular events, but current evidence does not conclusively sup­port the use of omega-3 fatty acid supplements for CVD prevention.

Sodium Restriction Observational data have linked increased sodium intake in overweight patients to an increased risk of stroke, CVD mortality, and all-cause mortality.19 Increased sodium intake is associated with higher rates of stroke and CVD. Based largely on observational data, the AHA published an updated recommendation in 2012 reaffirming that dietary sodium intake should not exceed 1,500 mg per day.20 However, a 2014 Cochrane

review of eight RCTs evaluating dietary sodium restriction in normotensive and hypertensive patients showed no effect on cardio­vascular outcomes and allcause mortality.21 Current evidence suggests a J-shaped association between sodium intake and CVD, with the lowest risk occurring with consumption of 3 to 5 g of sodium per day.22 Prospective evidence currently does not support sodium restriction.

PHYSICAL ACTIVITY Physical activity is routinely recommended to promote optimal cardiovascular health. Physical inactivity and a less active lifestyle have been linked to significant increases in CVD risk.23 Elimination of a sedentary life­ style may reduce CVD by 15% to 39% and stroke by 33%.23 A meta-analysis of prospective cohort studies estimated that reducing the time spent sitting to less than three hours per day would result in a two-year increase in average life expectancy.24 Observational studies con­ sistently show an association between increased physical activity and reduction of CVD. A study of 9,181 men and women 50 years and older used self-reports of physical activity to categorize participants into low, moderate, and high levels of activity.25 The primary outcome was incident or fatal CVD. When adjusted for age, sex, and other comorbid conditions, a high level of physical activ­ity was associated with a reduction in incident CVD (HR = 0.77; 95% CI, 0.68 to 0.89) and cardiovascular mortality in patients with baseline CVD (HR = 0.77; 95% CI, 0.65 to 0.89). Additionally, high (HR = 0.68; 95% CI, 0.56 to 0.84) and moderate (HR = 0.78; 95% CI, 0.64 to 0.94) levels of physical activity were associated with a reduction in cardiovascular mortality in patients with­out baseline CVD.25 Objective parameters of exercise tolerance also show that increased exercise capacity is associated with lower mortality. In one observational study, 6,213 men (mean age = 59 years) were referred for treadmill stress testing and followed for a mean of 6.2 years. Among the men without CVD, there was a significantly increased risk of all-cause mortality (RR = 4.5; 95% CI, 3.0 to 6.8) for those with an exercise capacity of less than six metabolic equivalents compared with those achieving a capacity of at least 13 metabolic equivalents. Additionally, the age-adjusted RR of death incrementally increased with decreasing exercise capacity, both among otherwise healthy participants and those with CVD.26 The 2008 Physical Activity Guidelines for Americans provide recommendations for physical activity (Table 3).27 Adults healthy enough to exercise should engage in a total of 150 minutes of moderate-intensity

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AMERICAN FAMILY PHYSICIAN aerobic activ­ity or 75 minutes of vigorous-intensity aerobic activity per week. A systematic review of 33 studies evaluated dif­ferent levels of physical activity on the risk of coronary heart disease.28 Adults who were physically active at half of the level suggested by the 2008 guidelines had reduced risks of coronary heart disease (RR = 0.86; 95% CI, 0.77 to 0.96), similar to the degree of risk reduction observed in those who met the recommended physi­cal activity targets. Those who met the standard for additional health benefits had an additional risk reduction (RR = 0.80; 95% CI, 0.74 to 0.88).28 These data suggest that any physical activity is associated with lower cardiovascular risk, and the Table 3. 2008 Physical Activity Guidelines for Americans yy All adults should avoid inactivity. Adults who participate in any form of physical activity gain health benefits. yy For substantial health benefits, adults should engage in at least 150 minutes of moderate-intensity aerobic activity per week, 75 minutes of vigorous-intensity aerobic activity per week, or an equivalent combination. Aerobic activity should be performed in at least 10-minute bouts and preferably spread throughout the week. yy For additional health benefits, adults should engage in 300 minutes of moderate-intensity aerobic activity per week, 150 minutes of vigorous-intensity aerobic activity per week, or an equivalent combination. Additional health benefits are gained by increasing physical activity above this amount. yy Adults should perform muscle-strengthening activities that are moderate to high intensity and involve all major muscle groups at least twice per week, because these activities are associated with health benefits.

Information from reference 27.

benefit increases as the amount of weekly physical activity increases. Analysis of data from the 1999 to 2004 National Health and Nutrition Examination Survey showed that the adjusted HR for all-cause mortality was 44% lower among previously insufficiently active adults who engaged in muscle-strengthening activity at least twice per week.29 The benefits of physical activity on reducing cardiovascular events and mortality have also been demon­strated in men with diabetes. A subset of 2,803 men in the Health Professionals Follow-up Study with self-reported type 2 diabetes at 30 years or older were grouped into quintiles of physical activity and followed for 14 years. Compared with those in the lowest quintile, men who performed in the second quintile of physical activity had a lower risk of fatal CVD (RR = 0.55; 95% CI, 0.32 to 0.96), and continued risk reduction was demonstrated to the highest quintile of physical activity (RR = 0.45; 95% CI, 0.24 to 0.84).30 Data on the effects of physical activ­ity on mortality and cardiovascular events in other high-risk populations are limited.

Recommendations for physical activity should be tailored to individual patients’ long-term goals. Various examples of physical activity and their associated levels of intensity are provided in Table 4.23,27 These are general associations; individual effort in each of these activi­ ties will determine the intensity of the activity. Inactive adults who are otherwise healthy can gradually increase their activity to moderate intensity without consulting a physician.27 Likewise, adults with a baseline regimen of regular moderate-intensity

Table 4. Intensity Levels for Various Forms of Physical Activity Activity category

Mild intensity

Moderate intensity

Vigorous intensity

Gym activities

Slow swimming

Body pump

Climbing

Tai chi

Moderate swimming

Jumping rope

Yoga or Pilates

Water aerobics

Swimming competitively

Physical activities

Walking < 3 mph

Ballroom dancing

Aerobic dancing

Bicycling (< 10 mph)

Bicycling (≥ 10 mph)

General gardening

Hiking uphill or with a heavy pack

Walking briskly (3 mph)

Intense gardening (continuous digging or hoeing) Racewalking, jogging, or running

Sporting activities

Golf

Horseback riding

Canoeing

Hunting

Leisurely canoeing

Mountain biking

Sport fishing

Tennis (doubles)

Tennis (singles)

mph = Miles per hour.

Information from references 23 and 27.

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AMERICAN FAMILY PHYSICIAN activity can safely advance to vigorous-intensity activities without consultation.27 PUTTING IT TOGETHER Research on the effect of combined dietary and physical activity interventions on cardiovascular events suggests that there may be more benefit than with either intervention alone. A 2014 population-based cohort study of Swedish men 45 to 79 years of age followed for 12 years showed that the combination of high-quality diet (the highest quintile of adherence to a diet high in fruits and vegetables, legumes, nuts, reduced-fat dairy products, whole grains, and fish) and physically active lifestyle (at least 40 minutes of walking or biking per day and one hour of additional physical activity per week), when added to moderate alcohol consumption and tobacco cessation, was associated with a reduced risk of MI (RR = 0.24; 95% CI, 0.12 to 0.47) compared with those who adopted none of the healthy lifestyle behaviors.31 The U.S. Preventive Services Task Force (USPSTF) currently recommends that physicians consider initiating behavioral counseling in adults without preexisting CVD or CVD risk factors to promote adherence to a healthy diet and physical activity on an individual basis. In addition to CVD risk, they should consider other factors, such as a patient’s readiness to change, social support, and community resources that can provide support. The USPSTF did not find high-quality evidence that behavioral counseling interventions in adults at average risk of CVD reduces CVD events or mortality.32 The USPSTF is currently in the process of updating this recommendation.

Benefits of counseling interventions may be more pro­nounced in groups at higher cardiovascular risk.

A 2011 Cochrane review of 55 RCTs reporting on pooled data for multiple counseling and educational methods showed no effect on primary prevention of all-cause or cardio­vascular mortality or cardiovascular events. However, all-cause mortality was reduced when including only studies recruiting patients with diabetes or hypertension (RR = 0.78) or in patients taking antihypertensives or lipid-lowering therapy at baseline (RR = 0.86).33 Specific counseling strategies promoting dietary compliance and increased physical activity were not recommended based on this review.

The USPSTF found four good-quality trials involving more than 3,900 patients with cardiovascular risk factors that evaluated combined lifestyle-counseling interventions promoting healthy diet and physical

activity. None of the tri­als showed a reduction in mortality or cardiovascular events. One trial that did show benefit had high baseline rates of CVD and allowed for pharmacologic therapy in patients who did not respond to counseling.34 For adults who are overweight (body mass index greater than 25 kg per m2) or obese (body mass index greater than 30 kg per m2) with CVD risk factors (e.g., hypertension, dyslipidemia, impaired glucose tolerance, metabolic syndrome), the USPSTF recommends providing intensive behavioral health counseling to promote a healthy diet and physical activ­ity or referring patients for such services.

Effective coun­seling strategies have involved face-toface sessions with information on diet and physical activity and behavioral change strategies, typically delivered by dietitians or health educators.35 REFERENCES 1. Yoon PW, et al; Centers for Disease Control and Prevention.

Potentially preventable deaths from the five leading causes of death—United States, 2008-2010. MMWR Morb Mortal Wkly Rep. 2014;63(17):369-374.

2. Lloyd-Jones DM, et al. Defining and setting national goals for cardio­vascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond. Circula­tion.

2010;121(4):586-613.

3. Troiano RP, et al. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc.

2008;40(1):181-188.

4. Miller RR, Sales AE, Kopjar B, Fihn SD, Bryson CL. Adherence to heart-healthy behaviors in a sample of the U.S. population. Prev Chronic Dis. 2005;2(2):A18.

5. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity among adults: United States, 2011-2012. NCHS Data Brief. 2013;(131):1-8.

6. Akesson A, et al. Low-risk diet and lifestyle habits in the primary preven­tion of myocardial infarction in men: a population-based prospective cohort study. J Am Coll Cardiol. 2014;64(13):1299-1306.

7. Hlebowicz J, et al. A high diet quality is associated with lower incidence of cardiovascular events in the Malmö diet and cancer cohort. PLoS One. 2013;8(8):e71095.

8. Schwingshackl L, Hoffmann G. Comparison of effects of long-term low-fat vs high-fat diets on blood lipid levels in overweight or obese patients: a systematic review and meta-analysis. J Acad Nutr Diet. 2013;113(12):1640-1661.

9. Bazzano LA, Hu T, Reynolds K, et al. Effects of lowcarbohydrate and low-fat diets: a randomized trial. Ann Intern Med. 2014;161(5):309-318.

10. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ ACC guideline on life­ style management to reduce cardiovascular risk: a report of the Ameri­can College

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AMERICAN FAMILY PHYSICIAN of Cardiology/American Heart Association Task Force on Practice Guidelines [published corrections appear in Circulation. 2014;129(25 suppl 2):S100-S101, and Circulation.

2015;131(4):e326].

Circulation.

2014;129(25 suppl 2): S76-S99.

11. Salehi-Abargouei A, et al. Effects of Dietary Approaches to Stop Hyper­tension (DASH)-style diet on fatal or nonfatal cardiovascular diseases—incidence: a systematic review and meta-analysis on observational prospective studies.

Nutrition. 2013;29(4):611-618.

12. de Lorgeril M, Salen P. Mediterranean diet and n-3 fatty acids in the prevention and treatment of cardiovascular disease. J Cardiovasc Med (Hagerstown). 2007;8(suppl 1): S38-S41.

13. Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis.

Am J Clin Nutr. 2010;92(5):1189-1196.

14. Estruch R, Ros E, Salas-Salvadó J, et al.; PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet [published correction appears in N Engl J Med. 2014;370(9):886]. N Engl J Med. 2013;368(14):1279-1290.

15. Michas G, Micha R, Zampelas A. Dietary fats and cardiovascular disease: putting together the pieces of a complicated puzzle. Atherosclerosis. 2014;234(2):320-328.

16. Chowdhury R, Stevens S, Gorman D, et al. Association between fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascu­lar disease: systematic review and meta-analysis. BMJ. 2012;345:e6698.

17. Bonds DE, Harrington M, Worrall BB, et al. Effect of longchain ω-3 fatty acids and lutein + zeaxanthin supplements on cardiovascular outcomes: results of the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial.

JAMA Intern Med. 2014;174(5):763-771.

18. Mozaffarian D, Micha R, Wallace S. Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat: a systematic review and metaanalysis of randomized controlled trials. PLoS Med. 2010;7(3):e1000252.

23. Giada F, Biffi A, Agostoni P, et al.; Joint Italian Societies’ Task Force on Sports Cardiology. Exercise prescription for the prevention and treat­ment of cardiovascular diseases: part I. J Cardiovasc Med (Hagerstown). 2008;9(5):529-544.

24. Katzmarzyk PT, Lee IM. Sedentary behaviour and life expectancy in the USA: a cause-deleted life table analysis.

BMJ Open. 2012;2(4):e000828.

25. Franco OH, de Laet C, Peeters A, Jonker J, Mackenbach J, Nusselder W. Effects of physical activity on life expectancy with cardiovascular disease. Arch Intern Med. 2005;165(20):2355-2360.

26. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exer­cise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002;346(11):793-801.

27. U.S. Department of Health and Human Services. 2008 physical activ­ity guidelines for Americans. Office of Disease Prevention and Health Promotion publication no.

U0036. October 2008. http://health.gov/paguidelines/pdf/ paguide.pdf. Accessed October 27, 2015.

28. Sattelmair J, Pertman J, Ding EL, Kohl HW III, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: a meta-analysis. Circulation.

2011;124(7):789-795.

29. Zhao G, Li C, Ford ES, et al. Leisure-time aerobic physical activity, muscle-strengthening activity and mortality risks among US adults: the NHANES linked mortality study.

Br J Sports Med. 2014;48(3):244-249.

30. Tanasescu M, Leitzmann MF, Rimm EB, Hu FB. Physical activity in rela­tion to cardiovascular disease and total mortality among men with type 2 diabetes. Circulation.

2003;107(19):2435-2439.

31. Åkesson A, Larsson SC, Discacciati A, Wolk A. Lowrisk diet and life­style habits in the primary prevention of myocardial infarction in men: a populationbased prospective cohort study. J Am Coll Cardiol.

2014;64(13):1299-1306.

32. Moyer VA. Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):367-371.

19. He J, et al. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. JAMA. 1999;282(21):2027-2034.

33. Ebrahim S, et al. Multiple risk factor interventions for primary pre­vention of coronary heart disease. Cochrane Database Syst Rev. 2011;(1):CD001561.

20. Whelton PK, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations [published correction appears Circulation. in Circula­tion.

2013;27(1):e263].

2012;126(24):2880-2889.

34. Lin JS, et al. Behavioral counseling to promote a healthy lifestyle for cardiovascular disease prevention in persons with cardiovascular risk factors: an updated systematic evidence review for the U.S. Preventive Services Task Force. Evidence synthesis no. 113. Rockville, Md.: Agency for Healthcare Research and Quality (US); August 2014. http://www.ncbi.nlm.nih.gov/books/NBK241537/.

Accessed January 26, 2015.

21. Adler AJ, Taylor F, Martin N, Gottlieb S, Taylor RS, Ebrahim S. Reduced dietary salt for the prevention of cardiovascular disease. Cochrane Data­base Syst Rev. 2014;(12):CD009217.

22. O’Donnell M, Mente A, Yusuf S. Sodium intake and cardiovascular health. Circ Res. 2015;116(6):1046-1057.

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35. LeFevre ML. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force recom­mendation statement. Ann Intern Med. 2014;161(8):587-593.

AMERICAN FAMILY PHYSICIAN

Practice Guidelines ACCP RELEASES GUIDELINE FOR THE TREATMENT OF UNEXPLAINED CHRONIC COUGH Persistent cough with an unknown etiology is difficult to treat and can significantly affect quality of life.

Although the evidence for the diagnosis and treatment of adults with unex­plained chronic cough is limited, the Ameri­ can College of Chest Physicians (ACCP) has released guidelines based on the best available evidence. Further study is needed to establish universal terminology and the optimal method of investigation.

Recommendations Diagnosis Unexplained chronic cough should be diag­ nosed if cough persists for longer than eight weeks with no etiology identified after evalu­ation and supervised therapeutic trial(s) that follow published best-practice guidelines. Key to the definition of unexplained chronic cough are adequate assessment, investigation, and therapy.

Source: Adapted from Am Fam Physician. 2016;93(11):950.

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Adults with unexplained chronic cough should undergo a guideline/protocol-based assessment, including objective test­ing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic cor­ticosteroid trial.

Treatment Multimodality speech pathology therapy (e.g., education, counseling, cough sup­pression techniques, breathing exercises) is recommended for adults with unexplained chronic cough. A therapeutic trial of gabapentin is also recommended. However, the evidence is limited, and there is a possibility of adverse effects. The risk-benefits profile should be discussed with the patient before initiating gabapentin and reassessed at six months.

Inhaled corticosteroids should not be used in patients with unexplained chronic cough and negative results chial hyperresponsiveness and on testing for bron­ eosinophilia (sputum eosinophils, exhaled nitric oxide).

Proton pump inhibitors should not be used in patients with a negative workup for acid reflux disease.

AMERICAN FAMILY PHYSICIAN

Photo Quiz HYPERKERATOTIC PLAQUES ON HANDS A 10-year-old boy presented with a rash on both hands that had been present for at least several weeks.

He had not worn any new gloves or other clothing.

He had received a new video game at Christmas about five months prior and had played it for at least three to four hours every day since.

On physical examination, he was not in distress. There were hyperkeratotic plaques on the lateral aspect of both of his index fin­gers (Figure 1). The lesions were symmetric, lichenified with erosions, and painful. The rest of the dermatologic examination was unremarkable.

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

A. Frictional hyperkeratotic hand dermatitis.

B. Irritant contact dermatitis.

C. Palmoplantar keratoderma.

D. Psoriasis.

E. Tinea manuum.

Discussion The answer is A: frictional hyperkeratotic hand dermatitis. The patient’s lesions developed at the sites of direct contact with his video game controller, and the diagnosis was made based on the repetitive friction and trauma caused by overuse of the video game. He was successfully treated by significantly reducing his video game use and applying topical emollients.

With the increased use of computers and electronic devices by persons of all ages over the past 20 years, new manifestations related to repetitive mechanical activities may occur, affecting superficial structures, such as the skin, and less commonly deeper structures, such as nerves and tendons. Frictional hyperkeratotic hand dermatitis develops as a result of repetitive mechanical

Source: Adapted from Am Fam Physician. 2016;93(11):945-946.

Figure 1.

friction, trauma, vibration, or pressure. Several terms have been used to describe injuries from overuse of elec­tronic devices, including “Nintendonitis,” “Wiitis,” and “Playstation thumb.”

Irritant contact dermatitis is a localized inflammatory response to physical, environmental, or chemical agents.

It usually presents as erythema, erosions, and scaling and may cause pruritus or a burning sensation. Mild symptoms result from prolonged or repeated exposure to the irritants. Strong chemicals may produce a direct reaction similar to that of a thermal burn.1 Palmoplantar keratodermas are a heterogeneous group of disorders with hyperkeratotic thickening of the palms and soles.2 These disorders may be hereditary or acquired. The diffuse form has a thick, symmetric hyperkeratosis involving the entire palm and sole.

The focal form has hyperkeratotic lesions at sites of recurrent friction, mainly on the feet. The punctate form is char­acterized by punctate keratotic papules on the palms and soles.3

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AMERICAN FAMILY PHYSICIAN Summary Table Condition

Characteristics

Etiology

Frictional hyperkeratotic hand dermatitis

Hyperkeratotic plaques of the hands that are Repetitive mechanical friction, trauma, vibration, or symmetric, lichenified with erosions, and painful pressure

Irritant contact dermatitis

Erythema, erosions, and scaling; possibly pruritus or Localized inflammatory response to physical, a burning sensation environmental, or chemical agents

Palmoplantar keratodermas

Diffuse form: thick, symmetric hyperkeratosis involving Localized inflammatory response to physical, environmental, or chemical agents the entire palm and sole Focal form: hyperkeratotic lesions at sites of recurrent Hereditary (autosomal recessive, autosomal dominant, or X-linked), or acquired friction, mainly on the feet Punctate form: punctate keratotic papules on the palms and soles

Psoriasis

Erythema, thickening, and scaling of skin; deep, painful Immune-mediated inflammatory disease fissures or palmoplantar pustulosis

Tinea manuum

Diffuse, dry, scaling hyperkeratotic lesions; possibly Superficial, noninflammatory dermatophyte infection vesicular, exfoliating, erythematous, annular lesions on the dorsal surface of the hand

Psoriasis is a chronic, immune-mediated inflammatory disease.4 It presents as erythema, thickening, and scaling of the skin. It may be accompanied by deep, painful fissures or palmoplantar pustulosis.

2. Schiller S, Seebode C, Hennies HC, Giehl K, Emmert S. Palmoplantar keratoderma (PPK): acquired and genetic causes of a not so rare dis­ease. J Dtsch Dermatol Ges. 2014;12(9):781-788.

Tinea manuum is a superficial, noninflammatory dermatophyte infection of the hand. It usually presents as diffuse, dry, scaling hyperkeratotic lesions, although vesicular, exfoliating, erythematous, annular lesions on the dorsal surface of the hand have also been reported.

Unilateral tinea manuum is associated with moccasintype tinea pedis or onychomycosis, a pattern sometimes referred to as two feet, one hand disease.5

3. Zamiri M, van Steensel M, Munro C. Inherited palmoplantar keratoder­mas. In: Fitzpatrick TB, Goldsmith LA, eds. Fitzpatrick’s Dermatology in General Medicine.

8th ed. New York, NY: McGraw-Hill Medical; 2012: 538-550.

4. Rallis E, Kintzoglou S, Verros C. Ustekinumab for rapid treatment of nail psoriasis. Arch Dermatol.

2010;146(11):1315-1316.

5. Schieke SM, Garg A. Superficial fungal infection.

In: Fitzpatrick TB, Goldsmith LA, eds. Fitzpatrick’s Dermatology in General Medicine. 8th ed. New York, NY: 1. Usatine RP, Riojas M. Diagnosis and management of McGraw-Hill Medical; 2012:2277-2327. contact dermatitis. Am Fam Physician. 2010;82(3):249-255.

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REFERENCES

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2016

ALTERNATIVE MEDICINE

A Comparative Clinical Study on Efficacy of Leech Therapy in the Management of Osteoarthritis K MOHAMMAD NASAR*, ARIFUDDINâ&#x20AC; , YASMIN*

ABSTRACT Introduction: Osteoarthritis is one of the most common chronic conditions and over half of the patients with osteoarthritis report being limited in their daily activities because of pain. Physical activity and exercise reduce the pain, but not relieve the cause.

Material and methods: This study was done to emphasize the efficacy of leech therapy in the management of Waja-ul-Mafasil (osteoarthritis) in the Dept. of Moalijat (General Medicine), Govt. Nizamia Tibbi College and Hospital, Hyderabad during the year of 2005-2008. The study consisted of 20 patients each in both, test and comparative group. Patients between 36-65 years of age with the complaints of pain in both knee joints during movement and which was relieved by rest, difficulty in walking and in standing after prolonged sitting on the ground, persistent for at least 6 months were included in the study. Patients were given treatment i.e., oral decoction of unani herb and local application of leech in test group, whereas in comparative group oral and local unani herbal formulation was given for 4 weeks and follow-up done after 1 month. Intensity of pain was assessed by visual analogue scale (VAS) before and after trial. Results were assessed by using the Student t-test and two groups were compared regarding pain relief by chi-square test. Results: The result of the study showed a significant reduction in pain by both test (p < 0.05) and comparative groups (p < 0.01). Conclusion: Local application of leech on osteoarthritis is significant in comparison to local application of unani herbal medicine.

Keywords: Osteoarthritis, leech therapy, Irsale Alaq, morbid humors and unani herbal formulation

O

steoarthritis is one of the most common chronic conditions and over half of the patients with osteoarthritis report limitations in their daily activities because of pain. Physical activity and exercise reduce the pain and improve physical function.

However, the majority of patients with osteoarthritis are physically inactive after exercise.

Osteoarthritis is a chronic degenerative disorder of multifactorial etiology characterized by loss of articular cartilage, hypertrophy of bone at the margins, subchondral sclerosis and range of biochemical and morphological alterations of the synovial membrane and joint capsule.1 Pathological changes in the late

*Lecturer Dept. of General Medicine Dr Abdul Haq Unani Medical College, Andhra Pradesh â&#x20AC; Professor Dept. of General Medicine Govt. Nizamia Tibbi College, Hyderabad, Andhra Pradesh Address for correspondence Dr Arifuddin Professor Dept. of General Medicine Govt. Nizamia Tibbi College, Hyderabad, Andhra Pradesh

stage of osteoarthritis include softening, ulceration and focal disintegration of the articular cartilage; synovial inflammation also may occur. 2 This is the most common cause of locomotor disability in the elderly.3,4 It affects women more than men, and its prevalence increases with age.

The worldwide prevalence of symptomatic osteoarthritis among those aged above 60 years is estimated to be 9.6% in men and 18.0% in women. Osteoarthritis affects an estimated 139 million worldwide.5 Generally, it has an insidious onset and a variable relationship of symptoms and functional impairment with slowly accumulating radiographic and pathologic evidence of its presence. As yet, there is no clinical evidence that treatment changes its course.

Primary osteoarthritis is mostly related to aging. It can present as localized, generalized or as erosive osteoarthritis.6 Secondary osteoarthritis is caused by another disease or condition.7 Knee joint is commonly involved in osteoarthritis. In this condition, changes in the knee joints lead to pain and disability. Diagnosis is made on the basis of history, clinical examination and X-rays.8,9 Typical treatment for knee osteoarthritis includes oral and topical analgesics, or steroids to

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ALTERNATIVE MEDICINE decrease pain and inflammation. In severe conditions, surgical replacement of the knee is recommended.

Unfortunately, these therapies often provide little or no relief. Regiminal therapies often prove to be helpful in pain relief by elimination of morbid humors as the cause of osteoarthritis. Application of leeches has been used for medical purposes since ancient times.

Leech saliva contains many substances, which are responsible for their therapeutic effects. Hirudin is one of the constituents of leech saliva, which reduces inflammation. Since inflammation is responsible for the symptoms of osteoarthritis it is supposed that leeches might relieve the pain in patients with osteoarthritis.10 In Unani system of medicine, osteoarthritis is mentioned under the name of Waja-ul-Mafasil. It is due to accumulation of morbid material in the joint spaces.

This material resembles pus but it’s not pus.11 Other causes are dilatation of the Majarie Tabiya, Sue Mizaj Bari (Cold Ill temperament) and Tahajur Mafasil in which joints become stiff and hard and it appears like chunna (Lime). Unani physicians documented the sign and symptoms, diet and management of osteoarthritis.11-15 It is also mentioned that arthritis is treatable only in its early stages as the disease progresses it become difficult to treat.

Various therapies have been used for this condition but all are with poor response and limitations. For example, nonsteroidal anti-inflammatory drugs (NSAIDs) are only recommended as add-on therapy if pain relief is not sufficient. Gastrointestinal toxicity is present in 50% of NSAIDs users and 5.4% develop a more serious event requiring hospitalization due to its frequent use.16,17 Many herbal drugs have been mentioned in the classical texts and they are in use and giving good results to the patients.18 According to the Unani system of medicine, leech therapy works on the principles of Tanqiyae Mawad (evacuation of morbid humors) and Imalae Mawad (diversion of humors). Tanqiyae Mawad means the resolution and excretion of morbid humors and excess fluids from the body, thereby maintaining the homeostasis in the quality and quantity of four body humors, which is actually responsible for the maintenance of normal health. Imalae Mawad refers to the diversion of the morbid fluids from the diseased site to the site where from it is easily expelled from the body tissues. Based on this holistic approach, leech therapy was selected for the management of osteoarthritis. The effectiveness of this therapy may also be attributed to the Mussakin (sedative) and Muhallil (anti-inflammatory) actions of saliva of leeches.19,20 The treatment with Unani medicine offers the best option because of better acceptability, safety and efficacy,

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potency and low cost with least side effects. Keeping in view the above consideration, in test group, decoction of Ushba Desi (Smilax ornata) 6 g for oral use and leech application locally, whereas in comparative group along with 6 g decoction of Ushba Desi, powder of Karnajawa (Caesalpinia bonducella) 2 g, Chobchini (Smilax china) 5 g, Suranjan (Colchicum antumnale) 3 g21-23 for oral use and Roghan Barg Shambhalu locally were selected for the clinical trial to validate its efficacy and safety in patients with osteoarthritis.

A randomized comparative study was conducted to observe the effectiveness of leech therapy in reducing the pain in patients with osteoarthritis of the knee joints.

OBJECTIVES ÂÂ

To compare the efficacy and safety of leech therapy and local application of unani herbal formulation in the management of osteoarthritis.

ÂÂ

To improve the quality-of-life.

MATERIAL AND METHODS Study design: Randomized comparative clinical study.

Duration of Study: One year.

Sample size: Twenty subjects in each group.

Method of Collection of Data: 1) By signs and symptoms and 2) By visual analogue scale (VAS) for pain rating.

Selection Criteria Inclusion Criteria ÂÂ

Patients of either sex with age between 36-65 years.

ÂÂ

Persistent osteoarthritic symptoms for at least 6 months.

ÂÂ

Crepitation on examination of knee joint.

ÂÂ

Osteoarthritic X-ray findings like narrowed joint space, osteophytes, increased density of subchondral bone.

ÂÂ

Willing to give consent.

Exclusion Criteria ÂÂ

Patients with any systemic manifestations like hepatic or renal impairment, hypertension, diabetes mellitus, tuberculosis and human immunodeficiency virus (HIV).

ÂÂ

Patients of secondary osteoarthritis.

ÂÂ

All pregnant and lactating women.

ÂÂ

Patients with history of intra-articular injections

ALTERNATIVE MEDICINE or using corticosteroids during the preceding 3 months. ÂÂ

History of surgery of the affected knee joints during the last 3 months or joint replacement.

ÂÂ

Participation in another interventional study.

Criteria for Selection of the Leech Leech with small head and of small size like rat tail, having two golden lines on its back and of red color were taken from clean water in which small frogs were present.

Criteria for Selection of the Drugs Drugs were selected on the basis of their temperament and Munzij Balgham (expectorant), Muhallil Auram (antiinflammatory), Masakkin (analgesic) properties.

Criteria for Efficacy ÂÂ

Relieved: Fifty percent relief in pain by VAS rating score.

ÂÂ

Partially relieved: Twenty-five percent relief in pain by VAS rating score.

ÂÂ

No response: No relief in pain by VAS rating score.

The clinical study entitled “A comparative clinical study on efficacy of leech therapy in the management of osteoarthritis” was carried out in Government Nizamia Tibbi College and Hospital during the period 2005-2008.

Before starting the trial, Ethical Committee approval was taken. A total of 40 patients with complaints of pain in both knee joints on movement and relieved by rest, difficulty in walking, especially difficulty in standing after prolong sitting, for at least 6 months were included in the study. They were randomly divided into test and comparative group.

A detailed history regarding age, socioeconomic status, occupation, presenting complaints with onset and duration was noted in Case Record Form (CRF).

Medical, past and family histories were also recorded.

Patients were thoroughly examined for assessment of their general health to rule out any other disease and routine laboratory investigations along with X-rays were done before and after the trial. After taking informed consent, patients were included in the trial.

At the time of their 1st visit, the subjects were provided a VAS for pain rating.

Test group was administered decoction of Ushba Desi 6 g orally and leech application locally. After application of leech, Haldi powder (Curcuma longa) was sprinkled over application site to control oozing and also prevent local infection, whereas in comparative group, along

with decoction of Ushab Desi and powder of Karnajawa 2 g, Chobchini 5 g, Suranjan 3 g was given orally and locally Roghan Barg Shambhalu was massaged. Dosage was calculated after literature survey.

In both groups, patients were advised to take oral medicine once-daily for 4 weeks and in test group two leeches were applied on either side of both knee joints once in a week for four sittings. Leeches were allowed to suck as much as blood, they could and fall spontaneously. In comparison group, patients were advised to massage oil once-daily on both knee joints for 15 minutes at bedtime for 4 weeks. Follow-up was done weekly, and after 1 month of completion of trial, follow-up was done to observe any recurrence or adverse effect.

After completion of the treatment, they were followed up for 1 month. The study outcome measures were recorded at baseline and immediately following completion of trial. Pain relief outcome measure was done by VAS score in both groups. A statistical analysis was done to compare pre- and post-intervention pain relief in both groups and intergroup comparison was done.

RESULTS AND DISCUSSION Osteoarthritis is one of the most common degenerative disorders. It is a group of syndrome with destruction of cartilage, in which biomechanical factors play an important role. The risk factors are age, sex, weight, hereditary, race and occupation.

Other causes for cartilage loss are rheumatoid arthritis, osteoporosis, osteochondritis and septic arthritis. Early stage of osteoarthritis is asymptomatic and silent.

Pain is the predominant symptom that prompts the diagnosis of osteoarthritis and initially often involves only one joint, with others become painful subsequently, associated with joint stiffness that follows period of inactivity in the morning and after prolonged sitting.

It is aggravated by movements and may radiate to surrounding structures. In early stage of disease pain is relieved by rest.

Among 40 patients, 23 (57%) patients were females and 17 (42%) were males. Females are affected more than males. This finding was correlated with the survey of Centers for Disease Control and Prevention (CDC).

Its prevalence is slightly higher in the age group of 56-65 years (55%) and least in the age group of 36-45 years (17%). The incidence gradually increases as the age advances. Out of 40 patients, 7 (17%) were in the age group of 36-45 years, 12 (30%) were in the

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ALTERNATIVE MEDICINE

According to the Mizaj (temperament), out of 40 patients, 11 (27%) patients were of Damvi Mizaj, 10 (25%) patients were of Balghami, 7 (17%) patients were of Safravi and 12 (30%) patients were of Saudavi Mizaj.

It reveals that osteoarthritis is more common in the patients with Saudavi Mizaj and least common in Safravi Mizaj (Table 2 and Fig. 2).

As regards the occupation of the patients; out of 40 patients, 15 (37%) patients were hard workers, 6 (15%) were normal workers, whereas 19 (47%) patients were sedentary (Table 3 and Fig. 3). Therapeutic response of Table 1. Age Group and Sex-wise Distribution of Patients in Both Groups Age (years)

Test group

Control group

Male

Female

Total

Male

Female

Total

36-45

1

2

3

2

2

4

46-55

3

3

6

2

4

6

56-65

4

7

11

5

5

10

Total

8

12

20

9

11

20

the test group revealed that out of 20 cases; 15 (75%) cases were relieved from pain, 3 (15%) were partially relieved and 2 (10%) patient had no response, whereas in comparative group, 11 (55%) patients were relieved of the pain, 5 (25%) patients got partial relief and 4 (20%) patients did not get any response (Table 4 and Fig. 4).

In a study conducted in Germany, the effectiveness of leech therapy in osteoarthritis of knee was established.

The patients (n = 51) received a single sitting of leeches (4 to 6 in number). The primary endpoint of pain at Test group

12

Control group 10

10 No. of patients

age group of 46-55 years and 21 (52%) were in the age group of 56-65 years (Table 1 and Fig. 1).

8

8 6 4

5 5

5

3

2

2

2

0 Balghami

Damvi

Safravi

Saudavi

Figure 2. Mizaj (temperament of the patients).

Test group

12

Control group 11

No. of patients

10

Table 3. Distribution of Patients According to Lifestyle (Occupation)

10

Lifestyle

8 6

6 4

4

5

3

2 0

46-55

36-45

Test group

Control group

Male Female Total Male Female Total

56-65

Hard work

2

6

8

3

4

7

Normal work

1

1

2

2

2

4

Sedentary work

2

8

10

4

5

9

Total

5

15

20

9

11

20

Years

Figure 1. Age group and sex-wise distribution of patients in both groups.

Test group

Test group

Mizaj Male

Female

Control group Total

Male

Female

Total

Damavi

1

2

3

3

5

8

Balghami

2

3

5

1

4

5

Safravi

1

1

2

2

3

5

Saudavi

2

8

10

1

1

2

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No. of patients

8

Table 2. Distribution of Patients According to Mizaj of the Patient

Control group

10

10 9

8 7

6 4

4 2

2 0

Hard work

Normal work

Sedentary life

Figure 3. Distribution of patients according to lifestyle (occupation).

ALTERNATIVE MEDICINE Table 4. Therapeutic Response of Both Leech Therapy and Unani Herbal Formulation

11 were relieved, 5 were partially relieved and 4 got no response.

Groups

Relieved

Test group

15 (75%)

3 (15%)

2 (10%)

Comparative group

11 (55%)

5 (25%)

4 (20%)

On the basis of above observation, it can be concluded that the management of osteoarthritis with leech therapy has significant therapeutic potential and that it should be managed properly at the right time; otherwise it decreases the physical activity, work efficiency and also affects the health and quality-of-life.

Partially relieved

Test group

No. of patients

16

No response

Control group

15

1. “Osteoarthritis” at Dorland’s Medical Dictionary, 2009.

14 12

11

10 8 6

5

4

3

2 0

REFERENCES

Relieved

Partially relieved

4 2 No response

Figure 4. Response of the treatment.

7th day was reduced from 53.5 ± 13.7 to 19.3 ± 12.2 in leeching group compared to the control group, where the pain was reduced from 51.5 ± 16.8 to 42.4 ± 19.7 with topical application of diclofenac. Results were assessed by using the Student t-test and the two groups were compared regarding pain relief by chi-square test. The result of the study showed a significant pain reduction both test (p < 0.05) and in the comparative groups (p < 0.01) (Table 4).

At 1 week follow-up, patients who received leech therapy along with unani formulation reported significantly less pain than those who were on unani therapy only. At the end of 1 month, no patient reported any adverse effect or recurrence.

SUMMARY AND CONCLUSION It is concluded that the present study “A comparative clinical study on efficacy of leech therapy in the management of osteoarthritis” was carried out to observe the effect of leech therapy and unani herbal formulation in patients with osteoarthritis.

The incidence of osteoarthritis increases as the age advances. In this study, out of 40 cases, 21cases (52%) were found in the age group of 56-65 years and only 7 cases (17%) was in the age group of 36-45 years. It’s prevalence was higher in patients with Soudavi Mizaj.

Therapeutic response of leech therapy was remarkable.

In test group, 15 were relieved, 3 were partially relieved and 2 had no response, whereas in comparative group,

2. National Collaborating Centre for Chronic Conditions (UK). Osteoarthritis: National Clinical Guideline for Care and Management in Adults. London: Royal College of Physicians (UK); 2008. (NICE Clinical Guidelines, No. 59.) Available at: https://www.ncbi.nlm.nih.gov/books/ NBK48984/ 3. McAlindon T, Formica M, Schmid CH, Fletcher J. Changes in barometric pressure and ambient temperature influence osteoarthritis pain. Am J Med. 2007;120(5):429-34.

4. Medline Plus. Encyclopaedia Osteoarthritis. 2009, 88 5. Centers for Disease Control and Prevention (CDC).

Prevalence of disabilities and associated health conditions among adults - United States, 1999. MMWR Morb Mortal Wkly Rep. 2001;50(7):120-5. Erratum in: MMWR Morb Mortal Wkly Rep 2001;50(8):149.

6. Simon H, Zieve D. “Osteoarthritis”. University of Maryland Medical Centre. 2005. pp. 233-6.

7. Brandt KD, Dieppe P, Radin EL. Etiopathogenesis of osteoarthritis. Rheum Dis Clin North Am. 2008;34(3): 531-9.

8. Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis.

Ann Rheum Dis. 2010;69(3):483-9.

9. Bierma-Zeinstra SM, Oster JD, Bernsen RM, Verhaar JA, Ginai AZ, Bohnen AM. Joint space narrowing and relationship with symptoms and signs in adults consulting for hip pain in primary care. J Rheumatol.

2002;29(8):1713-8.

10. Kamaluddin H. Basic Principles of Regimental Therapy of Unani Medicine. 1st Edition, New Delhi: Aijaz Publishing House; 2004.

11. Ibn Sina, Al-Qanoon’, 1925, 854-57.

12. Mazhar S. The General Principles of Avicenna’s Canon of Medicine. 1st Edition, Daryaganj, New Delhi: SH Offset Press; 2007. pp. 544-8.

13. Rabban Tabri, Al-Moalijat-Al-Boqratia, Vol-1, CCRUM, 2011, 365.

14. Rbban Tabri, ‘Firdous-ul-Hikmat’ chap-10, 1928, 764.

15. Ismail Jurjani ‘Zakheera-E-Quarzam Shahi’, 2009, 384.

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ALTERNATIVE MEDICINE 16. Flood J. The role of acetaminophen in the treatment of osteoarthritis. Am J Manag Care. 2010;16 Suppl Management:S48-54.

17. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence.

Osteoarthritis Cartilage. 2007;15(9):981-1000.

19. Kabeeruddin. Kulliyate Qanoon. Lahore: Basheer & Sons, Urdu Bazar; 2007;350-2.

20. Razi AMBZ. Kitab al Mansoori (Urdu Translation by CCRUM), New Delhi. Ministry of Health and Family Welfare, Government of India; 2002;284:391-4.

21. Anonyms. Wealth of India, Raw materials CSIR New Delhi, India; 1966;7:96-7.

22. Nadkarni KM. Myrtus caryophyllus. In: Nadkarni AK (Eds.). Materia Medica. Mumbai, India: Popular Prakashan (Pvt. Ltd.); 2012. pp. 835-6.

18. Zakriya Razi, “Kitabe Wajaul Mafasil” and “Kitabe Hayate Mafasil”. Vol. VI, New Delhi: CCRUM. 2001;20: 23. Ansari Y, Mufradat M. Aijaz Publication, New Delhi; 2006. p. 177, 376, 396.

30-3.

■■■■

Chemotherapy and Genetic Susceptibility Influence Risk of VTE in Breast Cancer Patients A Swedish population-based study published November 1, 2016 in the journal Clinical Cancer Research has suggested that risk stratification by chemotherapy and genetic susceptibility identifies patients with breast cancer who are at high risk of venous thromboembolism (VTE) and who could potentially benefit from thromboprophylaxis. The study further says that genetic testing is more informative in older patients with breast cancer.

Rituximab has Favorable Effect on Lung Function and Skin Fibrosis in Systemic Sclerosis A multicenter, open-label, comparative study of B-cell depletion therapy with rituximab for systemic sclerosisassociated interstitial lung disease has shown that rituximab has a beneficial effect on lung function and skin fibrosis in patients with systemic sclerosis. The study is published October 13, 2016 in Seminars in Arthritis & Rheumatism. Patients treated with rituximab showed an increase in forced vital capacity (FVC) on follow-up at 2 years. Skin thickening improved in both groups, but direct comparison between groups strongly favored RTX at all time-points.

WHO Draft Guidelines on Suspected Spurious, Falsely-labeled, Falsified and Counterfeit Medicines The World Health Organization (WHO) has issued draft guidelines on testing of “suspect” spurious/falselylabeled/falsified/counterfeit medicines. These are available for comments to be submitted by 10th January 2017.

The guidelines divide substandard/spurious/falsely-labeled/falsified/counterfeit (SSFFC) medicines into two main categories: ÂÂ

Substandard products that are produced and distributed—in principle—in accordance with 100 legal provisions but that do not meet their quality specifications due to error and/or negligence during the manufacturing process and/or inappropriate storage

ÂÂ

Spurious, falsely-labeled, falsified and/or counterfeit (SFFC) products, which are the result of deliberate actions intended to deceive patients and health workers.

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COMMUNITY MEDICINE

Prevalence of Sexually Transmitted Infections and Condom Use Among Female Sex Workers of Urban Vadodara, Gujarat PREETI P PANCHAL*, JR DAMOR†, VS MAZUMDAR‡, K SHRINGARPURE#, K MEHTA¥

ABSTRACT Objective: To measure the prevalence of sexually transmitted infections (STIs) and practices of condom use among female sex workers (FSWs). Material and methods: This cross-sectional study was conducted at a targeted intervention site in Vadodara city from March 2011 to September 2011 in which 132 FSWs were enrolled. They were counseled for human immunodeficiency virus (HIV) and STI testing, and were interviewed using a pretested semi-structured study instrument after taking written informed consent. This was followed by clinical examination for STI and oropharyngeal, vaginal, urethral, anorectal swabs and blood samples were collected. Results: Nearly 88%, 77% and 54% of FSWs used condom with one time partners, regular partners and spouse, respectively. Consistent condom use differs significantly (p < 0.0001) with types of partner. On serological tests, maximum were positive for chlamydia (7%) followed by HSV-2 (4.7%), HBsAg (2.4%) and syphilis (0.79%). Only one sample found to be seropositive for HIV and none of the samples were found to be HCV positive. Conclusion: Prevalence of STI/RTI (reproductive tract infection) was 25.95% among FSWs and chlamydia was the most common STI. Consistent condom use varied by type of sexual partners.

Keywords: Prevalence, sexually transmitted infection, female sex workers, urban Vadodara

S

exually transmitted infections (STIs) are a major global cause of acute illness, infertility, longterm disability and death, with severe medical and psychological consequences for millions of men, women and children. The exact magnitude of STI is largely unknown and a large number of infections are asymptomatic.

Both symptomatic and asymptomatic infections can lead to the development of serious complications with severe consequences for the individuals and for the community. Apart from being serious diseases on

*Assistant Professor †Associate Professor ‡Professor and Head #Tutor Dept. of PSM Medical College Baroda, Vadodara, Gujarat ¥Assistant Professor Dept. of PSM GMERS Medical College, Gotri, Vadodara, Gujarat Address for correspondence Dr Preeti P Panchal Assistant Professor Dept. of PSM, Medical College Baroda, Vadodara - 01, Gujarat E-mail: ppanchal86@gmail.com

their own, STI intensify the transmission of sexually transmitted human immunodeficiency virus (HIV) infections.1 Sex workers are among the groups at highest risk for contracting HIV. The nature of their work makes them susceptible to STIs, violence, irregular or absent condom use and alcohol and substance abuse, all of which increase their risk of contracting HIV.2,3 A study done in Surat has shown high prevalence of STI (47.5%) and HIV (43.2%) among female sex workers (FSWs).4 Repeated cross-sectional STI surveys among high risk groups can be a powerful tool for monitoring the effects of HIV and STI programs because they can demonstrate the combined effects of changes in risk behavior, changes in health-seeking behavior and improved quality of care, while adapting to changing patterns of causation and antimicrobial susceptibility.5 As the dynamics of STI and HIV are similar and STI increases the risk of transmission of HIV, a reduction in the prevalence of STI is likely to reduce transmission and therefore incidence of HIV. Thus STI can act as a proxy indicator to assess the impact of efforts towards HIV/AIDS (acquired immune deficiency syndrome) prevention.

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COMMUNITY MEDICINE The main aim of National AIDS Control Programme (NACP)-III was to halt and reverse the tide of the HIV epidemic in India by 2012. In order to develop strategic program initiatives, NACP-III had given great importance to evidence-based planning and strengthening of surveillance, research and monitoring.6 It is essential to have realistic estimates of the prevalence and incidence of STI infections as these may help the healthcare providers in more effective implementation of existing strategies and the policy makers in planning suitable interventions for the future.

The present study was carried out at a targeted intervention (TI) site with an objective to measure the prevalence of STI/RTI (reproductive tract infection) among FSWs using laboratory facilities of Regional RTI/STI Centre, Medical College Baroda, Vadodara practices of condom use among them.

MATERIAL AND METHODS The current cross-sectional study was conducted at a TI site for FSWs identified by Gujarat State AIDS Control Society (GSACS) of Vadodara city from March 2011 to September 2011. There were 8 outreach workers (ORWs) at this TI site. Twice a week visits to this TI site were scheduled. ORWs were informed beforehand about the visits. During each visit 3-4 ORWs were asked to bring their key population (FSW) to the TI site.

During 7 months of data collection 149 FSW reported, out of which 17 refused to participate, thus making a sample of 132.

Before starting enrollment of the participants, necessary clearances and permissions were obtained from concerned authorities including GSACS and Institutional Ethics Committee for Human Research (IECHR). FSWs were enrolled in the study only after taking informed and written consent.

The participants were counseled regarding HIV and other STI testing by counselors of TI site. After counseling, they were interviewed using a pretested semi-structured study instrument. Information regarding sociodemographic status, sexual behavior, present and past history of STI and health seeking behavior was collected using a pretested study instrument. This was followed by clinical examination for presence of any signs of STI and sample collection (oropharyngeal, vaginal, urethral and anorectal swab), which was conducted in an examination room by Residents from Obstetrics and Gynecology and Skin and VD departments. Blood samples were collected by the laboratory technician of TI site.

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All the collected samples were transported to Regional RTI/STI Centre, Dept. of Microbiology, Medical College and Shree Sayaji General Hospital (SSGH), Vadodara, where swabs were Gram stained and examined under microscope and serological tests were done for syphilis, hepatitis B and C, chlamydia, herpes simplex virus 2 (HSV-2) and HIV. Individual reports were given to the participants after post-test counseling by TI counselor. Those who tested positive for any of the STI were given appropriate treatment and followed up at SSGH and TI clinic. The data were entered in Microsoft Excel 2007 and were analyzed using SPSS Statistics 17.0 software.

RESULTS Sociodemographic profile of FSWs is described in Table 1. Mean age of FSWs was 34.26 years; 44% of them were divorced/separated or widowed; 28% of them were illiterate, 35% and 31% of FSWs had reported having received primary and secondary level education, respectively. Nearly 42% of FSWs were currently married and half of the females earned less than ` 5,000/month. Nearly one-fifth of the FSWs had migrated from other states of India as shown in Figure 1. Majority of them were having less than 10 partners per month. Three-fourths of the FSWs had sex with one time partners in last month, while 60% had regular partners and 43% had spouse as their sexual partner in last month. Amongst them 88%, 77% and 54% of FSWs used condom with one time partners, regular partners and spouse, respectively. Consistent condom use differs significantly (p < 0.0001) with types of partner as shown in Table 2. This association declined from one time partner to regular partner to spouse.

The females who could not convince their one time partner stated: ‘‘refusal by clients and offer for more money for unprotected sex” (33%) and ‘‘ignorance by FSW” (33%) as the main reasons. Few females were uncomfortable with condom use (17%), while few said ‘‘condom was not available every time” (17%).

In case of condom use by regular partner, ‘‘being loyal” (40%) was the main reason behind not using condom.

Other reasons were ‘‘refusal by partner”, ‘‘feeling uncomfortable” and ‘‘ignorance”. Most of the FSW (90%) got free condoms from the TI site. Serological tests were carried out on 127 samples. As seen in Table 3, maximum were positive for chlamydia (7%) followed

by HSV-2 (4.7%), hepatitis B surface antigen (HbsAg) (2.4%) and syphilis (0.79%). None of the samples was found to be hepatitis C virus (HCV) positive. Only one sample was found to be seropositive for HIV out

COMMUNITY MEDICINE Table 1. Sociodemographic Profile of FSWs of Urban Vadodara Parameter

Outside India (1%) Within Gujarat (13%)

Number (n = 132)

Percentage (%)

18-25

31

23.48

26-35

37

28.03

36-45

54

40.91

46-55

9

6.82

>55

1

0.76

Hindu

114

86.36

Muslim

17

12.88

Other

1

0.76

Table 2. Association Between Condom Use with Different Types of Partners Among FSWs

Married

58

43.94

Never married

18

13.64

Divorced

16

12.12

Type of partners during last month*

Separated

18

13.64

One time

Widowed

22

16.66

Age (years)

West Bengal (10%)

Other States (17%)

Maharashtra (4%)

Vadodara (69%)

Uttar Pradesh (1%) Madhya Pradesh (1%) Rajasthan (1%)

Religion

Marital status

Education Ιlliterate

37

27.95

Primary

46

35.05

Secondary

41

30.78

Higher Secondary

6

5.22

Graduate

2

1

<5,000

71

53.79

5,000-10,000

29

21.97

10,001-15,000

20

15.15

>15,000

12

9.09

None

81

61.36

Tobacco chewing

44

33.33

Smoking

7

5.30

Alcohol

15

11.36

Drugs

1

0.75

Income (per month)

Addiction

of 90 samples tested. Among all the swabs collected, maximum positivity was found in vaginal swabs (8.3%), followed by urethral swabs (6.7%) and oropharyngeal swabs (1.68%). But none of the anorectal swabs was found positive. In all, 34 out of 132 FSWs were found to be positive for any of the STI, therefore giving a prevalence of 25.95%. As shown in Table 4, persistent condom use was significantly associated with the absence of STI among the FSW. But this association

Figure 1. Place of origin of FSWs.

Condom used consistently

Condom not used consistently

Total number of FSWs (n = 132, %)

89

12

101 (76.51)

Regular

62

18

80 (59.85)

Spouse

31

26

57 (43.18)

*Multiple answers possible. χ2 test (p value): 23.11 (<0.0001).

Table 3. Investigations Results Among FSWs Investigation

No. of samples positive (n = 132)

Percentage (%)

Nugent’s score >7

3

8.82

Nugent’s score >7 & bacterial vaginosis

3

8.82

Nugent’s score >7 & urethral swab positive

4

11.76

Urethral swab positive

4

11.76

Oral swab positive

2

5.88

RPR/TPHA

1

2.94

HBsAg

3

8.82

Chlamydia

8

23.53

HSV

5

14.70

Chlamydia & HSV

1

2.94

HIV*

1

2.94

Total (Any STI)

34

100

*FSW seropositive to HIV had been positive for HSV too so not included in total.

varied with the type of partners. Presence of STI was maximally associated with ‘‘not using condom consistently” with one time partners (odds ratio: 7.37).

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COMMUNITY MEDICINE Table 4. Association Between Condom Use and Presence of STI Among FSWs STI present

STI absent

χ2 value

P value

OR

95% CI of OR

8.89

0.0008

7.3684

2.0022-27.1167

4.6834

0.0304

3.33

1.0842-10.2478

0.4737

0.4912

1.85

0.54-6.27

One time partners Not using condom

8

4

Using condom

19

70

Regular partners Not using condom

8

10

Using condom

12

50

Not using condom

8

18

Using condom

6

25

Spouse

DISCUSSION The report of the Joint United Nations Programme on HIV/AIDS (UNAIDS) on ‘‘HIV/AIDS, Gender and Sex work”, described that high rates of infection among sex workers may not be due to the fact that they have multiple partners but rather due to a combination of factors that compound this risk. These factors include poverty, low educational level and consequent low level of knowledge about HIV/AIDS and its prevention; limited access to healthcare services and prevention commodities, such as condoms; gender inequalities and limited ability to negotiate condom use; social stigma and low social status; drug or substance abuse and compromised sexual interactions and lack of protective legislation and policies.7 Majority of the females in this study were between 36 and 45 years age. The median age of FSW was 35 years in contrast to the National level Behavioral Surveillance Survey (BSS), where it was found to be 30 years in BSS (2006) and 27 years in BSS (2001).8 Overall, the proportion of those currently married was much lower (42%) and of those separated/divorced/ widowed much higher (44%) among FSW as compared with women of Vadodara city, for whom these proportions were 74% and 5%, respectively.9 Women who are separated/divorced from their husbands or are widowed have limited rights, and economic independence.10 In addition, if they are illiterate, they are likely to have even fewer labor market opportunities other than sex work.11 It can be speculated that their impetus to get into sex work is to contribute to family income and they could, in some cases, be the sole supporters of their families.

In this study, 40% females were addicted to tobacco or other substance abuse and 11.36% females reported

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alcohol addiction. However, no association was found between addiction and STI. But in a study, conducted

by Population Council among FSWs of Karnataka, it was found that mobile FSWs who consumed alcohol (compared with those who do not) reported less condom use, more STI symptoms and said that they continued to have sex, while experiencing STI symptoms. Sex workers who consumed alcohol also perceived that they are at higher risk for HIV than those who do not. So, the extent of alcohol consumption on both the clients’ and the women’s part is likely underestimated as a factor hindering condom use.12 Moreover, 28% FSWs were illiterate and 35% had received only primary level education in this study.

Illiteracy, again, is associated with less economic opportunities. The literacy rate in India among men is 82.14% and is 65.46% among women as per Census 2011.13 Traditionally in the Indian Society, women after marriage are expected to take care of the household, children and assist the work of the men of the household but are not encouraged to work outside their household for generating income as that responsibility lies with the men. However, with increasing poverty and decreasing economic opportunities, married women are increasingly seeking work outside their households to generate income. And, it is likely that the earning potential in sex work for the poor and illiterate women is larger to what they could earn through other types of work.11 Migration and sex work are often linked, as poor migrants who have newly arrived in an area sometimes turn to sex work because they cannot find any other way to make money. As well as being sex sellers, migrants may also become the clients of sex workers, sometimes as a means of escaping the loneliness that often accompanies migration.14 In our study, 17% of the FSW reported that they have migrated from other states of India like West Bengal, Maharashtra, etc; 1%

COMMUNITY MEDICINE reported to be native of Nepal (Fig. 1). Similar findings were revealed in a study conducted by Talsania in Jyotisangh of Ahmedabad where 21% of the FSWs were from other states.15 But in a study conducted by Kosambiya in the red light area of Surat city, almost all the FSWs were migrant from other states and around 33% of them were from Nepal.4 Interviews with FSWs revealed that the consistency of condom use differed significantly with different type of partners. It was found that majority of the FSWs used condom consistently with one time clients as compared to their regular partners or spouse. Study done in Cambodia by Sopheab et al reported consistent condom use with clients by 80% of the FSW but, only 38% of the FSW used it consistently with sweethearts or casual partners.16 In the present study, out of the 132 FSWs screened, 1.11% (1 out of 90 FSW) were reactive for HIV and 0.79 were rapid plasma reagin (RPR) and Treponema pallidum hemagglutination assay (TPHA) positive. Maximum seropositivity was for chlamydia (7%) followed by HSV-2 (4.7%) and HBsAg (2.4%) (Table 3). In the study done in Cambodia, prevalence of syphilis was 2.3%; chlamydia, 14.4%; gonorrhea, 13.0% and any STI, 24.4%.16 Similarly in the study from Ahmedabad in 2007, 3.2% FSWs were reactive for HIV and 3.7% were venereal disease research laboratory (VDRL) positive; 1.11% were hepatitis B virus (HBV) positive, 1.44% FSWs were positive for HCV. Although Gujarat state has moderate prevalence of HIV/AIDS (>5% prevalence in high-risk group and <1% in low-risk group), the results are well-matched with published data of GSACS, showing that the prevalence of HIV is gradually reducing among high-risk group due to improved awareness among sex workers.15 In report of Epidemiological Fact Sheet on HIV and AIDS published in 2008, HIV positivity among FSWs was found to be 6.4% for Gujarat state and 8% for FSW of Paras PSH Project of Surat in the year 2006.17 In the present study, overall STI prevalence among FSWs was 25.95%.

Similarly, a study conducted in Cambodia showed high prevalence of STI among the FSW. Prevalence of syphilis was 2.3%; chlamydia, 14.4%; gonorrhea, 13.0% and any STI, 24.4%.16 A study in Lahore also showed prevalence of syphilis (3.6%), gonorrhea (9.8%), chlamydia (5.2%), trichomonas (5.2%) and bacterial vaginosis (27.4%) among FSWs.18 Although lower prevalence of STI may be attributed to the services provided by the NGO under TI, majority of the females who found to be seropositive for any of the STI were asymptomatic at the time of

interview. This shows that to measure the real burden of STI and to tackle it effectively, laboratory services should be incorporated wherever feasible. There was significant association between presence of STI and not using condoms with one time partners (p < 0.001) and regular partners (p < 0.05), while the association was not significant with spouse as partners (Table 4). It was found that 88% of the FSW used condom during last intercourse; while 9 out of 16, who did not use condom during last intercourse, were found to be positive for STI in this study.

Consistent condom use was an important factor in reducing chances of acquiring STI in our study. Similar finding was observed in Sonagachi Project, which is the World Health Organization (WHO) model of STD/HIV prevention that HIV prevalence decreases below 10% when condom use rates increases to 90% among sex workers in Kolkata.19 Comparable finding was also observed by Rojanapithayakorn in Thailand among sex workers in which, on increasing condom use rate, the STD rate declined from 25% to less than 1%.20 Other studies also indicate that a condom, when used consistently and correctly, is an effective method for protection against STI for sexually active persons.21-25 CONCLUSIONS AND RECOMMENDATIONS Prevalence of STI/RTI was 25.95% among FSWs and chlamydia was the most common STI followed by HSV2, HBsAg and syphilis. Consistent condom use varied by type of sexual partners. FSWs used condom maximally with one time partner and least with their spouse. Association of STI with condom use also differed among different types of partners. FSWs should be regularly screened and promptly treated for STIs. The linkage between TI clinic at the NGO site, the Regional RTI/STI Centre and SSG Hospital should be considered as a comprehensive package for RTI/STI for these high-risk groups, which will provide effective STI services to those who need it the most as well as track any changes in sensitivity to drugs. FSWs should be counseled using behavior change communication at each contact with NGO regarding importance of correct and consistent condom use with all the clients including their regular partners.

Acknowledgment Laboratory tests for this study were done by Regional RTI/ STI Centre, Medical College Baroda. We acknowledge the support from Dept. of Obstetrics and Gynecology and Skin and VD for clinical examination of the participants.

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20. Rojanapithayakorn W. The 100% condom use programme in Asia. Reprod Health Matters. 2006;14(28):41-52.

21. Stone K, Timyan J, Thomas E. Barrier methods for the preventionof sexually transmitted diseases. In: Holmes KK, Mardh P, Sparling PF, Lemon SM, Stamn WE, Piot P, Wasserheit JN (Eds.). Sexually Transmitted Diseases. New York: McGraw-Hill; 1999. pp. 1307-21.

22. Gallo MF, Steiner MJ, Warner L, Hylton-Kong T, Figueroa JP, Hobbs MM, et al. Self-reported condom use is associated with reduced risk of Chlamydia, gonorrhea, and trichomoniasis. Sex Transm Dis. 2007;34(10):829-33.

23. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections.

Bull World Health Organ. 2004;82(6):454-61.

24. Ness RB, Randall H, Richter HE, Peipert JF, Montagno A, Soper DE, et al; Pelvic Inflammatory Disease Evaluation and Clinical Health Study Investigators. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. Am J Public Health.

2004;94(8):1327-9.

12. Karnataka Health Promotion Trust (KHPT) Population Council: Patterns of migration/mobility and HIV risk 25. Jana S, Bandyopadhyay N, Mukherjee S, Dutta N, among female sex workers. Karnataka. Bangalore: KHPT; Basu I, Saha A. STD/HIV intervention with sex workers in West Bengal, India. AIDS. 1998;12 Suppl B:S101-8.

2008. Available at: http://www.popcouncil.org ■■■■

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ENT

Globus Hystericus Not Only Headache to Doctor But Also Lump Problem in Throat for Patient: A Study in 100 Patients SHAMENDRA KUMAR MEENA

ABSTRACT A sensation of lump in throat expressed by patients is real and needs a thorough investigation of upper aerodigestive tract. Gastroesophageal reflux disease/laryngopharyngeal reflux was found to be the most common cause followed by emotional instability (females) and chronic granular pharyngitis, others being sinusitis (post-nasal drip), cervical osteophytes, hypothyroidism, lingual tonsil, laryngopharyngeal malignancy, etc. Globus sensation can may an early malignant lesion sign.

Hence investigations like video laryngoscopy, direct laryngoscopy, barium swallow and esophagoscopy should be done in all patients. Psychotropic drugs have an important role in the management of these patients especially, where no organic lesions were found. Globus pharyngeus is a term which denotes a symptom rather than a diagnosis. Treatment with proton pump inhibitors, antidepressants/anxiolytics, saline gargles and avoidance of cold water and certain food items, in patients with no definite cause, was found to be very effective. And this combination of treatment can be taken as an initial line of treatment until detailed evaluation and investigation results are not obtained.

Keywords: Laryngopharyngeal reflux, globus hystericus, globus pharyngeus

G

lobus sensation can have underlying physiological or anatomical causes and it is thought that it could be due to a number of potential etiologies.1 Globus sensation is a common symptom, accounting for 4-5% of new referrals to ear, nose and throat (ENT) outpatient clinics.2 The classical sign of lump in the throat sensation is described as a median or paramedian sensation of an unidentified object in the pharynx mainly at or around the cricopharyngeal level in neck region. True dysphagia and weight loss are absolutely absent.

Hippocrates was the first one to have described globus sensation. (Latin word globus means lump), but accurate definition of globus was given by John Purcell in 1707. The term “Globus pharyngeus” was proposed by Malcomson3 in 1968, as it was assumed to

Medical Officer (Clinical Tutor) Dept. of ENT Government Medical College Kota, Kota, Rajasthan Address for correspondence Dr Shamendra Kumar Meena KR-21 Civil Line, Nayapura, Kota, Rajasthan - 324 001 E-mail: shamendrameena82@gmail.com

be of psychic origin. It was Pratt4 who coined the term “Globus hystericus” in 1976. Purcell postulated that it was due to contraction of strap muscles of neck pressing on thyroid cartilage and therefore globus symptoms were “not vain imaginations and groundless fancies” expressed by the patient but were real sensations actually felt by the patient.

Wareing et al5 believed that this throat sensation could be caused by excessive pharyngolaryngeal tension, therefore, neck and shoulder exercises to reduce the laryngeal muscle tension general relaxation techniques, together with voice exercises and voice hygiene may be of benefit especially for those whose globus is accompanied by dysphonia.

Many regarded cricopharyngeal spasm as the principal generator of the symptom, but evidence to support this is scanty. In the past decade, there has been an increasing acceptance that globus is not merely a hysterical manifestation, but is related to some underlying dysfunction of the pharyngoesophageal segment. It was postulated that the condition described as globus sensation may be no more than a variant presentation of reflux esophagitis, the basis of these symptoms being an esophageal motility disturbance consequent upon the irritant effect of gastroesophageal reflux, though

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ENT many workers disagree to this assumption. Still, etiology is unknown but appears to be multifactorial; recent study focuses on gastroesophageal reflux disease (GERD). Role of pepsin-induced laryngeal injury is an exciting concept. Multifactorial causes are hiatus hernia, maxillary sinusitis, lingual tonsillitis, dental malocclusion, cervical osteophytes, vallecular cyst, hypothyroidism; it is also found to be associated with sideropenic anemia prior to the development of Paterson-Brown Kelly syndrome. Indeed, throat clearing is the most common single symptom endorsed when direct enquiry is made of a voice clinic population.6 Now, there is a general consensus that these patients are presenting with treatable conditions and the expression globus hystericus should be discarded in favor of globus pharyngeus, a symptom rather than diagnosis.

There is always a female predominance seen in many studies. Patients observe: “If I swallow something, I feel nothing, but if I swallow nothing, I feel something”.

OBJECTIVE Investigations for clinical features and etiology of lump.

MATERIAL AND METHODS A total of 100 patients from the OPD with complaints of lump in the throat sensation were selected for study during the period (2015-2016). All went through detailed history taking, clinical examination and investigations like diagnostic nasal endoscopy, video laryngoscopy, X-ray PNS (post-nasal drip), barium swallow and X-ray soft tissue neck - lateral view and anteroposterior view.

Thyroid function tests and psychiatric evaluation were also done.

Patient selection criteria was as follows:

Inclusion Criteria7 ÂÂ Age between 15-65 years of both sexes.2 ÂÂ No previous treatment taken for the same complaints.

Exclusion Criteria8 ÂÂ Patients with malignancies of oropharynx, oral cavity, esophagus and stomach. ÂÂ Patients with symptoms of less than 14 days duration.

Patients with definite etiology were treated as per the cause. Patients without any specific association or causes were treated with proton pump inhibitors (PPIs), antidepressants plus anxiolytics and saline gargles. All patients were followed up for 5-7 months.

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RESULTS AND OBSERVATIONS Out of hundred patients studied, 66% patients were females and 34% were males with ratio of 1.9:1. This indicates a female predominance in the study. In 91% of patients, the site of sensation was at and above the level of cricoid and in 9% it was below the cricoid level.

None of the patients had any true dysphagia. The onset of symptoms was gradual in 72% and precipitating events were recollected only by 8%. Fear of cancer was a major contributing factor and was present in more than 50% of the patients. Majority of patients fell in the age group of 25-45 years (45%), followed by 46-60 years (35%). In both groups, female predominance was been observed. Emotional instability was shown by 31% patients, of which, 25% were males and 75% were females. All those patients with GERD and emotional instability had undergone gastro as well as psychiatric evaluation.

Most common association found was laryngopharyngeal reflux (LPR), then emotional instability, followed by chronic granular pharyngitis; 53% patients showed symptoms related to GERD like acid regurgitation, retrosternal pain, abdominal distension and belching.

Third common association was chronic granular pharyngitis, consisting of 19% of the study population, 55% of them being males and 45% females, which is almost equal. Hypothyroidism was seen in 2%, PND in 2% and cervical osteophytes in 3% as shown in the X-ray of neck - lateral view. No patient showed any esophageal web or growth. Lingual tonsil (1%) and hypopharyngeal malignancy (1%) were observed, both were females.

All those patients without specific reasons were given reassurance, PPIs twice-daily, antidepressants plus anxiolytics in the night and saline gargles twice-daily.

They were also advised to avoid intake of cold water and cold food items. Patients with specific reasons were treated accordingly. Follow-up for 5-7 months revealed approximately complete relief of symptoms.

DISCUSSION Lump in the throat is a persistent or intermittent, nonpainful sensation of foreign body in the throat.

Commonly seen in clinical practice, usually longstanding, difficult to treat and has a good tendency to recur. Due to undefined etiology, it remains difficult to establish standard investigations and treatment plans. Condition is classically considered to occur most frequently in middle-aged people but other studies have shown that both younger and older age groups

ENT are also affected. In our study, age of patients varied from 15 to 65 years. The maximum incidence was found in the age group of 31-40 years.

Hippocrates considered that lump in throat sensation was a disease of menopausal woman. Now, it has been proven that both sexes are affected, but there is always a female predominance. This study also showed a female predominance of 1.9:1. The duration of symptoms of patients included in this study varied from 14 days to 5 months; average duration of history was found to be 2.5 months. This is in difference with the study

by Batch,8 where average duration of symptoms was 20 months. Osteophytes in the region of C5, C6, C7 cause lump, pain on swallowing. Malcomson3 has also reported it as a positive finding in 60 out of 307 patients. In our study, only 3% patient reported cervical osteophytes.

Psychological evaluation showed that majority of patients were either anxious, worried or depressed mainly due to this disease. In two different studies by Pratt et al4 and Puhakka,9 it was found that patients have higher than average score on depression and hypochondriac scales. But in this study, majority patients (76%) were having anxiety when compared to depression. The percentage of malignancy in this study was negligible i.e., only 1%. This is different from that of the study by Bradley et al, in which it was 3% and 5%, respectively.10 CONCLUSION In this study, most of the cases of lump in the throat sensation was found in the age group of 25-40 years, followed by the age group of 41-55 years. Lump in throat sensation, expressed by patients, is real and needs a full investigations of upper aerodigestive tract. LPR was found to be the most common cause followed by emotional instability (females) and chronic granular pharyngitis, others being sinusitis (PND), cervical osteophytes, hypothyroidism, lingual tonsil, laryngopharyngeal malignancy, etc. Globus sensation may be a sign an early malignant lesion.

Hence investigations like video laryngoscopy, direct laryngoscopy, barium swallow, esophagoscopy should be done in all patients. Psychotropic drugs have an important role in the management of these patients especially, where no organic lesions are found. Globus pharyngeus is a term which denotes a symptom rather than a diagnosis. Treatment with PPIs, antidepressants/ anxiolytics, saline gargles and avoidance of cold water and certain food items, in patients with no definite cause was found to be very effective. And this combination of teatment can be taken as an initial line of treatment until detailed evaluation and investigation results are not obtained.

REFERENCES 1. Lee BE, Kim GH. Globus pharyngeus: a review of its etiology, diagnosis and treatment. World J Gastroenterol.

2012;18(20):2462-71.

2. Cashman EC, Donnelly MJ. The natural history of globus pharyngeus. Int J Otolaryngol. 2010;2010:159630.

3. Malcomson KG. Globus hystericus vel pharyngis (a recommaissance of proximal vagal modalities).

J Laryngol Otol. 1968;82(3):219-30.

4. Pratt LW, Tobin WH, Gallagher RA. Globus hystericus office evaluation by psychological testing with the MMPI. Laryngoscope. 1976;86(10):1540-51.

5. Wareing M, Elias A, Mitchell D. Management of globus sensation by the speech therapist. Logoped Phoniatr Vocol. 1997;22(1):39-42.

6. Wilson JA, Webb A, Carding PN, Steen IN, MacKenzie K, Deary IJ. The Voice Symptom Scale (VoiSS) and the Vocal Handicap Index (VHI): a comparison of structure and content. Clin Otolaryngol Allied Sci. 2004;29(2):169-74.

7. Ardran GM. Feeling of a lump in the throat: thoughts of a radiologist. J R Soc Med. 1982;75(4):242-4.

8. Batch AJ. Globus pharyngeus (Part I). J Laryngol Otol.

1988;102(2):152-8.

9. Puhakka H, Lehtinen V, Aalto T. Globus hystericus - a psychosomatic disease? J Laryngol Otol. 1976;90(11): 1021-6.

10. Bradley PJ, Narula A. Clinical aspects of pseudodysphagia.

J Laryngol Otol. 1987;101(7):689-94.

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INTERNAL MEDICINE

Dengue Fever Complicated with Pleural Effusion: A Case Report and Review of Literature MONIKA MAHESHWARI

ABSTRACT Dengue is a mosquito-borne infection that, in recent years, has become a major international public health problem. The clinical spectrum of disease, may range from asymptomatic infection to the most severe form of the disease - dengue hemorrhagic fever. The World Health Organization (WHO) has stated: Dengue is one disease entity with different clinical presentations and often unpredictable clinical evolution and outcome. If untreated, mortality from the complications of dengue fever is as high as 20%. Hence, it is worth reporting its varied clinical presentation, so as to create awareness among treating physicians so that they can take early therapeutic measures and thereby reduce mortality and morbidity.

Keywords: Dengue fever, pleural effusion, pulmonary complications

T

he dengue fever (DF) is caused by an arthropodborne flavivirus. The main vector is the mosquito Aedes aegypti. There are four distinct serotypes of dengue virus (DEN1-4). Varied thoracic manifestations include pleural effusion, pneumonia, pulmonary hemorrhage and hemoptysis. Dengue shock syndrome (DSS) is reported to be the third leading cause of acute respiratory distress syndrome (ARDS). Increased permeability of the alveolar-capillary membrane results in edema in the alveoli and interstitial spaces, which leads to pulmonary dysfunction. We report herein a case of DF complicated with bilateral pleural effusion.

Laboratory investigation showed normal hemoglobin, total leukocyte count - 6,200 cells/mm3 and total platelet count - 1.2 lacs/mm3. Peripheral blood film was negative for malarial parasite, while serological test for DF (rapid NS-1 antigen) was positive. Liver and renal function tests were within normal limits. Chest X-ray film showed blunt bilateral costophrenic angles consistent with pleural effusion (Fig. 1). Ultrasonography (USG) confirmed moderate pleural effusion and ascitis (Figs. 2 and 3). Pleurocentesis was done under ultrasonic

CASE REPORT A 30-year-old male presented in casualty department with complaints of fever, bodyache and progressively increasing breathlessness since 1 week. On examination, he was febrile (100â&#x2014;ŚF), tachypneic with respiratory rate - 30/min, pulse - 100/min and blood pressure 100/76 mmHg. Chest auscultation revealed diminished breath sounds in right infrascapular zone. Rest of the systemic examination revealed no abnormality.

Associate Professor JLN Medical College, Ajmer, Rajasthan Address for correspondence Dr Monika Maheshwari Naveen Niwas, 434/10 Bapu Nagar, Ajmer, Rajasthan E-mail: opm11@rediffmail.com

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Figure 1. Blunt bilateral costophrenic angles consistent with pleural effusion.

INTERNAL MEDICINE DISCUSSION The global incidence of dengue hemorrhagic fever (DHF) has increased dramatically in recent decades.1 Resurgence is noted, mostly in Asian countries.2 Many cases of DF are self-limiting but its complications like hemorrhage and shock can be life-threatening. If untreated, mortality from the complications of DF is as high as 20%.

Figure 2. Ultrasonography showing moderate pleural effusion.

The endothelium is the target of the immunopathological mechanisms in dengue and DHF. The hallmark is vascular permeability and coagulation disorders. These mechanisms can explain varied systemic involvement.3 DHF can result in ARDS.4 Dengue virus antigen is found in alveolar lining cells of the lung. Increased permeability of the alveolar-capillary membrane results in edema in the alveoli and interstitial spaces, which leads to pulmonary dysfunction.5 Pulmonary hemorrhage with or without hemoptysis has also been reported in DHF.6 Pleural effusion, ascites can be consistent with increased vascular permeability, plasma leakage, abnormalities of hemostasis and protein losing shock syndrome, which commonly occur in the pathogenesis.7 Syed et al8 found that when the various parameters suggested by the World Health Organization (WHO) as indirect evidences of capillary leak (hemoconcentration and hypoalbuminemia) were compared with USG and radiography. USG was found to have the highest sensitivity and negative predictive value in detecting pleural effusion. They have suggested that USG would be ideal, owing to its safety, in that it is nonionizing and would assist detecting plasma leakage even before it manifests clinically. Similar findings have been reported in a study from Indonesia.9

Figure 3. Ultrasonography showing moderate ascites.

guidance. Pleural effusion analysis showed transudative picture and yielded no organisms growth. The patient was treated with intravenous fluids judiciously along with antibiotics and analgesics. The patient responded to the treatment and was discharged symptomatically better, after 7 days of treatment. Follow-up repeat chest X-ray showed resolution of pleural effusion and ascitis.

Srikiatkhachorn et al10 found that USG detected plasma leakage in multiple body compartments starting from 2 days before defervescence and was detected in some cases within 3 days after fever onset. USG detected plasma leakage in 12 of 17 DHF cases who did not meet the criteria for significant hemoconcentration suggesting that USG signs of plasma leakage are detectable even before changes in hematocrits occur in DF. In a study performed by Venkata Sai et al, the yield of USG was found to be higher in the later stages of the disease. Repeat USG on the 5th to 7th days detected pleural effusion in a significantly higher number of patients with dengue fever.11 In most cases of pleural effusion, it occurs first in the right side. If it occurs bilaterally, the amount of fluid is

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INTERNAL MEDICINE usually greater than the left side, which is explained by anatomical phenomenon. The right pleural cavity is a natural reservoir of first choice based on gravity and resistance because left lung consists of 2 lobes, and the right one was 3, then its most likely that right lobe of the lung provides more mass of organ than the left side, thus the amount of blood vessels are greater on the right side than the left side. So, pleural effusions tend to occur first, or more, on the right side.

USG is superior to chest radiography in detecting pleural effusions.12 On chest X-ray, the extent of plasma effusion in DSS can be identified better in the right lateral decubitus position than posteroanterior view and is quantified by the pleural effusion index (PEI), calculated from the maximal height of pleural fluid/ width of hemithorax × 100.10 PEI >15% is a risk factor for mortality in children with DSS.13 A pilot study of Thai children hospitalized with acute dengue virus infection demonstrated that minimal daily muscle oxygen saturation (SmO2) as measured by near-infrared spectroscopy was found to correlate with pleural effusions in hospitalized children with acute dengue virus infection. Receiver operating characteristics (ROC) analysis revealed a cut-off value for SmO2 (48%), which yielded high specificity and sensitivity.14 REFERENCES 1. World Health Organization. WHO report on global surveillance of epidemic-prone infectious diseases. 2001.

Available at: http://www.int/emc.documents/surveillance/ docs/ whocdsesrisr2001.htm.

2. Ahsan T. Dengue fever: a regular epidemic? J Pak Med Assoc. 2008;58(1):1-2.

4. Sen MK, Ojha UC, Chakrabarti S, Suri JC. Dengue hemorrhagic fever (DHF) presenting with ARDS. Indian J Chest Dis Allied Sci. 1999;41(2):115-9.

5. Lum LC, Thong MK, Cheah YK, Lam SK. Dengueassociated adult respiratory distress syndrome. Ann Trop Paediatr. 1995;15(4):335-9.

6. Setlik RF, Ouellette D, Morgan J, McAllister CK, Dorsey D, Agan BK, et al. Pulmonary hemorrhage syndrome associated with an autochthonous case of dengue hemorrhagic fever. South Med J. 2004;97(7):688-91.

7. Venkata Sai PM, Dev B, Krishnan R. Role of ultrasound in dengue fever. Br J Radiol. 2005;78(929):416-8.

8. Zaki SA. Pleural effusion and ultrasonography in dengue fever. Indian J Community Med. 2011;36(2):163.

9. Setiawan MW, Samsi TK, Wulur H, Sugianto D, Pool TN. Dengue haemorrhagic fever: ultrasound as an aid to predict the severity of the disease. Pediatr Radiol.

1998;28(1):1-4.

10. Srikiatkhachorn A, Krautrachue A, Ratanaprakarn W, Wongtapradit L, Nithipanya N, Kalayanarooj S, et al.

Natural history of plasma leakage in dengue hemorrhagic fever: a serial ultrasonographic study. Pediatr Infect Dis J. 2007;26(4):283-90; discussion 291-2.

11. Venkata Sai PM, Dev B, Krishnan R. Role of ultrasound in dengue fever. Br J Radiol. 2005;78(929):416-8.

12. Thulkar S, Sharma S, Srivastava DN, Sharma SK, Berry M, Pandey RM. Sonographic findings in grade III dengue hemorrhagic fever in adults. J Clin Ultrasound.

2000;28(1):34-7.

13. Hawarini N, Kosim MS, Supriatna M, Istantil Y, Sudijanto E. The relationship between pleural effusion index and mortality in children with dengue shock syndrome.

Paediatrica Indonesiana. 2012;52(4):239-42.

14. Soller B, Srikiatkachorn A, Zou F, Rothman AL, Yoon IK, Gibbons RV, et al. Preliminary evaluation of near infrared spectroscopy as a method to detect plasma leakage in children with dengue hemorrhagic fever. BMC Infect Dis. 2014;14:396.

3. Gulati S, Maheshwari A. Atypical manifestations of dengue. Trop Med Int Health. 2007;12(9):1087-95.

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Withholding versus Continuing ACEI/ARB Before Noncardiac Surgery Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. These findings from an Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) trial were published on October 23, 2016 in the journal Anesthesiology and also presented Anesthesiology 2016 from the American Society of Anesthesiologists in Chicago.

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INTERNAL MEDICINE

Tuberculous Meningitis: A Case Report MOHAMMAD RASHID FAROOQUI*, ABDUL SALAM GHULAM SHAH†

ABSTRACT Introduction: Central nervous system (CNS) tuberculosis includes three clinical entities: meningitis, intracranial tuberculoma and spinal arachnoiditis. Tuberculous meningitis is infection of the meninges, the system of membranes, which envelop the CNS. Objective: Describe a difficult case of tuberculous meningitis (difficult diagnosis). Case report: A 24-year-old patient was admitted to the medical ward through emergency department because of sudden onset of abnormal behavior, irritability and loss of consciousness. The treatment received was anti-tubercular (4 drugs) and steroids. Patient is improving and on treatment till date. Conclusion: Tuberculous meningitis is Mycobacterium tuberculosis infection of the meninges - the system of membranes, which envelops the CNS. It is the most common CNS tuberculosis.

Keywords: Tuberculous meningitis, anti-TB drugs, culture

C phase.

linical manifestations in a patient with tuberculous meningitis progress through 3 phases: prodromal, meningitic and paralytic

ÂÂ

Prodromal phase: The prodromal phase, lasting 2-3 weeks, characterized by the insidious onset of malaise, headache, low-grade fever and personality change.

ÂÂ

Meningitic phase: The meningitic phase, with more pronounced neurologic features (e.g., meningismus, protracted headache, vomiting, lethargy, confusion and varying degrees of cranial nerve involvement).

ÂÂ

Paralytic phase: The paralytic phase, in which the pace of illness accelerates rapidly; confusion gives way to stupor and coma, seizures and often hemiparesis.

CASE REPORT A 24-year-old, Pakistani National, male patient was brought by his father to Emergency Department

*Assistant Professor Dept. of Internal Medicine †Intern Doctor Ras al-Khaimah Medical and Health Sciences University, Ras al-Khaimah, UAE Address for correspondence Dr Mohammad Rashid Farooqui Assistant Professor Dept. of Internal Medicine Ras al-Khaimah Medical and Health Sciences University Ras al-Khaimah, UAE - 11172

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because of sudden onset of the abnormal behavior, irritability and loss of consciousness. The patient was having low-grade intermittent fever for the last 2 weeks, since he came from his homeland. Past medical history was unremarkable and family history was noncontributory. Contact with a patient suffering from active tuberculosis was suspicious. According to his father, apart from low-grade fever and occasional headache, his condition otherwise was good when he came from Pakistan, but after 1 day, early morning, he suddenly became socially isolated and he kept himself alone in his room. His condition worsened and by night-time, he became irritable, unconscious and unresponsive.

On physical examination, his vitals were: temperature 37.5°C, heart rate (HR) - 69 bpm, respiratory rate (RR) - 20 bpm, blood pressure (BP) - 148/80 mmHg, O2 saturation at 99% in right atrium.

Neck: Neck stiffness was present. Signs of meningeal irritation were present.

Neurologic: Disoriented, irritable, consciousness level was decreased and Kernig’s sign was positive. He had positive meningeal signs without focal weakness.

His treatment started soon after admission. He was given chlorpromazine 50 mg IM; acetaminophen 1,000 mg IV, t.i.d.; ceftriaxone 2 g IV, b.i.d.; acyclovir 500 mg IV, q8-hr.

Investigations Complete blood count showed mild leukocytosis (13.80 × 103/µL). Absolute neutrophil count was

INTERNAL MEDICINE 12.4 × 103/µL which is high, while absolute lymphocyte count was low (0.6 × 103/µL). Electrolytes showed sodium on lower normal side, whereas others were within the normal range. Liver function tests and renal function tests were normal.

Blood glucose, capillary point-of-care - 140 mg%.

Cerebrospinal fluid (CSF) analysis: Glucose 1.1 mmol/L (low), protein CSF - 169.00 mg/dL (high) and lymphocytes - 65%.

Acid-fast bacilli (AFB) smear: Negative.

CSF culture: No growth, no AFB seen.

Blood culture: No growth at 116 hours.

Urine culture: No growth.

Radiological Examination His chest X-ray showed right pleural effusion. Pleural tap resulted in exudative fluid. Computed tomography (CT) scan was done and it showed hydrocephalus.

Course of Stay in Hospital During his stay in the hospital, patient used to have fever on and off. Steroids and another antibiotic was added to the plan. His condition improved and he became conscious and oriented. When steroids were stopped, the next day, patient's condition suddenly deteriorated and he developed the same signs and symptoms as on admission plus he had bilateral ptosis, ophthalmoplegia, divergent sequence on the left eye.

He developed 3rd nerve palsy and a dilated pupil.

Mannitol drip was started and the patient was put on steroids again.

Finally patient was diagnosed to have TB meningitis.

Since his chest X-ray show right pleural effusion, pleural tap resulted in exudative fluid and repeat CT scan showed communicating hydrocephalus; neurosurgeon was consulted, who advised conservative treatment.

Patient was then put on anti-TB treatment with 4 drugs

along with steroids. When the patient was on 18th day of antitubercular treatment, his father wanted to take him back to his home country. Since his general condition had become stable, he was allowed to travel on aeroplane sitting on a wheel chair.

DISCUSSION Tuberculous meningitis may prove to be fatal in a few weeks but complete recovery is the rule if treatment is started before the appearances of focal signs or stupor. When the treatment is started late, then the recovery rate is less than 60% and the survivors show permanent neurological deficit. Clinical features of tuberculous meningitis are headache, vomiting, lowgrade fever, behavioral changes, confusion, lassitude and depression. Signs are meningism, oculomotor palsies, papilledema, focal hemisphere and depression of conscious level. In tuberculous meningitis, the CSF in under pressure. It is usually clear but when allowed to stand, a fine clot, spider web may form. The CSF fluid contains up to 5 × 108 cells/liter, predominantly lymphocytes with increase in protein content with marked decrease in glucose. Detection of bacillus in a smear of centrifuged deposit from the CSF is difficult.

The CSF showed be cultured but the results may not be available up to 6 weeks, but treatment should be started without waiting. Antitubercular drugs should be started as early as possible. Recent evidence suggests that steroids improve mortality but not the focal neurological damage. Surgical ventricular drainage may be needed if obstructive hydrocephalus develops.

Skilled nursing is essential during the acute phase of illness and systems should be put in place to maintain adequate hydration and nutrition.

BIBLIOGRAPHY 1. Davidson’s Principles and practice of Medicine.

2. http://www.uptodate.com

3. www.mayoclinic.com ■■■■

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OBSTETRICS AND GYNECOLOGY

Conservative Surgical Techniques in Management of Morbidly Adherent Placenta: A 5-year Study REKHA RANI*, SURENDRA KUMAR†, SHIKHA SINGH‡, RUCHIKA GARG*, URVASHI VERMA*, RACHANA AGRAWAL*, SAROJ SINGH#, HIMANI¥

ABSTRACT Objectives: To evaluate the role of various conservative surgical techniques in management of morbidly adherent placenta.

To estimate the fertility and pregnancy outcomes after successful conservative surgical treatment for placenta accreta.

Material and methods: This retrospective study included women with a history of conservative management for placenta accreta. The study was conducted in SN Medical College, Agra from December 2010 to November 2015 (5 years review) on 131 patients. The aim of our study was to estimate the postoperative and future reproductive outcomes after performing various successful conservative surgical techniques in management of morbidly adherent placenta. Results: Compressive sutures, intrauterine packing and vessel embolization, etc. may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation. Conclusion: Successful conservative treatment for placenta accreta does not appear to compromise the patients’ subsequent fertility or obstetrical outcome.

Keywords: Placenta accreta, pelvic vessel embolization, compressive sutures, fertility

P

lacenta accreta/percreta is a leading cause of third trimester hemorrhage and postpartum maternal death. The current treatment for third trimester hemorrhage due to placenta accreta/percreta is cesarean hysterectomy, which may be complicated by large volume blood loss. The incidence of placenta accreta is increasing parallel with the increase in cesarean delivery.

AIM AND OBJECTIVES ÂÂ

ÂÂ

To evaluate the role of various conservative surgical techniques in management of morbidly adherent placenta.

To estimate the fertility and pregnancy outcomes after successful conservative surgical treatment for placenta accreta.

MATERIAL AND METHODS

Type of Study ÂÂ

This retrospective study was conducted in SN Medical College, Agra from December 2010 to November 2015 (5 years review) on 131 patients.

ÂÂ

The present study was undertaken among all pregnant patients attending OPD and labor room.

ÂÂ

Success of conservative treatment was defined by uterine preservation.

ÂÂ

Data were retrieved from medical files and telephone interviews.

ÂÂ

An informed consent was taken from all women included in the study.

ÂÂ

Thorough history taking, physical examination and investigations were done in all patients.

Inclusion Criteria *Assistant Professor †Consultant Anesthesia ‡Associate Professor #Professor and Head ¥3rd Year Junior Resident Dept. of Obstetrics and Gynecology, SN Medical College, Agra, Uttar Pradesh Address for correspondence Dr Rekha Rani Assistant Professor Dept. of Obstetrics and Gynecology, SN Medical College, Agra - 282 003, Uttar Pradesh E-mail: drrekha.gynae@gmail.com

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Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

ÂÂ

Reproductive age group (21-35 years).

ÂÂ

Parity (≤4).

ÂÂ

Elective cesarean cases.

ÂÂ

All pregnant patients with placenta previa in previous one or more than one cesarean section.

ÂÂ

Women with a history of conservative management for placenta accreta.

OBSTETRICS AND GYNECOLOGY ÂÂ

Patients booked in antenatal period.

ÂÂ

Hemoglobin ≥11 g/dL in elective cases.

Exclusion Criteria ÂÂ

Age more than 35 years.

ÂÂ

Grand multipara more than 4 children.

ÂÂ

Patients undergoing emergency cesarean section.

ÂÂ

Patients with previous history of scar rupture or dehiscence in which repair of uterus or hysterotomy done.

ÂÂ

Any medical and coagulation disorders (diabetes, epilepsy, heart diseases), history of bronchial asthma.

Whatever the option chosen, when placenta accreta is suspected before delivery in a woman with an anterior placenta previa, it is recommended to perform a vertical fundal uterine incision to avoid the placenta and reduce the risk of massive postpartum hemorrhage (PPH) (Fig. 4).

Placenta

Storm flow

Diagnosis For diagnosis, high resolution ultrasound with color Doppler findings at gestational Week 29 consistent with placenta accreta, included irregularly shaped placental lacunae (vascular spaces) within the placenta, thinning of the myometrium overlying the placenta, loss of the retroplacental ‘clear space’, protrusion of the placenta into the bladder, increased vascularity of the uterine serosa - bladder interface and turbulent blood flow through the lacunae on Doppler ultrasonography (Fig. 1).

Figure 1. High resolution ultrasound with color Doppler findings at gestational Week 29 consistent with placenta accreta.

Caesarean section scar

Uterine findings during laparotomy included cesarean section scar at uterine fundus and bulging isthmic part with placenta accreta/percreta (Fig. 2). In addition, placenta accreta was seen involving the urinary bladder (Fig. 3 a and b) .

Procedures There are some basic options for management of placenta accreta: ÂÂ

The cesarean hysterectomy

ÂÂ

Conservative treatment zz

Localized packing of thinned placental site with absorbable gel (Abgel) followed by compression sutures

zz

Ligation of individual vessels in the placental bed - Simple or box stitches where continuous oozing is present

zz

Temporarily packing of uterine segment.

zz

The stepwise surgical approach if preservation of fertility is desired

zz

B-Lynch and Cho sutures

zz

Methotrexate adjuvant treatment to hasten the placental resolution.

Prominent isthmic portion of uterus

Figure 2. Uterine findings during laparotomy. Note cesarean section scar at uterine fundus and bulging isthmic part with placenta accreta/percreta.

a

b

Figure 3 a and b. Placenta accreta/percreta invading lower uterine segment and bladder.

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OBSTETRICS AND GYNECOLOGY Cesarean Section Hysterectomy Performing a hysterectomy after the birth of the child without attempting removal of the placenta when placenta accreta is strongly suspected antenatally or after an attempted placental removal when the diagnosis of placenta accreta is not made until during delivery.

Figure 5 shows opened hysterectomy specimen with placenta previa percreta left in situ.

Placenta accreta

Conservative Treatment This option consists of delivering the child, tie and then cut the umbilical cord at its base to leave the placenta in place adhering either partially or totally to the myometrium, and to close the hysterotomy.

Conservative treatment avoids a hysterectomy in about 75-80% of cases, but is associated with a risk of transfusion requirements, infection and severe maternal morbidity. Figure 6 shows image obtained 20 minutes after delivery. It is seen that if the placenta is not dislodged, bleeding does not occur. B-Lynch suture with intrauterine packing may be given to prevent PPH (Fig. 7).

Figure 5. Hysterectomy specimen opened. Note placenta previa percreta left in situ.

The one step-conservative surgery (Fig. 8 a-c) It consists of resecting the invaded area together with the placenta and performing the reconstruction as a one-step procedure. The main stages of this alternative technique achieved through a median or transverse suprapubic incision are: ÂÂ

Vascular disconnection of newly-formed vessels and the separation of invaded uterine from invaded vesical tissues

ÂÂ

Performing an upper-segmental hysterectomy

ÂÂ

Resection of all invaded tissue and the entire placenta in one piece with previous local vascular control

Figure 4. After delivery of baby through vertical fundal uterine incision.

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Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

Figure 6. Image obtained 20 minutes after delivery. Note that if the placenta is not dislodged, bleeding does not occur.

Figure 7. B-Lynch suture with intrauterine packing.

OBSTETRICS AND GYNECOLOGY ÂÂ

Use of surgical procedures for hemostasis

ÂÂ

Myometrial reconstruction in two planes

ÂÂ

Bladder repair if necessary.

put some pieces of Abgel to pack the involved area tightly and obliterate the cavity by putting compression sutures.

To cover the uterine defect, a reabsorbable mesh is used.

When fixed, it will allow an accurate uterine repair and prevent postoperatory injuries (Fig. 9). Sutures are placed on second layer. Fibrin glue and collagen are placed (Fig. 10). After the second layer has been closed uterine repair is performed (Fig. 11). Under temporary aortic clamping, the placenta is safely removed (Fig. 12).

Localized Packing of Thinned Placental Site with Absorbable Gel (Abgel) After delivery of baby and placenta if there is local thinning of uterus with bleeding seen, you have to

Triple-P procedure Reconstruction of the uterine wall-as a safe and effective alternative to conservative management or peripartum hysterectomy.

It involves: ÂÂ

Perioperative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta

ÂÂ

Pelvic devascularization

ÂÂ

Placental nonseparation with myometrial excision.

Uterus body

Uterus body

Bladder a Absorbable mesh

Figure 9. To cover the uterine defect, a reabsorbable mesh is used. When fixed, it will allow an accurate uterine repair and prevent postoperatory injuries.

Fundal hysterotomy b

c

Figure 8 a-c. The one step-conservative surgery.

Figure 10. Sutures are placed on second layer. Fibrin glue and collagen are placed.

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OBSTETRICS AND GYNECOLOGY Follow-up ÂÂ Full documentation of the case is imperative. ÂÂ Careful explanation of events and interventions must be given to the patient and family. ÂÂ Caregivers must be available and approachable for questions. ÂÂ Implications and recommendations for future pregnancies may be discussed during the postoperative stay and reinforced at the postdischarge visit.

Main Outcome Measure(s) ÂÂ Comparison of the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus). ÂÂ Fertility rate (subsequent pregnancies or the return of regular menstrual cycles).

ÂÂ

Complication rate of the procedure.

ÂÂ

The outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications.

RESULTS Follow-up data were available for 96 (73.3%) of the 131 women included in the study (Fig. 13).

Compressive sutures, intrauterine packing and vessel embolization, etc. may be considered life-saving procedures by achieving the best hemostatic efficacy.

Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation.

Demographic and obstetrical characteristics at the first conservative treatment for the women included in the study and those lost to follow-up is given in Table 1 and 2.

Complications Immediate

Figure 11. After the second layer has been closed uterine repair is performed.

Fundus

ÂÂ

Hemorrhage (3,000-5,000 mL).

ÂÂ

Disseminating intravascular coagulation (DIC).

ÂÂ

Transfusion reactions.

ÂÂ

Other complications accompanying blood transfusion (human immunodeficiency virus [HIV] and hepatitis).

ÂÂ

Surgical complications (emergency hysterectomy, bowel injury, urological injuries, etc.).

ÂÂ

Pulmonary embolism.

ÂÂ

Adult respiratory distress syndrome (ARDS).

Round ligament

96 patients

8amenorrheic 88-normal menses

6 (placenta accreta) 4 asso. With placenta previa

27-wanted children

21-3rd trim preg del healthy baby

3-attempting 24-preg

1ectopic

2miscarriages

4 developed PPH

Figure 12. Under temporary aortic clamping, the placenta is safely removed. Through the uterine defect, the surgeon's fingers are clearly seen.

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Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

Figure 13. Follow-up data of 96 of the 131 women included in the study.

OBSTETRICS AND GYNECOLOGY Table 1. Demographic Characteristics at the First Conservative Treatment for the Women Included in the Study and those Lost to Follow-up Demographic characteristics

Women included in the study (n = 96)

Women lost to follow-up (n = 35)

P value

Age (years)

33.3 ± 4.6

32.5 ± 5.2

0.38

Parity

1 (0-8)

0 (0-5)

0.80

Number of pregnancies

3 (1-12)

3 (1-11)

0.82

Table 2. Obstetrical Characteristics at the First Conservative Treatment for the Women Included in the Study and those Lost to Follow-up Obstetrical characteristics

Women included in the study (n = 96)

Women lost to follow-up (n = 35)

P value

5 (5.2)

5 (14.3)

0.13

Gestational age at delivery (week)

33.9 ± 5.2

35.0 ± 4.4

0.27

Cesarean section

74 (77.1)

29 (82.9)

0.63

Placenta left entirely in situ

35 (36.4)

13 (37.1)

>0.99

Primary PPH*

41 (42.7)

15 (42.9)

>0.99

Additional uterine devascularization procedure†

66 (68.8)

21 (60.0)

0.40

Transfusion patients

30 (31.2)

9 (25.7)

0.67

Transfer to ICU

15 (15.6)

8 (22.3)

0.44

Infection‡

23 (24.0)

8 (22.3)

>0.99

1 (1.0)

0

>0.99

Placenta percreta

Severe maternal morbidity$ Data are mean ± SD, n (%) or median (range).

*Primary PPH was defined as bleeding requiring medical or interventional treatment in the 24 hours after delivery. †Uterine devascularization procedures included pelvic arterial embolization, surgical vessel ligation (uterine or hypogastric artery ligation, stepwise uterine devascularization) and/or uterine compression sutures (B-Lynch and Cho sutures).

Infection included endometritis, wound infection, peritonitis, pyelonephritis, vesicouterine fistula, uterine necrosis and isolated postpartum fever higher than 38.5°C for 24 hours. ‡

§Severe maternal morbidity was defined as any of the following: sepsis, septic shock, peritonitis, uterine necrosis, post-partum uterine rupture, fistula, injury to adjacent organs, acute pulmonary edema, acute renal failure, deep vein thrombophlebitis or pulmonary embolism, or maternal death.

Delayed ÂÂ

Hypopituitarism following severe PPH (Sheehan syndrome) is due to critical ischemia of the hypertrophied pituitary.

ÂÂ

Complications like sterility, uterine perforation, uterine synechiae (Asherman syndrome).

ÂÂ

Venous thrombosis and embolic events.

DISCUSSION Our results suggest that successful conservative treatment for placenta accreta does not appear to compromise women’s subsequent fertility or obstetric outcome, but that the risk of recurrence of placenta accreta during future deliveries is high. An additional strength is the systematic follow-up of a relatively large cohort (n = 96), including evaluation of desire and attempts to conceive, in order to obtain information

about women with presumed preserved fertility who either had no desire for pregnancy, or did desire pregnancy but have not become pregnant.

Their demographic and obstetric characteristics for the first conservative treatment did not differ from those of women who were included in the study. It is possible that some women did not actually have placenta accreta; pathological confirmation is of course impossible after successful conservative treatment (i.e., in cases without a hysterectomy specimen). Nevertheless, our results reflect the long-term consequences in real-life of conservative treatment for placenta accreta. Placenta accreta is thought to be due to an absence or deficiency of Nitabuch’s layer or the decidua spongiosa, following the failure of the endometrium/decidua basalis to reform after trauma to the endometrium from surgical procedures. The pathophysiology of placenta accreta

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OBSTETRICS AND GYNECOLOGY is therefore similar to that of intrauterine synechiae, based as it is on endometrial alteration that might promote abnormal implantation, resulting in infertility, miscarriage or recurrent placenta accreta. Our results are therefore reassuring in suggesting that successful conservative treatment for placenta accreta does not appear to compromise the patients’ subsequent fertility or obstetrical outcome.

The absence of pregnancy complications observed in our study, except for abnormal placentation and PPH, is consistent with the few previous reports on pregnancy after conservative treatment for placenta accreta. Four earlier studies report similar results: women with a history of severe PPH requiring pelvic arterial embolization and/or uterine-sparing surgical procedures are likely to decide against another pregnancy because of their fear of another hemorrhage.

CONCLUSIONS Successful conservative treatment for placenta accreta does not appear to compromise the patients’ subsequent fertility or obstetrical outcome. Nevertheless, patients should be advised of the high risk that placenta accreta may recur during future pregnancies. Intrauterine packing, pelvic vessel embolization and compressive sutures are associated with high rates of restoration of regular menses and successive pregnancies.

Randomized trials would be desirable to define the best management of PPH. A review of the literature demonstrates a 76.9% success rate and an 11% complication rate.

SUGGESTED READING 1. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus.

Am J Obstet Gynecol. 1994;171(3):694-700.

2. Alanis M, Hurst BS, Marshburn PB, Matthews ML. Conservative management of placenta increta with selective arterial embolization preserves future fertility and results in a favorable outcome in subsequent pregnancies. Fertil Steril. 2006;86(5):1514.e3-7.

3. Committee on Obstetric Practice. ACOG committee opinion. Placenta accreta. Number 266, January 2002.

American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2002;77(1):77-8.

4. Bretelle F, Courbière B, Mazouni C, Agostini A, Cravello L, Boubli L, et al. Management of placenta accreta: morbidity and outcome. Eur J Obstet Gynecol Reprod Biol. 2007;133(1):34-9.

5. Daskalakis G, Anastasakis E, Papantoniou N, Mesogitis S, Theodora M, Antsaklis A. Emergency obstetric hysterectomy. Acta Obstet Gynecol Scand. 2007;86(2):223-7.

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6. Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta accreta. BJOG. 2009;116(5):648-54.

7. Kayem G, Pannier E, Goffinet F, Grangé G, Cabrol D. Fertility after conservative treatment of placenta accreta.

Fertil Steril. 2002;78(3):637-8.

8. Kayem G, Davy C, Goffinet F, Thomas C, Clément D, Cabrol D. Conservative versus extirpative management in cases of placenta accreta. Obstet Gynecol. 2004;104(3):531-6.

9. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol.

1997;177(1):210-4.

10. Nizard J, Barrinque L, Frydman R, Fernandez H. Fertility and pregnancy outcomes following hypogastric artery ligation for severe post-partum haemorrhage. Hum Reprod. 2003;18(4):844-8.

11. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol. 2006;107(4):927-41.

12. Salomon LJ, deTayrac R, Castaigne-Meary V, Audibert F, Musset D, Ciorascu R, et al. Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum Reprod.

2003;18(4):849-52.

13. Sentilhes L, Trichot C, Resch B, Sergent F, Roman H, Marpeau L, et al. Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage. Hum Reprod. 2008;23(5):1087-92.

14. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization. Acta Obstet Gynecol Scand.

2008;87(10):1020-6.

15. Sentilhes L, Gromez A, Descamps P, Marpeau L. Why stepwise uterine devascularization should be the firstline conservative surgical treatment to control severe postpartum hemorrhage? Acta Obstet Gynecol Scand.

2009a;88:490-2.

16. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage. Obstet Gynecol. 2009;113(5):992-9.

17. Sentilhes L, Ambroselli C, Kayem G, Provansal M, Fernandez H, Perrotin F, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526-34.

18. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage. BJOG. 2010;117(1):84-93.

19. Sentilhes L, Descamps P, Marpeau L. Has B-Lynch suture hidden long-term effects? Fertil Steril. 2010;94(4):e62.

20. Tseng JJ, Hsu SL, Wen MC, Ho ES, Chou MM. Expression of epidermal growth factor receptor and c-erbB-2 oncoprotein in trophoblast populations of placenta accreta.

Am J Obstet Gynecol. 2004;191(6):2106-13.

21. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol.

2005;192(5):1458-61.

OBSTETRICS AND GYNECOLOGY

Analysis of Cesarean Section in a Tertiary Care Center: A Retrospective Study GURDIP KAUR*, PARMJIT KAUR†, RUBY BHATIA*, SATINDER KAUR‡, RAMITI GUPTA#, AMAN DEV¥

ABSTRACT Objective: The aim of the study was to assess the prevalence and different indications of cesarean delivery in a tertiary care center. Material and methods: The present study was a retrospective study conducted in Dept. of Obstetrics and Gynecology, Government Medical College and Rajindra Hospital, Patiala from January 2016 to June 2016. Results: A total of 1,656 births occurred during this period, out of these 718 were by cesarean section. Thus, prevalence of cesarean section was 43.36% during the given period of study in our institution. Most of the cesarean deliveries were referrals (76.1%) done in emergency and not booked at our institute. It was seen that 67.9% of women were in 21-30 years age group, 29% were between 31-40 years, while only 3.06% were less than 20 years of age. Also, 52.78% were between gravida 2-4, while 44.29% were primigravida and only 2.92% pregnant women were grand multipara. Majority were primary cesarean deliveries (64.62%), while 35.38% were secondary cesarean sections. Commonest indication of cesarean delivery was previous one cesarean section in 27.3% followed by fetal distress in 17.27%. However, commonest indication in primigravida was fetal distress (27.99%). Cesarean section due to previous 2 or more cesarean section was done in 8.08%, while in 7.66% it was done for cephalopelvic disproportion. Conclusion: Prevalence of cesarean section was 43.36%. Commonest indication of cesarean delivery was previous one cesarean section in 27.3% followed by fetal distress in 17.27%.

Keywords: Cesarean delivery, indication, prevalence, trial of labor after cesarean delivery, vaginal delivery

P

regnancy and delivery are considered normal physiological phenomena in women but still childbirth by its very nature carries potential risk for both the woman and her baby. Advancement in healthcare system and access to medical facilities has greatly reduced the maternal and perinatal mortality due to complications of pregnancy and childbirth.

Cesarean section is the surgical intervention in serious delivery complications and has been lifesaving for a long period of time. In the past century, the most common change in obstetric practice that has came, is the increase in cesarean delivery rate, to ensure a

*Associate Professor †Professor ‡Assistant Professor #Postgraduate Student Dept. of Obstetrics and Gynecology ¥Postgraduate Student Dept. of Preventive and Social Medicine Govt. Medical College and Rajindra Hospital, Patiala, Punjab Address for correspondence Dr Ramiti Gupta Postgraduate Student Dept. of Obstetrics and Gynecology Rajindra Hospital, Patiala, Punjab E-mail: gupta.ramiti@gmail.com

healthy outcome of the mother and newborn. According to World Health Organization (WHO), cesarean section rates should not be more than 15%1 (with evidence that cesarean section rates above 15% are not associated with additional reduction in maternal and neonatal mortality and morbidity).2 But, both in developed and developing countries, cesarean section rate is on the rise. In 2011, one in 3 women who gave birth in United States did so by cesarean section. The advent of better anesthesia, availability of improved surgical technique and prophylactic antibiotics have made cesarean section, a relatively safer and common procedure.

The study aims at analyzing the incidence and indications of cesarean section performed in a tertiary care center over a period of 6 months.

MATERIAL AND METHODS It is a retrospective study conducted in Dept. of Obstetrics and Gynecology, Government Medical College and Rajindra Hospital, Patiala, a tertiary care hospital. The study period was from January 2016 to June 2016. A total of 718 cesarean deliveries were analyzed from data on case sheets. Data collected included the age, parity, booked or unbooked cases,

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OBSTETRICS AND GYNECOLOGY elective or emergency procedure and indications of cesarean section.

Age distribution (years)

RESULTS AND OBSERVATIONS A total of 1,656 women delivered during the study period, of which 718 had undergone cesarean section (Table 1). The prevalence of cesarean section at our hospital comes to be around 43.36% during the study period. Out of these, 125 patients (17.4%) had elective cesarean deliveries, while 593 (82.6%) had emergency cesarean deliveries (Table 2). Majority of the patients, 546 in number (76.1%) were unbooked, while only 172 (23.9%) were booked (Table 3a). Demographic analysis showed maximum number of patients i.e., 488 cases (67.9%) were between 21-30 years. Those less than 20 and more than 30 years were 22 (3.06%) and 208 (29%), respectively (Table 3b). Out of 718, 318 patients (44.29%) were primi and 379 patients (52.78%) were G2-G4, while 21 patients (2.92%) were grand multipara (Table 3c).

Detailed analysis of cases showed that number of patients who underwent primary section were 464 (64.62%) and repeat cesarean were 254 (35.38%) (Table 4). Table 5 showing the indications of cesarean deliveries reveals that overall the commonest indication Table 1. Proportion of Cesarean Deliveries (Total Births 1,656 = 100%) No. of cases

Percentage (%)

Deliveries by cesarean section

718

43.36

Vaginal deliveries

938

56.64

Total deliveries

1,656

100

Table 2. Proportion of Elective/Emergency Cesarean Deliveries (Total Cesarean Deliveries 718 = 100%) No. of cases

Percentage (%)

Elective cesarean section

125

17.4

Emergency cesarean section

593

82.6

Total cesarean sections

718

100

Table 3a. Sociodemographic Characteristics (Total Cesarean Section 718 = 100%) No. of cases

Percentage (%)

Booked

172

23.9

Unbooked

546

76.1

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Table 3b. Sociodemographic Characteristics (Total Cesarean Deliveries 718 = 100%)

Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

No. of cases

Percentage (%)

<20

22

3.06

21-30

488

67.9

31-40

208

29

Table 3c. Sociodemographic Characteristics (Total Cesarean Deliveries 718 = 100%) Parity

No. of cases

Percentage (%)

Primi

318

44.29

G2-G4

379

52.78

>G4

21

2.92

Table 4. Proportion of Primary/Repeat Cesarean Section (Total Cesarean Deliveries 718 = 100%) No. of cases

Percentage (%)

Primary cesarean deliveries

464

64.62

Repeat cesarean deliveries

254

35.38

for cesarean delivery was previous one cesarean section (27.3%) followed by fetal distress (17.27%). Previous two or more cesarean section (8.08%) and cephalopelvic disproportion (7.66%) were next common indications.

Table 6 shows that the commonest indication for cesarean section among primigravida was fetal distress (27.99%) and among multigravida patients was previous one cesarean section (49%).

DISCUSSION Prevalence rate of cesarean deliveries at our center during the study period was 43.36%, as it is a tertiary care hospital catering to all high risk referred cases. The increase in LSCS rate has been a global phenomenon.

There has been a steady increase in the rate of lower segment cesarean section (LSCS) in both developed and developing countries. LSCS rate in USA was 32% in 2014,3 while it was 26.2% during (2013-2014) in England.4 Haider et al from Hyderabad-Pakistan and Shamshad from Abbottabad reported cesarean section rate as high as 67.7% and 45.1% in 2007, respectively.5,6 Prevalence of repeat cesarean deliveries was 35.38%, while primary cesarean was done in 64.62%. In our study, previous 1 cesarean section accounted for 27.3% and previous 2 or more cesarean sections accounted for 8.08% of cases.

Repeat sections, constitute the commonest indication

OBSTETRICS AND GYNECOLOGY Table 5. Indications for Cesarean Deliveries (Total = 100%) Indication of cesarean section

No. of cases among primi patients (total = 318)

No. of cases among multi patients (total = 400)

Total no. of cases (718)

Total % (100%)

Emergency no. of cases (total = 593)

Elective no. of cases (total = 125)

196

196

27.3

150

46

35

124

17.27

124

58

58

8.08

40

18

7

55

7.66

37

18

Previous one cesarean section Fetal distress

89

Previous 2 or more cesarean sections CPD

48

Breech presentation

32

19

51

7.1

43

8

Severe pre-eclampsia

35

13

48

6.68

36

12

Obstructed labor

20

11

31

4.32

31

Nonprogress of labor

23

6

29

4.04

29

Eclampsia

20

4

24

3.34

24

Placenta previa

11

13

24

3.34

16

8

IUGR

15

4

19

2.65

14

5

Abruptio placenta

8

10

18

2.51

16

2

Malpresentations other than breech

7

11

18

2.51

15

3

Multiple pregnancy

3

5

8

1.11

6

2

Failed induction

2

4

6

0.84

6

Medical disorders complicating pregnancy

3

2

5

0.69

2

Cervical dystocia

2

2

4

0.56

4

3

CPD = Cephalopelvic disproportion; IUGR = Intrauterine growth restriction.

Table 6. Commonest Indication for Cesarean Delivery in Primigravida/Multigravida (Primigravida 318 = 100%, Multigravida 400 = 100%) Parity

Total no. of cesarean sections N (%)

Most common indication

No. of cases with this indication

Percentage (%)

Primigravida

318 (100)

Fetal distress

89

27.99

Multigravida

400 (100)

Previous one cesarean section

196

49

for LSCS in most countries. It varies from 35% of all LSCS in the USA to 23% in Norway, the lowest 18% being in Hungary.7 After 1 LSCS, there is 67% chance of having repeat cesarean delivery.8 The low threshold for performing vaginal birth after cesarean (VBAC) delivery is probably due to fear of uterine rupture in labor, which is 5.2/1,000 for VBAC as compared to 1.6/1,000 elective repeat cesarean deliveries (ERCD) and it can be catastrophic leading to perinatal death (1/2,000) and very rarely maternal death.9-11 High prevalence of repeat cesarean deliveries in our study is because of unbooked emergency admissions in labor with multiple high risk factors.

In our study, trial of labor after cesarean (TOLAC) delivery was given very judiciously as many patients had more than one risk factors and were not having records and of previous LSCS so were not candidates for TOLAC delivery. We are working on this group to decrease the rate of repeat cesarean deliveries. In our setup, no trial for vaginal delivery was given to previous two or more cesarean deliveries due to presumed risk of maternal and fetal complications.12 Fetal distress was the second most common indication (17.27%) of LSCS. Strengthening of staff, availability of round the clock nurse and doctor and better facilities (cardiotocography, electronic fetal monitor) has made

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OBSTETRICS AND GYNECOLOGY the detection of fetal distress possible at the earliest.

Computerized interpretation of cardiotocography or use of scalp pH can be applied to definitely diagnose distress, which could save a few cesarean sections.13

REFERENCES

Breech presentation, as indication for cesarean delivery, accounted for 7.1% cases, which is higher than the average incidence of breech at term. This might be due to higher referral from periphery after diagnosing malpresentation. More skills in vaginal assisted breech delivery should be practiced and breech presentation with favorable Zatuchni-Andros score may be given trial of vaginal delivery. Severe pre-eclampsia accounted for significant proportion of cesarean deliveries (6.68%) indicating the need for early detection and so better control of pre-eclampsia before it progresses to severe pre-eclampsia leading to intrauterine growth restriction (IUGR) and eclampsia, both of which accounted for 2.65% and 3.34% of cesarean deliveries, respectively.

2. Althabe F, Belizán JM. Caesarean section: the paradox.

Lancet. 2006;368(9546):1472-3.

Nonprogress of labor was another major indication contributing 4.04% of cesarean deliveries. Failure to progress is an ill-defined terminology, arrest of dilatation or arrest of descent are often over diagnosed.

We used partogram to definitely diagnose nonprogress of labor, which helped us to reduce cesarean deliveries.

Different studies from India showed incidence of emergency cesarean deliveries to be 82.7% and 85.92%.14 In our study, we found 83.94% cases underwent emergency cesarean delivery, corroborating with previous studies as ours is a tertiary care referral institute. The high cesarean section rate in our study was because of the fact that majority of the pregnant women were referred with more than one high risk factor from peripheral public and private hospitals of rural and urban Patiala district and adjoining states.

CONCLUSION Though cesarean delivery is becoming increasingly safer due to improved surgical technique and modern anesthetic skill, it still carries a slightly greater risk than normal vaginal delivery and the risk is more in subsequent pregnancies. Attempt should be made to decrease the rate of primary cesarean deliveries and judicious use of trial of labor after cesarean delivery should be used to decrease rate of repeat cesarean deliveries. In subsequent pregnancies, risks can be decreased by providing regular antenatal care and doing elective repeat cesarean deliveries if the indications are recurrent ones.15

1. World Health Organization. Monitoring Emergency Obstetric Care: A Handbook. Geneva, Switzerland; 2009.

3. Hamilton BE, Martin JA, Osterman MJK, Curtin SC. Births: Preliminary data for 2014. Hyattsville, MD: National Center for Health Statistics. National Vital Statistics Reports. 2015; Vol 64, No. 66.

4. Health and Social Care Information Centre (2015). NHS Maternity Statistics – England, 2013-2014. Available at: http://www.hscic.gov.uk/catalogue/PUB16725/nhs-mateeng-2013-14-summ-repo-rep.pdf 5. Haider G, Zehra N, Munir AA, Haider A. Frequency and indications of cesarean section in a tertiary care hospital.

Pak J Med Sci. 2009;25(5):791-6.

6. Shamshad. Factors leading to increased caesarean section rate. Gomal J Med Sci. 2008;(1):1-5.

7. Magann EF, Winchester MI, Carter DP, Martin JN Jr, Bass JD, Morrison JC. Factors adversely affecting pregnancy outcome in the military. Am J Perinatol.

1995;12(6):462-6.

8. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists. Clinical Effectiveness Support Unit.

National Sentinel Caesarean Section Audit Report. RCOG Press; 2001.

9. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med. 2001;345(1): 3-8.

10. Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999. Am J Obstet Gynecol.

2000;183(5):1187-97.

11. Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: a risk evaluation. Swiss Working Group of Obstetric and Gynecologic Institutions. Obstet Gynecol. 1999;93(3):332-7.

12. Nizam K, Haider G, Memon N, Haider A. A caesarean section rates much room for reduction. Rawal Med J. 2010;35:19-2.

13. Chanthasenanont A, Pongrojpaw D, Nanthakomon T, Somprasit C, Kamudhamas A, Suwannarurk K. Indications for cesarean section at Thammasat University Hospital. J Med Assoc Thai. 2007;90(9):1733-7.

14. Pardey JS, Jain M, Pandy LK. Ten years profile of LSCS. J Obstet Gynaecol India. 1986;36:448.

15. Nahar K. Indications of caesarean section - study of 100 cases in Mymensingh Medical College Hospital. J Shaheed Suhrawardy Med Coll. 2009;1(1):6-10.

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Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

FOR PRODUCTIVE COUGH

FOR DRY, IRRITATING AND ALLERGIC COUGH

FOR NOCTURNAL COUGH

2016 2015

in Cough Management

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

OBSTETRICS AND GYNECOLOGY

A Comparative Study Between Oral Iron, Intravenous Iron Sucrose and Ferric Carboxymaltose in the Management of Postpartum Anemia DIVYA YADAV SHARMA*, SAROJ SINGHâ&#x20AC; , ABHILASHA YADAV, ASHA NIGAM, DEEPTI TANDON, ALOK SHARMA

ABSTRACT Introduction: Parenteral iron helps to restore iron stores faster and more effectively than oral iron. Intravenous (IV) iron sucrose is safe, effective and economical in comparison to oral iron. IV ferric carboxymaltose (FCM) has a neutral pH, physiological osmolarity, is dextran free, which makes it possible to administer its higher single doses over shorter time periods. Material and methods: A total of 90 postnatal women were randomly categorized in three groups of 30 each to receive oral iron (ferrous sulfate) equivalent to elemental iron 100 mg daily (Group I), IV iron sucrose (Group II) or IV FCM (Group III) after calculating their doses. Changes in hemoglobin (Hb) and serum ferritin levels after 1 week and after 4 weeks of treatment were measured.

Results: In our study, an increase in 0.8 g/dL was achieved in 4 weeks of oral iron therapy; an increase of 1.4 and 2.1 g/dL was seen at the end of 1 week and 4 weeks, respectively of IV iron sucrose, which was significant (p < 0.0001); an increase of 2.5 g/dL and 4.9 g/dL was observed after 1 week and 4 weeks of IV FCM, which was again significant (p < 0.0001). Conclusion: Intravenously administered iron elevates serum Hb and restores iron stores better that oral iron (ferrous sulfate). Both drugs are effective and offer a rapid normalization of Hb after delivery. The single administration of FCM shows advantages of lower incidence of side effects at the injection site, a shorter treatment period and better patient compliance.

Keywords: Ferric carboxymaltose, iron sucrose, intravenous, postpartum anemia

T

he World Health Organization (WHO) has defined postpartum anemia (PPA) as hemoglobin (Hb) <10 g/dL in postpartum period. PPA may aggravate puerperal sepsis, thromboembolic complications and lead to subinvolution of uterus, delayed wound healing and failure of lactation. It is associated with an impaired quality-of-life, lactation failure, reduced cognitive abilities, emotional instability and depression. Oral iron therapy was conventionally the treatment of choice but it has disadvantages.

Parenteral iron helps to restore iron stores faster and more effectively than oral iron. Intravenous (IV) iron sucrose is safe, effective and economic in comparison to oral and repeated, painful intramuscular iron injections; however, multiple doses and hospital visits

*Lecturer â&#x20AC; Professor and Head (Principal) Dept. of Obstetrics and Gynecology SN Medical College, Agra, Uttar Pradesh Address for correspondence Dr Divya Yadav Sharma Lecturer SN Medical College, Agra, Uttar Pradesh

are typically required. IV ferric carboxymaltose (FCM) has a neutral pH, physiological osmolarity, is dextran free, which makes it possible to administer its higher single doses over shorter time periods. Iron is released slowly thereby reducing toxicity and oxidative stress.

The objective of the present study was to compare the safety and efficacy of FCM, and IV iron sucrose in the treatment of PPA. MATERIAL AND METHODS This randomized control trial was carried out in the Dept. of Obstetrics and Gynecology, SN Medical College, Agra from July 2015 to February 2016. After informed, written consent and attaining permission from Ethical Committee, a total of 90 postnatal women, diagnosed as cases of iron deficiency anemia (IDA) (Hb <8 g/dL), were randomly categorized in three groups of 30 each to receive oral iron (ferrous sulfate) equivalent to elemental iron 100 mg daily (Group I), IV iron sucrose (Group II) or IV FCM (Group III).

Patients with types of anemia other than IDA and known hypersensitivity to iron were excluded from the study. Detailed history of age, parity, socioeconomic

Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

555

OBSTETRICS AND GYNECOLOGY status, type of delivery, obstetric complications like pregnancy-induced hypertension (PIH), postpartum hemorrhage (PPH), history of blood transfusions, etc. were obtained. Patients were examined in detail and initial Hb, serum ferritin, iron studies and peripheral smear to diagnose the type of anemia was done in all patients.

Changes in Hb and serum ferritin levels after 1 week and after 4 weeks of treatment were measured. The adverse effects to drugs in the three groups were noted and treated. The cumulative dose required for Hb restoration and repletion of iron stores was calculated

by Ganzoni formula: Cumulative iron deficit (mg) = 2.4 × W × D + 500, Where W= body weight in kg, D = Target Hb Actual Hb. 2.4 derived from blood volume, which is 7% of body weight and iron content of Hb, which is 0.34%. 0.07 × 0.0034 × 100 = 2.4 (conversion from g/dL to mg). ÂÂ

In patients receiving iron sucrose, 200 mg of elemental iron diluted in 100 mL saline, was the maximum dose given in 30 minutes period, on alternate days, when necessary.

ÂÂ

In patients receiving FCM, maximum single dose of 1,000 mg (20 mL), diluted in 250 mL saline, infused in 15 minutes, not more than once a week.

OBSERVATIONS AND RESULTS The mean age and body mass index (BMI) in the three groups were comparable i.e., 24.5 years, 23.6 years, 24.9 years and mean BMI was 21.3, 22.3, 23.1 in the oral iron, iron sucrose and FCM group, respectively. All the patients belonged to Class III socioeconomic status, according to BJ Prasad Classification. The mean parity was 2.6, 3.1 and 2.9 in the three groups. Antenatal anemia was present in 68% patients in Group I, 69% cases in Group II and 67.9% cases in Group III. The percentage of cesarean section was 20%, 17.7% and 18.8% in Group I, Group II and Group III, respectively.

Thirty-one percent patients in Group I, 33% cases in Group II and 36% cases in Group III had history of PPH of any cause in this delivery. Twenty-eight percent patients in Group I, 32% patients in Group II and 27% patients in Group III had a history of PIH (Table 1).

Table 2 shows the comparison of initial Hb and rise of Hb after 1 week and after 4 weeks. The mean initial Hb was similar in all the three groups i.e., 7.1 g/dL, 7.1 g/dL and 7 g/dL in Group I, Group II and Group III, respectively. After 1 week of treatment, the Hb rose to 7.2 g/dL, 8.5 g/dL and 9.4 g/dL in Group I, II and III, respectively. After 4 weeks, the Hb rose to 7.9 g/dL, 10.6g/dL and 11.9 g/dL in Group I, Group II and Group III, respectively.

Table 3 shows the mean difference of Hb. The mean difference of Hb from initial to 1 week was 0.1 g/dL,

Table 1. Patient Profile Parameters

Oral iron (Group I)

Iron sucrose (Group II)

FCM (Group III)

Mean age (years)

24.5

23.6

24.9

Mean BMI

21.3

22.3

23.1

Socioeconomic status

Class III

Class III

Class III

Mean parity

2.6

3.1

2.9

Presence of antenatal anemia (%)

68

69

67.9

Percentage of LSCS (%)

20

17.7

18.8

History of PPH (%)

31

33

36

PIH (%)

28

32

27

BMI = Body mass index; LSCS = Lower segment cesarean section; PPH = Postpartum hemorrhage; PIH = Pregnancy-induced hypertension.

Table 2. Comparison of Mean Hemoglobin with Different Iron Preparations Time period

Oral iron (Group I)

Iron sucrose (Group II)

FCM (Group III)

Day 0 (g/dL)

7.1

7.1

7

After 1 week (g/dL)

7.2

8.5

9.4

After 4 weeks (g/dL)

7.9

10.6

11.9

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Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

OBSTETRICS AND GYNECOLOGY 1.4 g/dL and 2.4 g/dL in Group I, Group II and Group III, respectively. The difference of Hb from 1 week to 4 weeks of treatment was 0.7 g/dL, 2.1 g/dL and 2.5 g/dL in Group I, Group II and Group III, respectively.

After 4 weeks, the difference of Hb from initial level (i.e., 0-4 weeks) was 0.8 g/dL, 3.5 g/dL and 4.9 g/dL in Group I, Group II and Group III, respectively. Table 4 shows the comparison of mean initial ferritin levels and rise of ferritin after 1 week and after 4 weeks. The mean initial ferritin was similar in all the three groups i.e., 35 ng/mL, 36 ng/mL and 35 ng/mL in Group I, Group II and Group III, respectively. After 1 week of treatment, the ferritin levels rose to 43 ng/mL, 122 ng/mL and 143 ng/mL in Group I, Group II and Group III, respectively. After 4 weeks, the ferritin levels rose to

Oral iron (Group I)

Iron sucrose (Group II)

FCM (Group III)

0-1 week (g/dL)

0.1

1.4

2.4

1-4 weeks (g/dL)

0.7

2.1

2.5

0-4 weeks (g/dL)

0.8

3.5

4.9

Table 4. Mean Ferritin Levels Time period

Table 5 shows the side effect profile of the different iron preparations. It was observed that most common side effect with oral iron was constipation, nausea and vomiting. Eight had diarrhea and 6 had abdominal pain; while few patients (2 each) had headache, joint pain and tingling sensation. In the patients receiving iron sucrose, maximum patients i.e., 9 had injection site pain, 7 had tingling sensation, 6 had joint pain, 3 had headache, nausea/vomiting and 2 each had shivering of heat sensation and abdominal pain. Those receiving FCM, maximum patients i.e., 10 had injection site pain, 5 had tingling sensation, 2 each had joint pain and headache.

DISCUSSION

Table 3. Comparison of Rise in Mean Hb Difference of Hb at

52 ng/mL, 156 ng/mL and 164 ng/mL in Group I, Group II and Group III, respectively.

Oral iron Iron sucrose FCM (Group I) (Group II) (Group III)

Day 0 (ng/mL)

35

36

35

After 1 week (ng/mL)

43

122

143

After 4 weeks (ng/mL)

52

146

164

Table 5. Side Effects of Different Iron Preparations Drug-related adverse effects Adverse effects

Oral iron (n= 30)

Iron sucrose (n = 30)

FCM (n = 30)

Injection site pain

0

9

10

Headache

2

3

2

Nausea/vomiting

13

3

1

Constipation

12

1

1

Sensation of heat

0

2

1

Shivering

1

2

1

Diarrhea

8

1

0

Abdominal pain

6

2

1

Joint pain

2

6

2

Tingling sensation

2

7

5

Postpartum anemia imposes a substantial disease burden during a critical period of maternal-infant interaction and may give rise to lasting developmental deficits in infants of the affected mothers. IDA is the most common cause of anemia world-wide. Each mL blood loss results in loss of 0.5 mg of iron. This study was conducted to compare the safety and efficacy of IV FCM, IV iron sucrose and oral iron in the treatment of PPA. This comparative study was conducted in SN Medical College, Agra on 90 patients of PPA. Patients were equally divided in three groups and were given 100 mg oral iron daily or IV iron sucrose or FCM after calculating their dose.

It was observed that maximum patients in the study were parous and belonged to Class III socioeconomic status because anemia mainly affects low income parous women. More than half of the patients were already anemic in their antenatal period because antenatal anemia is a risk factor of PPA. Other risk factors of PPA are PPH and PIH, which was present in many patients in our study.

The initial Hb was comparable in all the three groups.

Various studies had reported increase of Hb level by 2-3 g/dL within 4-12 weeks of oral iron therapy (Table 6). In our study, an increase of 0.8 g/dL was achieved in 4 weeks of oral iron. Giannoulis et al2 reported an increase of Hb by 4-6 g/dL in patients receiving iron sucrose, whereas in our study an increase of 1.4 and 2.1 g/dL is seen at the end of 1 week and 4 weeks, respectively, which was significant (p < 0.0001). Rathod et al6 reported an increase of Hb 2.4 g/dL and 3.4 g/dL after 2 weeks and 6 weeks of iron sucrose, respectively. Van Wyck et al3 reported an increase of Hb by 2 g/dL in 7 days and 3 g/dL

Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

557

OBSTETRICS AND GYNECOLOGY Table 6. Comparison of Our Study with Various Other Studies Done in the Past Study

Time (weeks) period

Rise of Hb (g/dL) Iron sucrose

FCM

Van Wyck et al

1

2

Seid et al

6

-

3

Rathod et al

2

2.4

3.2

6

3.4

4.4

4

Rise in serum ferritin by FCM (ng/mL) -

3 238

Breymann et al

1

568

Giannoulis et al

4

4-6

Our Study

1

1.4

2.4

143

4

3.5

4.9

184

in 2-4 weeks, while Rathod et al6 reported an increase of Hb 3.2 g/dL and 4.4 g/dL after 2 weeks and 6 weeks, respectively in patients receiving FCM. Similarly, in our study, an increase of 2.5 g/dL and 4.9 g/dL was observed after 1 week and 4 weeks of FCM, which was again significant (p < 0.0001). Seid et al4 reported that ferritin levels replenished in 42 days in FCM group but not in oral iron group, similar to our study in which there is only minimal rise of ferritin in oral iron group.

Adverse reactions do occur with various iron therapies.

Gastrointestinal disorders are the most common with various oral iron preparations. This led to poor compliance among these patients. The incidence of adverse effects reported by various studies is between 6.8% and 24.2%.3,4 The adverse drug reactions were least in the parenteral preparations (p < 0.0001). Few patients (9 in Group II and 10 in Group III), had injection site pain, which subsided by itself after discontinuation of the drug. Some patients in IV iron group had joint pain, tingling sensation, which too subsided by itself.

Patient satisfaction and general well-being was highest in subjects treated with FCM followed by iron sucrose and lastly with oral iron. The incidence of adverse effects reported by various studies is between 6.8% and 24.2%.2-4 Aggarwal reported fever, arthritis, dysgeusia and anaphylaxis Grade I in patients receiving iron sucrose therspy.5 In our study, 30% had injection site pain and 20% had tingling sensation in patients receiving iron sucrose and FCM. All patients made an uneventful recovery after receiving treatment in the form of analgesics.

558

Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

CONCLUSION The prophylaxis of PPA should begin early in pregnancy in order to ensure a good iron status prior to delivery and preventing further PPA. In India, 36% of total maternal deaths are attributable to PPH or anemia. IV FCM is as safe as iron sucrose in the management of postpartum IDA despite five times of higher dosage. Both iron sucrose and FCM are a safe and effective treatment option for PPA, but the ability to administer 1,000 mg doses in a single sitting, fewer adverse reactions and better compliance makes FCM, the first-line drug in the management of postpartum IDA, causing a faster and higher replenishment of iron stores and correction of Hb levels.

So, we conclude that, intravenously administered iron elevates serum Hb and restores iron stores better than oral iron (ferrous sulfate). Both drugs are effective and offer a rapid normalization of Hb after delivery. The single application of FCM shows advantages of lower incidence of side effects at the injection site, a shorter treatment period and better patient compliance.

Out of the two different IV iron preparations used in this study, FCM proved to be statistically better than iron sucrose.

REFERENCES 1. Sutherland T, Bishai DM. Cost-effectiveness of misoprostol and prenatal iron supplementation as maternal mortality interventions in home births in rural India. Int J Gynaecol Obstet. 2009;104(3):189-93.

2. Giannoulis C, Daniilidis A, Tantanasis T, Dinas K, Tzafettas J. Intravenous administration of iron sucrose for treating anemia in postpartum women. Hippokratia.

2009;13(1):38-40.

3. Van Wyck DB, Martens MG, Seid MH, Baker JB, Mangione A. Intravenous ferric carboxymaltose compared with oral iron in the treatment of postpartum anemia: a randomized controlled trial. Obstet Gynecol. 2007;110(2 Pt 1):267-78.

4. Seid MH, Derman RJ, Baker JB, Banach W, Goldberg C, Rogers R. Ferric carboxymaltose injection in the treatment of postpartum iron deficiency anemia: a randomized controlled clinical trial. Am J Obstet Gynecol.

2008;199(4):435.e1-7.

5. Aggarwal RS, Mishra VV, Panchal NA, Patel NH, Deshchougule VV, Jasani AF. Comparison of oral iron and IV iron sucrose for treatment of anemia in postpartum Indian Woman. Natl J Commun Med. 2012;3(1):48-54.

6. Rathod S, Samal SK, Mahapatra PC, Samal S. Ferric carboxymaltose: A revolution in the treatment of postpartum anemia in Indian women. Int J Appl Basic Med Res. 2015;5(1):25-30.

OBSTETRICS AND GYNECOLOGY

Fundus Changes and Fetomaternal Outcomes in Pregnancy-induced Hypertension URMILA KARYA*, MUQUADDAS AAFREEN†, ANUPAM‡, GANESH SINGH#, CHARU MITTHAL¥, ABHA GUPTA$

ABSTRACT Introduction: Pre-eclampsia and eclampsia are a leading cause of maternal and fetal mortality with vasospasm and endothelial dysfunction as underlying pathophysiology. Considering the high incidence of maternal and fetal complications, obstetricians are confronted to identify the clinical feature or any parameter, which would alarm them of the high risk to the mother or the fetus. The various pathological changes in different organs in the body can be studied directly by viewing the ocular fundus, which may act as a window to systemic vascular system. Objectives: Our aim was to determine the prevalence of fundus changes and its relevance to maternal and fetal outcome in patients of pre-eclampsia and eclampsia. Study design: Crosssectional analytical study. Material and methods: A total of 150 pregnant mothers with pre-eclampsia and eclampsia were recruited in the study. They were evaluated for hypertensive retinopathy by direct ophthalmoscope and classified according to Keith-Wagener’s classification. Maternal outcomes were assessed in terms of complications, mode of termination of delivery and maternal mortality. Fetal outcomes were noted in terms of birth weight, Apgar score at birth, need for NICU admissions and perinatal mortality. Data obtained were subjected to statistical analysis using SPSS software and chi-square and student t-test was applied for the test of significance. Results: Hypertensive retinopathy was observed in 46% of patients. Statistically significant association of fundus changes were seen with severity of hypertension, mode of termination of pregnancy, maternal complications and perinatal outcome. Conclusions: Fundoscopy is a safe, simple, noninvasive and cost-effective procedure which can be used as a valuable tool to assess severity of pre-eclampsia and eclampsia and predicting adverse pregnancy outcome.

Keywords: Pre-eclampsia, hypertensive retinopathy, fundoscopy

P

complications and ultimately results in multiorgan involvement with a clinical spectrum ranging from barely noticeable to life-threatening cataclysmic pathophysiological deterioration.1

*Professor †MS Student ‡Assistant Professor Dept. of Obstetrics and Gynecology #Associate Professor Dept. of Community Medicine ¥Associate Professor Dept. of Ophthalmology $Professor Dept. of Medicine LLRM Medical College, Meerut, Uttar Pradesh Address for correspondence Dr Urmila Karya Professor Dept. of Obstetrics and Gynecology LLRM Medical College and SBVP Hospital, Meerut - 250 004, Uttar Pradesh E-mail: urmila726@gmail.com

Pre-eclamptic and eclamptic disorders also affect visual pathways, from the anterior segment to visual cortex with their potential impact on ocular fundus affecting 30-100% cases.2 The underlying pathophysiology is endothelial dysfunction and vasospasm of vessels in the retina similar to that, which occurs elsewhere in the body.3 Retinal angiospasm is an almost constant accompaniment of toxemia of pregnancy. When marked spastic changes occur early in pregnancy, they indicate presence of severe toxemic process which, unless controlled or pregnancy terminated, endangers the viability of the fetus and life of mother.4 Recent epidemiological studies have indicated that retinal vasculature reflects changes in systemic vasculature and shares anatomical and physiological similarities with microvasculature in other major organs such as brain, heart and kidney.5 The retinal blood vessels of 100-300 μm in size can be visualized noninvasively

re-eclampsia and eclampsia syndrome is a specific pregnancy disorder which occurs in late pregnancy and has potentially devastating consequences for both mother and baby. Together they form one member of the deadly triad along with hemorrhage and infection that contribute greatly to maternal morbidity and mortality. It causes myriad

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OBSTETRICS AND GYNECOLOGY by fundoscopy which is a simple and cost-effective procedure. The ocular fundus has proved to be valuable and a valid prognostic procedure for assessment of severity of pre-eclampsia and neonatal outcome.6 Hence, the present study was designed with a view to find out prevalence and spectrum of fundus changes in patients with pre-eclampsia and eclampsia, association of fundus changes with fetomaternal outcome and various clinical and laboratory manifestations.

a. Normal fundus

b. Grade 1 hypertensive retinopathy

c. Grade 2 hypertensive retinopathy

d. Grade 3 hypertensive retinopathy

e. Grade 4 hypertensive retinopathy

f. Retinal detachment

MATERIAL AND METHODS This study was conducted in the Dept. of Obstetrics and Gynecology, LLRM Medical College and associated SVBP Hospital, Meerut from November 2013 to May 2015. A total number of 150 cases of pre-eclampsia and eclampsia were enrolled in the study.

Inclusion Criteria ÂÂ Age group 18-38 years. ÂÂ Women with ≥20 weeks of gestation diagnosed as pre-eclampsia and eclampsia. ÂÂ Cases with singleton or multiple pregnancy. ÂÂ All primigravida and multigravida fitting into the criteria of inclusion.

Exclusion Criteria ÂÂ Cases with known case of essential hypertension. ÂÂ Patients with diabetes/gestational diabetes. ÂÂ Patients with cardiovascular disease. ÂÂ Patients of collagen vascular disease. ÂÂ Patients with ocular media opacity (cataract, corneal opacity). ÂÂ Patients with chronic renal failure/disease.

Detailed history of women including present and past pregnancies, duration of gestation, any associated complaint, past history of any medical illness, epilepsy, chronic hypertension, diabetes, cardiovascular and collagen vascular disease was taken. A thorough general and obstetric examination was done and routine and specific investigations were undertaken.

Antihypertensive drugs, magnesium sulfate regime and further management was tailored as per requirement of individual patient.

Ocular evaluation was done which included bedside visual acuity and torch light examination to rule out any gross anterior segment pathology and to elicit pupillary reflex. Fundus examination was done using direct ophthalmoscope after dilating the pupils with one drop of plain tropicamide (1%) instilled in

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Figure 1 a -F. Keith-Wagener's classification of fundus changes in hypertensive retinopathy.

each eye thrice at 10 minutes interval. Hypertensive retinopathy changes were graded according to KeithWagener’s classification (Fig. 1 a-f). Maternal outcomes were recorded in relation to fundus changes, mode of delivery and complications. Fetal outcomes were noted in terms of weight, age, Apgar score, neonatal intensive care unit (NICU) admissions and mortality.

The data obtained was subjected to statistical analysis.

P < 0.05 indicated statistically significant and <0.01 was considered highly significant.

RESULTS A total number of 150 cases were studied over a period of 1½ year. The study group comprised of 49.3% cases with nonsevere pre-eclampsia, 27.3% with severe preeclampsia and 23.3% with eclampsia. The mean age of the patients in our study was 25.87 years (standard deviation [SD] - 4.19 years) and the mean gestational age at the time of presentation was 37 weeks (SD 3 weeks). Majority of the cases were primigravidas (52%).

OBSTETRICS AND GYNECOLOGY Among our subjects most common symptom observed was swelling on legs and face in 89.3% of cases.

Headache was the next common symptom (40.7%) followed by epigastric pain (32%), blurring of vision (30%), convulsions (23.3%) and complete reversible loss of vision was reported in one patient.

fundus changes (p < 0.05). These results were statistically highly significant (Table 3).

Hypertensive retinopathy was observed in 46% of cases, 24% had Grade 1 changes. Grade 2 and Grade 3 changes were seen in 16% and 4.7%, respectively. Grade 4 changes were seen in 1.3% of cases and 2 women had retinal detachment (Table 1).

Higher incidence of maternal complications were seen in women with fundus changes. Statistically significant association was found between mode of termination of pregnancy and fundus changes (p = 0.047). More number of women with fundus changes were induced for obstetric reasons and uncontrolled blood pressure.

Incidence of maternal mortality was also significantly higher in cases with hypertensive retinopathy with p < 0.05 (Table 4).

Mean systolic and diastolic blood pressure in cases without fundus changes was 152.62 ± 11.71 mmHg and 97.68 ± 7.54 mmHg, respectively and in cases with fundus changes, it was 170.93 ± 14.53 mmHg and 105.71 ± 10.97 mmHg, respectively. The difference was significant with p value <0.05 (Table 2).

Fetal outcomes were assessed in all the cases as shown in Table 5. Cases with fundus changes had higher incidence of low birth weight babies (p < 0.05), intrauterine deaths (p < 0.05), early neonatal deaths (p < 0.05), Apgar <7 at 1 minute and NICU admissions (p < 0.05).

In our study, cases having 2+ proteinuria or more showed increased incidence of fundus changes (p < 0.001). It was seen that 76.8% cases with fundus changes had deranged liver function tests compared to 22.2% in women with normal fundus (p < 0.001).

Similarly, we observed higher incidence of deranged renal function in women with hypertensive retinopathy (39.1%) than women who had normal fundus (2.5%; p < 0.001).

Also, 30.4% cases with fundus changes had decreased platelet count compared to only 3.7% in those without Table 1. Prevalence of Hypertensive Retinopathy Fundus change

No. of subjects

Percent (%)

Normal

81

54

Grade 1

36

24

Grade 2

24

16

Grade 3

7

4.7

2 150

Grade 4 Total

With fundus change

Without fundus change

P value

Proteinuria ≥ +2

46

16

<0.001

Deranged LFT

53

18

<0.001

Deranged KFT

27

2

<0.001

Decreased platelet count

21

3

<0.001

LFT = Liver function test; KFT = Kidney function test.

Table 4. Correlation of Fundus Change with Maternal Outcome Without fundus change

P value

CVA

4

0

0.032

HELLP

5

1

0.061

1.3

Pulmonary edema

6

0

0.006

100

Renal failure

5

0

0.013

Abruption

4

3

0.54

Coagulopathy

4

0

0.028

Maternal mortality

6

1

0.001

With fundus change (mean ± SD)

Without fundus change (mean ± SD)

Systolic BP (mmHg)

170.93 ± 14.53

152.62 ± 11.71

Diastolic BP (mmHg)

105.71 ± 10.97

97.68 ± 7.54

BP = Blood pressure; SD = Standard deviation.

Variables

With fundus change

Table 2. Association of Fundus Change with Blood Pressure Variables

Table 3. Association of Fundus Change with Proteinuria and Laboratory Parameters

Complications

Mode of termination

0.001

Vaginal spontaneous

17

39

Vaginal induced

23

8

Cesarean

24

33

CVA = Cerebrovascular accident; HELLP = Hemolysis; Elevated Liver enzymes and Low Platelet counts.

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OBSTETRICS AND GYNECOLOGY Table 5. Correlation of Fundus Change with Fetal Outcome Variables

With fundus Without change fundus change

P value

Low birth weight

46

25

<0.05

IUD

19

4

<0.05

Neonatal death

12

2

<0.05

Apgar at 1 min <7

40

33

<0.05

NICU admissions

41

37

<0.05

IUD = Intrauterine device; NICU = Neonatal intensive care unit.

DISCUSSION Mean age of women in our study was 25.8 years. This was in consistence with other studies done by Jaeffe and Schatz,1 Tadin et al,2 Karki et al3 and Reddy et al.4 Majority, that is 52% of cases, were primigravidas.

Similar were the observation by Shah et al5 (50.7%).

Higher percentages were observed by Doddamani et al6 (65.3%) and Reddy et al4 (65.3%). Mean gestational age was 37 weeks in our study. This was in accordance to studies by Tadin et al2 (36.1 weeks), Saxena et al7 (37.4) and Nawaz et al8 (37.3).

Retinal changes have been observed in 30-100% of patients with pre-eclampsia and eclampsia according to literature. In the present study, 46% of subjects had hypertensive retinopathy. The prevalence rate was similar when compared to studies by Tadin et al2 (45%), Revathy9 et al (50%) and Bhandari et al10 (44%). On the contrary, lower prevalence was reported by Karki et al3 (13.7%) and Rasdi et al11 (21.5%). Further, Grade 1 hypertensive retinopathy, which consists of retinal arterial narrowing, was the most common grade of retinopathy, seen in 24% women. The results are similar to the studies of Rasdi et al,11 Reddy et al,4 Bhandari et al10 and Bharathi12 et al. Retinal detachment was seen in 1.3% subjects in our study, which was comparable to a recent study by Bharathi et al.13 Mean systolic and diastolic blood pressure for subjects without fundus change were 152 mmHg and 96 mmHg, respectively and for subjects with fundus changes were 170 mmHg and 106 mmHg, respectively. Our result is supported by Reddy et al,4 Bhandari et al,10 Karki et al3 and others except for the study done by Rasdi et al.11 Our study found significant association between severity of proteinuria and severity of hypertensive retinopathy (p < 0.05). This is supported by the studies conducted by Revathy et al,14 Shah et al,5 Mithila et al13 and Reddy et al.4 We found a statistically significant association between mode of termination of pregnancy

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and presence of fundus changes which is in accordance with study by Revathy et al.9 In contradiction, Javadekar et al,14 and Ranjan et al15 did not find a significant association.

Hypertensive retinopathy has long been known as a predictor of systemic morbidity and mortality. In our study, significant positive association was found between fundus changes, maternal complications and maternal mortality, which is supported by studies of Revathy et al,9 Ranjan et al15 and Rajalaxmi et al.16 Some studies reported poor fetal prognosis while others reported no prognostic implications on the fetus.

Our study found a significant correlation between fundus changes and various perinatal outcomes like prematurity, low birth weight, intrauterine death, neonatal death, Apgar score and NICU admissions (p < 0.05). Javadekar et al,14 found a significant association between fundus changes, prematurity and low birth weight. Mithila et al,13 found a significant association between birth weight and hypertensive retinopathy. Doddamani et al,6 observed higher incidence of low birth weight, perinatal mortality and NICU admissions in women with pre-eclampsia and eclampsia having hypertensive changes in their fundus.

Our study contradicts the study of Karki et al,3 who observed no significant association between presence of fundus changes with fetal outcome in terms of Apgar score at 1 minute, neonatal death and stillbirth. Ranjan et al15 also did not find significant association between fundus changes and Apgar score (p > 0.05).

CONCLUSION The study implies that degree of hypertensive retinopathy in women with pre-eclampsia and eclampsia is a valid and reliable parameter that gives prognostic information in assessment of severity of pre-eclampsia and neonatal outcome. Ophthalmoscopy is a simple, bedside, cost-effective and noninvasive procedure serving as a window to systemic vasculature and hence helping the obstetrician in assessing the severity of disease and guiding subsequent obstetric management of the patient. Timely ophthalmoscopy should be called for in all cases of pregnancy-induced hypertension as it would affect the decision of termination, thereby preventing other complications.

Acknowledgment We are extremely thankful to all the women who participated in the study and the Dept. of Ophthalmology for their kind cooperation.

OBSTETRICS AND GYNECOLOGY REFERENCES 1. Jaffe G, Schatz H. Ocular manifestations of preeclampsia.

Am J Ophthalmol. 1987;103(3 Pt 1):309-15.

2. Tadin I, Bojić L, Mimica M, Karelović D, Dogas Z. Hypertensive retinopathy and pre-eclampsia. Coll Antropol. 2001;25 Suppl:77-81.

3. Karki P, Malla P, Das H, Uprety DK. Association between pregnancy-induced hypertensive fundus changes and fetal outcomes. Nepal J Ophthalmol. 2010;2(1):26-30.

4. Reddy SC, Nalliah S, George SR a/pKovil, Who TS. Fundus changes in pregnancy induced hypertension. Int J Ophthalmol. 2012;5(6):694-7.

5. Shah AP, Lune AA, Magdum RM, Deshpande H, Shah AP, Bhavsar D. Retinal changes in pregnancy-induced hypertension. Med J DY Patil Univ. 2015;8(3):304-7.

6. Doddamani UG, Doddamani GB. Perinatal outcome in pre-eclampsia: a prospective study. Sch J Appl Med Sci. 2014;2(1C):291-3.

7. Saxena S, Srivastava PC, Thimmaraju KV, Mallick AK, Dalmia K, Das B. Socio-demographic profile of pregnancy induced hypertension in a tertiary care centre. Sch J Appl Med Sci. 2014;2(6D):3081-6.

8. Nawaz F, Sultan S, Siddiqui I. Pregnancy outcome in primigravida complicated with pregnancy induced hypertension. J Med Sci. 2014;22(1):46-8.

10. Bhandari AJ, Bangal SV, Gogri PY. Ocular fundus changes in pre-eclampsia and eclampsia in a rural set-up. J Clin Ophthalmol Res. 2015;3:139-42.

11. Rasdi AR, Nik-Ahmad-Zuky NL, Bakiah S, Shatriah I. Hypertensive retinopathy and visual outcome in hypertensive disorders in pregnancy. Med J Malaysia.

2011;66(1):42-7.

12. Bharathi NR, Raju NRS, Prasad PK, Raju RS, Premalatha, Mayee K, et al. Fundus Changes in pregnancy induced hypertension: a clinical study. J Evolut Med Dent Sci. 2015;4(09):1552-62.

13. Mithila R, Narendra PD, Gomathy E, Krishnamurthy D. Study of association of fundal changes and fetal outcomes in pre-eclampsia. J Evolut Med Dent Res. 2014;3(21): 5894-901.

14. Javadekar SD, Javadekar DP, Joshi K, Khatiwala R. Fundoscopic changes in pregnant mother with hypertension complicating pregnancy and various parameters of foetus. Int J Recent Trends Technol.

2013;7(3):110-3.

15. Ranjan R, Sinha S, Seth S. Fundus changes and fetal outcomes in pregnancy induced hypertension: an observational study. Int J Sci Stud. 2014;2(7):6-9.

16. Rajalaxmi KK, Nayak SR. Preeclampsia/eclampsia and retinal micro vascular characteristics affecting maternal and foetal outcome: A prospective study amongst South 9. Revathy K, Varalakhshmi B. Fundoscopic changes in PIH Indian pregnant women. Int J Innovat Res Develop. and association with maternal and fetal outcomes. Indian 2011;2(11):444-8.

J Appl Res. 2015;5(9):473-4.

■■■■

Younger Pregnant Women are More Likely to Experience a Stroke Than Nonpregnant Women of Same Age Younger pregnant women are at an increased risk (more than twice) of stroke than nonpregnant women of the same age, suggests a study published in JAMA Neurology. The researchers studied the incidence of stroke for both pregnant and nonpregnant women across four age groups: 12-24 years, 25-34 years, 35-44 years and 45-55 years and found that the stroke events for pregnant or postpartum women aged 12-24 were 14 per 100,000, compared with 6.4 per 100,000 for nonpregnant women aged 12-24. Further, in women aged 25-34 and 35-44 years stroke incidence among pregnant or postpartum women were 1.6 times higher than and comparable to non-pregnant women of the same age, respectively. However, the incidence of stroke was higher (73.7 per 100,000) in nonpregnant women aged 45-55 years, compared with 46.9 per 100,000 for pregnant or postpartum women.

Anticancerous Role of Onion in Female Population A latest study published in the journal Scientific Reports, suggests that the a naturally occurring active constituent of onion called onion-A (ONA) is beneficial for the treatment of epithelial ovarian cancer in female population.

The researchers observed a decline in growth of epithelial ovarian cancer (EOC) cells in preclinical model of EOC, after the administration of ONA. Also, ONA directly suppressed the proliferation of epithelial ovarian cancer cell. The present study is first-of-its kind to report the antiovarian cancer effects of ONA.

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OBSTETRICS AND GYNECOLOGY

Intrapartum HELLP Syndrome Associated with Mild Pre-eclampsia: A Case Report JAYA KUNDAN GEDAM*, MINAL BHALERAO†, UTKARSH‡

ABSTRACT Pre-eclampsia can lead to a dreaded obstetric emergency, HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome, in a few cases leading to hemolysis, thrombocytopenia and liver enzymes dysfunction. It can occur mostly in third trimester of pregnancy and sometimes during postnatal period. We report a case of mild pre-eclampsia which was complicated with intrapartum HELLP syndrome. A 35-year-old pregnant woman with mild pre-eclampsia at 36 weeks of gestation was admitted to our hospital with labor pain. A cesarean section was performed, due to excessive bleeding per vagina during labor.

A prompt diagnosis and appropriate management helped us to reduce morbidity and mortality related to HELLP syndrome.

Keywords: Pregnancy-induced hypertension, pre-eclampsia, HELLP syndrome

H

ELLP syndrome is a life-threatening complication of pregnancy characterized by

hemolysis, elevated liver enzymes and low platelets. It is usually considered to be a variant or

complication of pre-eclampsia. However, in 20% of cases it may occur without pre-eclampsia during antenatal or intrapartum period. HELLP is a multisystemic disorder, leading to generalized vasospasm, microthrombi formation and coagulation defects. Clinical features include severe headache, malaise, nausea and vomiting, pain around upper abdomen and pedal edema. In about 20% of all women, disseminated intravascular coagulation (DIC) is also seen with HELLP syndrome.

CASE REPORT A 35-year-old pregnant woman, primigravida, was admitted in emergency to our hospital in the 36th week of gestation, with mild pregnancyinduced hypertension (PIH). Her antenatal checkups were infrequent but normal. On admission, her

*Associate Professor †Senior Resident Dept. of Obstetrics and Gynecology ‡Senior Resident Dept. of Medicine ESI-PGIMSR, MGM Hospital, Parel, Mumbai, Maharashtra Address for correspondence Dr Jaya Kundan Gedam L-1, RH-2 Ground Floor, L-1, RH-2, Sector-6, Vashi, Navi Mumbai, Maharashtra E-mail: jayagedam@gmail.com

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Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

blood pressure was 140/90 mmHg (after 2 hours; 170/100 mmHg). Urine albumin was trace. Capsule nifedipine 5 mg was given orally. Prophylactic injection magnesium sulfate (MgSO4) was started. Her cervix was 2 cm dilated, 25% effaced. Augmentation of labor was done with oxytocin. All laboratory findings including hematological, biochemical and coagulation profile, were within their normal limits (Table 1). Three hours after her admission, cervical dilatation was 3-4 cm and 50-60% effaced, bleeding per vagina started with passage of clots. Artificial rupture of membrane was done to rule out abruptio placenta, liquor was clear.

In view of excessive bleeding per vaginum, cesarean section was done under spinal anesthesia.

Peroperative findings: A live born, 2800 g, female fetus with a 9 Apgar at 5th minute was delivered.

As uterus was flabby, intravenous (IV) oxytocin infusion 30 units was started and injection carboprost 0.25 mg intramuscular (IM) given. Uterus became wellcontracted, but excessive oozing from raw areas around uterine incision, muscle, skin continued. So, injection tranexamic acid IV was given. Patient became severely pale. Frank hematuria was observed. Though patient’s vitals were maintained but due to excessive bleeding and with probable diagnosis of DIC central line was inserted in operation theater.

Patient was shifted to intensive care unit (ICU) postoperatively for further management. All necessary blood and urine investigations were sent. Injection vitamin K, IV antibiotics and injection tranexamic acids were given along with IV fluids.

OBSTETRICS AND GYNECOLOGY Table 1. Laboratory Findings Investigations

Preoperative findings

Postoperative findings 2 hours

8 hours

16 hours

24 hours

48 hours

64 hours

84 hours

Hemoglobin (g/dL)

10

7.8

7.2

7

7.6

8

8.4

9.2

Platelet count (/uL)

180

71

50

46

46

58

68

200

AST (IU/L) SGOT

20

170

122

82

72

49

44

20

ALT (IU/L) SGPT

12

111

76

72

62

40

32

22

LDH (IU/L)

-

1,538

1,618

1,680

1,701

1,240

1,213

Serum haptoglobin (mg/dL)

-

≤7.56

≤5.56

≤5.56

Peripheral blood smear

-

Schistocytes +

-

-

-

-

-

-

Spherocytes+ Urine albumin

Nil

Serum urea (mmol/L) Serum creatinine (µmol/L)

+

++

++

Trace

Nil

Nil

-

16

11.44

12

10

10

10

-

0.6

0.2

0.9

0.9

0.6

0.6

Total bilirubin (mg/dL)

1

3.1

7

7

3.6

Serum proteins (g/dL)

6.8

4.6

4.2

5

5.2

5.4

-

-

2

0.9

5.8

6.4

Fibrinogen (mg/L)

-

243

-

-

-

-

-

-

D-Dimer (mg/L)

-

1.4

-

-

-

-

-

-

Plasma FDP (µg/L)

-

2.91

-

-

-

-

-

-

APTT(s)

-

30

32

32

30

26

38

PT(s)

-

14

12

12

12

12

12

INR

-

1.07

1.02

1

1

0.9

0.9

Hb = Hemoglobin; Plt = Platelet count; ALT = Alanine aminotransferase; AST = Aspartate aminotransferase; LDH = Lactate dehydrogenase; INR = International normalized ratio; PT = Prothrombin time.

Postoperative hematological parameters were: hemoglobin - 7.80 g/dL and platelet count - 71,000/uL after 2 hours of operation. Hematological and biochemical parameters, including serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and lactate dehydrogenase (LDH), were detected to be higher than their respective reference intervals; 170.4 IU/L, 111 IU/L and 1,538 IU/L, respectively.

Peripheral blood smear-Schistocytes - occasional, spherocytes - present, urine albumin was trace, red blood cell (RBC) - 75-100/hpf, coagulation profile prothrombin time (PT) - 15 sec, mean PT/control value 13.3, fibrinogen - 243 mg/dL, D-dimer - 1.40 mg/L, plasma fibrin degradation products (FDP) level 2.91 µg/L. Diagnosis of HELLP syndrome was made.

Transfusion of 4 platelets, 2 units of fresh frozen plasma, 2 units of packed cells were done.

After 8 hours, the laboratory findings were consistent with those of HELLP syndrome, which included hemolysis (hemoglobin - 7.2 g/dL, LDH - 1,618 IU/L),

elevated liver enzymes (SGOT - 122.4 IU/L, SGPT 75.8 IU/L) and low platelet counts (platelet: 50,000/uL) (Table 1). Coagulation profile and other biochemical parameters such as electrolyte values were in normal limitation of references.

An ultrasound examination showed a normal liver structure and an empty uterine cavity. MgSO4 infusion (2 g/hour; 24 hours) and steroids were administered (dexamethasone; total 30 mg for 48 hours), with supportive therapy such as: IV fluids, fresh frozen plasma and packed red blood cells.

The laboratory findings improved dramatically after the treatment and at the 88th hour (4th day) of postpartum period, all of them completely regressed to normal value. Foley’s catheter was removed on post-op Day 5.

Patient was shifted to ward on post-op Day 7.

On Day 8, suture removal was done. Wound was healthy. Patient was discharged on iron and calcium supplements. Contraceptive counseling was done. She was discharged on the 10th day without any sequelae.

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OBSTETRICS AND GYNECOLOGY DISCUSSION Pregnancy-induced hypertensive disorders constitute 12-22% of all pregnancies and 17.6% maternal mortality.1 The HELLP syndrome is usually considered to be a variant or complication of pre-eclampsia.

However, in 20% of cases it may occur without preeclampsia during antenatal or intrapartum period. It is difficult for clinicians to predict the development of pre-eclampsia due to absence of obvious signs.2,3 HELLP is a multisystemic disorder, leading to generalized vasospasm, microthrombi formation and coagulation defects. It is the final manifestation of insult that leads to microvascular endothelial damage and intravascular platelet aggregation.4 There is an important role of coagulopathy in causation of HELLP syndrome suggested by clinically evident DIC as a secondary pathophysiological phenomenon to the primary process is seen in 4-38% of the patients. If not treated timely may lead to renal failure.5 HELLP syndrome is a dreaded obstetric emergency usually associated with pre-eclampsia. Its incidence is 0.5-0.9% of all pregnancies. It is related with severe pre-eclampsia (10-20%). Both conditions occur after 20 weeks of gestation and may occur after 5-12 weeks of childbirth.

Clinical features include severe headache (30%), malaise (90%), nausea and vomiting (30%), pain around upper abdomen (65%) and pedal edema. In about 20% of all women, DIC is also seen with HELLP syndrome.6 Our patient presented only with excessive bleeding per vaginum during first stage of labor. She had no other complaints.

Pregnant women who present with HELLP syndrome can be misdiagnosed in the early stages, thereby increasing the risk of maternal morbidity. In a patient with PIH and suspected to have HELLP, following blood tests should be performed: full blood count, liver function tests including enzymes, renal function tests, coagulogram, serum electrolytes and D-dimer. We conducted all the above investigations in our patient and we diagnosed our patient was suffering from HELLP syndrome as D-dimer was positive. A positive D-dimer test in a patient of pre-eclampsia is predictive of HELLP syndrome.7 D-dimer is a more sensitive indicator of subclinical coagulopathy and may be positive before other coagulation studies become abnormal. According to Mississippi classification3,8 and Tennessee classification, the disease can be classified as mild, moderate and

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severe. Our case was a severe variety of HELLP syndrome. Sibai has proposed strict criteria for true or complete HELLP syndrome platelet - <1,00,000, AST >70 IU/L, LDH - >600 IU/L.9 The definitive treatment of HELLP syndrome is immediate delivery of baby either by cesarean section or normal vaginal route.9 As our patient was hemodynamically stable, she was operated under spinal anesthesia. Corticosteroids can reduce the severity of intravascular endothelial injury and improve blood flow. They also decrease hepatocyte and platelet consumption in HELLP syndrome.10 CONCLUSION In conclusion, when patients present with mild-PIH presents with excessive bleeding per vagina during labor, it must be kept in mind that it can be one of the signs of HELLP syndrome and if we are aware of this, we can significantly reduce the maternal morbidity and prevent the development of maternal mortality.

REFERENCES 1. Walker JJ. Pre-eclampsia. Lancet. 2000;356(9237):1260-5.

2. Ezri T, Abouleish E, Lee C, Evron S. Intracranial subdural hematoma following dural puncture in a parturient with HELLP syndrome. Can J Anaesth. 2002;49(8):820-3.

3. Lurie S, Sadan O, Oron G, Fux A, Boaz M, Ezri T, et al.

Reduced pseudocholinesterase activity in patients with HELLP syndrome. Reprod Sci. 2007;14(2):192-6.

4. Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A review.

BMC Pregnancy Childbirth. 2009;9:8.

5. Gul A, Aslan H, Cebeci A, Polat I, Ulusoy S, Ceylan Y. Maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure. Ren Fail.

2004;26(5):557-62.

6. Crosby ET. Obstetrical anaesthesia for patients with the syndrome of haemolysis, elevated liver enzymes and low platelets. Can J Anaesth. 1991;38(2):227-33.

7. Ezri T, Abouleish E, Lee C, Evron S. Intracranial subdural hematoma following dural puncture in a parturient with HELLP syndrome. Can J Anaesth. 2002;49(8):820-3.

8. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesiarelated deaths during obstetric delivery in the United States, 1979-1990. Anesthesiology. 1997;86(2):277-84.

9. Sibai BM, Taslimi MM, el-Nazer A, Amon E, Mabie BC, Ryan GM. Maternal-perinatal outcome associated with the syndrome of hemolysis, elevated liver enzymes, and low platelets in severe preeclampsia-eclampsia. Am J Obstet Gynecol. 1986;155(3):501-9.

10. Rolbin SH, Abbott D, Musclow E, Papsin F, Lie LM, Freedman J. Epidural anesthesia in pregnant patients with low platelet counts. Obstet Gynecol. 1988; 71(6 Pt 1):918-20.

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OBSTETRICS AND GYNECOLOGY

Endometriosis and the Role of Resveratrol ANITA KANT

ABSTRACT Endometriosis is a very common yet very challenging disease that affects women in their reproductive age. Endometriosis causes severe pain and infertility in women. Endometriosis brings a huge economic burden and reduces quality-of-life. Role of estrogen has been established as a causative factor of endometriosis. Pharmacotherapy of endometriosis revolves around lowering levels of estrogen in the body. Hormone therapy for endometriosis has its limitations.

Keywords: Endometriosis, dysmenorrhea, resveratrol

E

ndometriosis is a very common yet very challenging disease that affects women in their reproductive age. Endometriosis causes severe pain and infertility in women. Endometriosis brings a huge economic burden and reduces quality-of-life. Though, an estrogen-dependent condition, the exact molecular and cellular basis of endometriosis pathogenesis remains unclear. Existing pharmacotherapy of the condition remains inadequate.

In this light, we shall discuss evidence in support of resveratrol as an option to manage endometriosis in women.1-4 Endometriosis manifests itself in the form of pelvic pain related to menstruation and infertility.

Symptoms of endometriosis are progressive and may include dysmenorrhea, heavy or irregular bleeding, lower abdominal pain, pelvic pain, dyspareunia (pain during sexual intercourse), dyschezia (pain on defecation), pain during micturition, inguinal pain, pain during exercise, nausea, vomiting and bloating.1,4,5 Pain is the principal reason for seeking medical help.

EPIDEMIOLOGY Exact number of subjects with endometriosis is difficult to tell. Endometriosis can only be diagnosed by laparoscopy. It is believed that endometriosis affects nearly 176 million women globally. Close to 26 million women in India suffer from endometriosis.6,7 In general population, prevalence of endometriosis may range from 4% to 10%.

Many subjects remain without any apparent symptom.

Incidence of endometriosis can high in teenagers (50%) with intractable dysmenorrhea, in infertile women (20-50%) and in women with pelvic pain (80%).

Approximately 4 per 1,000 women are hospitalized for endometriosis.4,5,8,9 ECONOMIC BURDEN In 2009, total annual healthcare cost to endometriosis was estimated to be USD 69.4 billion.10 Per person cost to healthcare for endometriosis was approximately USD 12,419. One-third of this is attributed to direct healthcare cost and remaining two-third relates to loss of productivity.3 In Indian subcontinent, where most medical expenses come out of pocket, endometriosis brings economic burden to patients due to high cost of diagnosis and cost of managing problem of infertility.5 RISK FACTORS Several risk factors endometriosis.

have

been

identified

for

Heredity Heredity is an important risk factor. Risk increases if first-degree relatives, e.g., mother/sister, suffer from endometriosis.2,4,8,11 Heritable traits like height (tall women) and weight (thin women) may have impact on occurrence of endometriosis.12

Age Consultant Gynecologist Asian Institute of Medical Sciences, Faridabad, Haryana

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Rate of endometriosis tends to increase with age. In females, in the age group 20-21 years, incidence of endometriosis was 45% compared to prepubertal girls.4

OBSTETRICS AND GYNECOLOGY implantation of endometrial lesions. Women with this disorder appear to exhibit increased humoral immune responsiveness and macrophage activation.

Lifestyle Personal lifestyle choices like delayed marriage, postponement of first conception, adoption of small family norm, consumption of alcohol and caffeine, may increase risk.4,9,12

Altered Menstrual Cycle Subjects with shorter cycle length, longer duration of flow or reduced parity are more likely to suffer from endometriosis.4,7

Others Defective fallopian tubes and uterus as well as iron deficiency and hypoxia may contribute towards endometriosis.4 PATHOPHYSIOLOGY Uterus plays a very important role in female reproductive system. Inner lining of uterus is endometrium. Endometrium is rich in glands and blood supply. For initiation and propagation of pregnancy, fertilized ovum gets implanted on endometrium.

In endometriosis, inner endometrial lining of uterus grows in places outside uterus. Such ectopic growth can happen in ovaries, fallopian tubes, vagina, cervix, uterosacral ligaments, pelvic peritoneum. In rare cases, endometrial growth has been seen in kidney, bladder, lung and brain as well.1-3 Etiology of endometriosis is poorly understood.

Endometriosis may be the clinical manifestation of an underlying disorder that affects the tubal motility or immune system and contribute towards progression of endometriosis. Several theories have been proposed.

None clearly explains occurrence of endometriosis. ÂÂ

ÂÂ

ÂÂ

Retrograde menstruation theory deals with flow of endometrial contents into peritoneal cavity. This is believed to result in implantation of endometrial lesion. Studies have shown that retrograde menstruation is a quite common yet most women do not have endometriosis.

Metaplasia hypothesis proposes transformation of specialized cells present in the mesothelial lining of visceral and abdominal peritoneum. It has been suggested that endogenous factors induce resident undifferentiated cells into endometrial tissue. However, appearance of endometriosis in prepubertal girls lacking estrogen cannot be explained by metaplasia hypothesis.

Immune dysfunction theory proposes defective removal of menstrual debris and promotes

At the cellular level, involvement of stem cells, activated macrophages and progrowth and antiapoptotic endometrial cells has been suggested. It is proposed that stem cells get settled in peritoneum and undergo transdifferentiation into endometrial tissue. Endometrial cells exhibit upregulation of antiapoptosis and prosurvival genes. Cytokines and chemokines released due to aberrant activation of immune system may also contribute towards inflammatory response.

At the molecular level, role of steroid hormones play a central role in the pathophysiology of endometriosis.

Estrogen acts as a promitogenic agent and promotes endometrial lesions. Synthesis of estrogen is increased due to enhanced activity of aromatase enzyme in endometrial tissue. Inactivation of active estradiol to less active estrone is reduced due to reduced expression of the metabolizing enzyme, 17β-hydroxysteroid dehydrogenase.

Prostaglandins play a role in endometriosis. Estrogen increases the synthesis of certain prostaglandins that may contribute towards pain and inflammation. Dioxin group of compounds, acting through aryl hydrocarbon receptor, may mimic activity of estrogen. Role of dioxins in human endometriosis remains inconclusive. Free radicals and lipid peroxidation products generated due to lifestyle and diet-induced enhanced oxidative stress, may contribute towards endometriosis.2-4,10 MANAGEMENT Endometriosis can be managed medically using drugs.

Alternatively, ectopic growth can be removed surgically.

Ideally, a combination of both approaches is employed.

Medical Management Medical management aims to create (1) a hypoestrogenic environment in the body using hormones and (2) manage pain. ÂÂ

Hypoestrogenic environment: Different approaches used to reduce estrogen levels in the body, include use of a (i) estrogen progesterone combination, (ii) progesterone only preparation, (iii) gonadotropic hormone release agonist, (iv) danocrine and (v) aromatase inhibitor. Hormone therapy is effective in managing endometriosis.1-3 Hormone therapy has side effects. Combinational birth control pills (contain both estrogen and progesterone) may

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OBSTETRICS AND GYNECOLOGY cause nausea, decrease sex drive and break through bleeding. Gonadotropin release hormone agonist may cause bone loss, mood alteration and possibly mental fog. Danazol is a synthetic hormone that is a cross between progesterone and testosterone.

Significant drawbacks include acne, oily skin, extra hair growth and deepening voice. ÂÂ

Pain management: Pain medications do not actually treat endometriosis. Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used to relieve dysmenorrhea by minimizing inflammation. A combination of NSAIDs with oral contraceptives can be used for treating endometriosis.

Pharmacotherapy of endometriosis has a lot of adverse effects. Drug therapy must be continued to maintain hypoestrogenic environment. Discontinuation of hormone therapy results in return of endometriosis.

This makes it important to find a new option to treat endometriosis, that is effective and safe.13

have shown that resveratrol reduces growth rate of lesions, size of lesions, cell proliferation and inhibits angiogenesis; resveratrol also promoted apoptosis within lesions.13,18,19 Similar results were also obtained in rat model of endometriosis. Resveratrol reduced implant volume, increased superoxide dismutase and glutathione peroxidase levels in serum and tissue samples.

Catalase and malondialdehyde levels were also elevated in serum and tissues.20 A reduction of vascular endothelial growth factor (VEGF) levels and monocyte chemotactic protein-1 (MCP-1) levels in plasma and peritoneal fluid was also observed in resveratrol treated rats.21,22 Exact mechanism of action of resveratrol is not known clearly. It is suggested that resveratrol may work through the following mechanisms: ÂÂ

Resveratrol has been shown to activate SIRT-1 enzyme in endometrial stromal cells. Through activation of SIRT-1 resveratrol exhibits antiinflammatory effect.23

ÂÂ

Inhibition of expression of hydroxymethylglutarylcoenzyme A (HMG-CoA) reductase mRNA and reduction of HMG-CoA reductase enzyme activity both in vitro24 and in in vivo.25 Since statin group of drugs have shown beneficial effect in treating endometriosis, inhibition of HMG-CoA reductase may contribute towards effect of resveratrol in endometriosis.

ÂÂ

Additional pathways may be targeted by resveratrol. For example, AKT, p38 MAP kinase, ERK and PPAR-g may all be modulated by resveratrol to a varying degree.18 Effect on multiple pathways may explain broad-spectrum of activities of resveratrol.

Surgical Treatment In surgical therapy, reports of recurrence are as high as 30% in patients followed 3 years postlaparoscopic surgery and 40-50% in patients 5 years after surgery.

Repeated surgeries are associated with increased morbidity and healthcare costs and damage to the ovarian reserve.2,3 RESVERATROL IN ENDOMETRIOSIS Sedentary lifestyle, stressful life, exposure to pollutants and consumption of refined foods create an oxidative environment with circulating free radicals. Studies have shown that consumption of diet rich in fruits and vegetables lowers risk of endometriosis.14 Health benefits of natural products like green tea, red wine, garlic, fresh fruits have been studied in the prevention of different diseases including endometriosis.13,15,16 Resveratrol (trans-3,5,4'-trihydroxystilbene) is a phytochemical compound of grapes, red wine, nuts and different berries. Resveratrol has previously been shown to exert beneficial effects in a variety of pathological conditions, such as cardiovascular diseases and cancer.15,17 Studies have shown that resveratrol exhibits antiproliferative, anti-inflammatory, antioxidant and antiangiogenic effects.

Based on promising efficacy in experimental animal models, resveratrol has been tested in humans. In one small study involving 12 patients, resveratrol was administered with an estrogen progesterone combination for 2 months. Results indicated reduction of pelvic pain and dysmenorrhea.26 In a separate study, expression of aromatase and cyclooxygenase enzyme was assessed. It was observed that when resveratrol was administered along with estrogenprogesterone combination, expression of aromatase and cyclooxygenase was inhibited to a great extent.

Studies have shown that resveratrol inhibited proliferation, promoted apoptosis13 and reduced invasiveness of human endometrial stromal cells, in vitro.18 Studies in mouse model of endometriosis, in vivo,

This study, however, has faced criticism.27 More controlled clinical studies must be undertaken to establish efficacy of resveratrol in the management of endometriosis.

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OBSTETRICS AND GYNECOLOGY CONCLUSIONS In summary, endometriosis is a common disorder in premenopausal women. Endometriosis results in infertility, affects quality-of-life and brings financial stress on women. Exact molecular and cellular basis of endometriosis is not known. Role of estrogen has been established as a causative factor of endometriosis. Pharmacotherapy of endometriosis revolves around lowering levels of estrogen in the body. Hormone therapy for endometriosis has its limitations. There is a need for a safer and more efficacious alternative. Resveratrol can be explored as a therapeutic option for endometriosis. More studies must be done under controlled conditions to establish efficacy of resveratrol.

REFERENCES 1. Brosens I, Benagiano G. Endometriosis, a modern syndrome. Indian J Med Res. 2011;133:581-93.

2. Suresh PS, Venkatesh T, Rajan T, Tsutsumi R. Molecular pathology and therapy of endometriosis: revisited.

Androl Gynecol. Curr Res. 2013;1(3):1-7.

3. Sourial S, Tempest N, Hapangama DK. Theories on the pathogenesis of endometriosis. Int J Reprod Med. 2014;2014:179515.

4. Davila GW. Endometriosis, Practice Essentials, Pathophysiology Etiology. Workshop 2016. Available at: http://emedicine.medscape.com/article/271899-workshop 5. Khawaja UB, Khawaja AA, Gowani SA, Shoukat S, Ejaz S, Ali FN, et al. Frequency of endometriosis among infertile women and association of clinical signs and symptoms with the laparoscopic staging of endometriosis. J Pak Med Assoc. 2009;59(1):30-4.

6. Bendigeri T, Warty N, Sawant R, Dasmahapatra P, Padte K, Humane A, et al. Endometriosis: Clinical experience of 500 patients from India. The Indian Practitioner.

2015;68(7):34-40.

7. Eskenazi B, Warner ML. Epidemiology of endometriosis.

Obstet Gynecol Clin North Am. 1997;24(2):235-58.

8. Cramer DW, Missmer SA. The epidemiology of endometriosis. Ann N Y Acad Sci. 2002;955:11-22; discussion 34-6, 396-406.

9. Thaim SA, Jha RK, Saheta A, Santra D, SamaThaim S. Comparison of effectiveness profile of danazol and gestrinone in pelvic endometriosis: a community based observational study in Wardha District-Eastern Maharashtra. IOSR Journal of Pharmacy. 2015;5(1): 8-15.

10. Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 2012;98(3):511-9.

11. Abbas S, Ihle P, Köster I, Schubert I. Prevalence and incidence of diagnosed endometriosis and risk of

endometriosis in patients with endometriosis-related symptoms: findings from a statutory health insurancebased cohort in Germany. Eur J Obstet Gynecol Reprod Biol. 2012;160(1):79-83.

12. Hediger ML, Hartnett HJ, Louis GM. Association of endometriosis with body size and figure. Fertil Steril.

2005; 84(5):1366-74.

13. Ricci AG, Olivares CN, Bilotas MA, Bastón JI, Singla JJ, Meresman GF, et al. Natural therapies assessment for the treatment of endometriosis. Hum Reprod. 2013;28(1): 178-88.

14. Halpern G, Schor E, Kopelman A. Nutritional aspects related to endometriosis. Rev Assoc Med Bras. 2015;61(6): 519-23.

15. Cucciolla V, Borriello A, Oliva A, Galletti P, Zappia V, Della Ragione F. Resveratrol: from basic science to the clinic. Cell Cycle. 2007;6(20):2495-510.

16. Khan N, Mukhtar H. Multitargeted therapy of cancer by green tea polyphenols. Cancer Lett. 2008;269(2):269-80.

17. Baur JA, Sinclair, DA. Therapeutic potential of resveratrol: the in vivo evidence. Nat Rev Drug Discov. 2006;5(6): 493-506.

18. Bruner-Tran K, Sokalska A, Osteen K, Taylor HS, Duleba AJ. Resveratrol inhibits development of experimental endometriosis and induces apoptosis of endometrial stroma. Fertil Steril. 2009;92(3):S64-65.

19. Rudzitis-Auth J, Menger MD, Laschke MW. Resveratrol is a potent inhibitor of vascularization and cell proliferation in experimental endometriosis. Hum Reprod.

2013;28(5):1339-47.

20. Yavuz S, Aydin NE, Celik O, Yilmaz E, Ozerol E, Tanbek K. Resveratrol successfully treats experimental endometriosis through modulation of oxidative stress and lipid peroxidation. J Cancer Res Ther. 2014;10(2):324-9.

21. Ergenoğlu AM, Yeniel AÖ, Erbaş O, Aktuğ H, Yildirim N, Ulukuş M, Taskiran D, et al. Regression of endometrial implants by resveratrol in an experimentally induced endometriosis model in rats. Reprod Sci. 2013;20(10): 1230-6.2.

22. Cenksoy PO, Oktem M, Erdem O, Karakaya C, Cenksoy C, Erdem A, et al. A potential novel treatment strategy: inhibition of angiogenesis and inflammation by resveratrol for regression of endometriosis in an experimental rat model. Gynecol Endocrinol. 2015;31(3):219-24.

23. Taguchi A, Wada-Hiraike O, Kawana K, Koga K, Yamashita A, Shirane A, et al. Resveratrol suppresses inflammatory responses in endometrial stromal cells derived from endometriosis: a possible role of the sirtuin 1 pathway. J Obstet Gynaecol Res. 2014;40(3):770-8.

24. Villanueva JA, Sokalska A, Cress AB, Ortega I, Bruner-Tran KL, Osteen KG, et al. Resveratrol potentiates effects of simvastatin on inhibition of mevalonate pathway in human endometrial stromal cells. J Clin Endocrinol Metab. 2013;98(3):E455-62.

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OPHTHALMOLOGY

To Study the Effect of Steroid Eye Drops on Intraocular Pressure After Cataract Surgery JITENDER PHOGAT*, SUMIT SACHDEVA, SUMEET KHANDUJA, CS DHULL, HIMANI ANCHAL

ABSTRACT Objective: To study the effect of steroid eye drops on intraocular pressure (IOP) after cataract surgery. Material and methods: This study was conducted in tertiary eye care center. Total of 300 eyes which underwent uncomplicated cataract surgery were studied for IOP change for up to 6 weeks after use of topical steroids and the pressures were measured with applanation tonometer. Results: After 6 weeks of steroid therapy, 18% patients had persistently raised IOP of which 1.3% still had raised IOP after 4 weeks of steroid omission. Conclusion: Topical steroid therapy after cataract surgery increases IOP in significant number of cases.

Keywords: Intraocular pressure, steroids, cataract, applanation tonometry

S

teroids are the mainstay of treatment to control inflammation after cataract surgery. Usually steroids are required for almost 6 weeks in tapering doses for effective control of inflammation and prompt recovery of visual acuity after cataract surgery.

Steroids are definitely more potent than nonsteroidal anti-inflammatory drugs (NSAIDs) and hence are used as primary drug in post surgical period.

Steroids cause elevation of intraocular pressure (IOP) when given by any route including topical, periocular and systemic. Maximum rise of IOP occurs with periocular route. The degree of IOP elevation depends up on the specific drug, the dose, the frequency of administration and the individual patient.1 There are three different mechanisms of increased resistance to the outflow of aqueous humor that act synergistically to produce corticosteroid-induced ocular hypertension.2 First is structural changes of trabecular meshwork, second is mechanical obstruction of the orbicular meshwork by steroid particles and last mechanism is inhibition of phagocytes by orbicular meshwork cells. Glucocorticoids exert their effect by increased

*Assistant Professor Regional Institute of Ophthalmology Pt BD Sharma, PGIMS, Rohtak, Haryana Address for correspondence Dr Jitendar Phogat 923/A-28, Bharat Colony, Rohtak, Haryana E-mail: drjitenderphogat@gmail.com

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expression of myocilin (MYOC) gene located on locus GLC1A on 1q25 chromosome.3 Glucocorticoids cause increased production of elastin, fibronectin and laminin by trabecular cells and decreased production of tissue plasminogen-activator, collagenase IV and stromelysin, ultimately causing accumulation of extracellular matrix (ECM) and increased resistance to aqueous outflow.

Cross-linked actin networks form within the trabecular cells which inhibit their proliferation, migration and phagocytic activity and hence causes accumulation of cellular debris and clogging of aqueous outflow channels.

MATERIAL AND METHODS The study was conducted in the Regional Institute of Ophthalmology, PGIMS, Rohtak. A total of 300 patients operated for cataract surgery were taken up for study. Patients were operated for cataract surgery by phacoemulsification and small-incision cataract surgery (SICS) technique with intraocular lens implantation.

Exclusion criteria was history of glaucoma, complicated cataract, pediatric patients, pathological myopia and patients with any complication during surgery. Patients were admitted in the hospital and informed and written consent was taken before surgery.

Detailed history of patient was taken including chief complaints, ocular history and systemic history.

Examination was done in detail which included best corrected visual acuity with Snellenâ&#x20AC;&#x2122;s chart, slitlamp examination, fundus examination and IOP

OPHTHALMOLOGY measurement with applanation tonometer. Patients were started preoperative topical antibiotics 3 days prior to surgery to minimize the risk of infection. Patients were operated under local and topical anesthesia with phacoemulsification and SICS technique and posterior chamber intraocular lens (PCIOL) was implanted.

Patients were examined on first postoperative day including visual acuity assessment, slit-lamp examination and IOP was recorded. Patients were started on antibiotic eye drop and steroid eye drop (1% prednisolone acetate) 6 times a day for first week and 4 times a day for 5 weeks. Patients who had IOP between 25 and 30 mmHg on first postoperative day were given tablet acetazolamide thrice a day for 3 days.

Patients who had IOP >30 mmHg on first postoperative day were treated with intravenous mannitol and tablet acetazolamide thrice a day for 3 days. Follow-up of all patients was done 1 week after surgery and another was done 6 weeks after surgery. Later, a follow-up was done after 4 weeks of omission of steroid eye drops and visual acuity, IOP were recorded.

RESULTS Medical records of 300 patients who were operated for cataract surgery showed that 30 (10%) had a rise of IOP >25 mmHg on first operative day. On 1 week followup, only 2 patients had persistently raised IOP after above treatment. Fifty-four patients (18%) had an IOP rise of >6 mmHg from baseline, of which 9 (3%) had >15 mmHg after 6 weeks of cataract surgery. Thus, the percentage of steroid responders was 3%. At the end of 6 weeks of cataract surgery, 82% (246) of the patients had an IOP <20 mmHg (low steroid responders), 15% (45) had between 20-30 mmHg (intermediate steroid responders) and 3% (9) had IOP of >30 mmHg (high steroid responders) (Table 1). At the end of 4 weeks of omission of steroid eye drop, 2 patients out of 9 patients had persistently raised IOP. These 2 patients were treated with topical antiglaucoma drugs and none of them required any surgical treatment for glaucoma.

Table 1. Classification of Steroid Responders on the Basis of Final IOP After 6 Weeks of Use of Topical Steroids (Prednisolone 0.1%) Eye Drops Type of responder Low Intermediate High

Final IOP (mmHg)

Patient (%)

<20

246 (82)

20-30

45 (15)

>30

9 (3)

Table 2. Rise of Intraocular Pressure Time interval after cataract surgery

Patients (%)

yy First postoperative day

30 (10)

yy First week

3 (1)

yy 6 weeks

54 (18)

yy 4 weeks after omission of steroid (10 weeks after surgery)

4 (1.3)

Table 3. Treatment Strategy Treatment protocol

Topical and systemic steroid

First-line of treatment

Discontinuation of steroids in all form if possible. Medical control of IOP for the wash off period of steroids

Second-line of treatment

Substitute with other nonsteroidal drugs or use minimal dose and duration of less potent steroid

Third-line of treatment

Medical treatment

Fourth-line of treatment

Laser or surgery

Thus, in this study of 300 patients operated for cataract surgery, 30 (10%) patients had raised IOP on first postoperative day, which may be due to intraocular inflammation or any retained viscoelastic substance or any retained cortical matter. Patients with higher IOP were treated accordingly. After first week of cataract surgery only 3 patients of higher IOP on first day had persistently raised IOP. All 300 patients were given steroid eye drops (prednisolone acetate 1%) for 6 weeks and raised IOP was observed in 54 (18%) of them.

After stoppage of steroids eye drops for 4 weeks, only 4 (1.3%) of total operated patients had persistently raised IOP, which required antiglaucoma treatment (Table 2).

DISCUSSION Cataract surgery is performed by removal of opaque natural lens and implantation of artificial transparent lens in eye with different techniques including newer phacoemulsification and conventional SICS. Steroids are used along with antibiotics for a prolonged postoperative time to control inflammation and for faster visual recovery. But topical steroid used also cause elevation of IOP in a significant number of patients. In most of the patients, elevated IOP is usually transient and harmless. But some patients may develop ocular complications including corneal edema, ocular discomfort and even vision threatening complications

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OPHTHALMOLOGY Table 4. Patients Responding to Steroids (IOP Changes After 6 Weeks of Steroid Use) in Present and Other Study Study Armaly et al

% of pts with rise of IOP after 6 weeks of steroid

IOP change >6-15 mmHg (%)

IOP change >15 mmHg (%)

34

29

5

Becker et al

36

-

-

Beidner et al

12

10

2.5

Present study

18

15

3

requiring further intervention. The increase in IOP may be marked and is the most frequent postoperative complication requiring specific treatment.4,5 Numerous studies have evaluated the risk of increase in IOP following demographics, etiology and the most effective way to treat it in short- and long-term.6 Treatment options include different antiglaucoma medications and sometime surgical option including trabeculectomy. In most of patients, IOP increase will return to baseline with or without treatment, some patients may experience ocular pain, corneal edema and even sight-threatening complications such as progressive field loss in advanced glaucoma and retinal vascular occlusion.7 Increase in IOP following cataract surgery is transient in most of patients.8 According to a recent study, as many as 25% of patients experience IOP spike >30 mmHg, 4-6 hours after uncomplicated phacoemulsification.9,10 At 24 hours postoperatively, the incidence of IOP spikes decreased to 10% and in all cases IOP was normal (<21 mmHg) 3 weeks later. Another study found >18% of nonglaucoma patients had an IOP of >28 mmHg, 3-7 hours postoperatively, which decreased to below preoperative levels by 4 days in most patients.2 As a general rule, patients with healthy eyes can tolerate transient rise in IOP with no damage to visual function, but in patients of risk factors like pre-existing glaucoma, high myopia damage affecting visual function may occur.

After cataract surgery, steroid-induced IOP elevation occurs within a few weeks of beginning of steroid therapy. After stoppage of steroids, the IOP lowers spontaneously to the baseline within few weeks without any antiglaucoma medications in majority of patients.

In rare cases, only IOP remains elevated and requires treatment to lower it. In our study, 10% patients had rise of IOP on first postoperative day, which is comparable to previous studies. Retained viscoelastic, cortical matter and intraocular inflammation are reasons for elevated IOP on first postoperative day. After 1 week of follow-up only 1% of patient had raised IOP. After 6 weeks of steroid use, 18% of the patients showed rise in IOP of >6 mmHg, which is comparable to other studies.

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Steroid responders (>15 mmHg) were 3%, which is similar to other studies.

In the present study, steroid eye drops were given for 6 weeks and 98.7% patients had normal IOP after 4 weeks of stoppage of steroid eye drops. In a similar study by Nema et al, 100% patient had normal IOP and in another study by Espilora et al 98% patients had normal IOP. CONCLUSION Steroids are primary drugs used after cataract surgery to control inflammation, but they also increase IOP in significant number of patients. But in almost all of patients increase in IOP is transient and returns to baseline after omission of steroid therapy spontaneously without causing any damage to visual function. Risk factors for IOP fluctuations include glaucoma, high myopia or high hypermetropia, intraocular inflammation, etc. Care must be taken while prescribing topical steroids in such patients and IOP monitoring should be done regularly in such patients to prevent vision threatening persistent ocular hypertension.

REFERENCES 1. Shingleton BJ, Gamell LS, Oâ&#x20AC;&#x2122;Donoghue MW, Baylus SL, King R. Long-term changes in intraocular pressure after clear corneal phacoemulsification: normal patients versus glaucoma suspect and glaucoma patients. J Cataract Refract Surg. 1999;25(7):885-90.

2. Drance SM. Glaucoma: a look beyond intraocular pressure. Am J Ophthalmol. 1997;123(6):817-9.

3. Gonzalez P, Epstein DL, BorrĂĄs T. Genes upregulated in the human trabecular meshwork in response to elevated intraocular pressure. Invest Ophthalmol Vis Sci. 2000;41(2):352-61.

4. Shields MB. The non-contact tonometer. Its value and limitations. Surv Ophthalmol. 1980;24(4):211-9.

5. Hildebrand GD, Wickremasinghe SS, Tranos PG, Harris ML, Little BC. Efficacy of anterior chamber decompression in controlling early intraocular pressure spikes after uneventful phacoemulsification. J Cataract Refract Surg.

2003;29(6):1087-92.

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CONFERENCE PROCEEDINGS

71st Annual Conference of The Association of Physicians of India (APICON 2016) increased physical activity in daily living, avoidance of tobacco, use of mass-media approaches, social marketing for health promotion.

MODERN INDIAN MEDICINE Prof Dr BM Hegde, Mangalore ÂÂ

Modernity does not come from the West. Modernity has to be developed in our own country.

ÂÂ

We need a new sickness care method incorporating all the good things from various systems including emergency methods from western medicine.

ÂÂ

We should build it with our own foundation but with doors and windows open from all sides.

MEDICINE IN INDIA: CHALLENGES, INNOVATIONS AND PRACTICES Dr Gurpreet S Wander, Ludhiana

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“Creating a better future, requires creativity in the present”.

-Matthew Goldfinger

CAN WE CHANGE THE NATURAL HISTORY OF TYPE 2 DIABETES? Dr V Mohan, Chennai ÂÂ

There is a section of people with the NGT who will progress to prediabetes and diabetes. We can modify the natural history of T2DM at every stage of the disorder.

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At the stage of prediabetes: Begin with lifestyle change. But, start medication (e.g., Metformin) early if IFG + IGT.

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At the stage of clinical diabetes: If HbA1c >8.5%, give a short course of insulin for 1-2 months to revive the β cells at the time of diagnosis. Aim for A1c <7% plus control of BP and lipids to prevent complications at every stage.

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At the stage of complications: Try to limit the damage, screen periodically for complications, treat complications aggressively, rehabilitate.

“The best way to have a good idea is to have a lot of ideas.”

-Dr Linus Pauling ÂÂ

NCDs contribute to 63% of total deaths (2008); 80% of these deaths occur in low/middle income countries; 80% of deaths due to NCD’s are due to 4 disease clusters (CVD, cancer, COPD and diabetes).

In 1987, William Osler described a typical heart patient as “A keen and ambitious man, the indicator of whose engine is always at full speed ahead”.

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CVD is an epidemic in India and is the most common cause of mortality. Over the last 6 decades, prevalence has increased from 1-2% to 9-10% in urban India and from <1% to 4-5% in rural India.

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Unique features of CHD in India: Increasing burden, younger age, more often with acute MI, diffuse and aggressive, death 10 years earlier.

ÂÂ

Genetically SAs have higher Lp(a) than the indigenous population (Lancet. 1995).

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There has been a significant increase in risk factors in last 20 years.

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Westernized Asians and CVD: Nurture (lifestyle factors) and nature (genetic).

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IHG III: In view of our special geographical, ethnic and climatic conditions, dietary habits, literacy levels and socioeconomic variables, significant differences need to be addressed.

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IGH-I: Data were collated keeping in mind the Indian published work and Indian conditions. The endeavor was to highlight certain differences in the Indian context.

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Remedial measures: Health and risk factor awareness, availability of health-promoting foods,

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IGH-II: Use of home monitoring of BP was discouraged; “lower the better policy” for target

INDIAN HT GUIDELINES: EVOLUTION AND KEY LESSONS Dr Siddharth N Shah, Mumbai A key message when considering guidelines for hypertension management is that they demonstrate evidence-based evolution, not revolution…

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CONFERENCE PROCEEDINGS BP was preferred. Better devices and newer data showing usefulness of HBP for follow-up, so now encouraged. J-shaped curve exists → caution in trying to ↓ BP to low target levels. ÂÂ

IGH-III: Considers diuretics at par with ACEI/ ARB/CCB. Chlorthalidone better than HCTZ and is preferred; β blockers no longer recommended as 1st-line agents, start therapy with combination if BP >20/10 mmHg, ACEI/ARB in combination with CCB forms a good combination, treatment of HT even in octogenarians (>80 years) is recommended, CKD is a common comorbidity, HFnEF to be recognized by physicians, Hg sphygmomanometers are being replaced by aneroid and digital ones.

LYMPH NODE TB: CONFLICTS AND CONTROVERSIES

disorders but needs aggressive research and support from the medical community as well as legal decriminalization. ÂÂ

Tablet devices like iPads are widely used for medical care in the US and pathogenic bacteria harbor on these devices. Their role in hospitalacquired infections needs to be studied and standard precautions and policy driven guidelines must be followed.

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Patient safety and quality of care are important concepts that drive medical care in the west but need significantly more focus from policymakers, public health officials, and medical scholars in developing countries like India to improve health outcomes.

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Telemedicine is the next big healthcare phenomenon and a very innovative method of medical care delivery, especially in countries like India where access to high quality and affordable care is problematic.

Prof MA Jalil Chowdhury, Dhaka ÂÂ

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Most cases of TB granuloma detected at the end of CAT-1 regimen were ultimately found culture negative for AFB (though RIF-sensitive MTB on GeneXpert) and majority improved after surgery irrespective of continuation of ATDs. This means that persistence of granuloma during/ at the end of CAT-1 treatment does not indicate active TB and should not be the justification of further anti-TB treatment.

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RIF-sensitive MTB on GeneXpert at the end of treatment regimen does not justify continuation of ATD.

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If you suspect alternate diagnosis for enlargement, please do histopathology.

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If you suspect DR-TB, please go for AFB culture and sensitivity.

RECENT ADVANCES IN MEDICINE

AMA: ITS STRATEGIC PLAN AND IMPACT ON HEALTHCARE IN THE US Dr Andrew W Gurman, USA ÂÂ

The American Medical Association (AMA) is the leading voice for physicians in the US, just as API is the leading voice for physicians in India.

ÂÂ

As individuals, we may not be heard; but as a unified voice of medicine, we will certainly be heard, by Congress and the public.

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Technological advances, the need for health equity among all citizens, and an emphasis on better outcomes are all factors that are changing the healthcare landscape.

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In the midst of all the change, the physician-patient relationship remains most fundamental and must be protected.

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AMA has developed a strategic plan focusing on three key areas.

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Our first area of focus is improving health outcomes for patients by reducing the burden of chronic disease, with a particular focus on raising awareness of prediabetes and HT.

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Our second area of focus is creating an innovative medical school of the future that trains physicians to better meet the needs of a diverse population.

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The third area of focus is helping physicians thrive as they practice medicine, by preventing burnout, enhancing teamwork and improving workflow.

Dr Tanu S Pandey, USA ÂÂ

Electronic cigarettes may be a novel therapy in smoking cessation but has its own risks and needs regulatory measures to prevent abuse.

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Stool transplant is a cost-effective, relatively easy, highly efficacious though cringe-inducing treatment with minor side effects for recurrent or severe Clostridium difficile infection.

ÂÂ

Bronchial thermoplasty is a novel procedure-based effective therapy for severe intractable asthma but must be done by experts skilled in the procedure.

ÂÂ

Medical marijuana has the potential to be a powerful drug in several debilitating medical

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CONFERENCE PROCEEDINGS ÂÂ

The API and the AMA should continue to work together to address the common challenges we face.

SHOULD SMARTPHONES OR TABLETS BE USED IN FRONT OF PATIENTS? Dr (Lt Col) Amitabh Sagar, Dehradun ÂÂ

The advent of the smart mobile devices (SMD) has made it possible to keep factual information on a device without the need to internalize it and yet have the ability to access the correct information for the correct section at the right time and without any error and automatically updated as per latest guidelines (in the background updating of software). This has constituted a major shift in the professional identity.

ÂÂ

Many hospitals in various countries are already using SMD for clinical decision-making in front of the patients. Our fears of “what will the patient think” are largely unfounded from review of literature and our own studies.

ÂÂ

Our fears of false eminence-based image, medieval mindset of “100% internalization of knowledge and emesis on demand” needs to change.

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While internalization of knowledge and concepts is required yet exact dosages of not so commonly used drugs, “point of care” drug interaction checking and complex clinical decision-making tools can be utilized on the bedside in front of the patients. One also need not memorize all evidencebased guidelines and should be “able to navigate the cloud”.

ÂÂ

Use of SMD brings us close to evidence-based medicine and current recommendations (with safety of patients) compared to the classical memory centric “eminence-based medicine”.

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The technology is there. The patients feel safe. The practice is already established in many countries.

Then why are we hesitant?

ÂÂ

It is important for headships in medical colleges and healthcare organizations to put the agenda in this fast evolving area and make the best use of the benefits of this powerful new technology.

ÂÂ

Initiate EN within 24-48 hours after admission to the ICU.

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Take steps as needed to reduce risk of aspiration or improve tolerance to gastric feeding.

ÂÂ

Implement feeding protocols to promote delivery of EN.

ÂÂ

Do not use gastric residual volumes as part of routine care to monitor ICU patients receiving EN.

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Start parenteral nutrition early when EN is not feasible.

BUSINESS PRIMER FOR PHYSICIANS Prof Amit Ghosh, USA ÂÂ

Knowledge of basic business skills is essential for physicians at work place today.

ÂÂ

Physicians should be able to articulate Vision, Mission and Value statements, understand various internal and external stakeholders in healthcare, appreciate various internal and external environmental forces affecting healthcare.

ÂÂ

Physicians should be master communicators and know how to resolve conflicts.

ÂÂ

Physicians should be able to understand strategic leadership.

A STEP CARE APPROACH TO THE MANAGEMENT OF CHRONIC SYSTOLIC HF Prof Dr Saumitra Ray, Kolkata ÂÂ

Chronic systolic HF is an increasing problem with increasing proportion of elderly population.

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Prognosis is worse than many malignancies and morbidity is huge.

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It produces the biggest economic burden on the healthcare system of all heart-related ailments.

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Identification and treatment at presymptomatic stage can abort the future devastation.

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Risk factors should be identified and treated adequately.

ÂÂ

Pharmacotherapy should be clearly divided between symptomatic therapy and diseasemodifying therapy. The former should be used at the lowest effective doses, and the latter at the highest tolerated doses.

ÂÂ

Devices for therapy are expanding in their scopes and technologies. Caution must be taken to use them appropriately. Genetic therapy holds promise for the future.

NUTRITION IN ICU Dr Rajesh Mahajan, Ludhiana ÂÂ

Assess patients on admission to the ICU for nutrition risk; calculate both energy and protein requirements.

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CONFERENCE PROCEEDINGS

69th Indian Dental Conference (IDC 2016) RESTORING PULPLESS TEETH: DO TRADITIONAL PRINCIPLES STILL APPLY? Dr Steve Morgano, USA Guidelines for restoring pulpless teeth are wellestablished; nevertheless the principles behind these guidelines were developed decades ago primarily from in vitro studies or retrospective studies of metallic posts cemented with conventional cements. New materials and techniques have been introduced for the restoration of pulpless teeth, and there are additional clinical studies in the literature, not only on traditional materials and methods but also on the more novel materials.

A BEAUTIFUL SMILE BENEFACTED BY IMPLANTS Dr Kanir Bhatia, Mumbai Look good and feel better - Mantra for a healthy smile.

The demands of the patient to have an eternal smile and a mouthful of teeth seems utopian. The reality of science and the realms of possibility allows a narrow window of execution. The stability of an implant, the precision of a prosthesis and the emotion of esthetics blend into a recipe for an implant smile based on good lab support.

ESSENTIALS AND RELEVANCE OF RESEARCH METHODOLOGY FOR DENTIST

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In vitro or laboratory research studies have good internal validity, whereas, clinical studies have good external validity.

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Steps involved in developing and testing a questionnaire: Research background, questionnaire conceptualization, format and data analysis and establishing validity and reliability.

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Statistical inference lays a foundation for the evidence deduced from any study.

FULL MOUTH FIXED PROSTHETIC RECONSTRUCTION: WHERE SHOULD I BEGIN? Dr Minaal Verma, US Diagnosis and treatment planning is essential for providing a comprehensive and effective dental solution. Treatment planning includes an array of critical components such as appropriate patient selection, complexity of dental and medical conditions, patient compliance and economic factors, that can collectively influence outcome of the treatment.

TOO EARLY OR TOO LATE: ORTHODONTIC POSSIBILITIES Dr Puja Khanna, New Delhi ÂÂ

Identify and diagnose orthodontic cases routinely overlooked and missed in day-to-day practice.

Dr Amandeep Chopra, Derabassi

ÂÂ

Planning a good research project forms the primary basis of meaningful publication.

Orthodontic evaluation of a child is recommended at age 7 years onwards.

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The first opportunity of preventive orthodontics starts with early loss of deciduous teeth.

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Early orthodontic treatment addresses the cause of malocclusion while the child is still growing, often without the need for extractions or fixed orthodontic treatment.

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Pre-teens and teens is not the only time to do orthodontic treatment.

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Orthodontic treatment can be done at any age provided the teeth and supporting tissues are healthy.

ÂÂ

General practitioner and orthodontist should collaborate and work jointly to give better restorative and esthetic results to patients.

A well-built research question should include four parts, referred to as the Problem, Intervention, Comparison and Outcome (PICO) format, which includes Patient/Population PICO. Feasibility in terms of time, cost, samples and infrastructure are vital to set a logistic time frame for the functioning and completion of the study.

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A study that does not adhere to ethical principles fails to answer clinically relevant questions.

ÂÂ

The possibility of a research study being acknowledged in scientific literature is often driven by the relevance of evidence that a particular research study can deliver.

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CONFERENCE PROCEEDINGS ÂÂ

Today’s braces are so advanced and less noticeable and do not cause much change in patient’s appearance during treatment.

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Introducing orthodontics in your practice can boost your overall revenue and enhance your practice.

KNOW YOUR PAIN Dr Prashanth Konatham Haribabu, USA The field of Orofacial Pain is concerned with the prevention, evaluation, diagnosis, treatment and rehabilitation of orofacial pain disorders. Such disorders may have pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be syndromes in which pain constitutes the primary problem, such as TMJ disorder pain, neuropathic pains or headaches.

Orofacial pain is evolving; the scope of the field is enlarging. At the present time the orofacial pain encompasses TMJ disorders, masticatory musculoskeletal pain, cervical musculoskeletal pain, neurovascular pain, neuropathic pain, sleep disorders related to orofacial pain, orofacial dystonias, headaches and intraoral, intracranial, extracranial and systemic disorders that cause orofacial pain.

Knowing the pathophysiology of painful conditions, neural pathways and the pharmacological interventions contribute greatly to relief from pain.

NATUROPATHY: THE WAY TO SMART LIVING Dr Brij Bhushan Goel, New Delhi Naturopathy is a method of treating diseases of human body using food, exercise and heat to assist the natural process of healing. The pathy believes in identifying and removing the cause of any disease. In this process, whole body is treated as one piece and not as per the problem concerned with a particular system. It is advised to consume food as per our natural alkaline acidic ratio of body which is 80:20, respectively. All raw foods are alkaline and the cooked ones are considered acidic “We are what we eat”. We have heard it, we know it. But whatever we are eating in today’s lifestyle, is making us believe that having high blood pressure, high blood sugar and other cardiac procedures are normal happenings in our life after a certain age. But naturopathy demystifies this belief.

In a way by adopting Naturopathy, we can treat ourselves without medicines and their side effects, live longer without diseases and keep ourselves fit with the help of natural processes of toxins elimination.

PREVENTIVE AND INTERCEPTIVE ORTHODONTICS: PLANNING THE OCCLUSION Dr Anil P Ardeshna, USA Early examination and treatment of the mixed dentition enables the practitioner to address specific problems in the growing child. The American Association of Orthodontists recommends that every child have an orthodontic examination by the age of seven.

Indications for early treatment are many. Preventive and/or interceptive orthodontics implies several possibilities: a) The guiding of erupting permanent teeth into an ideal position; b) using simplified procedures that are time and cost-effective; c) obtaining a more stable early result with less retention problems; d) possible avoidance of extraction of permanent teeth; e) elimination of deleterious habits and f) growth modification.

FUNCTIONAL ESTHETICS Dr Suhas Lele, Mumbai Esthetics without function is as well as Dentistry without Teeth! As, dentistry has evolved in different directions and verticals, it is prudent to understand and inculcate the same in practical dentistry.

ERGONOMICS OF SITTING: HEALTH BENEFITS Dr Velli Jussi Jalkanern, Finland Dentists have the most musculoskeletal problems among academic professions due to special ergonomic challenges in the dental work.

New Salli sitting and ergonomic dental concept, which is based on riding type of sitting, has clear ergonomic, mobility and physiological advantages in posture, spinal/joint health, muscle tensions and even on the health of pelvic and internal organs.

MEDICOLEGAL PROBLEMS... HOW TO AVOID? Dr Vishwas Puranik, Mumbai Medicolegal cases are an integral part of medical/ dental practice and are frequently encountered by practitioners.

Today’s consumer of our therapeutic services i.e., the patient, has tremendously increased expectations owing to awareness. If these expectations aren’t met, such situations may transform into a medicolegal complaint.

Media has also played a very important role in escalating certain such situations victimizing the doctor in most

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CONFERENCE PROCEEDINGS cases. Hence in today’s times, it has become customary for each practitioner to acquaint himself with the law related to medical/dental procedures practised by us.

ANTIMICROBIAL PHOTODYNAMIC THERAPY: A NEW DISINFECTION FRONTIER IN DENTISTRY Dr Arundeep Kaur Lamba, New Delhi Antimicrobial photodynamic therapy successfully stops inflammation without antibiotics, without surgical intervention and without any adverse effects with maximum therapeutic benefits in different oro-dental infections. Future directions should conduct researches involving new photosensitive compounds seeking improved photophysical and photochemical properties to maximize the photodynamic action in the biological environment.

DENTAL INFECTION CONTROL AND OCCUPATIONAL SAFETY Dr Raghunath Puttaiah, US Sterilization standards vary from country to country but the science of disease transmission remains the same. New innovations in sterility assurance and digital record preservation with new scientific innovations in Digital Indicator Technology is the future in patient safety standards, risk aversion and medical malpractice issues in Medicine and Dentistry.

of hypnosis. So, it can also change the perception of patient completely for better dental care acceptance. lt improves psychomotor skills for better treatment and enhances communication skill to avoid dissatisfied patient.

DIRECT VENEER Dr Deepak Muchhala, Mumbai Direct resin veneer is the glamour procedure in cosmetic dentistry and is most responsible for its exclusive growth. The technique is demanding, and learning to use direct resin predictably and successfully takes time and dedication.

MEDICAL EMERGENCIES IN DENTAL PRACTICE: PREVENTION IS BETTER THAN CURE! Dr Gautam Madan, Gujarat Advances in medical science have created walking bombs! People with serious medical problems are nowadays living an active life! Dental treatment of such patients without proper precautions can trigger a serious event! It is imperative that you, your staff and your clinic be prepared to handle such patients.

EQUIPPING THE DENTAL SURGERY WITH INFECTION CONTROL IN MIND Dr Sanjay Joshi, Mumbai

HYPNOSIS: AN ADJUNCT TO SUCCESSFUL DENTISTRY Dr Yogesh Chandrana, Gujarat Modern day’s dental practice demands high technical skills along with effective communication skills for better patient care. Dental profession being driven up by psychomotor skills can be enhanced with the knowledge and use of an age old science of hypnosis.

The stress of dental practice needs to be handled well by the dentist, which can be done with simple techniques

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Understand the routine application of various infection control protocol.

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Instrument processing and sterilization.

ÂÂ

Importance technique.

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A major goal of this presentation is to help dental professionals increase their understanding of the “why” as well as the “what” of infection control practices.

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of

practicing

aseptic

nontouch

CONFERENCE PROCEEDINGS

India’s Premier Interventional Experience (TCT India Next 2016) USE OF INTRAVASCULAR IMAGING IN pPCI AND ACS Dr Sandeep Nathan, USA ÂÂ

Intravascular imaging in STEMI PCI is performed relatively infrequently for a variety of reasons viz. the acuity of the clinical situation, with deference to door-to-balloon times, etc.

ÂÂ

But, it may offer significant incremental information over angiography by way of: zz Disease quantification in IRA and non-IRA

ABSORB III: PIVOTAL TRIAL MAIN RESULTS Dr Gregg W Stone, USA ÂÂ

The primary endpoint was met: Absorb BVS was noninferior to Xience for the composite safety and effectiveness endpoint of TLF at 1 year in the entire study population.

ÂÂ

Absorb BVS was highly effective, with ID-TLR rates comparable to Xience.

ÂÂ

ABSORB had similar safety profile as Xience when implanted in appropriately sized vessels. While, in very small vessels (those smaller than intended for this device), a signal for increased thrombosis was observed.

ÂÂ

The comparable overall outcomes between Absorb and Xience at 1 year sets the stage for the benefits of Absorb in restoring normal coronary physiology and adaptive vascular responses to translate into improved long-term clinical outcomes, a hypothesis being tested in the ABSORB IV trial (n = 5,000; results expected in 2022).

stenotic vessels

zz Guidance for lesion prep as well as device

choice, sizing and deployment

zz Clarifying mechanisms of ST and TVR in

vessels previously intervened upon.

ÂÂ

Plaque characterization with either spectral analysis (VH) or identification of lipid-rich plaque (NIRSIVUS) may offer some incremental prognostic or therapeutic information

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Grayscale IVUS ± color flow detection in pPCI may offer the best balance of useful information, accessibility, cost and technical ease of use among the currently available technologies.

HOW TO CHOOSE A GUIDE CATHETER?

STENT THROMBOSIS Dr Vipin Thomas, UAE ÂÂ

Stent thrombosis is a devastating complication of stent implantation due to multifactorial causes and strict attention to patient risk factors and adherence/compliance to medication should be assessed prior to stent implantation or selection.

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Need for continued DAPT should be assessed based on DAPT score.

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Meticulous care to technical details is necessary to optimize stent implantation and novel stents are emerging with the potential to inherently lower the risk of stent thrombosis.

Dr Ramesh Daggubati, USA ÂÂ

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Some important guiding catheter features include atraumatic tip, proper preformed shape (coaxial with vessel), torque control, kink resistance, radiopacity.

When using the guide catheter, aspirate vigorously (atheroma or thrombus ‘scooped up’ from the aorta), insist on bleed back (prevent air embolus), avoid blood standing in guide (flush frequently), avoid Amplatz in proximal or ostial disease and also take care with side holes and deep engagement.

Key Points ÂÂ Proper choice of equipment facilitates best results with PCI. ÂÂ It shortens procedure times, improves success rates and reduces complications and adverse events.

RCA CTO AND LMCA DISEASE: IS CABG THE ONLY OPTION? Dr Tarun Dave, Ahmedabad ÂÂ

PCI is safe and reliable alternative to CABG in patient with RCA-CTO and LMCA disease provided complete revascularization is achieved.

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CONFERENCE PROCEEDINGS ÂÂ

Long-term results of current DES in CTO and LMCA subsets are good and promising.

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Nonavailability of IVUS or OCT should not be a deterrent to carry out such complex PCI.

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In cases where microcatheter fails to advance, newer balloons like EMERGE

(Boston Scientific) help in successful accomplishment of the case.

AORTOARTERITIS INTERVENTIONS Dr Sanjay Tyagi, New Delhi ÂÂ

High efficacy of biological-targeted Rx (TNF-α antagonists, tocilizumab, IL-6 inhibitors) in refractory patients with TA with an acceptable safety profile.

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Intervention is safe and effective; result are better in short segment versus long segment stenosis.

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Cutting balloon angioplasty gives smoother results, reduces the need of stent, effective in instant restenosis.

DEDICATED BIFURCATION STENTS: WHERE DO WE STAND? Dr Ramesh Daggubati, USA ÂÂ

Provisional one-stent strategy remains the preferred approach.

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For complex true bifurcations, dedicated bifurcation stents may be useful but should be rigorously evaluated.

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In the future, expect a selective strategy with dedicated LM stents as a component of Rx strategy, hopefully!

TRADITIONAL TUMESCENCE-BASED THERMAL ABLATIONS AND NOVEL NONTHERMAL, NONTUMESCENCE ENDOVENOUS TREATMENT FOR VENOUS INSUFFICIENCY Dr NN Khanna, New Delhi ÂÂ

Endovenous thermal ablation techniques include laser, radiofrequency and steam; they are performed using tumescent anesthesia.

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Advantages of tumescent anesthesia: Reduction of rate of skin burns and the paresthesias, satisfactory treatment of even the most aneurysmal veins, effective analgesia.

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Disadvantages of tumescent anesthesia: Time consuming, tedious delivery, multiple injections, large volume of lidocaine, can be quite

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uncomfortable for some patients, learning curve for novice operators. ÂÂ

Nonthermal, nontumescence-based techniques include Mechanical Occlusive Chemical Ablation (MOCA), Varythema, Cyanoacrilate Glue and V block occlusive device.

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MOCA is done using Clarivein, a safe technique with immediate recovery. There are no long-term data results and cannot be used for tortuous veins.

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New evolving techniques are designed to eliminate the need for tumescent anesthesia.

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Thermal remains as a safe and effective means of venous insufficiency treatment and new techniques must be similar or better.

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Complex venous anatomy demands multiple tools available. Cost is important.

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Healthcare providers play a major role in which technique they will cover.

HOW TO APPROACH THE PROBLEM OF NONDEFLATING AND BROKEN BALLOON? Dr Nilkanth C Patil, Dr P Lal, Noida ÂÂ

Dilution usually works.

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Take balloon inside guiding - RCA vs. LCA.

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Rupture with hard end.

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Never inject contrast especially RCA.

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Surgery.

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Rupturing by overinflation is the last resort.

INCREASING HEAD AND NECK TUMORS AND ORTHOPEDIC RISKS IN INTERVENTIONAL CARDIOLOGISTS Dr NN Khanna, New Delhi ÂÂ

There is no safe dose of radiation. Brain and eyes are much more radiosensitive than previously thought.

ÂÂ

In the ‘interventional era’, the volume of cases per operator, the volume of cases per lab, the fluoroscopy time per case and case complexity, have led to an increase in radiation exposure.

ÂÂ

Occupational hazards, such as orthopedic risks, cervical and lumbar spine symptoms, occupational radiation exposure causing cataracts, thyroid cancer, skin cancer (hands) are increasing in number.

ÂÂ

Interventionalists are typically positioned with the left side of their body close to the patient’s chest

CONFERENCE PROCEEDINGS and X-ray source, leading to a higher risk of leftsided brain tumors. ÂÂ

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Interventionalists have high rates of orthopedic injury. Long hours of standing at the patient table and the weight of leaded personal protective equipment (PPE) exert continuous pressure on the musculoskeletal system.

Reducing scatter radiation can be done by modifying factors: TIDS (Time, Intensity, Distance and Shielding).

ÂÂ

Limiting fluoroscopy time, and using lowest fluoroscopy dose yielding adequate image should be followed.

ÂÂ

Increasing distance from X-ray tube and wearing appropriate PPE is imperative to protect from radiation hazards.

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IF 2-STENT, THEN WHICH STRATEGY AND WHY? Dr VK Bahl, New Delhi ÂÂ

“Single MB stent with provisional SB stent” remains the strategy of choice for majority (stents do not like bends).

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Techniques of choice: DK crush and Culotte for two-stent strategy and TAP for provisional stenting. When 2 stents are required - No Penalty, if results Optimal. Dedicated bifurcated stents/BRS need more refinements.

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More attention should be paid to optimizing the chosen technique than to choosing among techniques. Keep It Simple, Swift and Safe (KISSS)…

BIFURCATION STENTING: DK CRUSH IN ACS SETTING

RETRIEVAL OF A PARTIALLY DEGLOVED STENT STRUT

Dr Jeet Ram Kashyap, Chandigarh

Dr Mukesh Laddha, Navi Mumbai ÂÂ

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Factors that predispose to stent entrapment include calcification and long lesion, lack or inadequate pre-dilatation of lesion, angulated and tortuous vessel, repeated forth and back movements while trying to cross lesion and lack of guiding catheter support.

ÂÂ

Finding a CTO in ACS setting is not infrequent.

Strategy depends upon hemodynamic status.

ÂÂ

DK crush has the advantage of 6F catheter as a guide.

ÂÂ

Crossing and recrossing is relatively easier as only one layer of metal is encountered.

To prevent stent dislodgement or migration, predilatation with a balloon catheter or use of stents with a smaller profile and good tractability are recommended in case of severe angulated or calcified lesions.

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Outcome has been shown to be better. However, it involves extra steps compared to conventional mini crush.

ACUTE MI WITH MASSIVE THROMBUS BURDEN: WHAT TO DO - One Go or Stepwise Strategy?

TAVI: TRANSLATING DESIGN INTO CLINICAL OUTCOMES

Dr Syed Maqbool, Srinagar

Dr Haim Danenberg, Israel ÂÂ

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It is an exciting time to be an interventional cardiologist and it is just getting better.

Corevalve Evolut R valve is an easy to use, low profile, re-capturable and accurately positioned transcatheter valve system.

The Evolut R valve provides further safety and efficacy to those of the ‘classic’ Corevalve system, translating to excellent clinical outcomes.

Primary PCI in acute MI with massive thrombus burden may be accomplished in two steps with excellent results.

Step 1: Achieve flow with thrombosuction/small balloon inflation at low pressures followed by abciximab infusion for 24-48 hours.

Step 2: Stent deployment if required.

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EXPERT’S VIEW

What are the Salient Features of the Updated NICE Guidelines for Hypertension Management?

MANISH BANSAL

N

ational Institute for Health and Clinical Excellence (NICE) first issued guidance for the management of hypertension in primary care in 2004. This was followed by a quick update of the pharmacological treatment chapter of the guideline in 2006. In August this year, NICE released its updated guidelines on the diagnosis and treatment of high BP (hypertension) which are expected to further improve the management of hypertension. The salient new and updated recommendations are briefly discussed below.

FIRST GUIDELINE TO RECOMMEND ABPM FOR DIAGNOSIS In a major change from its 2006 guideline, the updated 2011 recommendations advocated use of 24-hour ambulatory BP monitoring (ABPM) to confirm a diagnosis of primary hypertension, particularly if a clinic BP reading is ≥140/90 mmHg, instead of depending only on BP readings taken in the clinic. The diagnosis of hypertension has traditionally been based on several BP measurements made in the clinic, which are typically undertaken after a raised initial reading.

A recent systematic review with meta-analysis concluded that compared with ambulatory monitoring, neither clinic nor home measurement had sufficient sensitivity or specificity to be recommended as a single diagnostic test. ABPM estimates ‘true’ mean BP more accurately than clinic measurement because multiple readings are taken; it also correlates better with a range of cardiovascular outcomes and end organ damage. Besides being a more accurate method to diagnose hypertension, the ABPM is also a more cost-effective option, for all age groups and in men and women.

ABPM reduces misdiagnosis and thus save costs of treatment for who have been erroneously labeled as

Heart Institute-Division of Cardiology Medanta − The Medicity Gurgaon

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hypertensive after an initial high reading in office or at home. A cost-effectiveness analysis published in The Lancet has established the cost-effectiveness of ABPM. It found that additional costs from ambulatory monitoring are counterbalanced by cost savings from better targeted treatment and recommends ABPM for most patients before the start of antihypertensive medication.

ABPM is indicated where there is uncertainty in diagnosis, irregular or diurnal variation, to rule out white-coat hypertension, to uncover apparent drug resistance (office resistance), to better define resistant hypertension, to identify hypotensive symptoms while the patient is being treated with antihypertensives and to monitor episodic hypertension. The updated 2011 NICE guidelines are the first guidelines to address problems like white-coat hypertension, masked hypertension, BP variability and recommend ABPM in all patients.

HOME BP MONITORING For the first time this change empowers patients to become more involved in the monitoring and care of their hypertension.

DRUG OPTIONS The updated guidelines recommend the use of a calcium channel blocker (CCB) as the preferred firstline treatment in patients over age 55, or black patients of any age. For patients aged under 55, angiotensinconverting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) remain first-line drugs, and CCBs should be added as a second-step drug.

If a CCB is not suitable for step 2 treatment, for example because of edema or intolerance, or if there is evidence of heart failure or a high-risk of heart failure, a thiazidelike diuretic such as indapamide or chlorthalidone should be prescribed. In a major departure from earlier recommendations, the 2011 update recommends that when starting treatment with a diuretic, thiazide-like diuretic, such as chlorthalidone or indapamide should

EXPERT’S VIEW be used ‘in preference to’ conventional thiazide diuretics such as, bendroflumethiazide or hydrochlorothiazide.

However, those people already treated with lowdose bendroflumethiazide and in whom BP is controlled and no undesirable effects are noticed, should not necessarily be switched to chlorthalidone or indapamide.

HYPERTENSION IN THE ELDERLY For the first time, the 2011 guideline offers advice on treating hypertension in the very elderly i.e., those aged 80 or above. It recommends the same antihypertensive drug treatment in people over aged 80 as in people aged 55-80 years, taking into account any comorbidities; a change from earlier recommendations that urged

caution in the elderly, out of concerns that adverse effects might offset benefits.

SUGGESTED READING 1. Hodgkinson J, Mant J, Martin U, Guo B, Hobbs FD, Deeks JJ, et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ. 2011;342:d3621.

2. Lovibond K, Jowett S, Barton P, Caulfield M, Heneghan C, Hobbs FD, et al. Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study. Lancet. 2011;378(9798):1219-30.

3. Rafey MA. Hypertension. Section 9. Nephrology. In: Cleveland Clinic: Current Clinical Medicine. 2nd Edition, Saunders: Elsevier; 2010. p. 868.

■■■■

...Cont'd from page 571

25. Cho IJ, Ahn JY, Kim S, Choi MS, Ha TY. Resveratrol attenuates the expression of HMG-CoA reductase mRNA in hamsters. Biochem Biophys Res Commun.

2008;367(1):190-4.

the association of resveratrol with oral contraceptives for management of endometriosis-related pain. Int J Womens Health. 2015;4:543-9.

27. Rosser M. Endometriosis update: That’s an awful lot of red wine 2012. Available at: www.endo-update.blogspot.in/ 26. Maia H Jr, Haddad C, Pinheiro N, Casoy J. Advantages of ■■■■

...Cont'd from page 574

6. Tranos PG, Wickremasinghe SS, Hildebrand D, Asaria R, Mearza A, Ghazi-Nouri S, et al. Same-day versus first-day review of intraocular pressure after uneventful phacoemulsification. J Cataract Refract Surg.

2003;29(3):508-12.

7. Vannas S, Tarkkanen A. Retinal vein occlusion and glaucoma. Tonographic study of the incidence of glaucoma and of its prognostic significance. Br J Ophthalmol.

1960;44:583-9.

8. Tranos P, Bhar G, Little B. Postoperative intraocular pressure spikes: the need to treat. Eye (Lond).

2004;18(7):673-9.

9. Ahmed II, Kranemann C, Chipman M, Malam F. Revisiting early postoperative follow-up after phacoemulsification.

J Cataract Refract Surg. 2002;28(1):100-8.

10. Gokhale PA, Patterson E. Elevated IOP after cataract surgery. Glaucoma Today. 2007;5(3):19-22.

Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

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MEDILAW

Time Limitation of Filing a Complaint A patient filed a case in the Medical Council against his treating doctor citing irregularity in the medical bills issued to him for expenses incurred on account of his treatment.

Proceed

This patient has filed a complaint after 9 years of the incident.

This is a timebarred complaint. It stands dismissed.

Lesson: If the period of limitation lapses and no complaint has been lodged then the complaint is treated as “Time-barred”. Period of limitation is the time period within which a complaint has to be lodged. There are many Delhi Medical Council orders where complaints filed after 3 years of the incident have been rejected.

•• In a case DMC/DC/F14/562/2009 decided on 2nd September, 2009, the Council rejected a complaint alleging professional misconduct on the part of the treating doctor on the ground that since the complaint had been made after a period of 9 years, the same did not merit consideration.

•• DMC/DC/F14/567/2009: The case was dismissed as the cause of action arose 6 years back.

•• DMC/DC/F14/580/2010: The case was dismissed as the cause of action arose 4 years back.

CASE SUMMARY

Case 1 Mr A filed a complaint against Dr B of Hospital X in the Medical Council alleging professional misconduct.

On examination of the complaint, it was found that the allegation of impropriety had been raised against Dr B for bills and/or certificates regarding treatment of patient A in the year 2000.

The Council observed that the complaint had been filed after 9 years of the said incident; so, it did not merit consideration and was rejected.1

Case 2 Mr C, as the complainant, alleged medical negligence on the part of Dr D in the treatment administered to him. According to the Medical Council, the complaint did not merit consideration as it was found to be made

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after almost 6 years of the cause of action in 2003. The Council rejected the complaint on this basis.2

Case 3 Mr E filed a complaint against Dr F alleging medical negligence in the treatment administered to him at Hospital Y. The complainant underwent cataract surgery on 7.1.2005 and the present complaint was filed with the Delhi Medical Council (DMC) on 3.6.2009, after almost a period of more than 4 years. The Council disposed off the complaint observing that to attribute loss of vision in operated eye due to surgery performed almost 3 years and 8 months before is medically untenable; hence, the complaint did not merit any consideration.3

References 1. DMC/DC/F-14/562/2009, dated 2nd September, 2009.

2. DMC/DC/F14/567/2009, dated 22nd May, 2009.

3. DMC/DC/F14/580/2010, dated 28th September, 2010.

MEDILAW However, in many laws, there is a provision empowering the authority/court to condone the delay if the complaint is lodged beyond time. This depends on the facts of each case.

WHAT THE INDIAN LAWS & REGULATIONS SAY ABOUT THE PERIOD OF LIMITATION

Consumer Protection Act, 1986 24A. Limitation period (1) The District Forum, the State Commission or the National Commission shall not admit a complaint unless it is filed within 2 years from the date on which the cause of action has arisen.

(2) Notwithstanding anything contained in Subsection (1), a complaint may be entertained after the period specified in Sub-section (1), if the complainant satisfies the District Forum, the State Commission or the National Commission, as the case may be, that he had sufficient cause for not filing the complaint within such period:

Provided that no such complaint shall be entertained unless the National Commission, the State Commission or the District Forum, as the case may be, records its reasons for condoning such delay.

23. Appeal. Any person, aggrieved by an order made by the National Commission in exercise of its powers conferred by Sub-clause (i) of Clause (a) of Section 21, may prefer an appeal against such order of the Supreme Court within a period of 30 days from the date of the order: Provided that the Supreme Court may entertain an appeal after the expiry of the said period of 30 days if it is satisfied that there was sufficient cause for not filing it within that period. Provided further that no appeal by a person who is required to pay any amount in terms of an order of the National Commission shall be entertained by the Supreme Court unless that person has deposited in the prescribed manner 50% of that amount or ` 50,000; whichever is less.

Medical Council of India (MCI) Clause 8.8 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. “Any person aggrieved by the decision of the State Medical Council on any complaint against a delinquent physician, shall have the right to file an appeal to the MCI within a period of 60 days from the date of receipt of the order passed by the said Medical Council: Provided that the MCI may, if it is satisfied that the appellant was prevented by sufficient cause from presenting the

appeal within the aforesaid period of 60 days, allow it to be presented within a further period of 60 days.”

In an appeal in the MCI against order DMC/DC/F.14/ Comp.580/2010, dated 23.09.2010 passed by the Council filed by Mr NK (F.No.839/2010), the Ethics Committee noted: “The MCI Ethics Committee noted that the complaint of the complainant has not been examined by DMC and the same has been rejected only on the grounds of delay in filling the complaint.

The Committee is of the opinion, that this cannot be a ground to reject the complaint, as manifestation of complication due to surgery, may arise even afterwards, so this alone cannot be a sufficient reason and the complaint should be examined on merit. Moreover, no reasons have been given by the DMC to come to the conclusion therefore, the matter be returned back to DMC to examine and give reasons for rejections.”

National Consumer Disputes & Redressal Commission (NCDRC) 14. Limitation (1) Subject to the provisions of Sections 15, 19 and 24A, the period of limitation in the following matters shall be as follows: (i)

Revision Petition shall be filed within 90 days from the date of the order or the date of receipt of the order as the case may be;

(ii) Application for setting aside the ex-parte order under Section 22A or dismissal of the complaint in default shall be maintainable if filed within 30 days from the date of the order or date of receipt of the order, as the case may be; (iii) An application for review under Sub-section (2) of Section 22 shall be filed to the National Commission within 30 days from the date of the order or receipt of the order, as the case may be; (iv) The period of limitation for filing any application for which no period of limitation has been specified in the Act, the rules of these regulations shall be 30 days from the date of the cause of action or the date of knowledge.

(2) Subject to the provisions of the Act, the Consumer Forum may condone the delay in filing an application or a petition referred to in Sub-regulation (1) if valid and sufficient reasons to its satisfaction are given.

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MEDILAW Code of Criminal Procedure (CrPC)

Section 470: Exclusion of Time in Certain Cases

Section 468: Bar to Taking Cognizance after Lapse of the Period of Limitation 1. Except as otherwise provided elsewhere in this Code, no Court, shall take cognizance of an offence of the category specified in Sub-Section (2), after the expiry of the period of limitation.

1. In computing the period of limitation, the time during which any person has been prosecuting with due diligence another prosecution, whether in a Court of first instance or in a Court of appeal or revision, against the offender, shall be excluded:

2.

3.

Provided that no such exclusion shall be made unless the prosecution relates to the same facts and is prosecuted in good faith in a Court which from defect of jurisdiction or other cause of a like nature, is unable to entertain it.

2.

Where the institution of the prosecution in respect of an offence has been stayed by an injunction or order, then, in computing the period of limitation, the period of the continuance of the injunction or order, the day on which it was issued or made, and the day on which it was withdrawn, shall be excluded.

3.

Where notice of prosecution for an offence has been given, or where, under any law for the time being in force, the previous consent or sanction of the Government or any other authority is required for the institution of any prosecution for an offence, than, in computing the period of limitation, the period of such notice or, as the case may be, the time required for obtaining such consent or sanction shall be excluded.

The period of limitation shall be: a.

six months, if the offence is punishable with fine only;

b.

one year, if the offence is punishable with imprisonment for a term not exceeding 1 year;

c.

three years, if the offence is punishable with imprisonment for a term exceeding 1 year but not exceeding 3 years.

For the purposes of this section, the period of limitation, in relation to offences which may be tried together, shall be determined with reference to the offence which is punishable with the more severe punishment or, as the case may be, the most severe punishment.

Section 469: Commencement of the Period of Limitation 1. The period of limitation, in relation to an offence, shall commence: a.

on the date of the offence; or

b. where the commission of the offence was not known to the person aggrieved by the offence or to any police officer, the first day on which such offence comes to the knowledge of such person or to any police officer, whichever is earlier; or c.

where it is not known by whom the offence was committed, the first day on which the identity of the offender is known to the person aggrieved by the offence or to the police officer making investigation into the offence, whichever is earlier.

2. In computing the said period, the day from which such period is to be computed shall be excluded.

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Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

Explanation: In computing the time required for obtaining the consent or sanction of the Government or any other authority, the date on which the application was made for obtaining the consent or sanction and the date of receipt of the order of the Government or other authority shall both be excluded.

1. In computing the period of limitation, the time during which the offender: a. has been absent from the India or from any territory outside India which is under the administration of the Central Government, or b. has avoided arrest by absconding or concealing himself, shall be excluded.

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Indian Journal of Diabetology

Emerging role of Cardiac MRI in Ischemic and Non-ischemic Cardiomyopathy

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Acute Renal Failure and Silent Myocardial Infarction Following Multiple Honey Bee Stings

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A Case of Left Atrial Myxoma Presenting as Severe Pulmonary Hypertension

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Double-Chambered Right Ventricle with Transient 2:1 Atrioventricular Block: A Rare Presentation

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AROUND THE GLOBE

News and Views WHO-led Alliance Awarded for Saving the Sight of Millions The World Health Organization (WHO) Alliance for the Global Elimination of Trachoma by the year 2020 (GET2020) has been awarded the Global Partnership Award by the International Agency for the Prevention of Blindness. The award is in recognition of the remarkable work accomplished by the Alliance in implementing the WHO-recommended SAFE strategy, which includes Surgery for trichiasis, Antibiotics to clear Chlamydia trachomatis infection, and facial cleanliness and environmental improvement to reduce transmission of the infection. … (WHO, October 28, 2016)

WHO Seeks Special UN Session on TB Frustrated with a lack of political will shown by nations with a high burden of tuberculosis, the World Health Organization (WHO) is calling for the first United Nations General Assembly on the deadly but curable infection. Speaking to The Hindu, Mario Raviglione, Director of the Global Tuberculosis Programme at the WHO, said, “We are now insisting on a UNGA on TB. We are not happy any more just talking to Ministers of Health because they have limited power.” (Vidya Krishnan, The Hindu, October 28, 2016)

300 Million Children Breathing Toxic Air, Says a UNICEF Report Almost one in seven of the world’s children, 300 million, live in areas with the most toxic levels of outdoor air pollution—six or more times higher than international guidelines—reveals a new report from the UNICEF ‘Clear the Air for Children’. The findings come a week ahead of the COP 22 in Marrakesh, Morocco, where UNICEF is calling on world leaders to take urgent action to cut air pollution in their countries. Together, outdoor and indoor air pollution are directly linked to pneumonia and other respiratory diseases that account for almost one in 10 under-five deaths, making air pollution one of the leading dangers to children’s health.

The satellite imagery used for the first time confirms that around 2 billion children live in areas where outdoor air pollution, caused by factors such as vehicle emissions, heavy use of fossil fuels, dust and burning of waste, exceeds minimum air quality guidelines set by the WHO.

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South Asia has the largest number of children living in these areas, at 620 million, with Africa following at 520 million children.

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The East Asia and Pacific region has 450 million children living in areas that exceed guideline limits. (Source: UNICEF)

Study Demonstrates Effectiveness of HPV Vaccine A study published in the November 2016 issue of Clinical Infectious Diseases observed substantial decline in vaccine-type human papillomavirus (HPV) among vaccinated young women during the first 8 years after HPV vaccine introduction in a community. The prevalence of vaccine-type HPV decreased >90% in vaccinated women, demonstrating high effectiveness in a community setting and >30% in unvaccinated women, providing evidence of herd protection.

A New Inhaled Antibiotic Trial Shows Encouraging Results in Patients with Bronchiectasis An investigational inhaled powder form of ciprofloxacin can significantly reduce the frequency of exacerbations in patients with noncystic fibrosis bronchiectasis, according to results from the phase 3 RESPIRE 1 trial. During the 48-week study period, the number of exacerbations was significantly lower with the 14-day regimen vs. placebo.

The study results were presented October 24, 2016 at CHEST 2016: American College of Chest Physicians Annual Meeting in Los Angeles.

Right Heart Thrombi are Prognostic in Patients with Acute Pulmonary Embolism In patients diagnosed with acute pulmonary embolism (PE), concomitant right heart thrombi were significantly associated with an increased risk of death within 30 days of PE diagnosis, says a systematic review and meta-analysis published in the October 2016 issue of the journal Chest. Right heart thrombi had a significant association with short-term all-cause mortality in all patients and with PE-related death.

Heavy Cannabis Use Reduces Bone Mineral Density Results of a cross-sectional study published online in the American Journal of Medicine show that the bone mineral density (BMD) of heavy cannabis users was approximately 5% lower than that among control

Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

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AROUND THE GLOBE smokers and that they had more than double the fracture risk of controls. Serum total 25-hydroxyvitamin D concentrations were reduced in heavy users compared with controls. Heavy cannabis use was also associated with low BMI and high bone turnover.

A Molecular Signature to Predict Response to Radiation Therapy in Prostate Cancer Researchers have developed a 24-gene molecular signature called PORTOS (Post-Operative Radiation Therapy Outcomes Score), which can predict which patients are likely to respond to postoperative radiation following radical prostatectomy with a significantly reduced risk for metastatic recurrence at 10 years.

Patients with a high PORTOS who had postoperative radiotherapy were less likely to have metastasis at 10 years than those who did not have radiotherapy.

A matched, retrospective analysis of results using this new score is published online October 12, 2016 in Lancet Oncology.

Metabolic Syndrome Increases Long-term Mortality Risk in Patients with Stable CAD Metabolic syndrome is independently associated with an increased 20-year all-cause mortality risk among patients with stable CAD, says a study published October 28, 2016 in Cardiovascular Diabetology. The excess of the very long-term mortality risk was consistent when either the IDF or NCEP definitions were used and similar across most population subgroups, yet less pronounced in patients of 65 year or older and absent in patients with renal failure.

A Behavioral Addiction Clinic at AIIMS The Dept. of Psychiatry at All India Institute of Medical Sciences (AIIMS), New Delhi and National Drug Dependence Treatment Center have initiated a Behavioral Addiction Clinic to cater to the needs of people with behavioral addiction problems such as internet addiction, gaming addiction, mobile addiction etc. The clinic is held every Saturday in the OPD of Dept. of Psychiatry alongside the general OPD. The clinic provides assessment as well as intervention services for behavioral addictions and comorbid mental health conditions.

Low Public Health Risk from Avian Influenza A H5N8 A number of wild birds died in National Zoological Park and Deer Park, both situated in Delhi and Zoological Park, Gwalior recently. Domesticated bird deaths (ducks)

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were also reported from Alappuzha District of Kerala.

In all these instances, samples tested at the National Institute of High Security Animal Diseases, Bhopal were found positive for Avian Influenza A H5N8. On the public health risk of Avian Influenza A H5N8, World Health Organization has informed that “based on current knowledge, the risk of zoonotic transmission is considered low for H5N8”, according to a press release of the Ministry of Health and Family Welfare on 27th October, 2016.

However, as a matter of abundant caution, the Ministry has advised the State Health Departments to use personal protective equipment by those handling dead/ sick birds, keep persons exposed to the dead/sick birds under surveillance and provide them chemoprophylaxis (Oseltamivir 75 mg once-daily for 10 days). (Press Information Bureau)

Factors Associated with Post-stroke Discharge to Home vs. Long-term Care According to a retrospective study, presented October 22, 2016 at the American Academy of Physical Medicine and Rehabilitation (AAPMR) 2016 Annual Assembly, the Functional Independence Measures (FIM) scores on admission for grooming, transfer, locomotion (walk/ wheelchair) and total functional independence were found to have high correlation with the patient being discharged home after acute inpatient rehabilitation admission.

Familial Hypercholesterolemia Screening in Primary Care Identifies at-risk Children and Parents Screening for familial hypercholesterolemia during early childhood vaccination visits in primary care could routinely identify children and parents who are at risk of cardiovascular disease, suggests a new study published in the October 27, 2016 issue of the New England Journal of Medicine. For every 1,000 children screened at routine child immunization visits, 8 persons (4 children and 4 parents) were identified as having positive screening results for familial hypercholesterolemia and were consequently at high risk for cardiovascular disease.

Patients at Risk of C. difficile Infection PostRoux-en-Y Gastric Bypass Surgery Rates of hospital admission and relapse related to Clostridium difficile infection are significantly higher after Roux-en-Y gastric bypass than after vertical sleeve gastrectomy or ventral hernia repair. These findings from a study were presented October 18, 2016 at the

AROUND THE GLOBE American College of Gastroenterology 2016 Annual Scientific Meeting. The risk for C. difficile infection was higher after Roux-en-Y gastric bypass than after vertical sleeve gastrectomy from days 1 to 30 post-procedure.

Compared to hernia repair surgery, C. difficle infection rate was higher after gastric bypass from days 31 to 120.

Empirical Electrical Isolation of LAA Checks AF Recurrence in Long-standing Persistent AF In patients with long-standing persistent (LSP) atrial fibrillation (AF) who are undergoing pulmonary vein (PV) antrum isolation and ablation of triggers outside the PVs, additional electrical isolation of the left atrial appendage (LAA) is associated with greater freedom from recurrent AF without increased complication rates. Patients who received LAA isolation on top of pulmonary vein ablation were more likely to be free of recurring AFib a year after treatment vs. those receiving pulmonary vein ablation only; 56% vs. 28%, respectively. These findings from the BELIEF trial were published online November 2016 issue of the Journal of the American College of Cardiology.

Depression in Diabetes Increases Risk of CKD In a large cohort of US veterans with diabetes and eGFR ≥60 mL/min/1.73 m2, the presence of depression was found to be associated with higher risk of incident chronic kidney disease (CKD). The study published in the November 2016 issue of the journal Diabetes Care also showed that comorbid depression is associated with higher all-cause mortality, incident cardiac events, and incident stroke in this group of patients. Depressed patients were younger, had higher eGFR, but had more comorbidities.

Knee Adduction Moment Key Factor in OA Development Post-ACL Reconstruction Surgery A study evaluating predictive factors of knee joint contact forces after anterior cruciate ligament (ACL) reconstruction sheds light on the mechanisms of posttraumatic osteoarthritis (OA) after ACL injury. External knee adduction moment to be a significant predictor of medial compartment contact forces in both limbs, while vertical ground reaction force and co-contraction only contributed significantly in the uninvolved limb. These findings were published online October 17, 2016 in the Journal of Orthopedic Research.

Study Clears Man of HIV’s Patient ‘Zero’ Label Findings of a study published online October 26, 2016 in the journal Nature has provided evidence that the AIDS

epidemic moved from Africa to the United States via the Caribbean rather than from the US to the Caribbean.

Researchers undertook serological screening and viral genome sequencing of more than 2000 archived serum samples, from the 1970s, originally collected from men who have sex with men in San Francisco and New York city. They found no evidence, biological or historical, that patient ‘zero’ was the primary case in the US and of subtype B as a whole. Patient ‘zero’ died in 1984.

Gene Therapy Shows Promise for Treating Niemann-Pick Disease Type C1 For the first time, National Institutes of Health (NIH) researchers have demonstrated in mice that gene therapy may be the best method for correcting the single faulty gene that causes Niemann-Pick disease, type C1 (NPC1).The gene therapy involved inserting a functional copy of the NPC1 gene into mice with the disease; the treated animals were then found to have less severe NPC1 symptoms. The study was published Oct. 26, 2016, in the journal Human Molecular Genetics.

Clinical Characteristics for Arthralgia at Risk of Progression to RA A European League Against Rheumatism (EULAR) task force identified clinical characteristics of patients with arthralgia who are at risk for progression to rheumatoid arthritis (RA). The “suspicious arthralgia” definition, published online October 6 in the Annals of the Rheumatic Diseases, comprises seven parameters: Joint symptoms of recent onset (duration <1 year), symptoms located in (metacarpophalangeal) joints, duration of morning stiffness ≥60 minutes, most severe symptoms present in the early morning, presence of a first-degree relative with RA, difficulty with making a fist and positive squeeze test of (metacarpophalangeal) joints.

USPSTF Recommends Primary Care Interventions to Support Breastfeeding In an update of its USPSTF recommendation on primary care interventions to promote and support breastfeeding, the USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding. Interventions include promoting the benefits of breastfeeding, providing practical advice and direct support on how to breastfeed and providing psychological support. The recommendation statement was published simultaneously in the Journal of the American Medical Association and on the website of USPSTF.

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AROUND THE GLOBE Cardiac Rehabilitation Reduces Mortality in Acute MI Patients Cardiac rehabilitation during the year following an acute myocardial infarction (MI) provides survival benefits by improving the health of the patient, suggests a study published online October 19, 2016 in JAMA Cardiology.

According to the researchers, 41% lower hazard rate of mortality was observed in those who were admitted to the cardiac rehabilitation centers during 7 years of follow-up. Researchers stated that due to the low quality of evidence further research is needed to establish a relationship between cardiac rehabilitation and health status outcomes following acute MI.

Statins Linked to Parkinson’s Disease New findings from a large national claims database presented at the recent American Neurological Association (ANA) 2016 Annual Meeting in Baltimore show the use of cholesterol-lowering statin drugs to be associated with an increased risk for Parkinson’s disease, contrary to previous research suggesting the drugs have a protective effect for Parkinson’s disease.

Quality of Sleep Determines Quality-of-life in COPD Patients Low sleep quality among patients diagnosed with chronic obstructive pulmonary disease (COPD) appears to get even worse as their breathing problems progress and it causes a deterioration of the patients’ overall qualityof-life, as per a study presented at the 2016 annual meeting of the American College of Chest Physicians in Los Angeles. COPD severity and female gender were also associated with a decreasing quality-of-life.

ADA New Recommendations on Physical Activity and Exercise for People with Diabetes The American Diabetes Association (ADA) has released updated, comprehensive guidelines for regular, structured physical exercise for all people with diabetes, including type 1, type 2 and gestational diabetes, and prediabetes and recommends less overall sedentary time every day. The most notable recommendation calls for 3 or more minutes of light activity, such as walking, leg extensions or overhead arm stretches, every

30 minutes during prolonged sedentary activities for improved blood sugar management, particularly for people with type 2 diabetes. “Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association,” will be published in the November 2016 issue of the journal Diabetes Care.

Study Shows Association Between First-episode Psychosis and Abnormal Glycemic Control Findings of a systematic review and meta-analysis published online October 5, 2016 in the Lancet Psychiatry suggest a potential association between prediabetic markers, in particular impaired glucose tolerance and insulin resistance, and first-episode psychosis suggesting that schizophrenia might share intrinsic inflammatory disease pathways with type 2 diabetes. Pooled analyses found first-episode psychosis to be related to insulin resistance, impaired glucose tolerance and the number of patients with impaired glucose tolerance, but not fasting plasma glucose.

FDA Adds New Warnings to Labels of Testosterone and Other Anabolic Androgenic Steroids The US Food and Drug Administration (FDA) has approved class-wide labeling changes for all prescription testosterone products, adding a new Warning and updating the Abuse and Dependence section to include new safety information regarding the risks associated with abuse and dependence of testosterone and other AAS. Testosterone and other AAS are abused by adults and adolescents, including athletes and body builders.

Abuse of testosterone, usually at doses higher than those typically prescribed and usually in conjunction with other AAS, is associated with serious safety risks affecting the heart, brain, liver, mental health and endocrine system. Reported serious adverse outcomes include heart attack, heart failure, stroke, depression, hostility, aggression, liver toxicity and male infertility.

Individuals abusing high doses of testosterone have also reported withdrawal symptoms, such as depression, fatigue, irritability, loss of appetite, decreased libido, and insomnia.

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LIGHTER READING

HUMOR

Lighter Side of Medicine PRISON VS. WORK Just in case you ever got these two mixed up, this should make things a bit more clear.

In PRISON you spend the majority of your time in an 8 × 10 cell. At WORK you spend the majority of your time in a 6 × 8 cubicle.

In PRISON you get three meals a day. At WORK you only get a break for one meal and you pay for it.

In PRISON you get time off for good behavior.

At WORK you get more work for good behavior.

In PRISON the guard locks and unlocks all the doors for you. At WORK you must carry around a security card and open all the doors for yourself.

In PRISON you can watch TV and play games.

At WORK you get fired for watching TV and playing games.

DOCTOR COMPLAINING TO MECHANIC A doctor is taking to a car mechanic, “your fee is several times more per hour then we get paid for medical care.”

‘Yeah, but you see, doc, you have always the same model! It hasn’t changed since Adam. But we have to keep up to date with new models coming every month”

light bulb.” The doctor asks, “If he’s your friend, don’t you think you should get him down from there before he hurts himself?”

“What? And I work in the dark!?!”

PEANUTS A doctor worked at a mental hospital. He wanted to take some patients to a ballgame, worked months to get them to follow simple commands, and finally decided they were ready.

When the star spangled banner played he said: “Stand up nuts” and they stood. When it was over he said: “Sit down nuts” and they sat. When a player got a hit he said: “Cheer nuts” and they cheered. When the umpire made a bad call he said: “Boo nuts” and they booed. He decided it was safe to leave them with his assistant and left to get a hot dog. He came back to a near riot. He asked his assistant what in the world happened.

He said: “Everything was fine ‘till some vendor came be and yelled ‘peanuts’.”

Dr. Good and Dr. Bad SITUATION: A diabetic heart patient developed depression.

Depression is not linked with diabetes

Depression is common in diabetics

A doctor of psychology was doing his normal morning rounds, and he entered a patient’s room to find his patient sitting on the floor, sawing at a piece of wood with the side of his hand.

Meanwhile, another patient was in the room, hanging from the ceiling by his feet. The doctor asked his patient what he was doing, sitting on the floor.

The patient replied in an irritated fashion, “Can’t you see I’m sawing this piece of wood in half?”

The doctor inquired, “And what is the fellow hanging from the ceiling doing?” “Oh. He’s my friend, but he’s a little crazy. He thinks he’s a

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© IJCP Academy

AND I WORK IN THE DARK

LESSON: T2DM, CVD and depression in nondiabetes subjects

are independently associated with raised concentrations of circulating inflammatory markers. A study that tested the hypothesis that higher depressive symptom scores in newly diagnosed T2DM patients were associated with higher concentrations of inflammatory markers came to the conclusion that increased inflammation may be involved in the pathogenesis of depressive symptoms in T2DM and contribute to the increased risk of complications and mortality in this group.

Diabetes Care 2014;37(8):2186-92.

Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767).

Indian Journal of Clinical Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.

The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript.

Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper.

Covering letter –

– –

The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper.

Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors.

Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript Three complete sets of the manuscript should be – submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures).

–

The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

–

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

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

Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed,

name of the corresponding authors, acknowledgment of financial support and abbreviations used.

– The title should be of no more than 80 characters and should represent the major theme of the manuscript.

A subtitle can be added if necessary.

– A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

– The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page.

– A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary – The summary of not more than 200 words. It must convey the essential features of the paper.

– It should not contain abbreviations, footnotes or references.

Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives.

Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others.

– Ethical guidelines followed by the investigations should be described.

Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected.

– Method of selecting the sample (cases, subjects, etc. from the statistical universe).

– Method of allocating the subjects into different groups.

– Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

–

Confidence intervals for the measurements should be provided wherever appropriate.

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

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Discussion –

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

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses).

At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution.

Examples of common forms of references are: Articles 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.

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

Indian Journal of Clinical Practice, Vol. 27, No. 6, November 2016

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

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