IJCP October 2018

ISSN 0971-0876 RNI 50798/1990 University Grants Commission 20737/15554

Indexed with IndMED Indexed with MedIND Indian Citation Index (ICI)

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A Multispecialty Journal Volume 29, Number 5

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October 2018, Pages 401–500

Peer Reviewed Journal

yy American Family Physician yy Cardiology

yy Community Medicine yy Endocrinology yy ENT

yy Gastroenterology

yy Internal Medicine yy Nephrology

yy Obstetrics and Gynecology yy Oncology

yy Pediatrics

yy Expert View

an i c i ys ians

yy Medicolegal

Phly Physic y l mi ami

yy Medical Voice for Policy Change yy Conference Proceedings

Fademy of F n ica Aca

yy Around the Globe yy Spiritual Update

er merican m A eA

yy Inspirational Story

ingurnal of th t a or d Jo

yy Lighter Reading

rp-reviewe o c In eer AP

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A Multispecialty Journal

Dr Sanjiv Chopra Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

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

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

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

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

Volume 29, Number 5, October 2018 From the desk of THE group editor-in-chief

405 The Spiritual Heart: Your Heart and My Heart are One

KK Aggarwal

American Family Physician

407 Diagnosis and Management of Sarcoidosis

Natalia Soto-Gomez, Jay I. Peters, Anoop M. Nambiar

417 Practice Guidelines 419 Photo Quiz CARDIOLOGY

422 Prescribing Pattern of Antihypertensive Drugs in a Tertiary Care Teaching Hospital in Lucknow Region

Vijay K Yadav, Shyam Sunder Keshari, Krishna Pandey

COMMUNITY MEDICINE

425 Study of Prevalence of Severe Acute Malnutrition in Children Under 5 Years in Chatra Area of Serampore Municipality Under the State of West Bengal

Pradip Kumar Das

ENDOCRINOLOGY

429 Posology of Antidiabetic Drugs and Insulins: A Review of Standard Textbooks

Garima Bhutani, Sanjay Kalra

ENT

436 Pleomorphic Adenoma of the Submandibular Gland: A Rare Occurrence

Subramaniam Vinayak Easweran, Raghvendra Udupa, Mamta Hegde

Gastroenterology

439 ALBI and Child-Pugh Score in Predicting Mortality in Chronic Liver Disease Patients Secondary to Alcohol: A Retrospective Comparative Study

Nagaraja BS, Madhumathi R, Sanjeet SB

INTERNAL MEDICINE

444 A Case of Marchiafava-Bignami Syndrome

Manish N Mehta, Pranav I Patel, Hemang K Acharya, Ac Tanna, Jemima Bhaskar

446 Detection of Pulmonary Nocardiosis Mimicking Tuberculosis: Role of Sputum Microscopy

Shashi Chopra, Shaveta Dhiman, Gomty Mahajan, Silky Mahajan

Nephrology

449 A Snapshot of Patients on Hemodialysis in July 2018, GGH, Jamnagar: A Cross-sectional Study

Ajay C Tanna, Pranav I Patel

OBSTETRICS AND GYNECOLOGY

454 Oocyte Donation: Pregnancy Results and Obstetric Outcome

Nandita P Palshetkar, Hrishikesh D Pai, Manisha Takhtani, Rutvij Dalal

458 Comparison of Myoinositol and Metformin in Women with Polycystic Ovarian Syndrome

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

Shayista Nabi, Raka Guleria

ONCOLOGY

464 Malignant Peripheral Nerve Sheath Tumor Arising in a Neurofibroma: A Case Report

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

Monica Kumbhat M, Leena Dennis Joseph, Archana B, Arulappan

PEDIATRICS

Copyright 2018 IJCP Publications Ltd. All rights reserved.

468 Chromosome 3p Duplication: A Rare Chromosomal Anomaly

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

Braja Kishore Behera, Rishav Raj, Sailabala Shaw, Mitali Mahapatra

Expert VIEW

471 Are β-blockers Contraindicated in Patients with Congestive Heart Failure?

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.

OP Yadava

MEDICOLEGAL

473 Medicolegal Corner

KK Aggarwal, Ira Gupta

Medical Voice for policy change

476 Medtalk with Dr KK Aggarwal CONFERENCE PROCEEDINGS

483 55th National Conference of Indian Academy of Pediatrics (Pedicon 2018) AROUND THE GLOBE

485 News and Views Spiritual Update

491 Understanding the Gunas

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.

KK Aggarwal

INSPIRATIONAL Story

492 Success Depends Upon Maturity!

Lighter reading

494 Lighter Side of Medicine

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From the desk of THE group editor-in-chief

Dr KK Aggarwal

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

The Spiritual Heart: Your Heart and My Heart are One “My Heart, Your Heart” … this is the theme for the World Heart Day this year, which happens to be today.

This means to not only look after our own hearts but also of our loved ones.

It’s important to lead a healthy lifestyle, not only as individuals, but also make sure that people we care about do the same.

yet in it is infinity". Here the sruti is speaking metaphorically, because actually the soul is atomic in size. Therefore in the next verse (Svet. U. 5.9) the soul is compared to a fraction of the tip of a hair.

These comparisons are meant to indicate that the individual soul is atomic rather than all-pervasive. ÂÂ

According to Vedanta Sutra, the idea that God resides in the physical heart the size of the thumb is for the sake of conceptualization during meditation, and is thus a metaphorical description. The size of the thumb refers to the size of the human heart.

God is in reality all pervading and atomic at the same time.

ÂÂ

Atharva Veda: The soul is a particle of God.

ÂÂ

Jain metaphysicists refer to it as of varying sizes, small in a child, big in adults and old people and very big in elephants.

ÂÂ

Nemi Chandra in Dravya sangrah-2: Soul is characterized by knowledge and vision, has the same extent as its own gross body.

ÂÂ

Katha Upanishad (1.2.20): Spirit, the size of a thumb "angush matra", is the inner soul, always seated in the heart of creatures.

ÂÂ

Katha Upanishad Part Fourth XII: The Purusha (Self), of the size of a thumb, resides in the middle of the body as the lord of the past and the future, (he who knows Him) fears no more. This verily is That. The seat of the Purusha is said to be the heart, hence it “resides in the middle of the body.”

Although it is limitless and all-pervading, yet in relation to its abiding-place. It is represented as

This is what our Vedas also expound.

“Tat tvam asi” is a mahavakya in the ancient Sanskrit texts of the Upanishads. It translates as “I am that” and means that “You and I are same” or “your heart and my heart are one”.

Whenever we point to our own self, we put our hand on our heart; we also put our hand on our heart when we say “I love you from the bottom of my heart”.

Does the consciousness reside in the celiac plexus (Manipura chakra) or thymus plexus (Anahata chakra)?

We do not know. Manipura chakra is associated with fire and the power of transformation. The Anahata chakra manifests unconditional love, forgiveness and patience.

Our ancient scriptures and the Bible say that the heart is the size of a thumb and it is in the heart that our consciousness (soul) resides. ÂÂ

In Svetasvatara Upanisad (5.8, 5.9): "Soul is the size of a thumb, bright as the sun, when coupled with conception and ego. But with only the qualities of understanding and soul, it appears the size of the point of an awl. This life is the hundredth part of the point of a hair divided a hundred times, and

IJCP Sutra 310: Travelers should avoid consuming tap water. Avoid ice made from tap water and any food rinsed in tap water.

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

limited in extension, “the size of a thumb.” This refers really to the heart, which in shape may be likened to a thumb. Light is everywhere, yet we see it focused in a lamp and believe it to be there only; similarly, although the life-current flows everywhere in the body, the heart is regarded as peculiarly its seat. ÂÂ

Garuda Puran: Ultimately, the soul, which is not more than the size of a thumb, reluctantly comes out from the body as the attachment with the world exists even after his.

ÂÂ

Gaudiya Acharya Sri Baladeva Vidyabhusana in his Govinda Bhasya commentary on the Vedanta Sutra (1.2.7, 1.3.24-25.): During meditation Paramatma does appear to the yogi or devotee as a localized form in his heart, but in general Paramatma is all-pervasive and all-knowing.

ÂÂ

Unknown: According to some Vedic scholars the soul enters the human form like 4-8 weeks after conception, like when the fetus is the size of a thumb.

ÂÂ

Bhagavad Gita 15.15: "I (soul) am seated in everyone's heart, and from Me come remembrance, knowledge and forgetfulness. By all the Vedas, I am to known. Indeed, I am the compiler of Vedanta, and I am the knower of the Vedas."

ÂÂ

Vedanta Sutra II, 6,17: "The person of the size of a thumb, the inner Self, is always settled in the heart of men. Let a man draw that Self forth from his body with steadiness, as one draws the pith from a reed. Let him know that Self as the Bright, as the Immortal."

ÂÂ

Swami Muktananda, Play of Consciousness, p. 85: The whole body is like a lotus which has four petals of four kinds, colors and sizes.... The first is the gross body, its color is red. The second petal is the subtle body, in which we sleep and experience dreams. It is the size of a thumb, and its color is white. The third petal is the causal body. It is the size of the tip of third finger, and its color is black.

The fourth petal is the supra-causal body, which is as small as a sesame seed. Its color is blue....

It is very brilliant; it is the foundation of sadhana; it is the highest inner vision.

406

ÂÂ

Matthew 5;8: Soul resided in the heart: "Blessed are the pure in heart, for they shall see God."

When we meet somebody and form a relationship with another person, we go through five stages: Euphoria, reaction, adjustment, liking and loving.

The stage of euphoria is due to release of phenylethylamine, dopamine and norepinephrine.

Dopamine makes them feel good and norepinephrine stimulates the production of adrenaline, which makes the heart beat faster. The stage of reaction is based on release of adrenaline and noradrenaline.

Adjustment is the balance of all hormones. Endorphins and serotonin abound in the stage of liking. The endorphins or opiate-like peptides calm and reassure with intimacy, dependability, warmth and shared experiences. The last phase is the real spiritual love or the state of ‘rasa’, where your emotions are one with the other. This is “made for each other” and denotes a parasympathetic state of mind.

Only the b-blockers have been proven to reduce mortality in heart disease. They block the sympathetic response of the body and convert it to the parasympathetic state, the relaxed state.

The parasympathetic state can also be achieved by doing parasympathetic exercises, which are healing, e.g., progressive muscular relaxation, yoga, pranayama, shavasana (also called kayotsarga, which means total relaxation of mind, body and speech with selfawareness) and meditation by thinking differently, thinking opposite and thinking positively.

A parasympathetic state can also be achieved by neutralizing the noise of attachment, expectations and desires or going through these, but bypassing them.

Increase in physical activity is recommended for a healthy heart. A long walk not only offers physical benefits, one also gets the benefits of nature as one’s inner stimuli are exposed to the outer stimuli during the parikrama. The proximity with nature helps in the inward spiritual journey and shifts one from the sympathetic (disturbed) to parasympathetic (relaxed) mode described by lowering of blood pressure and pulse rate.

IJCP Sutra 311: Chlorination kills most bacterial and viral pathogens but not giardia cysts.

American Family physician

Diagnosis and Management of Sarcoidosis NATALIA SOTO-GOMEZ, JAY I. PETERS, ANOOP M. NAMBIAR

Abstract Sarcoidosis is a systemic disease of unknown etiology characterized by the presence of noncaseating granulomas in any organ, most commonly the lungs and intrathoracic lymph nodes. A diagnosis of sarcoidosis should be suspected in any young or middle-aged adult presenting with unexplained cough, shortness of breath, or constitutional symptoms, especially among blacks or Scandinavians. Diagnosis relies on three criteria: (1) a compatible clinical and radiologic presentation, (2) pathologic evidence of noncaseating granulomas, and (3) exclusion of other diseases with similar findings, such as infections or malignancy. An early and accurate diagnosis of sarcoidosis remains challenging, because initial presentations may vary, many patients are asymptomatic, and there is no single reliable diagnostic test. Prognosis is variable and depends on epidemiologic factors, mode of onset, initial clinical course, and specific organ involvement. The optimal treatment for sarcoidosis remains unclear, but corticosteroid therapy has been the mainstay of therapy for those with significantly symptomatic or progressive pulmonary disease or serious extrapulmonary disease. Refractory or complex cases may require immunosuppressive therapy.

Despite aggressive treatment, some patients may develop life-threatening pulmonary, cardiac, or neurologic complications from severe, progressive disease. End-stage disease may ultimately require lung or heart transplantation for eligible patients.

Keywords: Sarcoidosis, noncaseating granuloma, pulmonary sarcoidosis, extrapulmonary sarcoidosis

S

arcoidosis is a multisystem granulomatous disease of unknown etiology that most often affects the lungs and intrathoracic lymph nodes but can involve any organ of the body (Table 1).1,2 The paucity of randomized controlled trials has led to limited evidence-based data for clinicians caring for patients with sarcoidosis. This article reviews the epidemiology, etiology, clinical presentation, diagnosis, and current evidence on the treatment of pulmonary and extrapulmonary sarcoidosis.

Epidemiology Although sarcoidosis may affect anyone, it is most common in certain age groups, races, geographic regions, and families. More than 80% of cases occur in adults between 20 and 50 years of age.1 There is a second peak incidence between 50 and 65 years of age, especially among women in Scandinavia and Japan.3 Children are rarely affected.4 The lifetime risk

NATALIA SOTO-GOMEZ, MD, is a senior research fellow in the Division of Pulmonary and Critical Care Medicine at the University of Texas Health Science Center at San Antonio.

JAY I. PETERS, MD, is a professor in the Division of Pulmonary and Critical Care Medicine at the University of Texas Health Science Center at San Antonio.

ANOOP M. NAMBIAR, MD, is an assistant professor in the Division of Pulmonary and Critical Care Medicine at the University of Texas Health Science Center at San Antonio.

Source: Adapted from Am Fam Physician. 2016;93(10):840-848.

of sarcoidosis in the United States is greater in blacks (2.4%) than whites (0.85%).5 Sarcoidosis is also more common in Swedes, Danes, and African-Caribbeans.1 Approximately 4% to 10% of patients have a first-degree relative with sarcoidosis.6 Pathogenesis and Etiology Sarcoidosis is the result of noncaseating granuloma formation due to ongoing inflammation that causes the accumulation of activated T cells and macrophages, which then secrete cytokines and tumor necrosis factor-Îą.1 The precise cause of sarcoidosis is unknown.

However, most studies suggest that it is the result of an exaggerated immune response in a genetically susceptible individual to an undefined antigen, such as certain environmental factors,7-9 microbes (e.g., Mycobacterium tuberculosis,10-12 Propionibacterium acnes13), or partially degraded antigens. According to familybased and case-control association studies, there is strong evidence of a genetic predisposition to develop sarcoidosis.6,14 Natural History and Prognosis Although spontaneous remission may occur in nearly two-thirds of patients, between 10% and 30% of patients with sarcoidosis experience a chronic or progressive course.1 Early in the course of the disease, the prognosis

IJCP Sutra 312: Boiled, treated and bottled water is safe. Carbonated drinks, wine and drinks made with boiled water are safe.

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for remission is more favorable, with spontaneous remission observed in 50% to 90% within the first two years of diagnosis, depending on disease stage.1 Patients who present with Löfgren syndrome have an excellent prognosis, with spontaneous remission in up to 80% of patients, usually within several months.1,15 Blacks are more likely to have a more symptomatic, severe, and chronic disease than whites.1,16 Radiologic stage by chest radiography at presentation is inversely correlated with the likelihood of spontaneous resolution (Table 21,2; Figure 1). Clinical staging systems predicting the risk of mortality have been proposed, but require further prospective validation in broader cohorts of patients.17 Overall lifetime sarcoidosis-related mortality is less than 5%.1 In the United States, mortality is usually associated with progressive respiratory or heart failure,1,18 especially in blacks and women, whereas in Sweden and Japan, the leading cause of death is predominantly myocardial involvement.19 Diagnosis

Clinical Presentation Sarcoidosis should be considered in young or middleaged adults presenting with unexplained cough, shortness of breath, or constitutional symptoms, especially in high-prevalence groups such as blacks or Scandinavians. A considerable percentage of patients are asymptomatic at presentation, and the diagnosis is based on incidental bilateral hilar lymphadenopathy on chest radiography. Common presenting symptoms are outlined in Table 1.1,2 Constitutional symptoms, such as fever, unintentional weight loss, and fatigue, occur in about one-third of patients.1 Up to 50% of patients present with respiratory symptoms, such as shortness of breath, dry cough, and chest pain.1 The acute onset of erythema nodosum associated with bilateral hilar lymphadenopathy, fevers, polyarthritis, and, commonly, uveitis is known as Löfgren syndrome.

Another classic sarcoidosis syndrome is Heerfordt syndrome, or uveoparotid fever. It is characterized by uveitis, parotitis, fever, and, occasionally, facial nerve palsy.20 Other presenting findings depend on the extent of specific organ involvement.

Differential Diagnosis and Initial Evaluation The differential diagnosis for sarcoidosis is broad because of the nonspecific symptoms and diverse clinical presentations. Many other diseases present with similar clinical, radiologic, and pathologic findings (Table 3).1 Infections (e.g., tuberculosis, histoplasmosis) and

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IJCP Sutra 313: Freezing does not kill the organisms that cause diarrhea.

malignancy (e.g., lymphoma) should be ruled out if suspected. The initial evaluation starts with a history and physical examination, specifically focusing on risk factors for infectious, occupational, and environmental exposures. Laboratory studies should include a peripheral white blood cell count, serum chemistries (including calcium and creatinine levels, and liver function tests), urinalysis, and human immunodeficiency virus and tuberculosis tests.1 Because reduced skin reactivity is common in patients with sarcoidosis,21 an interferon gamma release assay may be more sensitive than tuberculin skin testing for identifying latent tuberculosis infection.22,23 Additional recommended testing should include baseline chest radiography, pulmonary function testing, and electrocardiography.1 Further testing should be based on specific organ involvement.

Confirmation of the Diagnosis According to an international consensus statement, there are three criteria for diagnosing sarcoidosis: (1) a compatible clinical and radiologic presentation, (2) pathologic evidence of noncaseating granulomas, and (3) exclusion of other diseases with similar findings (Figure 2).1 Certain sarcoidosis-specific syndromes, such as Löfgren and Heerfordt syndromes, can be diagnosed based on clinical presentation alone, avoiding the need for tissue biopsy.24 An asymptomatic patient with stage I sarcoidosis (i.e., bilateral hilar lymphadenopathy on chest radiography) without suspected infection or malignancy does not require invasive tissue biopsy because the results would not affect the recommended management approach (i.e., monitoring). If there would be an indication for treatment with a confirmed diagnosis (eTable A), pathologic evidence of noncaseating granulomas should be obtained from the most accessible and safest biopsy site. In addition to chest radiography, various imaging studies, such as computed tomography of the chest and 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), are useful to support the diagnosis (Table 4).1,25,26 Reliable biomarkers for diagnosis do not currently exist for routine clinical practice, although some show promise.27,28 The serum angiotensin-converting enzyme (ACE) level may be elevated in up to 75% of untreated patients.29 However, the ACE level lacks sufficient specificity,29 has large inter-individual variability,30 and fails to consistently correlate with disease severity,31,32 which limits its clinical utility.

Because the lungs and intrathoracic lymph nodes are commonly affected, flexible bronchoscopy with biopsies have high diagnostic yields and low risk of

American Family Physician

Figure 1. Stages of sarcoidosis. (A) Stage I: bilateral hilar lymphadenopathy on chest radiography. (B) Stage I: bilateral hilar lymphadenopathy on computed tomography. (C) Stage II: bilateral hilar lymphadenopathy with interstitial lung disease on chest radiography. (D) Stage III: interstitial lung disease without bilateral hilar lymphadenopathy on chest radiography. (E) Stage IV: end-stage pulmonary fibrosis on chest radiography, which often does not regress. (F) Stage IV: end-stage pulmonary fibrosis on computed tomography, which often does not regress.

IJCP Sutra 314: Ice in drinks is not safe unless it has been made from adequately boiled or filtered water.

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Table 3. Differential Diagnosis for Pulmonary Sarcoidosis Category

Specific disease

Exposures/toxins

Drug-induced hypersensitivity (e.g., adalimumab, etanercept, infliximab, methotrexate) Foreign body granulomatosis (aspiration or intravenous injection of foreign materials) Hypersensitivity pneumonitis Pneumoconioses (aluminum, beryllium, cobalt, talc, titanium, zirconium)

Immunodeficiency Chronic granulomatous disease Common variable immunodeficiency Infections

Bacterial (brucellosis, nontuberculous mycobacteria, tuberculosis) Fungal (aspergillosis, blastomycosis, coccidioidomycosis, cryptococcosis, histoplasmosis, Pneumocystis jiroveci (formerly known as Pneumocystis carinii) Parasitic (echinococcosis, leishmaniasis, schistosomiasis, toxoplasmosis) Viral (human immunodeficiency virus)

Inflammations

Bronchocentric granulomatosis (usually associated with asthma and allergic bronchopulmonary aspergillosis) Eosinophilic granulomatosis (pulmonary Langerhans cell histiocytosis) Lymphocytic interstitial pneumonitis

Malignancy

Lymphoma Lymphomatoid granulomatosis

Extrapulmonary Sarcoidosis Although the skin and eyes are the most common extrapulmonary organs to cause clinical manifestations, the heart and nervous system are the most serious.1,38 Monitoring extrapulmonary organs is essential because early recognition and treatment may prevent irreversible or life-threatening disease.1 Cardiac or neurologic sarcoidosis can result in irreversible or life-threatening disease and often requires aggressive treatment with high-dose corticosteroids.39-42 Cutaneous involvement occurs in about 25% of patients and is often an early finding; although usually asymptomatic, pruritus and pain have been reported.1 Skin lesions include macules, papules, plaques, ulcers, pustules, erythroderma, or hypopigmented lesions.

Most lesions can be treated with topical agents, except in diffuse or unresponsive disease. The two most clinically important skin lesions are erythema nodosum (eFigure A), a nonspecific, non-granulomatous panniculitis that usually occurs in acute sarcoidosis, and lupus pernio (eFigure B), disfiguring red-topurple plaques and nodules affecting the nose and cheeks that represent chronic sarcoidosis and require systemic treatment.

Because asymptomatic inflammation of the eye can result in permanent impairment, patients require yearly examinations and additional monitoring when the disease flares. Ocular involvement occurs in 20% to 50% of patients and is the presenting symptom in 5%.1

Information from reference 1.

The most common manifestations are anterior uveitis (red, painful eye with photophobia or blurred vision) and keratoconjunctivitis (dry eye).43 These disorders can be treated with topical corticosteroids. Severe anterior or posterior uveitis requires systemic therapy. The most serious ocular complication is optic neuritis, which can result in rapid, irreversible loss of vision.

complications. These include transbronchial needle aspiration (TBNA), endobronchial biopsy, transbronchial lung biopsy, and, more recently, endosonography with nodal aspiration, either endobronchial ultrasoundguided TBNA or esophageal ultrasonography with fine-needle aspiration.33-35 Bronchoalveolar lavage with cell count may support a diagnosis of sarcoidosis if there is lymphocytosis of at least 15% and a CD4:CD8 T-lymphocyte ratio greater than 3.5.36 If less invasive tests are inconclusive, surgical biopsy of the mediastinum through mediastinoscopy of the lung via thoracoscopy or thoracotomy may be necessary. However, these procedures are associated with increased morbidity.37

Although cardiac sarcoidosis is noted in 25% to 70% of autopsies, symptomatic cardiac involvement occurs in only about 5% of patients.39 Granulomas often infiltrate the conducting system, leading to arrhythmias and heart block, but cardiac involvement can also lead to dilated cardiomyopathy.40,41 Progressive heart failure and sudden death are the most serious complications of cardiac sarcoidosis. It is essential to evaluate palpitations and syncope or near syncope, and perform baseline electrocardiography. Any suggestion of cardiac involvement requires echocardiography and prompt referral to a cardiologist. Further cardiac imaging with magnetic resonance imaging or 18F-FDG PET should be considered if a diagnosis of cardiac sarcoidosis remains

Sarcoid-like granuloma reactions (primary tumors, regional lymph nodes) Vasculitis

Churg-Strauss syndrome Granulomatosis with polyangiitis (Wegener granulomatosis)

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IJCP Sutra 315: Hot tea and coffee are the best alternates to boiled water.

American Family Physician

Diagnosis of Sarcoidosis Symptoms consistent with sarcoidosis; evidence of classic syndrome or asymptomatic bilateral hilar lymphadenopathy?

Yes No biopsy necessary; manage accordingly as sarcoidosis

No Any evidence of granulomatous disease (e.g., tuberculosis, histoplasmosis) or other causes of lymphadenopathy (e.g., lymphoma)?

Yes

No

Sarcoidosis excluded

Any evidence of pulmonary disease, such as bilateral hilar lymphadenopathy or parenchymal infiltrates?

No

Yes Bronchoscopy with endobronchial biopsy, transbronchial lung biopsy, or endosonography with nodal aspiration (endobronchial or esophageal ultrasonography)

Extrapulmonary disease; biopsy safest and most accessible site

Histopathologic evidence of noncaseating granulomas?

Yes Diagnosis of sarcoidosis confirmed; manage accordingly

No Consider other diagnosis

Figure 2. Algorithm for the diagnosis of sarcoidosis.

Information from reference 1.

uncertain.44 Although cardiac sarcoidosis often responds to corticosteroids and immunosuppressant therapy, heart transplantation has been required in patients with end-stage cardiomyopathy.

Neurologic involvement occurs in about 10% of patients with sarcoidosis.42,45 Cranial neuropathy, particularly palsy of the seventh cranial nerve, is the most common neurologic complication. Sarcoidosis can result in mass-like lesions with focal symptoms or seizures, as well as acute or chronic meningitis and peripheral neuropathies. There is a predilection for the involvement of the pituitary gland and the hypothalamus, resulting in adrenal or pituitary failure, diabetes insipidus, and hypogonadism.

Calcium metabolism may also be dysregulated, resulting in hypercalciuria, hypercalcemia, and nephrolithiasis with possible renal insufficiency.1 Granulomatous

inflammation activates vitamin D and leads to increased absorption of calcium from the gastrointestinal tract.

Based on expert opinion and pathophysiologic reasoning, patients with active sarcoidosis are advised to reduce dietary calcium and calcium supplement intake, avoid sunlight, and drink adequate amounts of fluids.46 Treatment of Pulmonary Sarcoidosis Treatment is not indicated for patients with asymptomatic stage I or II sarcoidosis because spontaneous resolution is common.1 Treatment with corticosteroids should be considered for patients with significant symptomatic or progressive stage II or III pulmonary disease or serious extrapulmonary disease. A meta-analysis identified 13Â studies with 1,066 patients treated with systemic corticosteroids for six to 24 months. The authors found improvements

IJCP Sutra 316: Bottled drinks should be requested without ice and should be drunk from the bottle with a straw rather than with a glass.

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Table 4. Radiologic Studies to Diagnose Sarcoidosis Study

Findings

Chest computed tomography

Useful particularly for the differential diagnosis of diffuse interstitial changes in lung parenchyma and pulmonary fibrosis

Chest radiography

Bilateral hilar lymphadenopathy and interstitial changes, necessary for staging

18F-fluorodeoxyglucose

Useful for finding areas to biopsy

positron emission tomography

May aid in the diagnosis of cardiac sarcoidosis May correlate with active inflammation and disease activity

Gallium scan

Lambda sign: increased uptake in the bilateral hilar and right paratracheal lymph nodes Panda sign: increased uptake in the parotid and lacrimal glands Combined lambda and panda signs may be specific for sarcoidosis

Magnetic resonance imaging

Central nervous system: useful for identification of lesions Cardiac magnetic resonance imaging: Findings include focal intramyocardial zones of increased signal intensity due to edema and inflammation Delayed gadolinium enhancement is a predictor of ventricular arrhythmias and poor outcomes

Thallium scan

In cardiac sarcoidosis: Nonspecific areas of decreased myocardial uptake, not delimited by coronary artery distribution Improvement or reverse distribution following dipyridamole administration allows differentiation from coronary artery disease

Information from references 1, 25, and 26.

in chest radiography findings, and limited data showed improvements in a global score incorporating symptoms and lung function in patients with stage II or III disease.47 However, there is no evidence that oral corticosteroids improve patient-oriented outcomes, such as mortality, or that they have any effect on long-term symptoms, lung function, radiologic findings, or disease progression. Nevertheless, corticosteroids remain the mainstay of treatment based on expert opinion and

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usual practice for patients with significant symptomatic or progressive stage II or III disease, or serious extrapulmonary disease.1,47,48 In addition, there are no validated protocols or algorithms for oral corticosteroid therapy. An international consensus statement recommended prednisone (or its equivalent) at a starting dosage of 20 to 40 mg per day for four to six weeks.1 If the patient’s condition is stable or improved, the dosage should be tapered slowly to approximately 5 to 10 mg per day. If there is no clinical response after three months of steroid therapy, a response to longer courses is unlikely. Treatment should be continued for a minimum of 12 months before tapering off.

Every-other-day dosing may be effective in some patients, but not all. There are limited data about the effectiveness of inhaled corticosteroids for pulmonary sarcoidosis. Some studies have found an improvement with endobronchial symptoms, such as cough, whereas others have not found a significant benefit.1,49,50 Patients should be monitored for clinical response and disease progression by symptoms, pulmonary function, and chest radiography after one to three months of treatment and every three to six months thereafter.1 There are no consistently reliable biomarkers (including serum ACE level) to aid in determining treatment response.1 Corticosteroid-related adverse effects (e.g., excessive weight gain, osteoporosis, diabetes mellitus, hypertension, gastritis, myopathy, opportunistic infections) should be assessed. Relapses after treatment are not uncommon and most often occur two to six months after corticosteroid withdrawal, but rarely after three years without symptoms.1 Second- and third-line therapies for pulmonary sarcoidosis,51,52 including methotrexate,51-55 55,56 57 azathioprine, leflunomide, biologic agents,58-60 and corticotropin gel61 are reserved for patients with corticosteroid-refractory disease, intolerable adverse effects, or toxicity from corticosteroids, as well as patients who choose not to take corticosteroids.

Corticosteroid refractory disease is defined as disease progression despite moderate dosages of prednisone (e.g., 10 to 15 mg per day) or frequent relapses. Secondline therapies are most often used in combination with prednisone, although data to guide the initiation, dosage, and duration of therapy are limited51,52 (eTable B). A Cochrane review of immunosuppressives and cytotoxic therapy for pulmonary sarcoidosis was unable to recommend the use of any of these agents.51 Among a group of sarcoidosis experts, methotrexate was the preferred second-line drug.54

IJCP Sutra 317: Boiling water for 3 minutes followed by cooling to room temperature will kill bacterial parasites.

American Family Physician Severe and progressive pulmonary sarcoidosis warrants prompt referral for possible lung transplantation.62 Posttransplantation outcomes for sarcoidosis are similar to outcomes for other lung diseases, and a median survival benefit may be achieved for appropriately selected patients

with high risk of short-term mortality.63-65 Although there have been reports of recurrent noncaseating granulomas in some lung allografts, these findings usually are not clinically relevant.66,67 Note: For complete article visit: www.aafp.org/afp.

eTable A. Indications for Treatment of Sarcoidosis Topical therapy

Systemic therapy

Skin lesions

Pulmonary compromise with symptomatic stage II to III disease, persistent infiltrates, decline in lung function

Anterior uveitis

Cardiac disease

Cough or airway obstruction

Neurosarcoidosis

Nasal polyps

Ocular disease not responding to topical therapy Symptomatic hypercalcemia Lupus pernio

Note: Indications listed from most to least common.

Information from Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med. 1999;160(2):736-755.

eTable B. Most Commonly Used Medications for Sarcoidosis Medication

Dosage

Indication by organs involved

Significant adverse effects

Monitoring

Prednisone

20 to 40 mg per day initially; 5 to 10 mg per day for long-term therapy

Pulmonary, cardiac, neurologic, ocular, cutaneous,† renal‡

Weight gain, diabetes mellitus, osteoporosis, hypertension, infections

Weight, glucose level, bone density, blood pressure

Methotrexate 10 to 15 mg per week

Pulmonary, cardiac, neurologic, ocular, cutaneous†

Nausea, leukopenia, liver/pulmonary toxicity, infections

Complete blood count, renal/liver indices every 1 to 3 months

Azathioprine

50 to 200 mg per day

Pulmonary, renal,‡ neurologic

Nausea, leukopenia, liver toxicity, infections

Consider thiopurine methyltransferase level and phenotype before initiation; complete blood count and liver function tests every 1 to 3 months

Leflunomide

10 to 20 mg per day

Pulmonary, ocular, cutaneous

Nausea, diarrhea, liver toxicity, rash, peripheral neuropathy

Liver function tests every 1 to 3 months

Hydroxy­ chloroquine

200 to 400 mg per day

Cutaneous,† pulmonary, cardiac, neurologic, renal‡

Retinopathy, rash, neuromyopathy

Eye examination every 6 to 12 months

Infliximab

5 mg per kg intravenously at weeks 0, 2, and 6, then monthly thereafter

Pulmonary, neurologic, cutaneous,† renal‡

Infections (especially reactivation of TB), allergic reactions, antibody formation

TB assessment at initiation; close monitoring during infusions

Adalimumab

40 mg subcutaneously every 1 to 2 weeks

Pulmonary, neurologic, cutaneous,† renal‡

Infections (especially reactivation of TB), allergic reactions

TB assessment at initiation; close monitoring during injections

Note: Medications listed in order of preferred use.

TB = Tuberculosis. †Use if the cutaneous indication is cosmetically disfiguring (e.g., lupus pernio), symptomatic, ulcerating, or progressive; otherwise, local therapies may be sufficient. ‡Renal disease includes hypercalcemia, nephrolithiasis, nephrocalcinosis, and acute interstitial nephritis.

Information from Vorselaars AD, Cremers JP, Grutters JC, Drent M. Cytotoxic agents in sarcoidosis: which one should we choose? Curr Opin Pulm Med. 2014;20(5):479-487.

IJCP Sutra 318: Adding two drops of 5% sodium hydrochloride (bleach) to quarter of water (1 liter) will kill most bacteria in 30 minutes.

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eFigure A. Erythema nodosum is a red, painful, tender, nodular lesion most commonly located in the front of the leg below the knee. It ranges in size from 1 to 5 cm and is caused by inflammation in the fatty layer of skin.

eFigure B. Lupus pernio is characterized by chronic, raised, indurated, bluish-red or violaceous nodules and plaques over the nose, cheeks, and ears. It is thought to be pathognomonic of sarcoidosis.

REFERENCES

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2. Wu JJ, Schiff KR. Sarcoidosis. Am Fam Physician.

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3. Baughman RP, Teirstein AS, Judson MA, et al.; Case Control Etiologic Study of Sarcoidosis (ACCESS) Research Group. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med. 2001;164(10 pt 1):1885-1889.

4. Hoffmann AL, Milman N, Byg KE. Childhood sarcoidosis in Denmark 1979-1994: incidence, clinical features and laboratory results at presentation in 48 children. Acta Paediatr. 2004;93(1):30-36.

5. Rybicki BA, Major M, Popovich J Jr, Maliarik MJ, Iannuzzi MC. Racial differences in sarcoidosis incidence: a 5-year study in a health maintenance organization. Am J Epidemiol. 1997;145(3):234-241.

6. Rybicki BA, Iannuzzi MC, Frederick MM, et al.; ACCESS Research Group. Familial aggregation of sarcoidosis. A case-control etiologic study of sarcoidosis (ACCESS). Am J Respir Crit Care Med. 2001;164(11): 2085-2091.

7. Newman LS, Rose CS, Bresnitz EA, et al.; ACCESS Research Group. A case control etiologic study of sarcoidosis: environmental and occupational risk factors.

Am J Respir Crit Care Med. 2004;170(12):1324-1330.

8. Izbicki G, Chavko R, Banauch GI, et al. World Trade Center “sarcoidlike” granulomatous pulmonary disease in New York City Fire Department rescue workers. Chest.

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10. Gupta D, Agarwal R, Aggarwal AN, Jindal SK. Molecular evidence for the role of mycobacteria in sarcoidosis: a meta-analysis. Eur Respir J. 2007;30(3):508-516.

11. Koth LL, Solberg OD, Peng JC, Bhakta NR, Nguyen CP, Woodruff PG. Sarcoidosis blood transcriptome reflects lung inflammation and overlaps with tuberculosis. Am J Respir Crit Care Med. 2011;184(10):1153-1163.

12. Maertzdorf J, Weiner J III, Mollenkopf HJ, et al.; TBornotTB Network. Common patterns and diseaserelated signatures in tuberculosis and sarcoidosis. Proc Natl Acad Sci U S A. 2012;109(20):7853-7858.

13. Eishi Y, Suga M, Ishige I, et al. Quantitative analysis of mycobacterial and propionibacterial DNA in lymph nodes of Japanese and European patients with sarcoidosis. J Clin Microbiol. 2002;40(1):198-204.

14. Müller-Quernheim J, Schürmann M, Hofmann S, et al.

Genetics of sarcoidosis. Clin Chest Med. 2008;29(3): 391-414, viii.

15. Löfgren S. Erythema Nodosum: Studies on Etiology and Pathogenesis in 185 Adult Cases. Stockholm: Norstedt; 1946.

16. Neville E, Walker AN, James DG. Prognostic factors predicting the outcome of sarcoidosis: an analysis of 818 patients. Q J Med. 1983;52(208):525-533.

17. Walsh SL, Wells AU, Sverzellati N, et al. An integrated clinicoradiological staging system for pulmonary sarcoidosis: a case-cohort study. Lancet Respir Med. 2014;2(2):123-130.

18. Swigris JJ, Olson AL, Huie TJ, et al. Sarcoidosis-related mortality in the United States from 1988 to 2007. Am J Respir Crit Care Med. 2011;183(11):1524-1530.

19. Morimoto T, Azuma A, Abe S, et al. Epidemiology of sarcoidosis in Japan. Eur Respir J. 2008;31(2):372-379.

IJCP Sutra 319: Adding five drops of tincture of iodine to a quarter of water (1 liter) will kill bacteria within 30 minutes.

American Family Physician 20. Dua A, Manadan A. Images in clinical medicine.

Heerfordt’s syndrome, or uveoparotid fever. N Engl J Med. 2013;369(5):458.

36. Costabel U, et al. Diagnostic modalities in sarcoidosis: BAL, EBUS, and PET. Semin Respir Crit Care Med. 2010;31(4):404-408.

21. Mathew S, et al. The anergic state in sarcoidosis is associated with diminished dendritic cell function.

J Immunol. 2008;181(1):746-755.

37. Reich JM, Brouns MC, O’Connor EA, Edwards MJ. Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis. Chest.

1998;113(1):147-153.

22. Gupta D, Kumar S, Aggarwal AN, Verma I, Agarwal R. Interferon gamma release assay (QuantiFERON-TB Gold In Tube) in patients of sarcoidosis from a population with high prevalence of tuberculosis infection. Sarcoidosis Vasc Diffuse Lung Dis. 2011;28(2):95-101.

23. Milman N, et al. Quantiferon test for tuberculosis screening in sarcoidosis patients. Scand J Infect Dis. 2011;43(9):728-735.

24. Mañá J, Gómez-Vaquero C, Montero A, et al. Löfgren’s syndrome revisited: a study of 186 patients. Am J Med. 1999;107(3):240-245.

25. Nunes H, Brillet PY, Valeyre D, Brauner MW, Wells AU. Imaging in sarcoidosis. Semin Respir Crit Care Med. 2007;28(1):102-120.

26. Sobic-Saranovic D, Artiko V, Obradovic V. FDG PET imaging in sarcoidosis. Semin Nucl Med. 2013;43(6):404-411.

27. Bargagli E, Bennett D, Maggiorelli C, et al. Human chitotriosidase: a sensitive biomarker of sarcoidosis. J Clin Immunol. 2013;33(1):264-270.

28. Bargagli E, et al. Analysis of serum amyloid A in sarcoidosis patients. Respir Med. 2011;105(5):775-780.

29. Studdy PR, Bird R. Serum angiotensin converting enzyme in sarcoidosis—its value in present clinical practice. Ann Clin Biochem. 1989;26(pt 1):13-18.

30. Rigat B, et al. An insertion/deletion polymorphism in the angiotensin I-converting enzyme gene accounting for half the variance of serum enzyme levels. J Clin Invest.

1990;86(4):1343-1346.

31. Shorr AF, Torrington KG, Parker JM. Serum angiotensin converting enzyme does not correlate with radiographic stage at initial diagnosis of sarcoidosis. Respir Med. 1997;91(7):399-401.

32. Vorselaars AD, van Moorsel CH, Zanen P, et al. ACE and sIL-2R correlate with lung function improvement in sarcoidosis during methotrexate therapy. Respir Med. 2015;109(2):279-285.

33. Shorr AF, Torrington KG, Hnatiuk OW. Endobronchial biopsy for sarcoidosis: a prospective study. Chest.

2001;120(1):109-114.

34. von Bartheld MB, Dekkers OM, Szlubowski A, et al.

Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial. JAMA. 2013;309(23): 2457-2464.

35. Gupta D, et al. Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146(3):547-556.

38. Rizzato G, Palmieri G, Agrati AM, Zanussi C. The organspecific extrapulmonary presentation of sarcoidosis: a frequent occurrence but a challenge to an early diagnosis.

A 3-year-long prospective observational study. Sarcoidosis Vasc Diffuse Lung Dis. 2004;21(2):119-126.

39. Bussinguer M, Danielian A, Sharma OP. Cardiac sarcoidosis: diagnosis and management. Curr Treat Options Cardiovasc Med. 2012;14(6):652-664.

40. Nery PB, Leung E, Birnie DH. Arrhythmias in cardiac sarcoidosis: diagnosis and treatment. Curr Opin Cardiol.

2012;27(2):181-189.

41. Birnie DH, Sauer WH, Bogun F, et al. HRS expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis. Heart Rhythm. 2014;11(7):1305-1323.

42. Stern BJ. Neurological complications of sarcoidosis. Curr Opin Neurol. 2004;17(3):311-316.

43. Herbort CP, Rao NA, Mochizuki M; Scientific Committee of First International Workshop on Ocular Sarcoidosis.

International criteria for the diagnosis of ocular sarcoidosis: results of the first International Workshop on Ocular Sarcoidosis (IWOS). Ocul Immunol Inflamm.

2009;17(3):160-169.

44. Ohira H, et al. Myocardial imaging with 18F-fluoro2-deoxyglucose positron emission tomography and magnetic resonance imaging in sarcoidosis. Eur J Nucl Med Mol Imaging. 2008;35(5):933-941.

45. Nowak DA, Widenka DC. Neurosarcoidosis: a review of its intracranial manifestation. J Neurol. 2001;248(5): 363-372.

46. Sharma OP. Vitamin D, calcium, and sarcoidosis. Chest.

1996;109(2):535-539.

47. Paramothayan NS, Lasserson TJ, Jones PW. Corticosteroids for pulmonary sarcoidosis. Cochrane Database Syst Rev. 2005;(2):CD001114.

48. Schutt AC, Bullington WM, Judson MA. Pharmacotherapy for pulmonary sarcoidosis: a Delphi consensus study.

Respir Med. 2010;104(5):717-723.

49. du Bois RM, Greenhalgh PM, Southcott AM, Johnson NM, Harris TA. Randomized trial of inhaled fluticasone propionate in chronic stable pulmonary sarcoidosis: a pilot study. Eur Respir J. 1999;13(6):1345-1350.

50. Baughman RP, Iannuzzi MC, Lower EE, et al. Use of fluticasone in acute symptomatic pulmonary sarcoidosis.

Sarcoidosis Vasc Diffuse Lung Dis. 2002;19(3):198-204.

51. Paramothayan S, Immunosuppressive

IJCP Sutra 320: Develop healthy habits including eating, sleeping and exercising right.

Lasserson TJ, and cytotoxic

Walters therapy

EH. for

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sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2006; 23(3):201-208.

52. Vorselaars AD, Cremers JP, Grutters JC, Drent M. Cytotoxic agents in sarcoidosis: which one should we choose? Curr Opin Pulm Med. 2014;20(5):479-487.

60. Sweiss NJ, Noth I, Mirsaeidi M, et al. Efficacy results of a 52-week trial of adalimumab in the treatment of refractory sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2014;31(1):46-54.

53. Baughman RP, Winget DB, Lower EE. Methotrexate is steroid sparing in acute sarcoidosis: results of a double blind, randomized trial. Sarcoidosis Vasc Diffuse Lung Dis. 2000;17(1):60-66.

54. Cremers JP, Drent M, Bast A, et al. Multinational evidencebased World Association of Sarcoidosis and Other Granulomatous Disorders recommendations for the use of methotrexate in sarcoidosis: integrating systematic literature research and expert opinion of sarcoidologists worldwide. Curr Opin Pulm Med. 2013;19(5):545-561.

55. Vorselaars AD, Wuyts WA, Vorselaars VM, et al.

Methotrexate vs azathioprine in second-line therapy of sarcoidosis. Chest. 2013;144(3):805-812.

56. Müller-Quernheim J, Kienast K, Held M, Pfeifer S, Costabel U. Treatment of chronic sarcoidosis with an azathioprine/prednisolone regimen. Eur Respir J. 1999;14(5):1117-1122.

57. Sahoo DH, Bandyopadhyay D, Xu M, et al. Effectiveness and safety of leflunomide for pulmonary and extrapulmonary sarcoidosis. Eur Respir J. 2011;38(5): 1145-1150.

58. Baughman RP, Drent M, Kavuru M, et al.; Sarcoidosis Investigators. Infliximab therapy in patients with chronic sarcoidosis and pulmonary involvement. Am J Respir Crit Care Med. 2006;174(7):795-802.

59. Rossman MD, Newman LS, Baughman RP, et al.

A double-blinded, randomized, placebo-controlled trial of infliximab in subjects with active pulmonary

61. Baughman RP, Barney JB, O’Hare L, Lower EE. A retrospective pilot study examining the use of Acthar gel in sarcoidosis patients. Respir Med. 2016;110:66-72.

62. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014—an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation.

J Heart Lung Transplant. 2015;34(1):1-15.

63. Arcasoy SM, Christie JD, Pochettino A, et al. Characteristics and outcomes of patients with sarcoidosis listed for lung transplantation. Chest. 2001;120(3):873-880.

64. Shorr AF, Helman DL, Davies DB, Nathan SD. Sarcoidosis, race, and short-term outcomes following lung transplantation. Chest. 2004;125(3):990-996.

65. Shlobin OA, Nathan SD. Management of end-stage sarcoidosis: pulmonary hypertension and lung transplantation. Eur Respir J. 2012;39(6):1520-1533.

66. Schultz HH, Andersen CB, Steinbrüchel D, Perch M, Carlsen J, Iversen M. Recurrence of sarcoid granulomas in lung transplant recipients is common and does not affect overall survival. Sarcoidosis Vasc Diffuse Lung Dis. 2014;31(2):149-153.

67. Banga A, Sahoo D, Lane CR, Farver CF, Budev MM. Disease recurrence and acute cellular rejection episodes during the first year after lung transplantation among patients with sarcoidosis. Transplantation. 2015;99(9): 1940-1945.

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American Family Physician

Practice Guidelines CDC Updates Interim Guidance on Caring for Women with Possible Exposure to Zika Virus The current Zika virus outbreak was identified in Brazil in May 2015, and knowledge about the virus, its transmission, and its potential adverse effects on pregnancy outcomes is evolving. Epidemiologic, clinical, laboratory, and pathologic evidence supports a link between infection during pregnancy and outcomes such as pregnancy loss, fetal microcephaly, intracranial calcifications, and fetal brain and eye abnormalities. The level of risk of these outcomes is not known. Studies suggest that it may be as high as 29%, but microcephaly caused by viral destruction of brain tissue is likely part of a spectrum of neurologic damage caused by Zika virus, and this percentage may substantially underestimate the proportion of infants affected.

Thirty-nine countries and U.S. territories had reported active Zika virus transmission as of March 23, 2016.

Updated information is available at http://wwwnc.cdc. gov/travel/notices. Based on limited evidence on the persistence of Zika virus RNA in blood and semen, the Centers for Disease Control and Prevention (CDC) has updated its interim guidance on caring for reproductiveaged women who may have been exposed to the virus, including those who do not live in areas with active transmission. Further updates to this guidance and other clinical information on Zika virus are available at http://www.cdc.gov/zika/hc-providers/index.html.

Preconception Counseling Physicians should provide preconception counseling to women who do not live in areas with active Zika virus transmission, but who may have been exposed to the virus. Discussions should include information about the signs and symptoms of Zika virus disease and the potential adverse outcomes associated with infection during pregnancy. Women with Zika virus disease should wait at least eight weeks after symptom onset before attempting to conceive. The risk of congenital infection in pregnant women with asymptomatic infection is not known. However, asymptomatic women

Source: Adapted from Am Fam Physician. 2016;93(10):874-878.

with possible Zika virus exposure should be advised to wait at least eight weeks after the last date of exposure before attempting to conceive.

Sexual transmission of Zika virus can occur, but it is not known whether men with asymptomatic infection can transmit the virus sexually. Based on the limited data currently available, men with possible Zika virus exposure and their female partners should wait to attempt conception until the risk of sexual transmission is minimal. Men who have been diagnosed with Zika virus disease should wait at least six months after symptom onset before attempting to conceive. Men who may have been exposed to the virus but do not have clinical illness consistent with Zika virus disease should wait at least eight weeks before attempting to conceive. If symptoms do not develop, the couple could consider attempting conception or waiting longer.

Testing in Persons Attempting to Conceive Serum testing for evidence of Zika virus infection should be performed in persons who have acute onset of fever, rash, arthralgia, or conjunctivitis within two weeks of possible exposure to the virus. Routine testing is not recommended for women or men who are attempting to conceive and have possible exposure but no clinical illness. Testing in asymptomatic persons may not be necessary, and results might be difficult to interpret. It is not known whether a positive serologic test result in an asymptomatic man indicates that the virus may be present in semen, or if a negative serologic test result precludes the presence of the virus in semen. Testing of semen for Zika virus is not recommended because a positive or negative result does not provide sufficient data to guide recommendations about attempting conception.

Women Undergoing Fertility Treatment Although there have been no documented instances of Zika virus transmission during fertility treatment, transmission through donated gametes or embryos is possible because the virus can be present in semen, and sexual transmission has occurred. Zika virus is not likely to be destroyed in the cryopreservation process.

Fertility treatment using a couple’s own gametes and embryos should follow the timing recommendations for persons attempting conception.

IJCP Sutra 322: Follow ancient wisdom. Do Yoga and Meditation for your mental and spiritual well-being and maintain equilibrium.

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The U.S. Food and Drug Administration recommends that persons be considered ineligible for anonymous donation if they have been diagnosed with Zika virus infection in the past six months; have lived in or traveled to an area with active Zika virus transmission within the past six months; or within the past six months had sex with a male partner who, within the six months before sexual contact, was diagnosed with or had an illness consistent with Zika virus disease or traveled to an area of active Zika virus transmission.

These recommendations apply to anonymous donors, but not to sexually intimate couples. Directed donors must undergo the same evaluation and eligibility determination as anonymous donors. However, gametes or embryos from ineligible directed donors may be used if the tissue is labeled to indicate potential increased risk, all participating parties are aware of and willing to incur the risk, and physicians are aware of the status of gametes or embryos.

Testing in Persons with Possible Exposure Physicians—especially those who care for pregnant women living near the U.S.–Mexico border—should assess their patient’s travel histories, including the frequency of cross-border trips. Pregnant women who

do not live in an area with active Zika virus transmission but who may have been exposed to the virus should be tested (Figure 1), and those who may have been exposed during the eight weeks before conception can be offered serologic testing within two to 12 weeks of the possible exposure. A negative immunoglobulin M test result obtained two to 12 weeks after exposure suggests that infection did not occur and may rule out the need for serial ultrasonography. Pregnant women who have had sex without a condom with a male partner who may have been exposed to Zika virus should be tested if they develop any sign or symptom of Zika virus disease, or if their partner is diagnosed with Zika virus disease or a clinical illness consistent with Zika virus disease.

Amniocentesis should be considered on a case-bycase basis. It is not known how sensitive or specific reverse transcription–polymerase chain reaction testing of amniotic fluid is for detecting congenital Zika virus infection or whether a positive result predicts subsequent fetal abnormalities. The optimal time to perform amniocentesis to diagnose congenital Zika virus infection is not known; Zika virus RNA has been detected in amniotic fluid as early as four weeks after maternal symptom onset and as early as 17 weeks’ gestation.

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Respect the Umbilical Cord

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IJCP Sutra 323: Allow your body to heal itself.

Chat with Dr KK

American Family Physician

Photo Quiz Annular Scaly Plaques A 57-year-old woman presented with a largely asymptomatic rash on her feet that began six months earlier. She had infrequent mild pruritus but no other symptoms related to the rash. She had no systemic symptoms such as fever, chills, myalgias, or arthralgias.

The rash did not improve after two months of treatment with terbinafine cream.

Physical examination demonstrated well-circumscribed, erythematous, annular plaques on the dorsa of her feet that were 3 to 4 cm in diameter (Figure 1). The plaques had no induration, but there was a trailing white scale.

They were nontender to palpation, and the surrounding skin was unaffected. Findings from a potassium hydroxide preparation of the scale were negative.

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

A. Erythema annulare centrifugum.

B. Granuloma annulare.

C. Psoriasis.

D. Tinea pedis.

Discussion The answer is A: erythema annulare centrifugum.

Erythema annulare centrifugum is an inflammatory disorder of unknown origin that is thought to be a reactive process, often in response to an infection, malignancy, or medication.1,2 There are two forms: superficial and deep. Both types of rashes are characterized by annular, erythematous plaques that expand centrifugally. They most commonly affect the trunk and proximal extremities, and migrate centrifugally.1-3 The superficial form displays the characteristic trailing white scale, whereas the deep form classically lacks the scale and has infiltrated borders.2-4 Most cases are asymptomatic, although mild pruritus is sometimes reported.1,4

Source: Adapted from Am Fam Physician. 2016;93(10):865-866.

Figure 1.

Erythema annulare centrifugum most commonly occurs in patients in their 50s, and affects men and women equally.1,3,4 Disease progression is variable. The rash may be episodic or may last for weeks to decades.1,2,4 Erythema annulare centrifugum does not cause systemic symptoms.1,4 Treatment with topical, intralesional, or systemic steroids may lead to involution and repression of plaques but generally does not prevent new eruptions or recurrences.2,4 Granuloma annulare is an asymptomatic rash of unknown etiology. It is characterized by indurated papules coalescing into annular plaques without scale, and typically occurs on the dorsal hands and feet. Central clearing or slight central depression is common. Granuloma annulare is often self-limited with spontaneous resolution in 50% of patients; however, there is a 40% recurrence rate.1 Psoriasis is a chronic autoimmune inflammatory dermatosis characterized by increased keratinocyte proliferation, resulting in well-demarcated pink plaques with thick overlying silvery scale. The scale is typically found throughout the plaque. Classic plaque-type psoriasis occurs on the extensor surfaces (elbows and knees), but the scalp and buttocks are often also affected.

Psoriasis may be accompanied by nail changes, such as onycholysis and pitting.5 Psoriatic arthritis affects up to 30% of patients with psoriasis.6 Tinea pedis is a common fungal infection of the feet caused by dermatophytes. It classically occurs in the interdigital spaces. Tinea causes serpiginous and annular patches and thin plaques, with a scale on the leading edge. Tinea is often pruritic or causes a burning

IJCP Sutra 324: Early detection of most health problems can help in correcting lifestyles to slow the degeneration process and lead a longer and healthier life.

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REFERENCES

Summary Table Condition

Characteristics

Erythema annulare centrifugum

Trailing white scale (superficial form); asymptomatic, annular, erythematous plaques; commonly occurs on the trunk and proximal extremities

Granuloma annulare

Absence of scale; asymptomatic, self-limited indurated papules coalescing into annular plaques, with central clearing or slight central depression; occurs on dorsal hands and feet

Psoriasis

Thick overlying silvery scale; well-demarcated pink plaques occurring on extensor surfaces, scalp, and buttocks; accompanied by nail changes and arthritis

Tinea pedis

Leading edge of scale; fungal infection on the feet causing serpiginous and annular patches and thin plaques; pruritus or burning is common

sensation.1 The diagnosis of tinea is often made clinically but can be confirmed with identification of hyphae on a potassium hydroxide preparation.2

1. Bolognia J, Jorizzo J, Schaffer JV, Callen JP, eds.

Dermatology. 3rd ed. Philadelphia, Pa.: Elsevier Saunders; 2012.

2. Marks JG, Miller JJ, eds. Lookingbill and Marks’ Principles of Dermatology. 5th ed. Philadelphia, Pa.: Elsevier Sanders; 2013.

3. Ziemer M, Eisendle K, Zelger B. New concepts on erythema annulare centrifugum: a clinical reaction pattern that does not represent a specific clinicopathological entity. Br J Dermatol. 2009;160(1):119-126.

4. Lebwohl M, ed. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. London, UK: Mosby; 2002.

5. Habif TP, ed. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 6th ed. St. Louis, Mo.: Elsevier; 2016.

6. Mease PJ, Gladman DD, Papp KA, et al. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol. 2013;69(5):729-735.

■■■■

Make sure During Medical Practice

Situation:

A patient with heart failure on ACEI was hospitalized.

© IJCP GROUP

Why did you not put him on valsartan?

Lesson:

The combined endpoint of mortality and morbidity was significantly lower with valsartan than placebo, largely due to a decreased number of hospitalizations for heart failure in the Valsartan Heart Failure Trial (Val-HeFT). The benefit in terms of morbidity and mortality was achieved in a population in which 93% of patients were treated with an ACEI and 35% were treated with a b-blocker.

N Engl J Med. 2001;345(23):1667-75.

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IJCP Sutra 325: Both active and passive smoking are harmful for the body.

CARDIOLOGY

Prescribing Pattern of Antihypertensive Drugs in a Tertiary Care Teaching Hospital in Lucknow Region VIJAY K YADAV*, SHYAM SUNDER KESHARI†, KRISHNA PANDEY‡

Abstract Aims and objectives: To evaluate the prescribing pattern of antihypertensive drugs in a tertiary care teaching hospital in Lucknow region. Material and methods: A cross-sectional study was carried out at Outpatient Department in a tertiary care teaching hospital in Barabanki to evaluate the prescribing pattern of antihypertensive drugs during August 2013 to July 2015.

Results: In the present study, 68.5% patients received monotherapy while 31.5% received combination therapy. In monotherapy, angiotensin-converting enzyme inhibitor (ACEI) (25.7%) was the most commonly prescribed while angiotensin receptor blockers (ARBs) + diuretics (11.9%) were most commonly prescribed combination therapy. Conclusion: In the present study, it was found that ACEIs were the most commonly prescribed antihypertensive drug followed by ARBs and calcium channel blockers (CCBs) in monotherapy. Combination therapy was given according to associated risk factors and comorbid conditions.

Keywords: Prescribing pattern, monotherapy, ARB, ACEI, CCB

H

ypertension is a major health problem in our country. There are several factors which are responsible for hypertension like age, ethnic background, family history of hypertension, obesity, sedentary lifestyle, food habits, smoking, alcoholism, stress and some chronic pathological conditions like diabetes, renal disease, etc. The estimated total number of adults with hypertension in 2000 was 972 million; 333 million in economically developed countries and 639 million in economically developing countries.

The number of adults with hypertension in 2025 was predicted to increase by about 60% to a total of 1.56 billion (1.54-1.58 billion). Worldwide data for the global burden of hypertension reveal that 20.6% of Indian men and 20.9% of Indian women were suffering from hypertension in 2005.1 It has been estimated that by the year 2030, 23 million cardiovascular deaths are projected to be due to hypertension, of which about 85% cases will be from low-resource settings and developing

*Assistant Professor †Professor ‡Tutor Dept. of Pharmacology Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh Address for correspondence

Dr Shyam Sunder Keshari Professor, Dept. of Pharmacology Mayo Institute of Medical Sciences, Gadia, Barabanki - 225 001, Uttar Pradesh E-mail: drsskeshari@gmail.com

422

nations.2 Recent studies from India have shown the prevalence of hypertension to be 25% in urban and 10% in rural people in India.3-4 The poor control of hypertension leads to further progressive cardiovascular complications like ischemic heart disease, heart failure, stroke and chronic renal insufficiency.5 Awareness and adequate control of hypertension in India is poor, only 69% people suffering with hypertension are aware that they have the disease, among them only 54% receive treatment and only 27.4% achieve adequate blood pressure control.6 Treatment of hypertension with monotherapy or combination therapy is updated time to time according to the Joint National Committee (JNC) I-VIII guidelines.

The blood pressure stages in the JNC-VIII definition/ classification are: Categories of Systolic blood Diastolic blood hypertension pressure (mmHg) pressure (mmHg) Normal <120 <80 Prehypertension 120-139 80-89 Stage I hypertension 140-159 90-99 Stage II hypertension >160 >100

Material and Methods A cross-sectional study was carried out at Outpatient Department of Medicine in Mayo Institute of Medical Sciences (MIMS), Barabanki, Uttar Pradesh during August 2013 to July 2015. Samples of 453 prescriptions

IJCP Sutra 326: Manage your blood cholesterol, blood pressure as well as blood sugar.

CARDIOLOGY were screened and written consent was taken.

Inclusion criterion for the selection of prescriptions was hypertensive patients according to the JNC-VIII guidelines. Fifty-three prescriptions having lifestyle modification and non-pharmacological measures were excluded from our study. The results are based upon the data obtained from 400 participants. Data were analyzed using MS Excel 2007 and summarized as counts and percentages.

Inclusion Criteria ÂÂ

Patients with age groups more than 18 years.

ÂÂ

Hypertensive patients with and without comorbid conditions i.e., cardiovascular disease, diabetes mellitus and chronic kidney disease.

ÂÂ

Patients on monotherapy and combination therapy.

ÂÂ

Patients with addiction or non-addiction to alcohol or nicotine.

Among combination therapy, 27% patients received two drugs combination therapy and the most commonly prescribed combination was ARB + diuretics (11.9%), followed by CCB + β-blockers (4%). Three drug combinations were received by 3% patients. Among three drug combinations, ARB + β-blocker + diuretics and ACEI + β-blocker + diuretics were used in 1.7% and 1.2% patients, respectively. Four drug combinations were received by only 1.5% patients. Equal number of patients (0.7%) received ARB + β-blocker + diuretic + CCB and ACEI + β-blocker + diuretic + CCB combinations (Table 3).

Table 2. Prescribing Pattern of Monotherapy Antihypertensive Drugs Antihypertensive drugs

Exclusion Criteria ÂÂ

Patients with age group less than 18 years.

ÂÂ

Prescriptions having lifestyle modifications and non-pharmacological measures.

Results and Observation In the present study, 55.7% hypertensives were male while 44.2% were female. Out of 400 prescriptions, 68.5% patients received monotherapy and 31.5% received combination therapy. Most of the hypertensives patients were in the age group of 50-59 years (28.2%) followed by 60-69 years (26.7%) (Table 1). Out of 274 monotherapy, Table 1. Demographic Characteristics of Hypertensive Patients (n = 400) Variables

angiotensin-converting enzyme inhibitors (ACEIs) (25.7%) were the most commonly prescribed, followed by angiotensin receptor blockers (ARBs) (22.7%) and calcium channel blockers (CCBs) (15%) (Table 2).

No. of prescriptions (274) Male (n = 144) No. (%)

Female (n = 130) No. (%)

ACEIs

52 (13)

51(12.7)

ARBs

41 (10.2)

50 (12.5)

β-blockers

4 (1)

4 (1)

CCBs

36 (9)

24 (6)

11 (2.7)

1 (0.2)

Diuretics

Table 3. Prescribing Pattern of Combination Therapy Antihypertensive Drugs Antihypertensive drugs ARB + Diuretics

No. of prescriptions (126) Male (n = 76) No. (%)

Female (n = 50) No. (%)

27 (6.7)

21 (5.2)

12 (3)

4 (1)

Male (n = 223) No. (%)

Female (n = 177) No. (%)

223 (55.7)

177 (44.2)

ARB + CCBs

10 (2.5)

6 (1.5%)

ACEI + Diuretics

5 (1.2)

3 (0.7)

Monotherapy

144 (36)

130 (32.5)

ARB + β-blockers

6 (1.5)

2 (0.5)

Combination therapy

76 (19)

50 (12.5)

ACEI + β-blockers

4 (1)

4 (1)

ARB+ β-blocker + Diuretics

4 (1)

3 (0.7)

ACEI + β-blocker + Diuretics

3 (0.7)

2 (0.5)

α-blocker + CCBs

1 (0.2)

3 (0.7)

ARB+ β-blocker + Diuretics + CCBs

2 (0.5)

1 (0.2)

ACEI + β-blocker + Diuretics + CCBs

2 (0.5)

1 (0.2)

Antihypertensive prescriptions

Age (in years) 20-29

4 (1.8)

2 (1.1)

30-39

30 (13.4)

23 (13.0)

40-49

43 (19.3)

36 (20.3)

50-59

51 (22.9)

62 (35.0)

60-69

67 (30.0)

40 (22.6)

70-79

14 (5.3)

9 (5.1)

80-89

8 (3.6)

5 (2.8)

IJCP Sutra 327: Maintain optimum body weight. Limit your salt intake.

CCB + β-blockers

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

Discussion

References

Reduction of systolic as well as diastolic blood pressure reduces the cardiovascular events. At ages 40-69 years, each difference of 20 mmHg systolic or 10 mmHg diastolic blood pressure was associated with more than a two-fold difference in the stroke death rate, and with two-fold differences in the death rates from coronary heart disease and other vascular causes.7 In the present study, it was found that the prevalence of hypertension was more in male patients (55.7%) as compared to females (44.2%), so male are affected more than female, which correlates with the previous study done by Farang et al.8 The maximum number of patients (74.7%) fall in the age group of 40-69 years. This indicates that risk of hypertension increases as the age advances.

A previous study revealed that increasing age, body mass index, smoking, diabetes and extra salt intake are common risk factors for hypertension.9 Present study shows monotherapy (68.5%) is more common than combination therapy (31.5%). These results were in accordance with previous study done by Kuchake et al.10 The combination therapy is given to those patients who are not controlled by monotherapy. In the present study, ACEIs (25.7%) were the most commonly prescribed drug in monotherapy followed by ARBs. These results were in accordance with the work of Pandey et al.11 Combination therapy in hypertensives, adequately controlled the blood pressure.12 Combination therapy also reduces the cardiovascular complications thus reduces mortality.13 In our study, CCBs were preferred in elderly patients which is in accordance to the guidelines of National Institute for Health and Care Excellence (NICE).14 ARBs were preferred in the patients of age less than 50 years of age. Diuretics were most preferred drugs in combination therapy with ARB, ACEI and CCB which was in accordance with the study done by Johnson et al.15 It is essential to combine diuretics with these drugs for reduction of blood volume, peripheral vascular resistance. Use of ACEI/ARB was higher in patients with nephropathy.

1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217-23.

Conclusion In the present study, it was found that ACEIs were the most commonly prescribed drug followed by ARBs and CCBs in monotherapy. In ACEIs, ramipril was the most commonly prescribed drug while telmisartan was the most common in ARBs. Amlodipine was most commonly prescribed drug in CCBs. Combination therapy was given according to associated risk factors and comorbid conditions. We feel that there is need of further studies from time to time to evaluate and improve the prescribing pattern of hypertension.

424

2. World Health Organization. A global brief on hypertension: silent killer, global public health crisis.

Geneva: WHO; 2013. (WHO/DCO/WHD/2013.2).

3. Thankappan KR, Sivasankaran S, Sarma PS, Mini G, Khader SA, Padmanabhan P, et al. Prevalence-correlatesawareness-treatment and control of hypertension in Kumarakom, Kerala: baseline results of a community-based intervention program. Indian Heart J. 2006;58(1):28-33.

4. Das SK, Sanyal K, Basu A. Study of urban community survey in India: growing trend of high prevalence of hypertension in a developing country. Int J Med Sci. 2005;2(2):70-8.

5. Bhimaray SK, Sandeep A, Ramanath KV. Assessment of prescription pattern of antihypertensive in a tertiary care hospital of rural population. AJPSCR. 2011;1(3):5-12.

6. Shirley C, Nagavi BG. Impact of community pharmacy based patient education on the quality of life of hypertensive patients. Indian J Pharm Educ Res. 2007;41(2):164-9.

7. Gupta R, Guptha S. Strategies for initial management of hypertension. Indian J Med Res. 2010;132:531-42.

8. Farag YM, Mittal BV, Keithi-Reddy SR, Acharya VN, Almeida AF, C A, et al. Burden and predictors of hypertension in India: results of SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol.

2014;15:42.

9. Devi P, Rao M, Sigamani A, Faruqui A, Jose M, Gupta R, et al. Prevalence, risk factors and awareness of hypertension in India: a systematic review. J Hum Hypertens. 2013;27(5):281-7.

10. Kuchake VG, Maheshwari Od, Surana SJ, Patil PH, Dighore PN. Prescription pattern of antihypertensive drugs in uncomplicated hypertensive patients at teaching hospital. Indian J Pharm Pract. 2009;2(2):74-80.

11. Pandey V, Hoda U, Aqil M, Sharma M, Akhtar M, Khandewal R, et al. Evaluation of prescribing patterns in diabetic and hypertensive patients in a South Delhi Hospital. Int J Basic Clin Pharmacol. 2014;3(3):490-5.

12. Hansson L, Dahlöf B, Gudbrandsson T, Hellsing T, Kullman S, Kuylenstierna J, et al. Antihypertensive effect of felodipine or hydralazine when added to beta-blocker therapy. J Cardiovasc Pharmacol. 1988;12(1):94-101.

13. Mancia G, Grassi G. Antihypertensive treatment: past, present and future. J Hypertens Suppl. 1998;16(1):S1-7.

14. National Clinical Guideline Centre. Hypertension. Clinical management of primary hypertension in adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Aug. 36 p. (Clinical Guideline; No. 127).

15. Johnson ML, Singh H. Patterns of antihypertensive therapy among patients with diabetes. J Gen Intern Med. 2005;20(9):842-6.

IJCP Sutra 328: Avoid traveling to places where mites are known to be present in large numbers.

COMMUNITY MEDICINE

Study of Prevalence of Severe Acute Malnutrition in Children Under 5 Years in Chatra Area of Serampore Municipality Under the State of West Bengal PRADIP KUMAR DAS

Abstract Malnutrition in India has been cited as “The silent emergency” because the proportion of under nutrition among children and women in India figures at the topmost position in the world as depicted by increased incidence of anemia and wasting in addition to several other indicators of malnutrition. The main purpose of this study was to make a survey of severe acute malnutrition (SAM) in children under five in the Chatra area under Serampore Municipality for the identification of the societal factors that may contribute to SAM in children, to provide clinical management and reduce mortality among the children with SAM and to render appropriate health education for the mothers and other caregivers regarding the proper way of feeding and caring practices towards the infants and young children.

Keywords: Severe acute malnutrition, caregivers, health education

M

alnutrition in India has been cited as “The silent emergency” because the proportion of under nutrition among children and women in India figures at the topmost position in the world as depicted by increased incidence of anemia and wasting in addition to several other indicators of malnutrition (the Maternal and Child Health Sustainable Technical Assistance and Research [MCH-STAR]). It is evident from the study report of the National Nutrition Monitoring Bureau (NNMB) Rural Third Report survey that only 36% of infants in India were starting breastfeeding within 1 hour of birth. Moreover, the third National Family Health Survey (NFHS-3) report shows that 48% of under five children are stunted, 43% are underweight and 20% have wasting. It is also revealed from another survey report done by the HUNGaMA (Hunger and Malnutrition) in 2011 that 34% of children under five were stunted, 16.4% were underweight and 3.3% had wasting. According to UNICEF, a study report done by Black et al on 2013, globally the prevalence of

Secretary, Swasthya Bhabna Welfare Society, Principal Investigator, Consultant Physician and Dermatologist, Master Trainers and Supportive Supervisor in GFATM-Project -7 Address for correspondence

Dr Pradip Kumar Das 15/C, Raja KL Goswami Street, Serampore, Hooghly - 712 201, West Bengal E-mail: pradipdr2@gmail.com

underweight children below 5 years is 16%, whereas in South Asia and Western Africa the figures are 30% and 20%, respectively.

In Indian scenario, the picture is quite different. In Sikkim and Mizoram, the prevalence of underweight is 20%, whereas in Madhya Pradesh it reaches about 60%.

In the state of Jharkhand and Bihar, the picture shows 50% and in Meghalaya, Chhattisgarh, Gujarat, Uttar Pradesh and in Odisha it is about 40%. The latest NNMB Rural Third Survey report done from 2011 to 2012 among the boys and girls under 5 years of age in 10 states of India, shows that the overall prevalence of underweight, stunting and wasting in boys are 42.1%, 44.3% and 22.5%, respectively, whereas in case of girls children these figures are 41.4%, 41.9% and 21.5%, respectively.

Methodology Integrated Child Development Services (ICDS) centers in Chatra areas were selected. Proper permission was taken from the Child Development Project Officer (CDPO) and concerned councillor of the Ward. After explaining the total procedure for our study to the mothers, verbal consent was taken from them regarding the check-up of their children and their interviews.

A good rapport was built up with the ICDS workers.

Vision and Mission of the present study was written

IJCP Sutra 329: Wear protective clothing when traveling to an endemic area. Long sleeved clothes can prove helpful.

425

Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

Results It is evident from the study of 50 children including boys and girls under the age group below 5 years taken for the study when categorized as percentage of reference for weight-for-age for children (both boys and girls), 38 children (76%) belonged to the normal group, 11 children (22%) were grouped as mild malnutrition and 1 child (2%) fell under moderate malnutrition.

It is good that no severe group of malnourished children was found in that center (Table 1 and Fig. 1). From the study, it was also revealed that out of 50 children when categorized as percentage of reference for height-for-age for children (both boys and girls), 44 (88%) categorized as normal children in respect of nutritional status, whereas 4 children (8%) belonged to mild malnutrition group, 1 children (2%) grouped as moderate malnutrition and 1 children (2%) as severe malnutrition (Table 2 and Fig. 2). Moreover, the study revealed that out of 50 children when categorized as percentage of reference for weight-for-height

426

IJCP Sutra 330: Apply mite repellents to exposed skin.

Total no. of children taken for study works (50) Normal (90-110%)

38

Grade I: Mild malnutrition (75-89%)

11

Grade II: Moderate malnutrition (60-74%)

1

Grade III: Severe malnutrition (<60%)

0

50 Total no. of children

Whenever identified the children with SAM were transferred to Best Health Facility and Feeding-based care under the Sub Divisional Hospital and monitored.

Referral children were properly monitored whenever they were admitted as inpatient in the Sub Divisional Hospital for their better care and treatment of medical complications. Enrollment register of the mothers and children linked to study was prepared for future reference. Patient care register and follow-up register were maintained. Group counseling register for the provision of health education towards the mothers was also maintained.

Table 1. Percentage of Reference Weight-for-age for Girls and Boys (0-5 Years)

40

38

30 20 11

10 0

01 Normal (90-110%)

Grade I: Mild malnutrition (75-89%)

0

Grade II: Moderate malnutrition (60-74%)

Grade III: Severe malnutrition (<60%)

Figure 1. Percentage of reference weight-for-age for boys and girls (under 5).

Table 2. Percentage of Reference for Height-for-age for Girls and Boys (0-5 Years) Total no. of children taken for study works (50) Normal (>95%)

44

Grade I: Mild malnutrition (90-95%)

4

Grade II: Moderate malnutrition (85-90%)

1

Grade III: Severe malnutrition (<85%)

1

Total no. of children

in bold letters at the ICDS center, so that it could be read from far distance. Growth monitoring chart, midupper arm circumference (MUAC) examination chart and pedal edema examination chart were displayed in the examination room. Height and weight were taken by using tape and weighing machine of 50 children under the age group of 5 years. Month-wise clinical attendance of children and mothers from May to September, 2015 was prepared. Steps were taken for establishment of regular communication between the mothers of severe acute malnutrition (SAM) children.

Steps were also taken for the preparation of followup care for SAM children. Clinical care guidelines for treatment (Algorithms) and criteria for referrals were developed. Ambulatory care facilities like treatment of clinical complications i.e., dehydration, infection, hypoglycemia, hypothermia and micronutrient supplementation were set up.

50 45 40 35 30 25 20 15 10 5 0

44

4 Normal (>95%)

Grade I: Mild malnutrition (90-95%)

1

1

Grade II: Moderate malnutrition (85-90%)

Grade III: Severe malnutrition (<85%)

Figure 2. Percentage of reference for height-for-age for girls and boys (under 5).

COMMUNITY MEDICINE Table 3. Percentage of Reference for Weight-forheight for Girls and Boys (0-5 Years) Total no. of children taken for study works (50) Normal (>90%)

38

Grade I: Mild malnutrition (80-90%)

9

Grade II: Moderate malnutrition (70-80%)

3

Grade III: Severe malnutrition (<70%)

0

40

38

30 20 10 0

9

3

0

No G rm m rad al e al nu I: tri M (>9 0% tio ild n ) (8 090 G % ) m rad al e nu II tri : M G tio o m rad n ( der al e 7 nu II 0-8 ate tri I: S 0% tio e n ve ) (< re 70 % )

Total no of children

Percentage of reference for weight-for-height for girls and boys (0-5 years): Total no. of children taken for study works (50)

Figure 3. Percentage of reference for weight-for-height for girls and boys (0-5).

for children (both boys and girls), 38 (76%) were categorized as normal children in respect of nutritional status, whereas 9 children (18%) belonged to mild malnutrition group, 3 children (6%) grouped as moderate malnutrition and no child was marked as severe malnutrition group (Table 3 and Fig. 3).

Discussion Through this study, it has become possible for providing knowledge and motivation to ICDS health workers has boosted their confidence in tackling SAM children.

Sensitization of staff of ICDS center has encouraged them to think of SAM children in their regular routine working procedures. Advocacy programs have enriched the knowledge and awareness among the Healthcare Providers of the said center.

Moderate-to-severe malnourished children are referred to better healthcare facility center of the district where they are given proper nutritional and clinical management under the supervision of the doctors and dieticians and mothers are given proper health education regarding the practice of appropriate

nutrition of their malnourished children. Number of malnutrition children (12) and their family members were given proper nutritional and clinical management advice and counseling. Prompt diagnosis and effective management of infections, diarrhea and others of the malnutrition children (12) have enabled them to have improved quality-of-life.

Conclusion In India, the prevalence of SAM in children depicts a high figure of approximately 8.1 million as per survey report of NFHS-3, despite overall economic growth in India. Children with SAM are more prone to higher risk of dying than well-nourished children. So for, the prevention of death due to malnutrition in children, proper nutritional and clinical management is required.

For this purpose, under National Rural Health Mission, Nutrition Rehabilitation Centres have been formed at different health facility centers of the districts to provide facility-based management to SAM children.

The facilities are proper monitoring of the child care for 24 hours, early treatment of medical complications, therapeutic feeding, proper counseling of the mothers on right methods of feeding, care and hygiene, education program for the mothers and practical demonstration and practices on the preparation of energy enriched child foods which are locally available, acceptable to the children and affordable food items to the mothers.

SAM children with complications like severe infections or diarrhea require hospital admissions for inpatient care and its incidence reaches less than 15% of children under 5 years. Eighty-five percent of such children can be managed in a home-based care. In this regard, a consensus statement by Indian Academy of Pediatrics (IAP) in the year 2013 regarding the integrated management of SAM states that management of SAM should not be a standalone program, but it should integrate with community management therapeutic programs and linkages with child treatment centers, district hospitals and tertiary level centers offering inpatient management of SAM and include judicious use of ready to use therapeutic foods.

SUGGESTED READING 1. International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005-06: India: Volume 1. Mumbai: IIPS. 2. The WHO Child Growth Standards. WHO 2006.

Available at: http://www.who.int/childgrowth/en/.

3. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Length/height-for-age, weightfor-age, weight-for-length, weight-for-height and body

IJCP Sutra 331: Those with risk factors and who work in an endemic area can be given once weekly dose of doxycycline.

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018 mass index-for-age: methods and development. Geneva: World Health Organization; 2006.

4. Child and Maternal Nutrition in India, USAID. Available at: http://www.usaid.gov/in/Pdfs/mch_star.pdf.

5. Wahiqvist ML, Kouris Bazos A, Ross KA, Setter TL, Tienboon P. Growth and aging. In: Gibney MJ, Margetts BM, Kearney JM, Lenore A (Eds.). Public Health Nutrition.

Blackwell Publishing; 2008. pp. 112-44.

6. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al; Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet.

2008;371(9608):243-60.

7. Ramakrishnan U, Nguyen P, Martorell R. Effects of micronutrients on growth of children under 5 y of age: meta-analyses of single and multiple nutrient interventions. Am J Clin Nutr. 2009;89(1):191-203.

8. Coutsoudis A, Bentley J. Infant feeding. In: Gibney MJ, MacDonald IA, Roche HM (Eds.). Nutrition and Metabolism. Blackwell Publishing; 2008. pp. 264-82.

9. Caulfield LE, de Onis M, Blössner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr. 2004;80(1):193-8.

10. Pelletier DL, Frongillo EA Jr, Habicht JP. Epidemiologic evidence for a potentiating effect of malnutrition on child mortality. Am J Public Health. 1993;83(8):1130-3.

11. Fishman SM, Caulfield LE, de Onis M, Blossner M, Hyder AA, Mullany L, et al. Childhood and maternal underweight. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL (Eds.). Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. Geneva: WHO; 2004. pp. 39-161.

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IJCP Sutra 332: Keep fit and active, as it helps reduce your blood pressure.

ENDOCRINOLOGY

Posology of Antidiabetic Drugs and Insulins: A Review of Standard Textbooks GARIMA BHUTANI*, SANJAY KALRAâ&#x20AC;

Abstract Objectives: The aim of this bibliographic review is to assess whether standard pharmacology, endocrinology and diabetology textbooks adequately mention the details regarding timings of administration, frequency and dose of various oral and injectable antidiabetic drugs. Material and methods: Four standard textbooks of pharmacology, two of diabetology and three of endocrinology were assessed for the published information regarding dose, timing and frequency of antidiabetic drugs. Results: Various omissions and contraindications were found in the coverage of glucose-lowering drugs in standard textbooks. Proper timing and frequency of administration of sulfonylureas, thiazolidinediones, SGLT2 inhibitors, GLP receptor agonists and DPP-4 inhibitors have been omitted in majority of the textbooks. Conclusions: This article stresses upon the need of a uniform source of information for providing adequate and standardized knowledge regarding timing, frequency and dose of antidiabetic drugs.

Keywords: Posology, antidiabetic drugs, postprandial hyperglycemia

C

orrect timing of glucose-lowering therapy is an important aspect of diabetes pharmacotherapeutics. Matching the dose of a particular drug with meals depends upon its mechanism of action and pharmacokinetic profile.

This timing varies from class-to-class and drug-todrug. Each drug has a specific time action profile. This should match with food absorption. Inappropriate timing/frequency/dose of administration may lead to unwanted hyperglycemia or hypoglycemia leading onto poor glycemic control or complications in the patients.

This glycemic variability is easily avoidable with the better knowledge and understanding of appropriate dose, timing of administration and frequency of drug administration. Pharmacology, diabetology and endocrinology textbooks are an important and reliable source of such information, both for students and

clinicians. This article aims at assessing the adequacy of the knowledge provided by these textbooks regarding posology (i.e., dose, frequency and timing of antidiabetic drugs).

Material and Methods Some of the most popular and most commonly read textbooks of pharmacology, diabetology and endocrinology were included in the study. Four standard textbooks of pharmacology (2 by Indian authors and 2 by US authors) were analyzed. Two textbooks of diabetology were also studied, out of which 1 textbook is by Indian author and other is by US author. Three textbooks of endocrinology (2 US and 1 Indian in origin) were also assessed for the desired information. Latest available editions of the textbooks were taken for analysis.

Results

*Assistant Professor Dept. of Pharmacology BPS Govt. Medical College for Women, Khanpur Kalan, Sonepat, Haryana â&#x20AC; Consultant Dept. of Endocrinology Bharti Hospital and BRIDE, Karnal, Haryana Address for correspondence

Dr Garima Bhutani H No. 517, Sector 15-A, Hisar, Haryana E-mail: garimaahuja2010@yahoo.com

The results of the analysis have been tabulated in Table 1, which shows the comparison of information about antidiabetic drugs available in different textbooks.

Discussion This bibliometric analysis highlights various omissions and contraindications in the coverage of glucoselowering drugs in standard textbooks.

IJCP Sutra 333: Monitor your blood pressure: It is also the most common cause of kidney damage.

429

5-20 mg daily

-

Glipizide extended release

Gliclazide

180-360 mg, 1-10 min before a meal

Nateglinide

5-40 mg o.d. or b.i.d.

0.5-16 mg preprandially

Repaglinide

4-8 mg o.d.

Rosiglitazone

Sulfonylureas Glipizide

Meglitinide analog

15-45 mg o.d.

Pioglitazone

Max dose is 2 g o.d., with meals

Metformin SR

Thiazolidinediones

0.5-2.5 g b.i.d., with meals

Metformin

Biguanides

Goodman and Gilmanâ&#x20AC;&#x2122;s the Pharmaceutical Basis of Therapeutics1

Drug

Drug class

-

40-240 mg in 1-3 doses, 20-30 min before meals8

40-320 mg6

-

40-240 mg, o.d. or b.i.d.

-

40-250 mg o.d. or b.i.d.

-

-

2.5-5 mg initially.

20 mg o.d. max dose

2.5-5 mg initially.

Max 40 mg divided b.i.d.

Once-daily dose6

Once-daily morning dose, max 20 mg/day

5-20 mg o.d. or b.i.d.

1.25-15 mg in 2-3 doses, 20-30 min before meals8

5-20 mg, o.d. or b.i.d.

2.5-20 mg6

5-30 mg, 30 min before breakfast

60-180 mg in 3-4 doses, just before or soon after starting a meal8

60-180 mg t.d.s., preprandial use6

60-120 mg t.i.d. with each meal

60-120 mg, shortly before each meal

180-480 mg, 3-4 doses per day, 10 min before meal

60-120 mg, just before meals

0.5-4 mg in 3-4 doses, just before or soon after starting a meal8

0.5-4 mg, 15-30 min before each main meal6

0.5-2 mg t.i.d. with each meal

-

4-8 mg6

0.25-4 mg shortly before each meal

-

15-45 mg/day6

1-8 mg, 3-4 doses/day, before each major meal

2-8 mg daily

15-45 mg daily

-

Once-daily in morning or b.i.d. (morning and evening)6

0.25-4 mg, just before each meal (max 16 mg/day)

11-45 mg o.d.

With evening meal

4-8 mg o.d.

15-45 mg o.d.

-

-

2-8 mg o.d. or b.i.d.

15-45 mg o.d.

-

-`

-

500 mg o.d.2,550 mg (divided doses) with meals or immediately before meals6

Start with 500 mg o.d.

Titrate up to 500-1,000 g b.i.d., given with meals

500 mg before breakfast and 500 mg with evening meal

0.5-2.5 mg, 1-2 doses per day

500 mg-2.55 g at bedtime for fasting hyperglycemia and before meals for postprandial hyperglycemia

RSSDI Text book of Diabetes Mellitus8-10

Textbook of Diabetes6,7

Endocrinology5

Basic and Principles of Essentials Clinical Pharmacology4 of Medical Pharmacology2 Pharmacology3

Table 1. Comparison of Information in Pharmacology, Endocrinology and Diabetology Textbooks

-

5-20 mg/day

5-40 mg/day

Preprandial dosing

Preprandial dosing

-

15-45 mg/ day o.d.

-

500 mg o.d. to 2,500 mg in divided doses

Manual of Clinical Endocrinology11

-

Initial 5 mg. Max 20 mg o.d.

Initial 5 mg, Max 40 mg, divided b.i.d.

120 mg with each meal

Max 4 mg with each meal

-

-

-

At least b.i.d.

Williams Textbook of Endocrinology12

DPP-4 inhibitors

αGlucosidase inhibitors

50-100 mg daily

-

100 mg daily

2.5-5 mg daily

-

Linagliptin

Sitagliptin

Saxagliptin

Alogliptin

25-100 mg before meals

Vildagliptin

Miglitol

-

1-8 mg o.d.

Glimepiride

Voglibose

0.75-12 mg daily

Micronized glyburide

25-100 mg, before meals

1.25-20 mg o.d. or b.i.d.

Glyburide (glibenclamide)

Acarbose

-

Gliclazide MR

-

2.5-5 mg daily

100 mg orally o.d.

-

-

25-100 mg just before ingesting the final portion of each meal

-

25-100 mg, just before ingesting the final portion of each meal

1-8 mg o.d.

-

1.25-20 mg, single morning dose

-

-

5 mg o.d.

100 mg o.d.

-

-

-

100 mg o.d. before meals

-

50 mg o.d. before meals

-

25-100 mg daily

25-100 mg o.d.

-

-

-

-

100 mg o.d. in morning6

12.5-25 mg/day

12.5-25 mg10

100 mg/day

5 mg/day

-

o.d.10

50 mg b.i.d.

-

-

-

1-8 mg/day

0.75-12 mg/day

1.25-20 mg/day

-

5 mg/day10

100 mg

-

50 mg o.d. or b.i.d., with or without food10

50 mg b.i.d.6

50-100 mg o.d. or b.i.d.

-

-

With meals6

25-100 mg t.i.d. with first bite of carbohydrate containing meal

-

25-100 mg t.d.s. at the beginning of each major meal

0.2 mg t.d.s., just before each meal - max of 0.3 mg t.d.s.9

With meals6

-

-

200-300 mg t.d.s. just before meals

25 mg t.d.s. at the start of each main meal to max of 100 mg t.d.s.9

50 mg o.d. to 200 mg t.d.s., with meals6

25-100 mg t.i.d. with first bite of carbohydrate containing meal

50-100 mg t.d.s. at the beginning of each major meal

50-100 mg t.d.s., at the beginning of each major meal

-

-

1-8 mg o.d., 20-30 min before meals8

1.25-20 mg in 1-3 doses/day, 20-30 min before meals8

1.25- 15 mg6

1-6 mg6

-

30-120 mg o.d.6

1-2 mg initially.

Maximum dose is 8 mg o.d.

1.5-3 mg initial dose.

Max dose is 6 mg, b.i.d.

1.25-5 mg initially. Max dose 20 mg, divided b.i.d.

-

1-6 mg o.d.

-

5-15 mg o.d. or b.i.d.

-

1-6 mg o.d. or b.i.d.

-

2.5-15 mg o.d. or b.i.d.

-

-

-

-

-

-

-

-

-

Cont’d...

1-8 mg o.d.

Initial 3 mg.

Max 6 mg b.i.d.

Initial dose 2.5 mg.

Max dose 20 mg, divided b.i.d.

-

Pramlintide

Colesevelam

Amylin analog

Bile acid binding resin

3 tab (625 mg) b.i.d. before lunch and dinner or 6 tab prior to largest meal

15-60 μg s/c inj in type 1 DM, 60-120 μg s/c inj in type 2 DM. Injected prior to meals

1.6-4.8 mg, with food in the morning within 2 h of awakening

-

Ipragliflozin

Bromocriptine

-

-

Dapaglifozin

Canagliflozin

-

Lixisenatide

15-60 μg s/c inj before meals as an adjunct to insulin in DM type 1 cases and 60-120 μg s/c inj before meals with insulin in type 2 DM.

s/c inj before meal

-

15-60 μg s/c inj in type 1 DM, 60-120 μg s/c inj in type 2 DM. Injected immediately before eating

1,875 mg b.i.d. or 3,750 mg o.d. orally

-

-

0.8-4.8 mg o.d., early in the morning

-

-

-

-

-

-

-

-

-

-

5-10 μg b.i.d., 30-60 min before meals

-

-

o.d.

-

-

-

-

s/c inj oncedaily

-

s/c inj

-

-

-

-

-

-

-

-

Dulaglutide

Semaglutide

-

-

Albiglutide

Started at 0.6 mg injectable dose

-

5-10 μg s/c b.i.d. inj, within 60 min before a meal

s/c inj o.d.

-

0.01-0.02 mg s/c inj, before meals

Liraglutide

Exenatide QW

Exenatide

Dopamine D2 receptor agonist

SGLT2 inhibitor

GLP receptor agonist

...Cont’d

-

60-120 μg t.i.d. (for DM type 2), 15-30 μg (for DM type 1), s/c before meals

-

-

-

-

-

-

-

-

-

-

5-10 μg b.i.d. s/c up to 60 min before main meals

-

-

60-90 μg, 3-4 times/day s/c prior to meals (type 1 DM).

Higher doses s/c b.i.d. in type 2 DM7

-

-

-

-

-

-

-

-

1.6-4.8 mg o.d. within 2 h after waking in the morning, with food9

-

-

-

-

-

-

-

-

-

-

-

Once weekly

weekly10 -

-

-

30 mg weekly7 Once

0.6-1.8 mg/day

-

-

Once weekly

Once-daily10

Once weekly7

5-10 µg b.i.d., s/c, 60 min prior to meals

Once weekly10

-

5-10 μg b.i.d. within 60 min of morning and evening meals7

-

15-60 µg before meals in type 1 DM; max 120 µg before meals in type 2 DM

Within 2 h of rising in the morning

-

-

-

-

-

-

-

-

-

-

ENDOCRINOLOGY Metformin is covered well by 8 out of 9 textbooks, with 6 of them mentioning relatively concordant doses, and 2 describing only frequency of administration. Timing of administration was reported by 5 books. Metformin SR preparation was listed by only 3 textbooks, both American in origin, though its use is widespread across the world. Pioglitazone usage is covered in 7 textbooks, with similar dosages, but relationship with meal timings is not stated by any author.6 Rosiglitazone, which is used in a restricted subset of patients, is covered by 5 texts. But none of the textbooks mention timings of this drug. The omission of this molecule’s details from majority of endocrinology and diabetology books reflects the decline in its popularity.

Meglitinide analogs are discussed in uniform detail by all 9 textbooks surveyed. This is a pleasant (and perhaps superfluous) exercise, as nateglinide is rarely used in clinical practice and repaglinide is relatively less commonly prescribed than sulfonylureas.

Sulfonylureas are the oldest class of glucose-lowering drugs currently in use. A large number of drugs and preparations are available, and are well-covered by most textbooks. Micronized glyburide, glipizide ER and gliclazide, which are not available in all countries, are discussed by relatively less authors (5 and 4, respectively). While information related to glipizide and glibenclamide is uniform in most books, there is conflicting advice regarding the frequency of dosage of glimepiride. Timing of administration is not mentioned by many authors. A blanket recommendation to prescribe all sulfonylureas 20-30 minutes before meals is given by the leading Indian textbook of diabetes. The maximum dose of glimepiride is mentioned as 6 mg by three, and 8 mg by six authors. This may reflect the difference in maximum doses approved by various regulatory authorities. A similar lack of consensus is seen for gliclazide, where maximum doses vary from 240 to 320 mg and frequency of dosage ranges from 1 to 3 per day.

Alpha-glucosidase inhibitors are discussed in detail by seven (acarbose), four (miglitol) and two (voglibose) authors. Most of the advice contained in these texts is concordant with each other. The dipeptidyl peptidase-4 (DPP-4) inhibitors are relatively newer class of drugs, which may explain why their dose is not mentioned in many texts. The timing of administration; however, is written differently in various books. While some authors omit this aspect of posology, others recommend vildagliptin and sitagliptin before meals, and yet others advise no regard to meal times. The glucagon-like peptide-1 (GLP-1) receptor agonists are

IJCP Sutra 334: The normal blood pressure level is less than 120/80.

covered by some, but not all, books. While exenatide’s timing of administration is discussed by six authors, no book makes mention of the timing of dosage of liraglutide. New once-weekly GLP-1 receptor agonists are discussed by one (dulaglutide, semaglutide) and three (exenatide QW) textbooks. Bromocriptine and colesevelam are nondiabetic drugs, which have recently been approved for use in type 2 diabetes.

They are prescribed infrequently. While four books mention bromocriptine, in a uniform manner, only two US textbook covers colesevelam. This poor coverage reflects the poor availability of this molecule. Another molecule which has limited availability, relevance and usage, is pramlintide. Approved for the management of postprandial hyperglycemia in both type 1 and type 2 diabetes, this is well-described, in a similar manner, by five texts. Sodium glucose co-transporter 2 (SGLT2) inhibitors, which are the latest class of oral glucoselowering drugs, have found mention in one current US pharmacology textbook.

Conclusion This bibliometric analysis highlights the need to have standardized, uniform sources of information regarding posology of glucose-lowering drugs. Such information will be of importance to students and professionals of diabetology, and will benefit their patients as well.

Limitations All textbooks of pharmacology, diabetology and endocrinology were not analyzed for the review.

However, the textbooks analyzed here are the most commonly used ones.

References 1. Powers AC, D’Alessio D. Endocrine pancreas and pharmacotherapy of diabetes mellitus and hypoglycaemia.

In: Brunton LL, Chabner BA, Knollmann BC (Eds.).

Goodman and Gilman’s the Pharmaceutical Basis of Therapeutics. 12th Edition, New York: Tata McGraw Hill; 2011. pp. 1237-74.

2. Nolte MS. Pancreatic hormones and anti diabetic drugs.

In: Katzung BG, Masters SB, Trevor AJ (Eds.). Basic and Clinical Pharmacology. 12th Edition, New York: Tata McGraw Hill; 2012. pp. 743-68.

3. Tripathi KD. Insulin, oral hypoglycaemic drugs and glucagon. In: Essentials of Medical Pharmacology. 7th Edition, New Delhi: Jaypee Brothers Medical Publishers; 2013. pp. 258-81.

4. Sharma HL, Sharma KK. Insulin and other anti diabetic drugs. In: Principles of Pharmacology. 2nd Edition, Hyderabad: Paras Medical Publisher; 2010. pp. 626-41.

433

Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018 5. Buse GB, Dungan KM. Management of type 2 diabetes mellitus. In: De Groot LJ, Jameson JL (Eds.). Endocrinology: Adult and Pediatric. 6th Edition, Philadelphia: Elsevier Saunders; 2010. pp. 897-915.

9. Singh J. Nutrient blockers and bromocriptine. In: Chandalia HB (Ed.). RSSDI Textbook of Diabetes Mellitus.

3rd Edition, New Delhi: Jaypee Brothers Medical Publishers; 2014. pp. 560-71.

6. Bailey CJ, Krentz AJ. Oral antidiabetic agents. In: Holt RI, Cockram CS, Flyvbjerg A, Goldstein BJ (Eds.). Textbook of Diabetes. 4th Edition, Malden: Wiley-Blackwell; 2010. pp. 452-77.

10. Kumar A. Incretin based therapy. In: Chandalia HB (Ed.).

RSSDI Textbook of Diabetes Mellitus. 3rd Edition, New Delhi: Jaypee Brothers Medical Publishers; 2014. pp.

546-59.

7. Holst JJ, Madsbad S, Schmitz O. Non-insulin parenteral therapies. In: Holt RI, Cockram CS, Flyvbjerg A, Goldstein BJ (Eds.). Textbook of Diabetes. 4th Edition, Malden: Wiley-Blackwell; 2010. pp. 478-93.

8. Sahay RK. Insulin secretagogues. In: Chandalia HB (Eds.).

RSSDI Textbook of Diabetes Mellitus. 3rd Edition, New Delhi: Jaypee Brothers Medical Publishers; 2014. pp.

527-37.

11. Bajaj S (Eds.). Manual of Clinical Endocrinology. 2nd Edition. New Delhi: Jaypee Brothers Medical Publishers; 2014. pp. 81-108.

12. Buse JB, Polonsky KS, Burant CF. Type 2 diabetes mellitus.

In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM (Eds.). Williams Textbook of Endocrinology. 12th Edition, Philadelphia: Elsevier Saunders; 2011. pp. 1371-435.

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Chat with Dr KK Jaroorat Bhi Hai Kya?

434

IJCP Sutra 335: A BP reading above 130/80 is high BP.

ENT

Pleomorphic Adenoma of the Submandibular Gland: A Rare Occurrence SUBRAMANIAM VINAYAK Easweran*, RAGHVENDRA UDUPA†, MAMTA HEGDE‡

Abstract Pleomorphic adenoma is the most frequent benign tumor of the salivary gland. It is a slow-growing tumor and is characterized by varying amount of myxochondroid stroma, produced by the myoepithelial cells. About 90% of benign neoplasm of major salivary glands is associated with the parotid gland. The occurrence of sub-mandibular gland pleomorphic adenoma is uncommon. Pleomorphic adenoma have low proliferative rate and have a good prognosis. Presented here is the case of a 35-year-old lady with a swelling below the right angle of the mandible.

Keywords: Pleomorphic adenoma, salivary gland neoplasm, sub-mandibular gland

S

alivary gland tumors are rare and account for nearly 3% of head and neck tumors. About 90% of benign neoplasm of major salivary glands is associated with the parotid gland. Pleomorphic adenoma is the most common benign tumor of the salivary gland.1 Pleomorphic adenoma is characterized by varying amount of myxochondroid stroma that is produced by the myoepithelial cells. Microscopic findings of necrosis, nuclear atypia, hyalinization, invasion of adjacent tissue and heightened abnormal mitotic activity are linked with an aggressive behavior or malignant transformation of pleomorphic adenoma. At times, histopathological confusion could occur due to extensive squamous differentiation, usually seen on fine-needle aspiration cytology (FNAC). Thus, at times, it could be misdiagnosed.

Capsule infiltration, though not associated with malignant transformation, might play a role in pleomorphic adenoma recurrence.2 Pleomorphic adenoma have low proliferative rate and have a good prognosis.3

*ENT Specialist Dept. of ENT †Anesthesiologist Dept. of Anesthesiology Pandit General Hospital, Sirsi, Uttar Kannada, Karnataka ‡Pathologist Dept. of Pathology Marikamba Hospital, Sirsi, Uttar Kannada, Karnataka Address for correspondence Dr Subramaniam Vinayak Easweran ENT Specialist Dept. of ENT Pandit General Hospital, Sirsi, Uttar Kannada - 581 401, Karnataka E-mail: vinoo121071@gmail.com

436

Case Report A 35-year-old lady presented to the outpatient department (OPD) with a swelling below the right angle of the mandible (Fig. 1 a and b).

The swelling was present since 2-3 years which was slowly growing in size. The swelling was nontender and mobile and measured 5 × 6 cm. There was no rise in temperature.

Patient was then planned for surgery after getting the basic preoperative investigations done which were: Hemoglobin (Hb) - 12.4 g/dL, total leukocyte count (TC) - 9,800 cells/mm3, differential count (DC) N55L38E6M1, erythrocyte sedimentation rate (ESR) 18 mm/hr, bleeding time (BT) - 2 minutes 15 seconds, clotting time (CT) - 3 minutes 35 seconds, blood group - B-ve, ICTC - negative, random blood sugar (RBS) - 104.5 mg/dL, urine - within normal limit. The surgery was done under general anesthesia (Fig. 2).

a

b

Figure 1 a and b. Swelling below the right angle of the mandible.

IJCP Sutra 336: High blood pressure is especially likely to cause kidney damage when associated with other factors like diabetes, high cholesterol and cardiovascular diseases.

ENT The gland was excised in toto (Fig. 3), hemostasis was checked for and achieved. The patient tolerated the procedure well.

with the diagnosis of pleomorphic adenoma (Fig. 5).

The microscopic picture showed proliferation of both epithelial and stromal elements.

The excised gland was sent for histopathological examination (Fig. 4). The microscopic picture coincided

The epithelial proliferation is in the form of acini, tubercles, trabeculae. The stromal component is of chondromyxoid; at places stroma were seen having cartilaginous tissue.

Patient was put on broad-spectrum antibiotic postoperatively for a week and discharged on the 5th postoperative day. On the 10th postoperative day, the patient was called for follow-up and subcuticular suture removal; wound was healthy (Fig. 6).

Figure 2. Intraoperative image.

Figure 3. Excised gland.

Figure 5. Microscopic picture pointed to diagnosis of pleomorphic adenoma.

Figure 4. Cut section of the gland.

Figure 6. Healthy wound on 10th day postoperatively.

IJCP Sutra 337: Keep your blood sugar levels controls as about half of people who have diabetes develop kidney damage.

437

Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

Discussion Cases of sub-mandibular gland pleomorphic adenoma are uncommon, though parotid gland cases are often encountered.1 Pleomorphic adenoma is the commonest benign tumor of the salivary glands4 and accounts for 90% of all salivary gland tumors.1 The sub-mandibular gland represents the second most common site of pleomorphic adenoma after the parotid gland.1 Pleomorphic adenoma, an epithelial tumor of complex morphology, has epithelial and myoepithelial elements intermingled with mucoid, myxoid or chondroid tissue arranged in varied patterns and embedded in a mucopolysaccharide stroma.1 The differential diagnosis includes basal cell adenoma, adenocarcinoma, mucoepidermoid carcinoma and lymphoma.

Investigations like magnetic resonance imaging (MRI) and computed tomography (CT) are gold standard, while adjunctive procedures such as ultrasound-guided needle aspiration and FNAC may not assist with confirmation of diagnosis.

A direct sub-mandibular incision is generally recommended, which gives easy access. The excision should be always in toto. Incomplete removal would result in recurrence. At times, the benign pleomorphic adenoma could transform into a malignant on (carcinoma ex-pleomorphic adenoma), with 25% of untreated pleomorphic adenomas estimated to undergo

malignant transformation;5 hence, early definitive treatment is needed.

Conclusion Pleomorphic adenoma is the most common benign neoplasm of the salivary gland and more commonly seen in parotid gland. It is uncommonly seen in submandibular gland. Surgical excision in toto is the treatment of choice. If left untreated, it could cause recurrence and long-standing pleomorphic adenoma could become malignant.

References 1. Rai S, Sodhi SPS, Sandhu SV. Pleomorphic adenoma of submandibular gland: An uncommon occurrence. Natl J Maxillofac Surg. 2011;2(1):66-8.

2. Alves FA, Perez DE, Almeida OP, Lopes MA, Kowalski LP. Pleomorphic adenoma of the submandibular gland: clinicopathological and immunohistochemical features of 60 cases in Brazil. Arch Otolaryngol Head Neck Surg. 2002;128(12):1400-3.

3. Kazanceva A, Groma V, Smane L, Kornevs E, Teibe U. Proliferative potential in benign mixed salivary gland tumors and its value in primary and recurrent neoplasms.

Stomatologija, Baltic Dent and Maxillofacial Journal.

2011;13(2):35-41.

4. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg.

1986;8(3):177-84.

5. Bagga M, Bhatnagar D, Bhatnagar D. An unusual presentation of pleomorphic adenoma: A case report.

J Indian Acad Oral Med Radiol. 2016;28:191-4.

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IJCP Sutra 338: Eat healthy and keep your weight in check as this can help prevent diabetes, heart disease and other conditions associated with chronic kidney disease.

Gastroenterology

ALBI and Child-Pugh Score in Predicting Mortality in Chronic Liver Disease Patients Secondary to Alcohol: A Retrospective Comparative Study Nagaraja BS*, Madhumathi R*, Sanjeet SB†

Abstract Background/Aims: The severity of liver dysfunction in chronic liver disease (CLD) is often estimated with Child-Pugh (CTP) classification or model for end‐stage liver disease (MELD) score. The albumin-to-bilirubin (ALBI) score is a new model for assessing the severity of liver dysfunction, which is simple and more objective. In the present study, we aimed to retrospectively compare the performance of ALBI score with Child-Pugh score for predicting the mortality in patients with CLD. Material and methods: Data of patients with CLD, irrespective of etiology, were retrospectively reviewed. Child-Pugh score and ALBI score were calculated for the patients and results from receiver operating characteristic (ROC) curves were analyzed. Results: The study was conducted on 299 patients of CLD; age distribution was between 20 and 85 years with mean age of patients being 45.7 ± 10.94 years, sex ratio male: female 265:34 with mortality rate of 19.73%. The area under curves (AUC) of ROC of ALBI and Child-Pugh were 0.586 and 0.549, respectively. Conclusion: Ability of ALBI score for predicting mortality was comparable with that of Child-Pugh score but Child-Pugh score of >10 had better performance of predicting mortality as compared to ALBI score.

Keywords: Chronic liver disease, liver cirrhosis, alcoholic liver disease, Child-Pugh score, MELD score, ALBI score

T

he World Health Organization (WHO) estimates 2 billion people as consuming alcohol and 76.3 million as having alcohol use disorders. Thirty percent of Indian adults use alcohol, among which 4-13% are daily consumers. The alcohol consumption rose by 30% in 2015. An estimate of 14 million has been made as heavy consumers. Looking at this data, the burden of alcoholic liver disease on the community is obvious. Alcohol abuse leads to spectrum of liver diseases ranging from fatty liver, alcoholic hepatitis to cirrhosis and hepatocellular carcinoma. Liver cirrhosis is a common cause of death worldwide.1,2 The accurate prognostification of liver cirrhosis is important in our daily practice. The most commonly used tool to predict the prognosis of liver cirrhosis is Child-Pugh score.3 However, it has been established for a long time, and its components are selected primarily based on the surgeons’ experiences. Model for end-stage liver disease

*Professor †Postgraduate Dept. of General Medicine Bangalore Medical College and Research Institute, Bangalore, Karnataka

(MELD) score is another tool for prognostic assessment of liver cirrhosis.4,5 Until now, there is lots of controversy regarding the comparison of Child-Pugh versus MELD scores.6-8 Of late, albumin-to-bilirubin (ALBI) score has been proposed as a novel, simple and readily available model calculated using mathematical formula -0.085 × (alb g/L) + 0.66 × log (bil µmol/L).

The ALBI score, by combining serum albumin and bilirubin, is a new model for assessing the severity of liver dysfunction. Johnson and colleagues reported that the ALBI score more accurately predicts patients’ mortality without requiring subjective determinants of liver failure, including ascites and encephalopathy, in patients with hepatocellular carcinoma.9 A retrospective study also investigated the prognostic significance of the ALBI score among patients with primary biliary cirrhosis.10 It was found that the ALBI score seems to outperform other scores (such as Child-Pugh and MELD score) for predicting the occurrence of hepatic events in such patients.

Furthermore, Chen et al11 demonstrated that ALBI score had a significantly better performance for long-term survival prediction in patients with hepatitis B virus (HBV)-related cirrhosis than the Child-Pugh or MELD

IJCP Sutra 339: Reduce your salt intake. The recommended sodium intake is 5-6 g of salt per day (around a teaspoon).

439

Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

scores. Herein, we attempted to study the ALBI score for in-hospital death in alcoholic cirrhotic patients.

Aims and Objectives

Numerical score 2

3

Ascites

None

Slight

Moderate-tosevere

To assess the utility of ALBI in predicting the mortality in CLD patients secondary to alcohol.

Encephalopathy

None

Slight-tomoderate

Moderate-tosevere

To evaluate the discriminative abilities of ALBI and Child-Pugh score in predicting the in-hospital mortality in CLD patients secondary to alcohol.

Bilirubin (mg/dL)

<2.0

2-3

>3.0

Albumin (g/dL)

>3.5

2.8-3.5

<2.8

Prothrombin time (Prolonged in seconds)

1-3 s

4-6 s

>6.0

To calculate ALBI and Child-Pugh score in chronic liver disease (CLD) patients secondary to alcohol.

ÂÂ

ÂÂ

Material and methods

Study Design The study was conducted at Bowring and Lady Curzon Hospital (Attached to Bangalore Medical College and Research Institute). Cirrhotic patients secondary to alcohol admitted in the hospital between January 2017 and December 2017 were retrospectively reviewed and the data of the patients were collected.

Approval was obtained from the Institutional Ethical Committee.

Inclusion Criteria ÂÂ

Age >18 years.

ÂÂ

Liver cirrhosis patients secondary to alcohol.

Exclusion Criteria CLD due to HBV, hepatitis C virus (HCV), malignancy, metabolic causes and autoimmune hepatitis.

Method of Collection of Data Detailed history and clinical examination was done for all patients. Routine investigations like complete hemogram, renal function test, liver function test, serum electrolytes, human immunodeficiency virus (HIV), hepatitis B surface antigen (HBsAg), HCV, prothrombin time/International Normalized Ratio (PT/INR), activated partial thromboplastin time (APTT), ultrasonography (USG) abdomen and other relevant investigations were noted. Diagnosis of liver cirrhosis was established by USG abdomen with shrunken liver with altered echo texture.

ALBI score and Child-Pugh score (Table 1) were calculated and compared.

ALBI score = (−0.085 × [alb g/L] + 0.66 × log [bil µmol/L])

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Parameter 1

ÂÂ

ÂÂ

Table 1. Calculation and Comparison of ALBI and Child-Pugh Score

Child-Pugh Class A = 5-6 points; Child-Pugh Class B = 7-9 points; Child-Pugh Class C = 10-15 points.

Method of Statistical Analysis All statistical analyses were performed using Medcalc software. Continuous data were expressed as the mean ± SD (standard deviation) and median with minimum and maximum. Categorical data were expressed as the frequency. The receiver operating characteristic (ROC) curve were performed to identify the discriminative ability of ALBI and Child-Pugh score in predicting in-hospital mortality. The area under the curve (AUC) were calculated and compared. The best cut-off value was selected as the sum of sensitivity and specificity was maximal. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) were reported.

Results and Analysis The sample size in our study was 299 patients. The age distribution was between 20 and 85 years with mean age of patient being 45.7 ± 10.94 years. Two hundred sixty-five were males and 34 were females. Among 299 patients, 59 patients had in-hospital mortality and 240 were discharged with mortality percentage of 19.73%.

Comparison of In-Hospital Mortality with ALBI and Child-Pugh Scores The in-hospital morality was 19.73%. The AUC of the ALBI score for predicting the in-hospital mortality was 0.586 (confidence interval [CI]: 95%; 0.528-0.642). The best cut-off value was −1.01, with sensitivity of 94.92%, a specificity of 32.5%, PLR of 1.406 and NLR 0.156 (Fig. 1).

The AUC of the Child-Pugh score for predicting the in-hospital mortality was 0.549 (CI 95%; 0.490-0.606).

The best cut-off value of the Child-Pugh score was 10, with a sensitivity of 76.27%, a specificity of 34.58%, PLR of 1.165 and NLR of 0.686 (Fig. 2).

IJCP Sutra 340: Maintain a healthy fluid intake: Traditional wisdom has long suggested drinking 1.5-2 liters (3-4 pints) of water per day.

Gastroenterology ALBI 100

AUC

SE

95% CI

Child-Pugh score

0.549

0.0401

0.490-0.606

ALBI

0.586

0.0382

0.528-0.642

100

60

80

40 20

Sensitivity

Sensitivity

80

Variable

AUC = 0.586 P = 0.025

0 0

20

40

60

80

100

100-Specificity

60

40

20

Child-Pugh score ALBI

0

Figure 1. ROC curve of ALBI score for predicting in-hospital mortality.

0

20

40

60

80

100

100-Specificity Child-Pugh score ~ ALBI

Child-Pugh score 100

Sensitivity

80 60

Difference between areas

0.0370

SE

0.0486

95% CI

−0.0582 to 0.132

Z statistic

0.762

Significance level

P = 0.4461

Figure 3. Comparison of ROC curves.

40

20

AUC = 0.549 P = 0.224

0 0

20

40

60

80

100

100-Specificity

Figure 2. ROC curve of Child-Pugh score for predicting inhospital mortality.

The AUC for predicting the in-hospital mortality was not significantly different between the ChildPugh and ALBI scores. (Child-Pugh and ALBI: p = 0.4461) (Fig. 3).

The performance of Child-Pugh score is higher than ALBI score.

Discussion Child-Pugh score and MELD score have been studied extensively for their prognostic abilities and have shown good performance in predicting the mortality of cirrhotic patients. But, the cumbersome calculation of scores and the variables included in them have subjective variability that has led to the development of ALBI score.

IJCP Sutra 341: Do not smoke as it slows the flow of blood to the kidneys.

ALBI score involves only two variables and has already been studied in various liver disorders such as HBV, hepatocellular carcinoma, primary biliary cirrhosis and has shown to perform well and is comparable with the Child-Pugh and MELD scores. In our study, an attempt has been made to compare the discriminative ability of ALBI score with that of the Child-Pugh score in predicting the in-hospital mortality in alcoholic cirrhosis patients. ALBI score showed better performance compared to Child-Pugh score in predicting mortality, but there was no statistical difference between them.

In a study by Shao et al, ALBI score demonstrated similar ability as that of Child-Pugh and MELD score in predicting in-hospital mortality in cirrhosis. It also suggested that ALBI score can be readily used as prognostic model.3 Another study by Chen et al showed that the ALBI score determined on admission indicates the likelihood of survival of acute-on-chronic liver failure patients.12 In a study conducted by Zou et al, in patients with alcohol-related liver cirrhosis, ALBI score had the largest AUC, followed by the Child-Pugh and MELD scores, so they concluded that ALBI score has moderate-to-high prognostic performance.13

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

A study conducted by Peng et al showed that there was no significant difference among the three scores in predicting in-hospital mortality in cirrhotic patients.14 A retrospective study done by Xavier et al on 111 patients between January 2011 and November 2015, came out with the conclusion that ALBI score is particularly useful in the assessment of short-term outcomes, with a better performance than the most commonly used scores.15 The limitations of our study were that it was a retrospective study, the late mortality was not considered and follow-up was not done.

Conclusion AUC of the ALBI score and the Child-Pugh score were comparable and there was no statistical difference between them. ALBI can be used in place of Child-Pugh score in peripheral centers to assess the prognosis of CLD patients secondary to alcohol in view of simple calculation, only two variables and no subjective variation of the score.

References 1. Blachier M, Leleu H, Peck-Radosavljevic M, Valla DC, Roudot-Thoraval F. The burden of liver disease in Europe: a review of available epidemiological data.

J Hepatol. 2013;58(3):593-608.

2. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095-128.

3. Shao L, Han B, An S, Ma J, Guo X, Romeiro FG, et al.

Albumin-to-bilirubin score for assessing the in-hospital death in cirrhosis. Transl Gastroenterol Hepatol.

2017;2:88.

4. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al. A model to predict survival in patients with end-stage liver disease.

Hepatology. 2001;33(2):464-70.

5. Kamath PS, Kim WR; Advanced Liver Disease Study Group. The model for end-stage liver disease (MELD).

Hepatology. 2007;45(3):797-805.

6. Gheorghe L, Iacob S, Simionov I, Vadan R, Gheorghe C, Iacob R, et al. Natural history of compensated

viral B and D cirrhosis. Rom J Gastroenterol. 2005; 14(4):329-35.

7. Cholongitas E, Marelli L, Shusang V, Senzolo M, Rolles K, Patch D, et al. A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation. Liver Transpl. 2006;12(7):1049-61.

8. Peng Y, Qi X, Dai J, Li H, Guo X. Child-Pugh versus MELD score for predicting the in-hospital mortality of acute upper gastrointestinal bleeding in liver cirrhosis.

Int J Clin Exp Med. 2015;8(1):751-7.

9. Johnson PJ, Berhane S, Kagebayashi C, Satomura S, Teng M, Reeves HL, et al. Assessment of liver function in patients with hepatocellular carcinoma: a new evidence-based approach-the ALBI grade. J Clin Oncol.

2015;33(6):550-8.

10. Chan AW, Chan RC, Wong GL, Wong VW, Choi PC, Chan HL, et al. New simple prognostic score for primary biliary cirrhosis: Albumin-bilirubin score.

J Gastroenterol Hepatol. 2015;30(9):1391-6.

11. Chen RC, Cai YJ, Wu JM, Wang XD, Song M, Wang YQ, et al. Usefulness of albumin-bilirubin grade for evaluation of long-term prognosis for hepatitis B-related cirrhosis. J Viral Hepat. 2017; 24(3):238-45.

12. Chen B, Lin S. Albumin-bilirubin (ALBI) score at admission predicts possible outcomes in patients with acute-on-chronic liver failure. Medicine (Baltimore).

2017;96(24):e7142.

13. Zou D, Qi X, Zhu C, Ning Z, Hou F, Zhao J, et al.

Albumin-bilirubin score for predicting the in-hospital mortality of acute upper gastrointestinal bleeding in liver cirrhosis: A retrospective study. Turk J Gastroenterol. 2016;27(2):180-6.

14. Peng Y, Qi X, Tang S, Deng H, Li J, Ning Z, et al. ChildPugh, MELD, and ALBI scores for predicting the inhospital mortality in cirrhotic patients with acute-onchronic liver failure. Expert Rev Gastroenterol Hepatol.

2016;10(8):971-80.

15. Xavier SA, Vilas-Boas R, Boal Carvalho P, Magalhães JT, Marinho CM, Cotter JBXavier SA, et al. Assessment of prognostic performance of Albumin-Bilirubin, Child-Pugh, and Model for End-stage Liver Disease scores in patients with liver cirrhosis complicated with acute upper gastrointestinal bleeding. Eur J Gastroenterol Hepatol. 2018;30(6):652-8.

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IJCP Sutra 342: Smoking also increases the risk of kidney cancer by about 50%.

2018

INTERNAL MEDICINE

A Case of Marchiafava-Bignami Syndrome MANISH N MEHTA*, PRANAV I PATEL†, HEMANG K ACHARYA‡, AC TANNA#, JEMIMA BHASKAR¥

Abstract Drinking alcohol is a serious social and health problem in our country and throughout the world. It causes varied diseases in different organs of the body, which many do not care to know about. Marchiafava-Bignami disease is one such rare but serious disorder. We are presenting this case to show the serious disorders associated with alcoholism.

Keywords: Corpus callosum, alcohol, mutism, alcohol dehydrogenase, neurological deficit

M

archiafava-Bignami syndrome is one of the central nervous system (CNS) complications of chronic alcohol intake. There is degeneration of the corpus callosum similar to a disconnection syndrome. It is possibly due to B complex deficiencies related to chronic alcohol intake. The prognosis is guarded as most patients present with coma.

Case Report A 50-year-old male, chronic alcoholic, laborer was admitted to Guru Gobind Singh Hospital, Jamnagar, Gujarat. He presented with fever, vomiting, altered mental status, disorientation to time-place-person and first episode of generalized tonic-clonic convulsions.

On examination, he presented with mutism, altered sensorium, no ophthalmoplegia, no nystagmus, inability to move all limbs, bilateral extensor plantars with semidilated reactive pupils bilaterally. Neck stiffness was not present. No focal neurological signs were present.

Fundus examination showed no signs of papilledema.

A clinical diagnosis of meningoencephalitis or hepatic encephalopathy was made. Meanwhile, contrastenhanced computed tomography (CECT) brain was

*Professor and HOD †Second Year Resident ‡Professor and HOU #Assistant Professor ¥Medical Officer Dept. of Medicine MP Shah Medical College and Guru Govind Singh Hospital, Jamnagar, Gujarat Address for correspondence Dr Jemima Bhaskar 404, King’s Palace, Opposite BSNL Telephone Exchange Mehulnagar, Jamnagar, Gujarat - 361 006 E-mail: jemimabhaskar@yahoo.com

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a

b

Figure 1. High signal intensity noted in axial FLAIR image with involevement of anterior and posterior portion of corpus callosum and periventricular white matter (a). Sagittal T1-weighted image with low signal intensity seen in entire length of corpus callosum shown with arrow (b).

done to look for secondary causes of convulsions.

Magnetic resonance imaging (MRI) cuts were taken in addition to CT which showed “Ill-defined nonenhancing hypodense area in middle part of corpus callosum, possibly degeneration due to MarchiafavaBignami syndrome” (Fig. 1 a and b). Hence, diagnosis of “Marchiafava-Bignami syndrome” was made.

Patient received injections (cefotaxime, metronidazole, mannitol, thiamine, vitamin B12, hydrocortisone, sodium valproate, IV glucose, amino acids, soybean oil and lecithin) and supportive treatment. On Day 3, he regained consciousness. On Day 4, he became oriented to surroundings. Later he was able to walk with support.

Discussion Marchiafava-Bignami disease is a rare and toxic encephalopathy seen mostly in alcoholics due to progressive demyelination and necrosis of corpus callosum, which may extend to adjacent regions and even up to subcortex. It was first described by Italian

IJCP Sutra 343: Do not take over-the-counter pills on a regular basis: Drugs like ibuprofen are known to cause kidney damage, if taken regularly.

INTERNAL MEDICINE pathologists, Marchiafava and Bignami, in alcoholic patients who died after having seizures and coma.

Most accepted cause for the pathogenesis of this disorder is deficiency of multiple vitamins of vitamin B complex. It can be divided into two subgroups as type A having altered consciousness, stupor, coma and upper motor neuronal signs with involvement of entire corpus callosum and type B having mild impairment of consciousness with small callosum lesion. Type B has good prognosis. Altered mental status, impaired walking and loss of consciousness is seen in more than 50% of patients with this disease.

Other symptoms are dysarthria, impaired memory, signs of disconnection, pyramidal signs, seizures, primitive reflexes, rigidity, hemi-/tetraparesis, incontinence, nystagmus, etc. Mutism, sensory symptoms and gaze palsy are seen in only 10% of patients, but when present, can be useful in differentiating this syndrome from other disorders. Hence, they are more specific for this disease. Diagnosis of this disease is made by history, presentation, examination and radio-imaging modalities such as CT scan and more preferably MRI brain, which shows hypodense lesion due to degeneration in corpus callosum. No specific treatment is available but treatment with parenteral thiamine within 15 days of presentation for 15 days along with other vitamins, proteins and high dose steroids shows better prognosis as compared to controls in previous studies. Antiparkinsonian drug amantadine showed improvement as per one study. Rest and supportive treatment should be given. Prognosis of this disease varies as some patients improve and some deteriorate to even death in spite of treatment.

Certain risk factors predispose to alcohol toxicity: ÂÂ

Pattern of drinking - more duration means more toxicity; continuous drinking is more dangerous than intermittent; drinking more than 80 g/day is dangerous.

ÂÂ

Women achieve higher blood levels of alcohol than men.

ÂÂ

Certain genes namely HLA-BB and ADH gene 2 are considered to increase alcohol toxicity.

ÂÂ

On the other hand, presence of food in the stomach, especially proteins, decreases alcohol toxicity.

Other than Marchiafava-Bignami syndrome, alcohol can cause other CNS effects - acute intoxication (from euphoria to coma), withdrawal syndrome, alcoholic dementia, cerebrovascular accidents, alcoholic cerebellar degeneration, central pontine myelinolysis, peripheral

neuropathy, Saturday night palsy, etc. Other than effects on the brain, alcohol has toxic effects on liver, blood cells, fetus, gastrointestinal tract, cardiovascular system, genitourinary system, skeletal system, endocrine system, respiratory system, etc. Addiction, social and psychological problems are also threats associated with alcohol intake. In addition, alcohol interacts with a lot of commonly used medications. Alcohol toxicity varies from gastric ulcers, which is easily treatable, to even malignancies which have serious prognosis.

In our case, the patient presented in a coma like state.

On examination, it was not a deep coma but patient had altered sensorium with mutism. Hence, there was no verbal output. Mutism is one of the rare presentations in this disorder. There was significant improvement with parenteral vitamin replacement although the prognosis is not good in most cases.

Conclusion This case has been presented to highlight the various serious CNS complications in chronic alcoholics. Because it is uncommon, it is rarely diagnosed clinically. This disease should be kept in the mind in chronic alcoholics presenting with coma. Thankfully, our patient recovered in spite of the guarded prognosis of the disease.

“Think before you drink, because if you drink, you may not be able to think again.” (Alcoholism can cause brain degeneration) “As there is no intervention, start with prevention.”

Suggested Reading 1. Alagappan R. Manual of Practical Medicine. 5th Edition, New Delhi: Jaypee Brothers Medical Publisher (P) Ltd.; 2014. pp. 926-32.

2. Marchiafava-Bignami Syndrome.

Patient Info. Retrieved 2017-12-13.

MBD

information.

3. Raina S, Mahesh DM, Mahajan J, Kaushal SS, Gupta D, Dhiman DS. Marchiafava-Bignami disease. J Assoc Physicians India. 2008;56:633-5.

4. Marchiafava E, Bignami, A. Sopra un alterazione del corpo calloso osservata in soggetti alcoolisti. Riv Patol Nerv Ment. 1903;8:544-9.

5. Ironside R, Bosanquet FD, Mcmenemey WH. Central demyelination of the corpus callosum (MarchiafavaBignami disease) with report of a second case in Great Britain. Brain. 1961;84:212-30.

6. Leong AS. Marchiafava-Bignami disease in a non-alcoholic Indian male. Pathology. 1979;11(2):241-9.

7. Kosaka K, Aoki M, Kawasaki N, Adachi Y, Konuma I, Iizuka R. A non-alcoholic Japanese patient with Wernicke’s encephalopathy and Marchiafava-Bignami disease. Clin Neuropathol. 1984;3(6):231-6.

IJCP Sutra 344: Consume a diet based on whole foods. This includes green leafy vegetables, quality protein, healthy fats and complex carbohydrates.

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INTERNAL MEDICINE

Detection of Pulmonary Nocardiosis Mimicking Tuberculosis: Role of Sputum Microscopy SHASHI CHOPRA*, SHAVETA DHIMAN†, GOMTY MAHAJAN‡, SILKY MAHAJAN#

Abstract Background: Nocardiosis is an opportunistic infection and most commonly presents as pulmonary disease. Unless investigations like Gram’s stain and modified acid-fast stain are specially done, pulmonary infection may be mistaken for tuberculosis. They are useful for early diagnosis of Nocardia infection. Hence, the present study was conducted for the early detection of pulmonary nocardiosis mimicking tuberculosis by sputum microscopy with Gram staining, modified Ziehl-Neelsen (ZN) staining. Material and methods: The current study was conducted on 2,466 sputum samples over a period of 4 years from July 2011 to June 2015 for ZN staining for evaluation of pulmonary tuberculosis. Those sputum samples which were negative with 20% H2SO4 and showed weakly stained acid-fast bacilli (AFB) were confirmed for Nocardia by modified ZN staining with 1% H2SO4, Gram’s staining and culture. Result: Out of 2,466 sputum samples, 433 (17.55%) were found positive for AFB by microscopic examination. Ten (2.30%) out of 433 cases were positive for Nocardia. Amongst the Nocardia positive samples 7 (70%) were of male and 3 (30%) were of female. Conclusion: Gram’s staining and modified acid-fast stain are useful for early diagnosis and appropriate treatment of pulmonary nocardiosis.

Keywords: Pulmonary nocardiosis, sputum microscopy, modified Ziehl-Neelsen staining

N

ocardiosis is a rare disorder caused by Grampositive, weakly acid-fast, filamentous aerobic actinomycetes, which tends to affect the lung, brain and skin. The genus Nocardia belongs specifically to the family Mycobacteriaceae and contains tuberculostearic acid but differ from the mycobacteria by possession of shorter-chained (40- to 60-carbon) mycolic acids.1

Pulmonary nocardiosis is the most common clinical presentation and have several features similar to tuberculosis. It is a major cause of morbidity and mortality in immunocompromised patients.2 Lack of suspicion, nonspecific clinicoradiological presentation, diagnostic intricacies and lack of systematic reporting are the probable reasons that have hindered the true

estimation of its incidence, worldwide.3 In tuberculosis endemic countries like India, nocardiosis should always be excluded among patients not responding to antitubercular treatment. Early recognition and appropriate individualized treatment is the key to a successful outcome.2 New methodologies were developed for the identification of Nocardia, but evaluation of appropriate specimens by smear and culture remains the principal method of diagnosis.4,5 Unless investigations like Gram’s stain and modified acid-fast stain are specially done, pulmonary infection may be mistaken for tuberculosis and are useful for early diagnosis of Nocardia infection.6 Hence, the present study was conducted for the early detection of pulmonary nocardiosis mimicking tuberculosis by sputum microscopy with Gram staining, modified Ziehl-Neelsen (ZN) staining.

Aim

*Professor †Tutor ‡Associate Professor Dept. of Microbiology #Tutor Dept. of Pathology Punjab Institute of Medical Sciences, Jalandhar, Punjab Address for correspondence Dr Shashi Chopra EJ 227-228, Chahar Bagh, Jalandhar City - 144 001, Punjab E-mail: dr.shashichopra@yahoo.com

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Early detection of pulmonary nocardiosis mimicking Mycobacterium tuberculosis by sputum microscopy.

Material and Methods The current study was conducted on 2,466 sputum samples which were received in the Microbiology Department of a tertiary care hospital in North India,

IJCP Sutra 345: Staying hydrated will help the lymphatic system flush out toxins and remove the metabolic waste out of the body. This is essential to detoxify, nourish and regenerate tissue.

INTERNAL MEDICINE over a period of 4 years from July 2011 to June 2015 for acid-fast bacilli (AFB) by ZN staining for evaluation of pulmonary tuberculosis.

Male patients

All the samples were processed in laboratory without delay in order to avoid contaminants to grow.

Homogenization of sputum samples were done by Petroff’s method.7 Next, concentrated specimens were used for smear preparation and culture. Few slides on ZN staining showed weakly stained AFB with some filamentary structure. Nocardia spp. are acid-fast and can survive the decontamination of clinical specimens with sodium hydroxide method.8 These patient’s sputum samples were repeated with another two fresh sputum samples to exclude Nocardia by doing Gram’s staining and modified ZN staining9 using 1% H2SO4. On microscopic examination, Gramstained smear showed thin, delicate, weakly to strongly Gram-positive, irregularly stained or beaded branching filament and Modified ZN staining revealed filamentous acid-fast organism suggestive of Nocardia.

Further 250 μL of each concentrated sputum specimen suspected to be Nocardia was inoculated onto Sabouraud’s dextrose agar (SDA) media and blood agar.

All cultures were incubated at 37°C with 5% CO2 and humidity. Cultures were examined daily for the growth of Nocardia species for up to 3 weeks. On SDA, colonies were white to brown in appearance and on blood agar, filamentous colonies having chalky-white or cotton-ball appearance were seen.4 Colonies were examined with Gram staining and modified ZN staining methods to confirm the growth of Nocardia (Fig. 1).

Figure 1. Microscopic picture of Nocardia (Gram’s staining).

Female patients

3

7

Figure 2. The percentage of Nocardia positivity in patients.

Results Two thousand four hundred sixty-six samples from patients of all ages and both sexes were studied during a period of 4 years (July 2011 to June 2015). Out of the total, 73.52% were males and 26.48% were females.

Of the total cases, 433 (17.55%) were found positive for AFB by microscopic examination. Ten (2.30%) out of 433 cases were positive for Nocardia, which were confirmed by Gram’s staining, modified ZN staining and culture. Out of these 10 cases 70% were males and 30% were female cases (Fig. 2).

Discussion Pulmonary nocardiosis is the most common clinical presentation of nocardial infection because inhalation is the primary route of bacterial exposure.10 It can be fatal if untreated. Untreated pulmonary nocardiosis is similar to tuberculosis and Nocardia asteroides is the most frequent cause of pulmonary infection in humans (85%).11 In the present study, we included 2,466 sputum samples, out of which 73.52% were from males and 26.48% were from female patients, whereas in a similar study done by other workers included 44.8% sputum samples of male and 55.2% sputum samples of females.12 Lungs are the most common site of involvement for tuberculosis and Nocardia.13 In our study, 17.55% sputum samples were found positive for AFB, whereas other workers reported 7.6% positivity by microscopy examination.14 Pulmonary nocardiosis is the most common clinical presentation of infection and can occurs in persons of all ages, even neonates.10 In our study, out of 433 AFB positive sputum 10 (2.30%) were positive for Nocardia, whereas other workers reported it to be 3.57%,15 which was confirmed

IJCP Sutra 346: Exercise is positive physiological stress for the body. Yoga, for example, is known to accrue great benefits to both the mind and body.

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

by Gram’s staining, modified ZN staining (1% H2SO4) and by culture. Nocardia incidence in pulmonary disease have been reported to be 1.4%, 2.7% and 4% by different workers in different area.16-18 McNeil and Brown highlighted the importance of direct microscopic examination because, despite the new methodologies developed, there is no test replacing it.4 Amongst the Nocardia positive samples, 70% samples were of male patients and 30% were of female patients almost similar results were reported by other workers also (75% and 25%, respectively).19 The exact reason for gender difference is not known though hormonal effect may be attributed to virulence or growth of Nocardia species.15 In India, the prevalence of Nocardia as reported in 1973 was 4.6% among patients who were suspected to have tuberculosis.20 The clinical diagnosis of nocardiosis is difficult.

Signs, symptoms and radiologic studies may suggest the diagnosis but are not pathognomonic. Serologic diagnosis is unreliable, and serologic tests are not available commercially,5 so isolation and identification of the organism from the clinical specimens form the backbone for diagnosis of pulmonary nocardiosis.

Conclusion This study highlights the importance of nocardiosis in differential diagnosis of pulmonary disease patients.

The initial diagnosis of pulmonary nocardiosis requires fast and accurate methodology for early recognition and appropriate individualized treatment due to the clinical aspects and bacteriologic similarity to the genus Mycobacterium. The direct microscopic examination of sputum specially, with Gram’s stain and modified acid-fast stain with 1% sulfuric acid highlighted the importance in early diagnosis despite of the development of new methodologies. Hence, a microbiologist should process the respiratory tract specimens not only for Mycobacteria but should also be alert to the fact that organisms such as Nocardia may cause pulmonary infection.

References 1. Saubolle MA. Aerobic actinomycetes. In: McClatchey KD (Ed.). Clinical Laboratory Medicine. 2nd Edition.

Philadelphia, Pa: Lippincott Williams & Wilkins; 2002. pp.

1201-20.

4. McNeil MM, Brown JM. The medically important aerobic actinomycetes: epidemiology and microbiology. Clin Microbiol Rev. 1994;7(3):357-417.

5. Saubolle MA, Sussland D. Nocardiosis: review of clinical and laboratory experience. J Clin Microbiol.

2003;41(10):4497-501.

6. Kulkarni SD, Baradkar VP, Kumar S. Pulmonary nocardiosis in an HIV infected patient. Indian J Sex Transm Dis. 2008;29(2):92-5.

7. Arora DR, Arora B. Textbook of Microbiology. 4th Edition, New Delhi: CBS Publishers & Distributors; 2012. p. 298.

8. World Health Organization. Laboratory Services in TB Control: Microscopy. Part II. Geneva, Switzerland; 1998.

9. Duguid JP. Staining methods. In: Colle JG, Duguid JP, Fraser AG, Marmion BP (Eds.). Mackie and McCartney Practical Medical Microbiology. 13th Edition, Edinburgh: Churchill Livingstone; 1989. pp. 46-9.

10. Lerner PI. Nocardia species. In: Mandell GL, Bennett JE, Dolin R (Eds.). Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 4th Edition, Vol. 2.

New York: Churchill Livingstone; 1995:227380.

11. Martínez R, Reyes S, Menéndez R. Pulmonary nocardiosis: risk factors, clinical features, diagnosis and prognosis.

Curr Opin Pulm Med. 2008;14(3):219-27.

12. Abu-Saeed MB, Akanbi AA, Abu-Saeed K. Prevalence of nocardiosis in sputum of HIV positive/AIDS patients in a tertiary health institution in North Central Nigeria. Br Microbiol Res J. 2014;4(9):959-67.

13. Vohra P, Sharma M, Yadav A, Chaudhary U. Nocardiosis: A review of clinicomicrobiological features. Int J Life Sc Bt Pharm Res. 2013;2:20-9.

14. Ekrami A, Khosravi AD, Samarbaf Zadeh AR, Hashemzadeh M. Nocardia co-infection in patients with pulmonary tuberculosis. Jundishapur J Microbiol.

2014;7(12):e12495.

15. Swami T, Pannu S, Sharma BP. Pulmonary nocardiosis in immunocompromised patients of Bikaner. Int J Basic Appl Med Sci. 2013;3(2):362-6.

16. Maria CCM, Mendoza MT. Pulmonary nocardiosis in renal transplant recipients. J Microbiol Infect Dis. 2001. pp. 144-52.

17. Alnaum HM, Elhassan MM, Mustafa FY, Hamid ME. Prevalence of Nocardia species among HIV-positive patients with suspected tuberculosis. Trop Doct.

2011;41(4):224-6.

18. Singh M, Sandhu RS, Randhawa HS, Kallan BM. Prevalence of pulmonary nocardiosis in a tuberculosis hospital in Amritsar, Punjab. Indian J Chest Dis Allied Sci. 2000;42(4):325-39.

2. Aggarwal D, Garg K, Chander J, Saini V, Janmeja AK. Pulmonary nocardiosis revisited: A case series. Lung India. 2015;32(2):165-8.

19. Shivaprakash MR, Rao P, Mandal J, Biswal M, Gupta S, Ray P, et al. Nocardiosis in a tertiary care hospital in North India and review of patients reported from India.

Mycopathologia. 2007;163(5):267-74.

3. Beaman BL, Burnside J, Edwards B, Causey W. Nocardial infections in the United States, 1972-1974. J Infect Dis. 1976;134(3):286-9.

20. Reddy SS, Reddy KM, Saraswathi K. A rare case of pulmonary nocardiasis in an AIDS patient. Indian J Med Sci. 2010;64(4):192-5.

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IJCP Sutra 347: Practice mindfulness including a combination of practices, habits, thoughts and behavior to help you get through your daily life.

Nephrology

A Snapshot of Patients on Hemodialysis in July 2018, GGH, Jamnagar: A Cross-sectional Study AJAY C TANNA*, PRANAV I PATEL†

Abstract Noncommunicable diseases (NCDs) are the leading causes of premature death and morbidity. Chronic kidney disease is a major factor linked with poor health outcomes of major NCDs. A study was recently carried out at Guru Govind Singh Hospital, Jamnagar, Gujarat, among patients undergoing hemodialysis, to assess demographic data, comorbid conditions, determine common medical problems in patients on dialysis, reinforce diet patterns and water intake patterns, assess risk factors that lead to cardiorespiratory events, and awareness of the drug intake and schedule. This crosssectional study revealed that hypertension, diabetes and liver parenchymal disease were the most common associated comorbidities. Cardiac, respiratory and cerebrovascular diseases were also the comorbidities in a significant number of patients, followed by hypothyroidism, fibrous bone dysplasia, hypopituitarism, mullerian agenesis syndrome. Most patients were found to have no idea about how much water they should drink. None of the patients were strictly following a diet. Additionally, none knew the exact amount of salt, protein and fat that they should take in a day. Awareness of drug intake was also low. The findings reinforce the importance of patient education and involvement of patients in their own treatment.

Keywords: Hemodialysis, chronic kidney disease, diet, water intake, comorbidities

N

oncommunicable diseases (NCDs) are the leading causes of premature death and morbidity and significantly affect the healthcare costs, productivity and growth. Chronic kidney disease (CKD) is a major factor linked with poor health outcomes of major NCDs. CKD is associated with an increase in cardiovascular mortality and heightens the risk in patients with diabetes and hypertension. Early detection and treatment of CKD has the potential to slow or prevent progression to end-stage renal disease (ESRD).

A large number of dialysis patients have comorbid conditions such as diabetes. Additionally, patients with ESRD on long-term dialysis therapy have a high mortality, largely due to cardiovascular causes.

A study was carried out at Guru Govind Singh Hospital, Jamnagar, Gujarat, among patients undergoing hemodialysis, with following aims and objectives: ÂÂ

To assess demographic data

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To assess comorbid conditions

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To find common medical problems in patients on dialysis

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To find incidence of catheter related issues and promoting asepsis

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To reinforce diet patterns and water intake patterns

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To assess risk factors that lead to cardiorespiratory events

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To assess adherence to schedule of hemodialysis

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To assess awareness of the drug intake and schedule.

Figure 1 provides a glimpse of the hemodialysis unit. *Assistant Professor †Second Year Resident Dept. of Medicine Shri MP Shah Medical College and Guru Govind Singh Hospital, Jamnagar, Gujarat Address for correspondence Dr Pranav I Patel 201, Shridhar Apartment, Near Amul Café, Walkeshwari Nagari Jamnagar, Gujarat - 361 001 E-mail: patel92pranav@gmail.com

Methods A proforma was made to assess above-mentioned aims in local language i.e., Gujarati. A single-blinded study (patients) was conducted with the only task given to patients as marking complaints and what food they eat even if they take it occasionally. Rest of the proforma

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

patients had a weight of more than 60 kg. Hypertension (40 patients-91%), diabetes (11 patients-25%) and liver parenchymal disease (10 patients-20%) were the most common associated comorbidities. Cardiac, respiratory and cerebrovascular diseases were also the comorbidities in a significant number of patients (total 11 patients had at least one of three-25%). Some other less common comorbidities found were hypothyroidism, fibrous bone dysplasia, hypopituitarism, mullerian agenesis syndrome, etc. In all, 6 patients had addictions. Only 15 (30%) patients were taking restricted amount of water. Rest had no idea about how much water they should drink. None of the patients had separate water container to measure total water intake for a day.

Most of the patients said that they followed diet but none of them were strictly following, when inquired further. Everyone told that they restricted salt intake but none knew the exact amount of salt that they should take in a day. Overall, 30 (68%) patients were taking fruits or dry fruits occasionally; 42 (95%) patients were taking salted products in one form or another, e.g., wafers, food packets, pickles, biscuits, popcorns, etc.; 9 patients were taking coffee. None of them knew how much protein and fat they should take.

Figure 1. A glimpse of the hemodialysis unit.

was filled by personal interview with each patient and previously marked boxes were confirmed. In the diet, detailed list of various food products was used to identify commonly use but harmful food products in CKD patients. Patients were also taught about various techniques of water restriction and diet preparation.

Statistics Population: Patients with CKD on dialysis.

Sample: Forty-four patients were randomly assessed at the end of the month.

Approximately half (48%) of the patients took tablets as given by their caretakers; only some of them could recall drug schedule and only very few could identify the tablets.

Most patients were regular in their dialysis schedule.

Only 2 patients missed their dialysis schedule due to higher center visits. On further investigation, rain, outdoor visits, ill health of patient or relatives, death of known person, etc. were found to be other reasons for missing dialysis in past. Five patients died in July 2018 4 were due to cardiorespiratory events and one was due to cerebrovascular accident.

Discussion

Results

As we can see in Figure 2, major areas of concern were found to be diet restriction, monitoring hypertension, water restriction, knowledge of drugs, reduction of obesity, control of diabetes and liver disease in descending order.

A total of 44 patients were analyzed in month of July, 2018. Out of these, 29 patients were males and 15 were females. Most patients had a functional arteriovenous (AV) fistula. None of the few patients with centralline in situ experienced bleeding or discharge from insertion site. Headache, fever, chills, rigors and nausea were common complaints from patients. Fifteen (30%)

On further inquiry, all patients told that they were explained about diet and water restriction at least once but majority of them forget it and lost the diet chart. Few were concerned about time in applying techniques and others were worried about cost. They were explained about importance of these restrictions and made aware about complications and prognosis if not followed. But

There was no control group or comparison group and data was analyzed as a cross-sectional study only.

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IJCP Sutra 349: One should take a full one-week Facebook holiday in case of a social media addiction.

Nephrology

100

91

90 80

Diabetes control is necessary as increase in blood sugar levels favors infection, increases thirst, impairs immunity, worsens kidney function, etc.

70

70 Percentage (%)

Kt/V formula). Weight reduction by proper diet and exercise should be advised.

Areas of concern

100

60

Patients with liver disease should be taken care of for extra risks of bleeding tendencies, glycemic control, risk of infection, control of liver disease itself, etc.

50

50 40

30

30

25

As cardiovascular events remain the most common cause of death, each patient on dialysis must be monitored by weight, blood sugar levels, ECG, Echo, digital X-rays, cholesterol levels, level of activity, etc. for risk factors.

20

20 10

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Conclusion

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Figure 2. Key areas of concern.

from this experience, we can say that water restriction and diet must be repeatedly explained and must be reinforced at regular intervals by providing posters, charts, etc. in local language. Avoidance of harmful food products like fruits, dry fruits, coffee, salted products, etc. should be the first target. Diet adequacy can be determined by serum electrolytes, albumin and cholesterol and sugar levels. Serum albumin <4 g/dL indicates poor prognosis. Water intake can be monitored by determining serial weight of the patients. Certain bad practices like eating food products like wafers, while on active hemodialysis should be discouraged as it takes time for food to reach stomach and be processed. Opinion of a dietician and demonstration of some prepared diet dishes with explanation about how it was made would be of great help.

Blood pressure (BP) monitoring is vital. Monitoring of BP during hemodialysis is as important as before and after. BP should be monitored as frequently as possible as major variations were observed during this study. For instance, one normotensive patient became hypertensive within just 2 minutes of detaching the machine. Most of the time when patient complains of high BP, headache and fever and chills, BP is observed to be high. So if possible, at every incident, BP should be measured.

Patient should be taught to identify their drugs and remember the schedule. Obesity decreases efficacy of hemodialysis (as increase in volume of distribution in

As healthcare workers, from our side, we are moving towards following guidelines regarding repeated monitoring, proper techniques, using advanced technologies, separate disposable instruments and maintaining total asepsis, etc. But at the same time, patient education and involvement of patients in their own treatment is necessary to achieve maximum results. We shall not forget the importance of nonpharmacological measures as they are universal, e.g., in this study, by monitoring random blood sugar, we helped 25% patients; by monitoring BP, we helped 91% patients but by explaining and reinforcing diet and water restriction, we helped 100% of patients.

“The doctor can have a stronger impact on the patient than any drug.” ―Paracelsus Suggested Reading 1. Alagappan R. Manual of Practical Medicine. 5th Edition, 2014. pp. 555-9.

2. Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. 2011;80(12):1258-70.

3. Fried LF, Katz R, Sarnak MJ, Shlipak MG, Chaves PH, Jenny NS, et al. Kidney function as a predictor of noncardiovascular mortality. J Am Soc Nephrol.

2005;16(12):3728-35.

4. Marks A, Macleod C, McAteer A, Murchie P, Fluck N, Smith WC, et al. Chronic kidney disease, a useful trigger for proactive primary care? Mortality results from a large U.K. cohort. Fam Pract. 2013;30(3):282-9.

5. Saravanan P, Davidson NC. Risk assessment for sudden cardiac death in dialysis patients. Circ Arrhythm Electrophysiol. 2010;3(5):553-9.

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IJCP Sutra 350: Everybody should have 30 minutes of electronic curfew before they sleep. This means not using mobile phones and other mobile devices for 30 minutes before sleep.

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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

Oocyte Donation: Pregnancy Results and Obstetric Outcome NANDITA P PALSHETKAR*, HRISHIKESH D PAI*, MANISHA TAKHTANI†, RUTVIJ DALAL‡

Abstract Objective: To evaluate the success rate after oocyte donation and the obstetric and neonatal outcome in these pregnancies.

Design: Prospective study. Setting: Babies and US, Infertility, IVF and ICSI Center, Lilavati Hospital, Mumbai.

Study group: A cohort of 65 women who conceived after oocyte donation. Main outcome measured: Obstetric charts of all these women were maintained and the incidence of obstetric complications and the perinatal outcome was studied.

Results: The most common antenatal complications were first trimester bleeding (31.2%) and pregnancy-induced hypertension (23.4%). The incidence of multiple gestations was 15.6%. No major peripartum events were observed. Conclusion: The incidence of obstetric complications is higher in oocyte donation pregnancies. The complications are usually manageable and most patients have a successful pregnancy outcome.

Keywords: Oocyte donation, pregnancy, outcome, bleeding, pregnancy-induced hypertension

O

ocyte donation has now become an essential part of therapeutic armamentarium of many infertility clinics. Since the time of its introduction, it has allowed many couples to overcome infertility secondary to factors like advanced age, diminished ovarian reserve, premature ovarian failure, heritable genetic illnesses and surgical menopause.

As more and more women delay childbearing these days, the use of donated oocytes and embryos has increased over the years. Though, it is now an established treatment method, the information regarding the obstetric outcome of these pregnancies is still scarce in literature. Because many of the candidates for oocyte donation are beyond the age of 35 years, concerns have been raised regarding the potential for increased medical and obstetric complications in this cohort. Many authors, so far, have reported a high incidence of complications during pregnancy.1,2 Advanced maternal age, primiparity and multiple gestations are the various reasons cited for

*Consultant Infertility Specialist †Past Fellow of National Board - Reproductive Medicine ‡Current Fellow of National Board - Reproductive Medicine Lilavati Hospital and Medical Research Centre, Mumbai, Maharashtra Address for correspondence Dr Rutvij Dalal 20, Shreerang Society, Near Football Ground, Kankaria Ahmedabad - 380 022, Gujarat

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such increased occurrence of complications. Some authors have also proposed that the allogeneic fetus may predispose the woman to hypertensive disorders, intrauterine growth restriction, placental abnormalities and gestational diabetes mellitus.3,4 The present study was a prospective study which analyzed the number of successful pregnancies post oocyte donation and the obstetric and neonatal outcomes in these pregnancies.

Material and Methods

Study Patients This prospective study was conducted at a tertiary center for infertility and human reproduction.

Between years 2004 and 2006, a total of 207 women underwent oocyte donation program. Of these 207 women, successful pregnancies were achieved in 65. Our study group comprised of these 65 women.

Various indications for oocyte donation in these women are summarized in Table 1. Obstetric charts were maintained for all these women. Registered obstetric variables included incidence of first trimester abortions, pre-eclampsia, preterm labor and premature rupture of membranes, intrauterine growth restriction (IUGR), placental abnormalities, oligohydramnios and gestational diabetes mellitus. Gestational age at the time of delivery and the mode of delivery were recorded. A record of neonatal weight and Apgar scores was also kept.

IJCP Sutra 351: Limit mobile talk time to less than 2 hours a day. Once the battery is discharged, call it a day for mobile use.

OBSTETRICS AND GYNECOLOGY Hormone Therapy

Results

All patients received exogenous estrogen (estradiol valerate) therapy for endometrial preparation before the embryo transfer. However, the protocol used was different in women with functional and non-functional ovaries. Pituitary down regulation with gonadotropinreleasing hormone (GnRH) analog was done in women who were menstruating, before endometrial preparation with estrogen. In nonmenstruating women, cyclical hormonal therapy was given till the following criteria were fulfilled:

The mean age of recipients (who conceived after oocyte donation), at the time of embryo transfer was 38.2 years (range 26-58). Of the 65 women who conceived after oocyte donation, 39 were more than 40 years of age and another 3 were above 50 years. All women were primigravidas. The baseline characteristics of the parturients are summarized in Table 2.

ÂÂ

Minimum 3 months of bleeding

ÂÂ

Uterocervical length ≥5-6 cm

ÂÂ

Endometrial thickness - 8-9 mm.

Micronized progesterone was added on the day of donor’s pickup. Day 3 or Day 5 embryo transfer was done. Post-transfer, luteal support was given to all the recipients in the form of estradiol valerate 6 mg/day and micronized progesterone 600 mg/day. β-hCG (human chorionic gonadotropin) was done on Day 14 posttransfer to confirm pregnancy. If pregnancy was confirmed, luteal support was continued till 12 weeks of gestation.

Antenatal Follow-up Obstetric charts were maintained for all these women.

One woman with confirmed ongoing pregnancy was lost to follow-up. Support during the first trimester included 6-8 mg of estradiol which was given orally for 10-12 weeks, natural micronized progesterone 600 mg/day for 14-16 weeks and folic acid 5 mg/day.

All women underwent triple marker screening test at 15-16 weeks of gestation. All women underwent regular monthly check-ups and a close check was kept on hemoglobin, urine and blood pressure. Monthly sonographies were done to confirm the fetal well-being.

Table 1. Indication for Oocyte Donation

The major antenatal events are summarized in Table 3.

First trimester bleeding happened in 20/64 (31.2%) women. Five women had spontaneous abortions in the first trimester and another one carrying twins aborted at 16 weeks with history suggestive of cervical incompetence. All these women were more than 40 years of age.

Ten (15.6%) women had multiple gestations. Of these, 8 women had twin gestation while 2 had triplets. One woman with twins aborted at 16 weeks of gestation.

Embryo reduction was performed at 11-12 weeks for the 2 women carrying triplets. There were no complications associated with the procedure.

All women underwent prenatal screening for chromosomal abnormalities with maternal serum triple marker test at 16 weeks. Two women tested screen positive. Amniocentesis was advised to these 2 women for confirming the risk. One woman refused amniocentesis and had a healthy baby.

Amniocentesis was performed for the other one and the karyotype was found to be normal. Pregnancyinduced hypertension (PIH) complicated 15 (23.4%) women. All these women were more than 40 years of age. Of these 15 women, 4 women had transient hypertension, 7 women had mild pre-eclampsia which was controlled with drugs; the remaining 4 had severe Table 2. Baseline Parameters

Number of women Primary ovarian failure (ovarian dysgenesis)

Antenatal Events and Complications

14

Secondary ovarian failure

Mean 100% Primi Age (years)

yy Premature ovarian failure/postmenopausal

18

Weight

yy Surgical castration

12

yy Chemotherapy/radiotherapy

0

BMI (kg/m2)

Repeated previous IVF failures

8

Diminished ovarian reserve

13

IJCP Sutra 352: Follow the formula of "20-20-20" to prevent dry eyes.

38.2 (26-58) 52.0 ± 7 22.5 ± 3.6

Parity Chronic hypertension

1

Pre-existing diabetes

0

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Table 3. Antenatal Events Antenatal events First trimester bleeding Abortion

No. of women 20 (31.2%) 6 (9.3%)

Multiple gestations

10 (15.6%) (8 twins; 2 triplets)

Pregnancy-induced hypertension

15 (23.4%)

Transient hypertension

4

Mild pre-eclampsia

7

Severe pre-eclampsia

4

Chronic hypertension

1

IUGR

8 (12.5%)

Preterm delivery

7 (10.9%)

Gestational diabetes

2 (3.1%)

pre-eclampsia and had to be delivered preterm. All women with severe pre-eclampsia had IUGR. One woman with chronic hypertension had worsening of blood pressure at around 30 weeks and was delivered preterm at 34 weeks in view of the same.

Seven out of 64 (10.9%) women delivered preterm.

Of these 7 women, 5 were delivered preterm in view of severe pre-eclampsia. One woman had spontaneous preterm labor at 32 weeks and lower segment cesarean section (LSCS) was done in view of fetal distress.

Another woman with twins had to be delivered at 29 weeks due to intrauterine fetal death (IUFD) of one twin.

IUGR was observed in 8 women (12.5%). Of these, 3 women had twins with mild IUGR, another woman delivered at 29 weeks due to IUFD of one twin and the other twin was growth restricted. The other 4 women had PIH and were delivered preterm between 33-35 weeks.

Only 2 women (3.1%) had gestational diabetes which was controlled by diabetic diet and no drugs were required. Fortunately no adverse pregnancy event cropped up in these pregnancies.

Peripartum Events and Neonatal Outcome All women were delivered by cesarean section in view of precious pregnancies. None but one had atonic postpartum hemorrhage, which was managed conservatively. No life-threatening complications were observed in any of the deliveries.

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A total of 67 infants were born (49 single and 18 twins). There was one stillborn: this mother had twin gestation with severe PIH, which led to IUGR and oligohydramnios. One twin died in utero. Cesarean section was done at 29 weeks. The other twin had Apgar score <7 at 5 minutes, was admitted in neonatal intensive care unit (NICU) for a period of 1 month. All fetus except one had (as mentioned above) Apgar >7 at 5 minutes. No major congenital malformations were observed except for one newborn that had a cleft lip. The 2 women who tested screen positive for chromosomal abnormalities had healthy babies.

Discussion As more and more women delay childbearing these days, the use of donated oocytes has increased over the years. Problems with conventional approaches to fertility treatment in older women are as follows: ÂÂ

Oocytes are of poor quality

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Ovulation is less likely

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Corpus luteum may be deficient

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Endometrial receptivity is decreased

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Blastocyst hatching is reduced

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Increased incidence of an embryonic trophoblast development is seen

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Pregnancy may end in abortion and IUFD.

The answer to these problems is oocyte donation.

It is highly successful in women of all ages. The use of donor eggs has proved to be a valuable means to achieve pregnancy in many couples with older wives whose egg quality and/or quantity is diminished.

Abdalla et al reported that pregnancy, implantation and miscarriage rates are independent of the age of the uterus.5 The mean age of women in the present study was 38.2 years (range 26-58 years).

First trimester bleeding is a common occurrence in oocyte donation pregnancies.2,6,7 It has been observed to occur in 35-70% of cases and this high incidence is associated with multiple implantations,8 early fetal loss9 and endometrial preparation therapy. In the present study, first trimester bleeding occurred in 31.25% women.

The incidence of multiple pregnancies in our study was 15.6%, which is comparatively lower than the incidence cited in other studies.9 Our policy of transferring 2 or 3 embryos at a time can explain this low incidence of multiple gestations. Transfer of more embryos increases the risk of multifetal gestations which are associated

IJCP Sutra 353: Every 20 minutes, focus the eyes on an object 20 feet (6 meters) away for 20 seconds or close the eyes for 20 seconds, at least every half hour.

OBSTETRICS AND GYNECOLOGY with higher obstetric and perinatal complications, especially in older women.

The most conspicuous complication in oocyte recipients is PIH. This is explained by the advanced maternal age, primiparity and the higher incidence of multifetal gestations. In the present study, PIH was seen in 15/65 (23%) women which is similar to incidence cited in other studies.1,2,7 The incidence was higher in women with multiple gestations compared to those with singleton pregnancies. In a recent study conducted by Krieg et al, obstetric complications were compared between women who conceived after oocyte donation, with women more than 38 years of age who conceived after in vitro fertilization (IVF). They observed that oocyte recipients and autologous oocyte controls had similar rates of complications of prematurity, hypertensive disorders of pregnancy, gestational diabetes and placental abnormalities. Infant birth weights and gestational age at time of delivery were similar between the two groups.10 PIH has been associated with high rate of premature delivery, IUGR and low birth weight. In our study, the incidence of IUGR was more in women with pregnancy complicated by PIH. All women were delivered by cesarean section because of higher anxiety amongst the mothers and higher level of concern in the medical team. The perinatal outcome was comparable to that after natural/spontaneous conception and most infants did well in their neonatal period with no major complications.

Donor oocyte program has proved to be a boon for many infertile couples and is now one of the essential parts of any infertility clinic. This study suggests that though the rate of obstetric complications is increased in women undergoing oocyte donation, most of these women thrive well in pregnancy and ultimately have a successful neonatal outcome. This

study is; however, limited by the absence of agematched controls.

References 1. Serhal PF, Craft IL. Oocyte donation in 61 patients.

Lancet. 1989;1(8648):1185-7.

2. Blanchette H. Obstetric performance of patients after oocyte donation. Am J Obstet Gynecol. 1993;168(6 Pt 1):1803-7; discussion 1807-9.

3. Salha O, Sharma V, Dada T, Nugent D, Rutherford AJ, Tomlinson AJ, et al. The influence of donated gametes on the incidence of hypertensive disorders of pregnancy.

Hum Reprod. 1999;14(9):2268-73.

4. Toner JP, Grainger DA, Frazier LM. Clinical outcomes among recipients of donated eggs: an analysis of the U.S. national experience, 1996-1998. Fertil Steril. 2002;78(5):1038-45.

5. Abdalla HI, Wren ME, Thomas A, Korea L. Age of the uterus does not affect pregnancy or implantation rates; a study of egg donation in women of different ages sharing oocytes from the same donor. Hum Reprod. 1997;12(4):827-9.

6. Pados G, Camus M, Van Steirteghem A, Bonduelle M, Devroey P. The evolution and outcome of pregnancies from oocyte donation. Hum Reprod. 1994;9(3):538-42.

7. Sauer MV, Paulson RJ, Lobo RA. Pregnancy in women 50 or more years of age: outcomes of 22 consecutively established pregnancies from oocyte donation. Fertil Steril. 1995;64(1):111-5.

8. Legro RS, Wong IL, Paulson RJ, Lobo RA, Sauer MV. Multiple implantation after oocyte donation: a frequent but inefficient event. Fertil Steril. 1995;63(4):849-53.

9. Rodríguez-González M, Serra V, Garcia-Velasco JA, Pellicer A, Remohí J. The “vanishing embryo” phenomenon in an oocyte donation programme. Hum Reprod. 2002;17(3):798-802.

10. Krieg SA, Henne MB, Westphal LM. Obstetric outcomes in donor oocyte pregnancies compared with advanced maternal age in in vitro fertilization pregnancies. Fertil Steril. 2008;90(1):65-70.

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Stages of CKD ÂÂ

Stage 1: Kidney damage with normal or increased GFR >90.

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Stage 2: Kidney damage with GFR 60-90.

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Stage 3: Kidney damage with GFR 30-60.

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Stage 4: Kidney damage with GFR 15-30.

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Stage 5: Kidney failure, dialysis or GFR <15 (>60, 30-60, < 30: >60 by GP, 30-60 by MD physician and <30 by DM).

IJCP Sutra 354: To prevent computer vision syndrome, spend less than 3 hours on a computer.

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OBSTETRICS AND GYNECOLOGY

Comparison of Myoinositol and Metformin in Women with Polycystic Ovarian Syndrome SHAYISTA NABI*, RAKA GULERIA†

Abstract Objective: The aim of the study was to compare the effects of 16-week treatment with two insulin-lowering therapies on the clinical, endocrine-metabolic and ovulatory parameters in women affected by polycystic ovarian syndrome (PCOS).

Material and methods: A total of 70 patients attending the Gynecology OPD of Holy Family Hospital, Okhla, New Delhi, with clinical features of PCOS in the age group of 17-35 years, between June 2015 and May 2016, were selected. Patients were randomly distributed into two groups with 35 patients each. Group 1 received myoinositol (MYO) 2 g/day, while Group 2 received metformin 500 mg/day twice-daily. Baseline anthropometry, biochemical investigations and pelvic ultrasonography were done and repeated after 16 weeks. Results: Modified Ferriman-Gallwey (mFG) score was reduced from 4.66 ± 4.06 SD to 3.56 ± 3.29 SD in Group 1 and 4.94 ± 4.05 SD to 3.87 ± 3.24 SD in Group 2; the fall in Group 1 was more significant than Group 2. Fasting insulin decreased from 13.90 ± 6.88 SD to 11.66 ± 6.05 SD in Group 1 and from 12.85 ± 4.46 SD to 11.78 ± 4.39 SD in Group 2; reduction was highly significant in Group 1 than Group 2. Results for luteinizing hormone (LH) were not significant. Free testosterone decreased from mean of 1.47 ± 0.37 SD to 1.37 ± 0.37 SD in Group 1 and from 1.43 ± 0.37 SD to 1.36 ± 0.36 SD in Group 2; the fall in Group 1 was more significant than Group 2. Conclusion: Metformin is effective in reducing the metabolic and hormonal parameters and improves fertility. MYO not only improves all the above parameters but also decreases insulin resistance significantly. Thus, MYO supplementation is essential in the management of PCOS to improve insulin sensitivity.

Keywords: Polycystic ovarian syndrome, myoinositol, metformin, fasting insulin

P

olycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age, affecting 5-10% of women worldwide. It is defined as a heterogeneous syndrome complex characterized by hyperandrogenism (clinical and/or bio-clinical), ovarian dysfunction (oligo- and/ or anovulation) and polycystic ovaries, with exclusion of related disorders. This is with the recognition that forms of PCOS may occur without overt incidence of hyperandrogenism.1

Initially defined by Stein and Leventhal in 1953, this syndrome has changed in definition over the years and is briefly defined in Table 1.

In 2003, Rotterdam proposed a revised criterion for PCOS that included ultrasound morphology of ovaries as potential criteria to define PCOS:2 ÂÂ

Menstrual irregularity (due to oligo- and/or anovulation)

ÂÂ

Clinical and/or biochemical signs of hyperandrogenism

ÂÂ

Polycystic ovaries (by ultrasound).

Table 1. Definition of PCOS National Institute of Health (NIH) - 1990

Evidence of clinical or Androgen excess (clinical biochemical hyperandrogenism and/or biochemical hyperandrogenism) Chronic anovulation

*Registrar †Senior Consultant Dept. of Obstetrics and Gynecology Holy Family Hospital, New Delhi Address for correspondence Dr Shayista Nabi 2nd Floor, 73, Sector 50, Woodstock, Nirvana Country, Gurugram - 122 017, Haryana E-mail: shayistanabi@gmail.com

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Androgen Excess Society (AES)

Ovarian dysfunction (oligoanovulation and/or polycystic ovarian morphology on ultrasonography)

All criteria require exclusion of other causes of hyperandrogenism such as adult onset congenital adrenal hyperplasia, hyperprolactinemia and androgen secreting tumors.

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OBSTETRICS AND GYNECOLOGY In addition, other etiology must be excluded (congenital adrenal hyperplasia, androgen secreting tumors, thyroid dysfunction, Cushing’s syndrome).

In young women with PCOS, insulin resistance may occur with higher frequency of about 30-40%.

Additionally, a defect in insulin signalling pathway seems to be implicated in the pathogenesis of insulin resistance. The exact cause of insulin resistance observed in PCOS women is not known; however, a post-receptor defect that could affect glucose transport has been proposed.3 The importance of insulin resistance in PCOS is suggested by the fact that insulinsensitizing drugs such as metformin, pioglitazone, troglitazone and myoinositol (MYO) have been proposed as treatment to resolve hyperinsulinemiainduced dysfunction of ovarian response to endogenous gonadotropins, metformin being the oldest drug in use whilst MYO being the recent development in insulinsensitizing drugs. The focus of this study is primarily based on these two insulin-sensitizing drugs, i.e, MYO and metformin.

MYO is one of the nine stereoisomeric forms of a C6 sugar alcohol that belongs to vitamin B-complex group.4 Studies have suggested that impairment in insulin pathway could be due to a defect in inositol phosphoglycans (IPGs) second messenger. In PCOS, defect in tissue availability or altered metabolism of inositol or IPGs mediators may contribute to insulin resistance.5 Therefore, supplying MYO can accelerate glucose disposal and decrease circulating insulin, serum testosterone and enhance ovulation. The commonly used dose is 200-4,000 mg once-daily before breakfast in PCOS. Very high doses of MYO can cause gastrointestinal side effects like nausea, diarrhea, dizziness, insomnia and possible worsening of bipolar disorder. No toxicity has been reported. There is no evidence for MYO drug interaction till date.

gastrointestinal distress in women with PCOS. There are; however, no published reports of lactic acidosis with metformin therapy in women with PCOS. Material and Methods This study was carried out at Holy Family Hospital, New Delhi, from June 2015 to May 2016. The patients attending Gynecological OPD, with clinical features suggestive of PCOS (menstrual abnormalities, infertility, obesity, acne, hirsuitism), were selected.

It was a randomized comparative study with sample size of 70. Patients were defined as having PCOS according to Rotterdam criteria (2003). The patients would have to satisfy a minimum of two criteria listed below in order to be diagnosed as PCOS: ÂÂ

Oligo- and/or anovulation: Oligomenorrhea would be defined if menses occurred less than 9 times a year or if 3 cycles more than 36 days long occurred during the last year.

ÂÂ

Clinical and/or biochemical signs of hyperandrogenism: Clinical hyperandrogenism would be diagnosed if the modified FerrimanGallwey (mFG) score is 8 or greater or the patient has moderate-to-severe acne, defined by the presence of inflammatory lesions and their extension.

ÂÂ

Polycystic ovaries (by ultrasound): Presence of 12 or more follicles in each ovary measuring 2-9 mm in diameter and/or increased ovarian volume (>10 mL, calculated using the formula 0.5 × length × width × thickness). Single ovary fitting this definition is enough to define PCOS.

The inclusion and exclusion criteria are mentioned in Table 2.

Metformin is an oral biguanide antihyperglycemic drug. It lowers blood glucose by inhibiting hepatic glucose production (by decreasing gluconeogenesis), enhancing peripheral glucose uptake by skeletal muscles and adipose tissue and reduces intestinal glucose absorption. It enhances insulin sensitivity at the post-receptor level and stimulates insulin mediated glucose disposal without producing hypoglycemia in PCOS women. It has been used to treat anovulatory infertility, insulin resistance and hyperandrogenism in PCOS patients. The action of metformin is limited due to low levels of inositol in PCOS. Dose of metformin can vary from 500 to 2,500 mg/day. Metformin causes a significant increase in nausea, vomiting and

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Table 2. Inclusion and Exclusion Criteria Inclusion criteria

Exclusion criteria

Women with PCOS, diagnosed in accordance with Rotterdam consensus conference criteria 2003 in the age group of 17-35 years.

yy Pregnancy yy Thyroid disorders yy Significant liver or renal impairment yy Unstable mental illness yy Diagnosis of diabetes mellitus or impaired glucose tolerance yy Use of drugs able to interfere with glucoinsulinemic metabolism for at least 3 months prior to entering the study yy Hypersensitivity to MYO

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

Patients were randomly allocated to two groups; Group 1 (MYO) and Group 2 (metformin). At the beginning of the study, baseline levels of various study variables were recorded. Patients were subjected to anthropometry - body weight, body mass index (BMI), waist-hip ratio (WHR) - and biochemical investigations which included fasting blood sugar (FBS), postmeal blood sugar (PMBS), fasting insulin, luteinizing hormone (LH), LH/follicle-stimulating hormone (FSH) ratio, free testosterone, prolactin (PL). Hirsutism was scored by mFG using 9 body sights - lip, chin, chest, upper abdomen, lower abdomen, upper arm, upper back, lower back and thigh. Each body area was visually scored on a scale of 0 to 4, where “0” indicated no terminal hair growth and “4” indicated full male pattern terminal hair growth. Cut-off was taken as score of “8” or more. Ovulatory activity was monitored with serum progesterone. It was recorded at the baseline and repeated every month in the mid-luteal phase. The peak value during the study was taken as final value.

Cut-off was taken as 8 ng/mL. In addition, a baseline ultrasonography was done for noting down the number of follicles and/or ovarian volume.

Participants of Group 1 received 2 g MYO daily and those of Group 2 received 500 mg metformin twicedaily. Patients were called for follow-up after 16 weeks of drug therapy and tests for all the study variables were repeated and compared with the baseline findings.

Patients who conceived after treatment were noted. The side effects experienced in each study group were noted down. Outcome was studied in terms of regularization of cycle, reduction in mFG score, improvement in anthropometric, biochemical and ultrasonographic parameters before and after the treatment in the two groups. The summary of the findings has been described in tables below.

Results In all, 70 patients were enrolled for the study within the age group of 17-35 years. Patients were randomly distributed into two groups with 35 patients each.

Two patients were lost during follow-up from Group 2 and 5 patients conceived during early stages of the study (3 from Group 1 and 2 from Group 2). The final study was based on 63 patients - 32 patients in Group 1 and 31 in Group 2. Since the age distribution of patients was from 17 to 35 years, the study covers the mean population age of 26.62 ± 5.38 in Group 1 and 26.23 ± 4.58 in Group 2. It is noteworthy that race, ethnicity, socioeconomic factors were almost similar in both the groups.

The most common complaint was irregular cycles (53.1% in Group 1 and 64.5% in Group 2) followed by scanty flow, secondary amenorrhea, weight gain, hirsutism and infertility. After treatment, in Group 1 53.1% of patients achieved regular cycles whilst in Group 2, 41.9% of patients achieved regular cycles (Table 3).

The fall in body weight and WHR was significant in both groups, but on comparing the two, it was more significant in Group 1 than Group 2. The fall in BMI was more significant in Group 2 than Group 1 (Table 4).

The fall in mFG score was more significant in Group 1 as compared to Group 2. While LH results were not significant, the fall in LH/FSH ratio was more significant in Group 2 than Group 1. The reduction in fasting insulin was highly significant in Group 1 than Group 2.

Free testosterone decrease was more significant in Group 1 than Group 2. FBS was normal in all patients; the fall in Group 2 was more significant than Group 1.

For postprandial blood sugar (PPBS), fall was more significant in Group 1 (Table 5).

In Group 1 serum, progesterone changed from mean of 3.73 ± 1.44 SD to 6.73 ± 1.90 SD and in Group 2 from mean of 3.76 ± 1.57 SD to 5.82 ± 2.03 SD. Change in serum progesterone value was more significant in Group 1 than Group 2. In Group 1, 36.1% of patients ovulated, 8.6% conceived and in Group 2, 27.6% ovulated and 5.7% conceived. The reduction in number of follicles was more significant in Group 1 than Group 2 whilst decrease in ovarian volume (mean ovarian volume of >10 mL) was almost same in both groups (Table 6).

Table 3. Regularization of Cycles Group 1

Group 2

P value

Frequency

%

Frequency

%

Improved (I)

17

53.1

13

41.9

Not improved (N)

15

46.9

18

58.1

Total

32

100

31

100

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0.374

OBSTETRICS AND GYNECOLOGY Table 4. Anthropometry Findings Item description

Body weight

BMI

WHR

Group 1

Group 2

P value

Group 1

Group 2

P value

Group 1

Group 2

P value

Before

65.99 ± 10.12

66.37 ± 7.84

0.869

22.26 ± 2.71

23.04 ± 2.94

0.272

0.80 ± 0.06

0.80 ± 0.07

0.907

After

63.25 ± 9.06

64.47 ± 7.05

0.556

20.82 ± 2.37

21.35 ± 2.70

0.410

0.77 ± 0.05

0.78 ± 0.06

0.557

Mean difference ± SD

-2.74 ± 2.24

-1.91 ± 1.91

0.116

-1.44 ± 0.80

-1.69 ± 1.27

0.338

-0.03 ± 0.04

-0.02 ± 0.03

0.443

P value

<0.001

<0.001

<0.001

<0.001

<0.001

<0.001

Table 5. Biochemical Parameters Item description

mFG score Group 1 Group 2

LH P value

Group 1 Group 2

LH/FSH ratio P value

Group 1 Group 2

Fasting insulin P value

Group 1 Group 2

P value

Before

4.66 ± 4.06

4.94 ± 4.05

0.786

3.21 ± 3.01

5.13 ± 2.14

0.254

1.97 ± 1.03

2.04 ± 0.96

0.768

13.90 ± 6.88

12.85 ± 4.46

0.479

After

3.56 ± 3.29

3.87 ± 3.24

0.709

5.13 ± 2.14

5.95 ± 3.24

0.241

1.79 ± 0.96

1.84 ± 0.86

0.829

11.66 ± 6.05

11.78 ± 4.39

0.928

Mean difference ± SD

-1.09 ± 1.03

-1.06 ± 0.10

0.909

-1.08 ± 3.31

-1.19 ± 3.53

0.899

-0.17 ± 0.18

-0.20 ± 0.26

0.664

-2.24 ± 2.09

-1.07 ± 1.51

0.013

P value

<0.001

<0.001

0.060

0.070

<0.001

<0.001

<0.001

<0.001

Item description

Free testosterone Group 1 Group 2

Prolactin

FBS

P value

Group 1 Group 2

P value

Group 1 Group 2

PPBS P value

Group 1 Group 2

P value

Before

1.47 ± 0.37

1.43 ± 0.37

0.717

14.31 ± 4.39

13.85 ± 3.53

0.653

89.81 ± 8.32

89.23 ± 0.812 11.04

115.97 ± 111.13 ± 0.134 12.03 13.25

After

1.37 ± 0.37

1.36 ± 0.36

0.895

14.09 ± 4.17

13.35 ± 2.94

0.421

88.50 ± 7.79

87.81 ± 0.764 10.32

113.03 ± 109.84 ± 0.291 12.00 11.76

Mean difference ± SD

-0.10 ± 0.10

-0.08 ± 0.08

0.339

-0.22 ± 1.73

-0.50 ± 2.23

0.574

-1.31 ± 1.66

-1.42 ± 2.01

-2.94 ± 4.01

-1.29 ± 3.24

0.078

P value

<0.001

<0.001

0.484

0.221

<0.001

<0.001

<0.001

0.034

0.818

Table 6. Ultrasonographic Parameters Item description

Reduction in no. of follicles

Mean ovarian volume

Group 1

Group 2

P value

Group 1

Group 2

P value

Before

14.59 ± 2.69

14.08 ± 1.84

0.382

13.51 ± 2.02

12.81 ± 2.35

0.213

After

12.19 ± 1.69

12.05 ± 1.75

0.749

11.93 ± 1.91

11.65 ± 1.96

0.575

Mean difference ± SD

-2.41 ± 1.49

-2.03 ± 1.66

0.350

-1.58 ± 0.98

-1.58 ± 0.98

0.057

<0.001

<0.001

<0.001

<0.001

P value

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30

Group 1

Cases (%)

25

Group 2

22.6

20 16.1 15 10

12.9

12.9

9.4 6.3

5 0.0

0.0

0

Menorrhagia

Nausea

Vomiting

0.0 Abdominal cramps

0.0 Weakening

Figure 1. Side Effects.

In the study, only 15.6% of patients experienced side effects in Group 1. Menorrhagia was a complaint seen only in Group 1. In Group 2, 64.5% experienced side effects. P value was significant only for abdominal cramps. Details of the side effects have been described in Figure 1.

Discussion PCOS is one of the most common endocrine disorders in women of reproductive age. Its etiology remains unclear. In young women with PCOS, insulin resistance is intrinsic to the syndrome and affects 30-40% of patients with PCOS. Studies have shown that insulin resistance in PCOS may be linked to abnormal ovarian steroidogenesis by means of altered insulin signal transduction.

The age distribution of patients in this study was 17-35 years. Mean age of patients was 26.62 ± 5.38 in Group 1 and 26.23 ± 4.58 in Group 2 which is similar to studies conducted by Immediata et al6 and Costantino et al.7 In the study, 53.1% of patients achieved regular cycles in Group 1 (MYO) compared to 41.9% in Group 2 (metformin), which is similar to results obtained by Leo et al.8 Our results are supported by the study carried out

by Awalekar et al.9 They studied the effect of MYO, metformin and lifestyle modification in PCOS patients.

In their study, BMI in the metformin group was reduced from a mean of 29.64 ± 3.49 to 27.13 ± 3.49 after 3 months of treatment, which is highly significant (p = 0.0000) and in MYO group, BMI changed from mean of 25.40 ± 6.53 to 24.40 ± 5.91 (p = 0.009). Similar results were seen in studies done by Le Donne et al,10 and Cheang et al.11 Immediata et al6 conducted a crossover

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study in which metformin was able to decrease body weight (p < 0.05), improve menstrual cycle (<0.001) and mFG score (0.05). None of these clinical changes were observed during MYO administration. These results are not in concordance with our study.

In the study by Leo et al,8 fall in mFG score in MYO group from 11.7 ± 2.7 to 7 ± 3.9 (p = 0.001) was significant than metformin group, as in our study.

Similar results were seen in a study by Zacche et al.12 Genazzani et al13 studied 20 overweight patients of PCOS. In MYO group, LH, PL, testosterone (T), insulin levels and LH:FSH significantly decreased along with improved insulin sensitivity. Similarly, in our study, there was highly significant decrease in fasting insulin and free testosterone in Group 1.

Our results are further supported by Angik et al.14 They studied 100 patients in a randomized controlled trial (RCT) (50 in each group). MYO decreased FBS, PPBS, fasting and post-meal insulin, homeostasis model assessment (HOMA), T levels, LH:FSH, ovarian volume significantly; whereas in metformin group, significant improvement occurred in FBS, PPBS, T, LH:FHS and ovarian volume but not in fasting insulin and HOMA index. Fasting insulin decreased from 16.51 ± 13.95 to 14.58 ± 9.79 in MYO group.

This result was significant, but in metformin group, the reduction was not significant. Similar results were seen in the study by Awalekar et al.9 In contrast, in the study by Gerli et al,15 no change in fasting glucose concentrations, fasting insulin or insulin responses to glucose challenge was recorded after MYO therapy.

In a study by Minozzi et al16 fasting insulin changed from 12.2 to 8.3 with mean difference of -3.9 ± 1.8; results were not significant.

Raffone et al17 studied 120 patients with PCOS and 14-16 months of infertility. The study demonstrated a statistically significant difference in restoration of spontaneous ovulation in patients receiving MYO. Though there was a higher overall rate of pregnancy in the MYO group, the effect was not significant.

In our study also, there was higher ovulation (36.1%) and conception rate (8.6%) in Group 1 compared to Group 2 (27.6% and 5.7%). Our results are in contrast to the study by Papaleo et al18 in which 88% restored at least one spontaneous menstrual cycle, of which 72% maintained normal ovulatory activity during the followup period and 40% pregnancies were achieved after MYO administration. Similar contrast results were seen in studies by Palomba et al19 and Abdelhamid et al.20 In the study by Angik et al,14 the number of follicles decreased from 11.40 ± 3.00 to 11.60 ± 2.13 (p = 0.001) in

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OBSTETRICS AND GYNECOLOGY MYO group and in metformin group from 10.20 ± 2.31 to 10.18 ± 2.0 (p = 0.001) and ovarian volume decreased from 14.45 ± 3.8 to 12.35 ± 2.83 (p = 0.001) in MYO group and in metformin group from 14.53 ± 3.44 to 12.24 ± 2.83 (p = 0.001), which is similar to our study.

Conclusion Metformin is effective in improving the metabolic and hormonal parameters and improves fertility. But MYO not only improves all the above parameters but also decreases insulin resistance significantly. MYO also has better patient compliance and is better tolerated than metformin. These beneficial effects of inositol support a future therapeutic role in women with PCOS. Inositol deficiency is the basic pathophysiology for PCOS and thus MYO supplementation is essential in the management of PCOS. MYO improves insulin sensitivity and thus, should be the first-line of therapy in PCOS. References 1. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al; Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril. 2009;91(2):456-88.

2. The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19(1):41-7.

3. Baillargeon JP, Nestler JE. Commentary: polycystic ovary syndrome: a syndrome of ovarian hypersensitivity to insulin? J Clin Endocrinol Metab. 2006;91(1):22-4.

4. Bizzarri M, Carlomagno G. Inositol: history of an effective therapy for polycystic ovary syndrome. Eur Rev Med Pharmacol Sci. 2014;18(13):1896-903.

5. Baillargeon JP, Diamanti-Kandarakis E, Ostlund RE Jr, Apridonidze T, Iuorno MJ, Nestler JE. Altered D-chiroinositol urinary clearance in women with polycystic ovary syndrome. Diabetes Care. 2006;29(2):300-5.

6. Immediata V, Romualdi D, De Cicco S, Tagliaferri V, Di Florio C, Cirella E, et al. Metformin versus myoinositol: which one is better in obese PCOS patients? A crossover study on clinical, endocrine and metabolic effects.

7. Costantino D, Minozzi G, Minozzi E, Guaraldi C. Metabolic and hormonal effects of myo-inositol in women with polycystic ovary syndrome: a double-blind trial. Eur Rev Med Pharmacol Sci. 2009;13(2):105-10.

8. Leo VD, Musacchio MC, Cappelli V, Sabatino AD, Tosti C, Piomboni P. A combined treatment with myo-inositol and monacolin K improve the androgen and lipid profiles

of insulin-resistant PCOS patients. J Metabolic Synd.

2013;2:127.

9. Awalekar JC, Awalekar C, Jadhav VM, Chivate CG, Patwardhan MH. Effect of metformin & myoinositol & life style modification in patients of polycystic ovarian disease (PCOD). Int J Biomed Res. 2015;6(09):698-704.

10. Le Donne M, Alibrandi A, Giarrusso R, Lo Monaco I, Muraca U. Diet, metformin and inositol in overweight and obese women with polycystic ovary syndrome: effects on body composition. Minerva Ginecol. 2012;64(1):23-9.

11. Cheang KI, Huszar JM, Best AM, Sharma S, Essah PA, Nestler JE. Long-term effect of metformin on metabolic parameters in the polycystic ovary syndrome. Diab Vasc Dis Res. 2009;6(2):110-9.

12. Zacchè MM, Caputo L, Filippis S, Zacchè G, Dindelli M, Ferrari A. Efficacy of myo-inositol in the treatment of cutaneous disorders in young women with polycystic ovary syndrome. Gynecol Endocrinol. 2009;25(8):508-13.

13. Genazzani AD, Lanzoni C, Ricchieri F, Jasonni VM. Myo-inositol administration positively affects hyperinsulinemia and hormonal parameters in overweight patients with polycystic ovary syndrome.

Gynecol Endocrinol. 2008;24(3):139-44.

14. Angik R, Jajoo SS, Hariharan C, Chimote A. A comparative study of metabolic and hormonal effects of myoinositol vs. metformin in women with polycystic ovary syndrome: a randomised controlled trial. Int J Reprod Contracept Obstet Gynecol. 2015;4(1):189-94.

15. Gerli S, Papaleo E, Ferrari A, Di Renzo GC. Randomized, double blind placebo-controlled trial: effects of myoinositol on ovarian function and metabolic factors in women with PCOS. Eur Rev Med Pharmacol Sci. 2007;11(5):347-54.

16. Minozzi M, D’Andrea G, Unfer V. Treatment of hirsutism with myo-inositol: a prospective clinical study. Reprod Biomed Online. 2008;17(4):579-82.

17. Raffone E, Rizzo P, Benedetto V. Insulin sensitiser agents alone and in co-treatment with r-FSH for ovulation induction in PCOS women. Gynecol Endocrinol. 2010;26(4):275-80.

18. Papaleo E, Unfer V, Baillargeon JP, De Santis L, Fusi F, Brigante C, et al. Myo-inositol in patients with polycystic ovary syndrome: a novel method for ovulation induction. Gynecol Endocrinol. 2007;23(12):700-3.

19. Palomba S, Orio F Jr, Falbo A, Manguso F, Russo T, Cascella T, et al. Prospective parallel randomized, doubleblind, double-dummy controlled clinical trial comparing clomiphene citrate and metformin as the first-line treatment for ovulation induction in nonobese anovulatory women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2005;90(7):4068-74.

20. Abdelhamid AMS, Ismail Madkour WA, Borg TF. Inositol versus metformin administration in polycystic ovarian disease patients: a case–control study. Evid Based Women’s Health J. 2015;5(2):61-6.

IJCP Sutra 360: HIV/AIDS is now a chronic manageable disease. The new mantra is test and treat and not to wait till the disease manifests.

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ONCOLOGY

Malignant Peripheral Nerve Sheath Tumor Arising in a Neurofibroma: A Case Report MONICA KUMBHAT M*, LEENA DENNIS JOSEPH†, ARCHANA B*, ARULAPPAN‡

Abstract Malignant peripheral nerve sheath tumor (MPNST) is a rare variety of soft tissue sarcoma of ectomesenchymal origin. These tumors present diagnostic difficulties in differentiating from other high-grade spindle sarcomas. This is a case of a 45-year-old lady who presented with pain and swelling in the groin for past 4 months, which on excision and histopathology revealed an MPNST in a neurofibroma.

Keywords: Malignant peripheral nerve sheath tumor, soft tissue sarcoma, ectomesenchymal, neurofibroma

M

alignant peripheral nerve sheath tumor (MPNST) is a malignant neurogenic tumor that occurs with high frequency (8-13%) in association with neurofibromatosis type 1 (NF-1), arising either de novo or in transition from neurofibroma.1 It either develops from peripheral nerves, pre-existing benign neurofibromas or schwann cells. NF-1 patients are more frequently diagnosed with MPNST in the third or fourth decades of life, whereas the sporadic form of MPNST is most frequently diagnosed in the sixth or seventh decades of life.

Case Report

On ultrasound, there was a well-defined heterogeneous mass involving predominantly deep subcutaneous and muscular planes of proximal right thigh measuring 9.7 × 5.7 × 5.8 cm. Fine needle aspiration cytology (FNAC) of the same lesion showed fibrocytes, mature adipocytes, a few spindle-shaped cells with sharp ends suggestive of wavy nerve fibers. She had history of excision of the swelling in the same region 2 years ago, which was histologically proved to be a neurofibroma.

In the same region, the patient presented with the present swelling. On excision of the mass, histologically it showed an undifferentiated pleomorphic sarcoma (Fig. 3), which was confirmed on immunohistochemistry

A 45-year-old female developed pricking type of pain in the right groin extending to right knee for a duration of 4 months. There was also a history of fever on and off for 1 month. She gave a history of neurofibromatosis for 35 years. On local examination, a large neurofibroma was seen in the right inguinal region. Neurofibromas were also seen in the knee and arms (Figs. 1 and 2).

*Postgraduate Student †Professor Dept. of Pathology ‡Professor Dept. of General Surgery Sri Ramachandra Medical College, Chennai, Tamil Nadu Address for correspondence

Dr Leena Dennis Joseph Professor Dept. of Pathology Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu E-mail: leenadj@gmail.com

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Figure 1. Single, small neurofibroma seen on lateral aspect of the left knee.

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ONCOLOGY to be positive for vimentin and S-100 (Fig. 4) suggesting a neural origin. The tumor cells were markedly pleomorphic with increased mitosis, many of them being atypical. Thus, a diagnosis of MPNST in a neurofibroma was given. Patient was referred to a radiation oncologist for further management.

Discussion MPNST is a rare malignant tumor with poor prognosis accounting for 3-10% of all soft tissue sarcomas. It is the second most common variety of soft tissue sarcomas seen. A combination of gross and microscopic findings along with immunohistochemical studies is commonly used to diagnose a case of MPNST.

Figure 2. Both arms showing multiple neurofibromas of varying sizes.

Figure 3. Pleomorphic tumor cells with mitotic figures (H&E x400).

Figure 4. S-100 positivity in the tumor cells (IHC x100).

These tumors occur in equal frequency in males and females and some series have shown a female preponderance. The majority of these tumors are seen involving the extremities; although tumor were also seen in unusual sites, such as the pelvis, retroperitoneum and infratemporal fossa. Imaging is routinely performed to assess the extent of the disease and plan surgical resection. However, it does not reliably determine the malignant transformation from neurofibroma to MPNST. Magnetic resonance imaging (MRI) is the investigation of choice because it can reveal the nerve of origin. Grossly, the tumor size ranges from 4 to 24 cm in greatest dimension.2 Histologically, following criteria are used for the diagnosis of MPNST: a) Gross fusiform tumors in relation to nerves; b) microscopic feature of spindle cell with fascicular pattern and varying degrees of mitosis, necrosis and tumor calcification; c) presence of associated benign neurofibroma or schwannanian cells and d) positive immunohistochemical staining for S-100 protein, neuron-specific enolase and others like actin, cytokeratin, smooth muscle actin and vimentin to differentiate from other spindle cell sarcomas.

The tumors are classified as low-grade and highgrade on the basis of their cellular differentiation, mitotic count, tumor necrosis and expression of MIB-1 proliferation marker.3 However, it is not always possible to demonstrate the origin from a nerve, especially when it arises from a small peripheral branch. This point was exemplified in a series by Nambisan et al, in which nerves could not be identified in 61% of cases of MPNST and in the series Bilge et al, in which nerve origin could be identified only in 45-56% cases.4 Still, there are several other distinct features, such as proliferation of tumor in the subendothelial zones of vessels with neoplastic cells

IJCP Sutra 362: ABC for safe sex: Abstain, be faithful to your partner and if you cannot, use condoms.

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herniating into vessel lumen and proliferation of small vessels in the walls of the large vessels, which are very characteristic features of MPNST. Syndromes that are associated with MPNST are NF-1 and NF-2.

Histologically, strict morphologic criteria must be applied to distinguish the spectrums of MPNSTs from cellular schwannoma, atypical and malignant meningioma and from a variety of rarely occurring intracranial sarcomas, such as high-grade pleomorphic sarcoma “malignant fibrous histiocytoma” fibrosarcoma, synovial sarcoma and leiomyosarcoma. On the benign side of the spectrum, cellular schwannoma is another tumor to be distinguished from MPNST. This tumor is particularly prone to be mistaken for malignancy, given the presence of hypercellularity, mitotic activity, and occasional locally aggressive growth. Strong S-100 protein as well as collagen IV/laminin immunoreactivity is the rule in this tumor. With respect to separating MPNST from benign nerve sheath tumors, p53 may be useful, strong immunostaining being seen in the majority of MPNSTs.5 Ten percent of MPNSTs exhibit focal divergent differentiation, either mesenchymal (rhabdomyosarcoma, chondrosarcoma, osteosarcoma, angiosarcoma) or epithelial (mucin-producing, neuroendocrine or squamous type).

Conclusion MPNSTs are aggressive, high-grade, therapy resistant and associated with poor prognosis. A combination of clinical, pathological and immunohistochemistry helps in diagnosing these tumors. Proliferation marker (MIB-1) can be a good adjunct to grade and tailor the

treatment in MPNST. Sex and cellular differentiation are the new adverse prognostic factors for survival of the patients. Postoperative radiotherapy has a definitive role in both disease free and overall survival.

Though multimodality therapy, including surgical resection and adjuvant radiotherapy, is available, the prognosis remains dismal. Modern clinical studies and the development of effective targeted chemotherapy are needed to gain control of the disease.

References 1. Sun D, Tainsky MA, Haddad R. Oncogene Mutation Survey in MPNST cell lines enhances the dominant role of hyperactive Ras in NF1 associated pro-survival and malignancy. Transl Oncogenomics. 2012;5:1-7.

2. Kar M, Deo SV, Shukla NK, Malik A, DattaGupta S, Mohanti BK, et al. Malignant peripheral nerve sheath tumors (MPNST) - clinicopathological study and treatment outcome of twenty-four cases. World J Surg Oncol. 2006;4:55.

3. Trojani M, Contesso G, Coindre JM, Rouesse J, Bui NB, de Mascarel A, et al. Soft-tissue sarcomas of adults; study of pathological prognostic variables and definition of a histopathological grading system. Int J Cancer.

1984;33(1):37-42.

4. Nambisan RN, Rao U, Moore R, Karakousis CP. Malignant soft tissue tumors of nerve sheath origin. J Surg Oncol.

1984;25(4):268-72.

5. Scheithauer BW, Erdogan S, Rodriguez FJ, Burger PC, Woodruff JM, Kros JM, et al. Malignant peripheral nerve sheath tumors of cranial nerves and intracranial contents: a clinicopathologic study of 17 cases. Am J Surg Pathol.

2009;33(3):325-38.

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Stroke Every 45 seconds, someone has stroke or paralysis.

Uncontrolled BP increases paralysis mortality by 45%.

Diagnosis of Acute Kidney Injury Increase in serum creatinine by ≥0.3 mg/dL within 48 hours or an increase to ≥1.5 times the presumed baseline value that is known or presumed to have occurred within the last 7 days or a decrease in urine volume to <3 mL/kg over 6 hours or 50% increase (viz., 0.3 mg/dL increase if baseline ≥0.6 mg/dL and 50% increase if baseline is ≤0.6 mg/dL).

Oliguria (typically defined as <0.3 mL/kg/hour).

Contrast-induced nephropathy: Either a 25% increase in serum creatinine from baseline or 0.5 mg/dL (44 μmol/L) increase in absolute value, within 48-72 hours of administration of IV contrast.

IJCP Sutra 363: People with STIs should seek prompt treatment and avoid sexual intercourse or practice safe sex.

DERMACON INTERNATIONAL 2019 INDIA Indian Mission - Global Vision 17th - 20th Jan 2019 Clarks Exotica Convention Resort & Spa, Bengaluru.

KEY HIGHLIGHTS

INTERNATIONAL EVENTS

The 47th Annual conference of IADVL, with an international outreach program and with a theme of “Indian mission with global vision” will bring together.

5 Sister Society has been confirmed (South Africa, Singapore, Iran, SriLanka & SARAD) we are expecting more.

9000 international & national delegates.

DERMACON International Quiz Competition.

Around 400 national & more than 60 international faculty and experts.

Around 150 worldwide industry participations from reputed pharmaceutical companies, lasers & dermatological technologies.

Well-structured plenary, orations, symposia, guest lectures, debates, national quiz, award papers, free communications and posters, apart from other official programs.

Well planned courses & workshops on dermatosurgery, aesthetic dermatology, lasers and other procedural dermatology.

Review Article Writing. (Alternative to Essay Competition Announced Earlier) DERM DERMACON International Scholarships to Young Dermatologists.

Global Leadership Session.

Scholarship Program for International Delegates.

Register early

CONFERENCE & CME REGISTRATION FEES

Dr S. Sacchidanand Dr R. Raghunatha Reddy Dr Savitha Organising Chairperson

Organising Secretary

Dr Venkataram Mysore

International Liaison Chairperson

Treasurer

Dr D.A. Satish

Organising Co-Chair

PEDIATRICS

Chromosome 3p Duplication: A Rare Chromosomal Anomaly BRAJA KISHORE BEHERA*, RISHAV RAJ*, SAILABALA SHAW†, MITALI MAHAPATRA‡

Abstract Partial trisomy 3p results from either unbalanced translocation or de novo duplication. Common clinical features consist of dysmorphic facial features, congenital heart defects, psychomotor and mental retardation, abnormal muscle tone and hypoplastic genitalia. In this paper, we report a case of partial trisomy 3p with rare clinical manifestations. A full-term, female newborn was admitted to our hospital with complaints of repeated seizures and developmental retardation. On evaluation chromosome 3p duplication was detected.

Keywords: Partial trisomy 3p, unbalanced translocation, seizures, developmental retardation, chromosome 3p duplication

C

hromosome 3p duplication is an anomaly that occurs with an extra copy of genetic material on the short arm (p) of third chromosomes. Another name for chromosome 3 duplication is, trisomy 3p. It is a rare chromosomal disorder, where a portion of the short arm (p) of chromosome 3 is duplicated, so there are three copies of it rather than the normal two.

The severity along with the signs and symptoms depends on location and the size of duplication.

Features that often occur in people with chromosome 3p duplication include developmental delay, behavioral problems, intellectual disability and distinctive facial features. Chromosome 3p duplication can be inherited from a parent with balanced translocation or de novo origin.1,2 Treatment is based on the signs and symptoms on individual basis.

Sign and symptoms are brachycephaly, square face, frontal bossing, flat back of skull, small jaw, full

cheeks, malformed auricles, widely spaced eyes, bushy eyebrows, downward slanting of eyes, short nose, large mouth, short upper lip, cleft lip and palate, short neck, short hand, stubby feet, excessive whorls, hemivertebrae, reduced muscle tone, seizure, congenital heart defect, esophageal atresia, hypoplastic kidney, ureteric duplication, growth retardation, speech retardation, mental retardation, feeding difficulty.

“De novo” duplications occurs randomly during the formation of the egg or sperm. In these cases, a person would have no family history of the condition but could pass the duplication on to children. Other cases of chromosome 3p duplication are the result of a balanced translocation in one of the parents. Carriers of a balanced translocation generally do not have any unusual symptoms or health problems; however, they have an increased risk of having children with chromosomal abnormalities.

Case Report

*Post Graduate Dept. of Pediatrics †Post Graduate Dept. of Obstetrics and Gynecology Utkal University, Bhubaneswar, Odisha ‡Consultant Dept. of Obstetrics and Gynecology Christian Hospital, Berhampur, Odisha Address for correspondence Dr Rishav Raj Post Graduate Resident (Final Year) Dept. of Pediatrics Hi-Tech Medical College, Pandra, Rasulgarh, Bhubaneswar - 751 010, Odisha E-mail: drrishavraj@gmail.com

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A 2½-year-old female child, a product of non consanguineous marriage with proper antenatal checkup and normal antenatal ultrasonography (USG) delivered through normal vaginal delivery (NVD) at hospital. Baby had not cried immediately after birth and was admitted to neonatal intensive care unit (NICU) and discharged after 3 days. At 2½ years baby came to the hospital with c/o delayed developmental milestones, repeated episodes of seizures at 20-25 days interval from the age of 7 months and poor weight gain.

Baby recognized mother at 6 months, neck holding at

IJCP Sutra 364: Used infected razor blades, knives or tools that cut or pierce the skin also carry some risk of spreading HIV.

PEDIATRICS 7 months, bi-syllable sound at 2 years, walked with support at 2 years. Baby was having head circumference of 40 cm, weight was 9 kg, mid-arm circumference was 12 cm, antimongoloid slant of eyes, brachycephaly, small jaw, broad and short nose, short neck, epicanthic fold, large mouth (Fig. 1), malformed auricle (Fig. 2),

Figure 3. CT scan of brain.

Figure 1. Facial anomaly.

Figure 4. Chromosomal anomaly showing 3p duplication.

reduced muscle tone, seizures, growth retardation, mental retardation and speech retardation. On evaluating the child, completed blood count was normal. Electroencephalograms (EEG) show normal sleep-wake cycle and normal EEG, CT brain showed no apparent anomaly (Fig. 3), on chromosomal analysis there was presence of duplication of segment between 3p22 and 3p25 (Fig. 4). For recurrent seizures, child was treated with levetiracetam and valproate, dietary modification advice and developmental counseling was properly given.

Discussion

Figure 2. Ear anomaly.

Our bodies are made of billions of cells. In each cell is a set of structures called chromosomes that carry all of the instructions (genes) for the cell to function.

We generally have 23 pairs of chromosomes and inherit one in each pair from each parent. Sometimes,

IJCP Sutra 365: HIV-positive people may remain asymptomatic but can still pass on the virus to others.

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a section from one chromosome of a particular pair changes places with a section from a chromosome of another pair. When the two breaks do not pass through a gene and there is no gain or loss of material when the chromosomes are looked at under a microscope, it is called a balanced translocation.

Some people discover from a blood test when they have had a child with special needs or health problems caused by a chromosome disorder. Some people have repeated miscarriages or other fertility problems.

Some people have a blood test as part of family investigations. Others find out by chance when they have a chromosome test for other reasons. Occasionally, a balanced translocation is found in a baby during pregnancy. Translocations can be new or they can be passed down in families from parent to child through the generations. New translocations occur when sperm or egg cells are forming or just after fertilization during the copying of the early cells that will become an embryo, then a fetus and then a baby. One study suggests that most new balanced translocations arise during sperm production and particularly in older fathers. They are not caused by men’s lifestyle, environment or work. Duplication of the short arm of chromosome 3 is associated with severe delay in mental development. More than 50% of children die within the first 2 years of life. Duplications may be due to paternal or maternal balanced translocation.

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Central nervous system: Seizures.

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Muscles: Severe hypotonia.

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Gastrointestinal: Esophageal atresia, atresia of the colon and rectum.

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Miscellaneous: Hemivertebrae, reduced muscle tone, accessory nipples, esophageal atresia, atresia of colon, rectal atresia, hypogonadism, hypospadias small penis, undescended testes, duplication of ureters, kidney hypoplasia, kidney cysts, hypercholesterolemia, growth retardation, motor retardation, speech retardation, mental retardation and feeding difficulty.

There are several different specialized tests that can be used to diagnose a chromosome 3p duplication. These include:1 ÂÂ

Karyotyping: A karyotype is a laboratory test that produces an image of a person’s chromosome. This test can be used to diagnose large duplications.

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FISH: A laboratory technique that is used to detect and locate a specific DNA sequence on a chromosome. A chromosome is exposed to a small DNA sequence called probe that has a fluorescent molecule attached to it. The probe sequence binds to its corresponding sequence on the chromosome.

This test can be used in combination with karyotyping for duplications that are too small to be seen on karyotype. However, FISH is only useful if the person ordering the test suspects there is a duplication of a specific region of 3p.

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Array CGH - A technology that detects duplications that are too small to be seen on karyotype.

The list of signs and symptoms mentioned in various sources for chromosome 3, trisomy 3p includes.3-5 ÂÂ

Skull: Brachycephaly, holoprosencephaly, flat back of skull, temporal indentations.

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Face: Square face, frontal bossing, small jaw, facial clefts, full cheeks.

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Eyes: Widely spaced eyes, iris coloboma, small eyes, telecanthus, bushy eyebrows, downward slanting space between eyelids, cyclopia, epicanthal folds.

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Nose: Short nose, broad nose, flat nose, prominent philtrum, choanal atresia.

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Ear: Malformed auricles.

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Mouth: Large mouth, short upper lip, cleft lip, cleft palate.

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Neck: Short neck.

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Extremities: Short hands, stubby hands, short feet, stubby feet, camptodactyly, syndactyly, brachymesophalangy, clubfoot, excessive fingertip whorls, joint contractures.

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Cardiac defects: Congenital heart defects including tetralogy of Fallot, ventricular septal defect, hypoplastic heart and transposition of the great vessels.

References 1. Han DH, Chang JY, Lee WI, Bae CW. A case of partial trisomy 3p syndrome with rare clinical manifestations.

Korean J Pediatr. 2012;55(3):107-10.

2. Natera-de Benito D, García-Pérez MA, Martínez-Granero MÁ, Izquierdo-López L. A patient with a duplication of chromosome 3p (p24.1p26.2): a comparison with other partial 3p trisomies. Am J Med Genet A. 2014;164A(2): 548-50.

3. Allen DL, Foster RN. Anaesthesia and trisomy 3p syndrome. Anaesth Intensive Care. 1996;24(5):615.

4. Kotzot D, Krüger C, Braun-Quentin C. De novo direct duplication 3 (p25-->pter): a previously undescribed chromosomal aberration. Clin Genet. 1996;50(2):96-8.

5. Walzer S, Favara B, Ming PM, Gerald PS. A new translocation syndrome (3/B). N Engl J Med. 1966;275(6):290-8.

IJCP Sutra 366: Wash your hands after sneezing, coughing or holding your hands near your mouth or nose.

EXPERT VIEW

Are β-blockers Contraindicated in Patients with Congestive Heart Failure?

OP Yadava

S

ince 1970s, usage of b-blockers in treatment of patients with heart failure was recommended by several investigators but the fact that if reduces myocardial contractility, precluded their use. The past decade has shown significant improvement in the understanding of heart failure, shifting from a hemodynamic to a neurohormonal basis.1

Recent primary evidence from randomized clinical trials has demonstrated a significant benefit to patients with heart failure when b-blockers therapy is added to standard therapy.2 While it is known that b-blockers do not cause overt heart failure, a large proportion of clinical heart failure is diastolic dysfunction, nearly 30-40%, which is improved by b-blocker therapy.3 The rationale for their use in heart failure is that the concentration of circulating catecholamines is increased in patients with congestive heart failure (CHF). Thus, constant adrenergic stimulation can adversely affect cardiac myocytes. b-blockers improve left ventricular systolic function, in the long run regress myocardial hypertrophy and normalization of ventricular shape can occur through a ‘reverse remodeling effect’.1 They also reduce oxygen demand and produce bradycardia,4 which restores contractility in left ventricular dysfunction.

When patients are treated with b-blockers postmyocardial infarction, mortality is lower amongst those who begin with a low ejection fraction.5 In patients who had previous heart failure, the incidence of sudden cardiac death is significantly lower with b-blockers and overall mortality is considerably reduced.6 A recent meta-analysis showed that b-blockers reduce all-cause mortality in CHF patients by 29%. Studies like the Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) pilot study have shown metoprolol-induced neurohormonal modifications by decreasing renin and angiotensin II

Chief Executive Officer and Chief Cardiac Surgeon National Heart Institute, New Delhi

concentrations. Their effect on exercise capacity and quality-of-life is not convincing. US Carvedilol Program, Cardiac Insufficiency Bisoprolol Study 2 (CIBIS-2) and Metoprolol CR/XL Randomized Intervention Trial in Chronic Heart Failure (MERIT-HF) testing carvedilol, bisoprolol and metoprolol, respectively, impressively established the fact that b-blockers in heart failure have reduced sudden death and total mortality, and led to decrease in hospitalization rate.1 Carvedilol was the first b-blocker to be approved

by US FDA (Food and Drug Administration) in 1997 for treatment of heart failure. Carvedilol Prospective Cumulative Survival (COPERNICUS) trial demonstrated 35% reduction in mortality by carvedilol versus placebo in patients with severe heart failure.7 Carvedilol reduced sudden death in patients with symptomatic heart failure and impaired left ventricular functions. It also has a vasoactive profile, increases vasodilatation in peripheries and high compliance, thus, reducing the occurrence of cold hands and feet among patients treated for heart failure.8 Hence, b-blockers are indicated in patients with chronic stable mild-to-moderate symptomatic heart failure (New York Heart Association [NYHA] functional class II and III) with depressed left ventricular function.1 Bisoprolol can be used effectively at the maximum recommended doses for outpatient treatment of heart failure. It significantly improves functional status, quality-oflife and ejection fraction.9 Carvedilol or Metoprolol European Trial (COMET) was initiated to evaluate effects of carvedilol and metoprolol on mortality in patients with CHF.7 In conclusion, it can be said that b-blockers are a heterogeneous group with regard to efficacy, safety profile, tolerability and ancillary properties. Hence, optimal selection and use of agents with better reverse remodeling effects and peripheral vasodilatation in the cardiovascular continuum will assist in providing improved management.10 Though once contraindicated, b-blockers are now an evidence-based recommendation for the treatment of heart failure.1

IJCP Sutra 367: Cover your mouth with a tissue when you cough, sneeze or laugh. Discard used tissues in a plastic bag, then seal and throw it away.

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References 1. Maggioni AP. Heart Failure: Treatment strategies for heart failure; beta-blockers and antiarrhythmics.

Heart. 2001;85(1):97-103.

2. Kennedy HL. Current utilization trends for beta-blockers in cardiovascular disease. Am J Med. 2001;110 Suppl 5A:2S-6S. 3. Cuocolo A, Betocchi S, Perrone-Filardi P, et al. Effects of beta-blocking therapy on left ventricular diastolic function in patients with hypertension. 11th Scientific Meeting of the International Society of Hypertension. Heidelberg 1986. Abstract 0444.

4. Nagatsu M, Spinale FG, Koide M, Tagawa H, DeFreitas G, Cooper G 4th, et al. Bradycardia and the role of beta-blockade in the amelioration of left ventricular dysfunction. Circulation 2000;101(6):653-9.

Multicenter Diltiazem Post-Infarction Research Group.

J Am Coll Cardiol. 1990;16(6):1327-32.

6. Chadda K, Goldstein S, Byington R, Curb JD. Effect of propranolol after acute myocardial infarction in patients with congestive heart failure. Circulation. 1986;73(3): 503-10.

7. Maack C, Elter T, Böhm M. Beta-blocker treatment of chronic heart failure: comparison of carvedilol and metoprolol. Congest Heart Fail. 2003;9(5):263-70.

8. Klemsdal TO, Mundal HH, Gjesdal K. Effects of carvedilol and atenolol on arterial pulse curves (plethysmography) and finger temperature after hand cooling. Euro J Clin Pharmacol. 1996;50(6):483-9.

9. González-Juanatey JR, Alegría Ezquerra E, García Saavedra V, Pérez Ojeda G, Ruiz Ros JA, Espinosa Caliani JS, et al; Investigadores del Estudio BISCOR. Use of bisoprolol in heart failure. The BISOCOR observational study. Rev Esp Cardiol. 2003;56(9):873-9.

5. Lichstein E, Hager WD, Gregory JJ, Fleiss JL, Rolnitzky LM, Bigger JT Jr. Relation between beta-adrenergic 10. Abraham WT. Switching between beta blockers in heart blocker use, various correlates of left ventricular function failure patients: rationale and practical considerations.

Congest Heart Fail. 2003;9(5):271-8. and the chance of developing congestive heart failure. The ■■■■

Make sure During Medical Practice

Situation:

An elderly patient with isolated systolic hypertension developed stroke.

© IJCP GROUP

Why did you not put him on candesartan?

Lesson:

Make sure to remember that as per the Study on Cognition and Prognosis in the Elderly (SCOPE) trial, in elderly patients with isolated systolic hypertension, antihypertensive treatment based on candesartan resulted in a significant 42% relative risk reduction in stroke in comparison with other antihypertensive treatment, despite little difference in BP reduction.

J Am Coll Cardiol. 2004;44(6):1175-80.

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IJCP Sutra 368: Do not attend work or school.

Medicolegal

Medicolegal Corner KK Aggarwal*, Ira Gupta

Can a patient dictate as what all a doctor should write instead of following the protocol?

No, the patient cannot dictate any doctor as to what write and doctors have to follow their protocol. As per the provisions of Clause 7.7 of the Indian Medical Council Professional Conduct, Etiquette and Ethics Regulations, 2002, the name of the doctor will be deleted from the register of Medical Council, if he is found to have signed or given under his name any certificate, report, etc., which is untrue or misleading. The provisions of Clause 7.7 are reproduced hereunder: 7.7 Signing Professional Certificates, Reports and other Documents: Registered medical practitioners are in certain cases bound by law to give, or may from time to time be called upon or requested to give certificates, notification, reports and other documents of similar character signed by them in their professional capacity for subsequent use in the courts or for administrative purposes, etc. Such documents, among others, include the ones given at Appendix –4. Any registered practitioner who is shown to have signed or given under his name and authority any such certificate, notification, report or document of a similar character which is untrue, misleading or improper, is liable to have his name deleted from the Register.

Thus, in view of the above clause 7.7 if the doctor writes what is dictated by the patient without following the proper protocol, procedure and the same is untrue, misleading or improper then the doctor shall have to delete his name from the Register of the respective Medical Council in which the doctor is registered.

Accordingly, the doctor shall be debarred from practicing medicine.

the pictures or video recording of surgery or any case notes other than the discharge summary to the patient or his legal representative as the patients generally have a right to review them, demand copies of them, and to demand their confidentiality as per the MCI ethics regulations.

As per the provisions of Clause 1.3 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulation, 2002 the doctor is under an obligation to maintain the medical record and to provide the same to the patient and/or his relative, if the patient and/or his relative ask for the same. The provisions of Clause 1.3 is reproduced hereunder: “1.3 Maintenance of medical records: 1.3.1. Every physician shall maintain the medical records pertaining to his/her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India and attached as Appendix 3.

1.3.2. If any request is made for medical records either by the patients/authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours.

1.3.3. A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he/she shall always enter the identification marks of the patient and keep a copy of the certificate. He/She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared as in Appendix 2.

Are doctors supposed to share the pictures or video recording of surgery or any case notes other than the discharge summary with the patient or his relative?

1.3.4. Efforts shall be made to computerize medical records for quick retrieval.”

Yes, it is obligatory for doctors, hospitals to provide the copy of the case record or medical record and also share

“7.2 If he/she does not maintain the medical records of his/her indoor patients for a period of three years as per regulation 1.3 and refuses to provide the same within 72 hours when the patient or his/her authorised representative makes a request for it as per the regulation 1.3.2.”

*Group Editor-in-Chief, IJCP Group

IJCP Sutra 369: Avoid close contact with others.

MCI ethics regulations 7.2 further clarifies that not giving records can amount to professional misconduct:

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

Further, in the matter titled as Medi. Supri. Loknayak Jaiprakash Narayan Hospital & Ors. V/s. K.M. Santosh.

F.A. No. 244/2008, decided on 14/03/2016, the Hon’ble National Consumer Disputes Redressal Commission has observed that: “5. It is the primary responsibility of the hospital to maintain and produce patient records on demand by the patient or appropriate judicial bodies. However, it is the primary duty of the treating doctor to see that all the documents with regard to management are written properly and signed. An unsigned medical record has no legal validity. The patient or their legal heirs can ask for copies of the treatment records that have to be provided within 72 hours. The hospital can charge a reasonable amount for the administrative purposes including photocopying the documents. Failure to provide medical records to patients on proper demand will amount to deficiency in service and negligence. It is the duty of doctor or hospital to preserve, maintain the medical record for certain specified period under different laws like Limitation Act, Consumer Protection Act and the Directorate General of Health Service (DGHS), Prenatal Diagnostic Test Act, 1994, the Clinical Establishments (Registration and Regulation) Act, 2010 (Central Act No. 23 of 2010). These records are required in medical negligence, accident, insurance claims and in criminal cases also in the Labour Courts.

Hon’ble Supreme Court and the National Consumer Commission in various judgments held the hospitals/ doctors liable for medical negligence for non-production of medical record.

Thus, in view of above, with the enforcement of the MCI Regulations, 2002, it is made clear that the patient has a right to claim medical records pertaining to his treatment and the hospitals are under obligation to maintain them and provide them to the patient on request.

What action can be taken if patient threatens filing an FIR? Threatening any person i.e., criminal intimidation is a criminal offence under Section 503 of Indian Penal Code and the same is punishable under Section 506 of the Indian Penal Code. If any person threatens the doctor, then the doctor can lodge an FIR under Section 503/506 IPC against the said persons for committing the offence of criminal intimidation.

The relevant provisions of Indian Penal Code are reproduced hereunder: “Section 503. Criminal intimidation. Whoever threatens another with any injury to his person, reputation or property, or to the person or reputation of any one in whom that person is interested, with intent to cause alarm to that person, or to cause that person to do any act which he is not legally bound to do, or to omit to do any act which that person is legally entitled to do, as the means of avoiding the execution of such threat, commits criminal intimidation.

Explanation: A threat to injure the reputation of any deceased person in whom the person threatened is interested, is within this section.

Section 506. Punishment for criminal intimidation.

Whoever commits, the offence of criminal intimidation shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both; If threat be to cause death or grievous hurt, etc.—And if the threat be to cause death or grievous hurt, or to cause the destruction of any property by fire, or to cause an offence punishable with death or 1 [imprisonment for life], or with imprisonment for a term which may extend to seven years, or to impute, unchastity to a woman, shall be punished with imprisonment of either description for a term which may extend to seven years, or with fine, or with both.”

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474

High-sensitivity C-reactive Protein High-sensitivity C-reactive protein (hs-CRP) is considered the most useful inflammatory marker for clinical practice.

Values should be reported in mg/L. hs-CRP <1 mg/L = low risk; 1-3 mg/L = intermediate risk; 3-10 mg/L = high risk.

Among patients with known coronary heart disease (CHD), a value >3 mg/L is appropriate for predicting outcomes in patients with stable CHD; a threshold >10 mg/L may be more predictive in patients with an acute coronary syndrome (ACS).

Patients with known CHD and hs-CRP <1 mg/L on contemporary medical therapy, including statins are at particularly low risk.

Use hs-CRP in conjunction with LDL-cholesterol to adjust the dose of statin therapy in patients with established CHD to achieve both an optimal LDL-C <70 mg/dL and, ideally, hs-CRP <1 mg/L.

IJCP Sutra 370: Sleep in a room away from other family members.

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Medical voice for policy change

Medtalk with Dr KK Aggarwal Free medicines and diagnostic tests will soon be available to patients with dementia as part of an action plan being worked out by the Centre (Union Minister for Health and Family Welfare, JP Nadda).

Do you know blood pressure (BP) is very dynamic?

A reading can change 10 or even 20 points over the course of seconds. That’s why the current BP guidelines recommend waiting 1 minute, retaking the reading and averaging the two numbers. If the systolic values (the first number in a BP reading) are more than around 10 points apart, consider doing a third reading a minute later. Averaging three values will likely provide an even more trustworthy result.

Best time to have coffee: Caffeine can increase alertness, so having a cup or two of coffee or tea can help boost your body and sharpen your mind. However, try not to have large amounts after 2 pm, as the caffeine may interfere with the sleep.

AHA’s list of BP measuring mistakes. Any of these errors may elevate your BP reading by several points (even as much as 10 points, in some cases), although they are generally not additive. ÂÂ

Having a full bladder. An uncomfortably full bladder might increase your reading.

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Having no support for your back or feet. Slouching or dangling your feet when sitting can increase your reading. Make sure you sit in a chair with your back supported and feet flat on the floor or a footstool. At home, don’t sit on a sofa or reclining chair.

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Sitting with crossed legs. Crossing your legs squeezes the large veins in your legs, which may raise the reading slightly.

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Not supporting your arm. Your arm should be totally relaxed so your biceps (upper arm) muscle isn’t contracted. Be sure to position your arm on a chair or counter, so that the BP cuff is level with your heart. Also, don’t clench your fist.

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Wrapping the cuff over clothing. Depending on the thickness of the fabric, putting a cuff over clothing can boost the reading by quite a bit. Wear a shortsleeved shirt (along with easily removable layers, if you’re chilly in the doctor’s office), so the cuff is placed on your bare arm.

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Using a cuff that’s not the correct size. Many people need a large-sized cuff. Using one that’s too small will be uncomfortable and may elevate your pressure by several points. Note that models with upper-arm cuffs are more reliable than those that fit on the wrist.

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Engaging in conversation. Chatting during the measurement - or even actively listening - can boost BP.

The US FDA has found an additional “unexpected impurity” in three lots of Torrent Pharmaceuticals’ recalled valsartan drug. Recently, the Food and Drug Administration (FDA) said that three lots of the drugs were contaminated with a second impurity, N-Nitrosodiethylamine, or NDEA which is also a suspected human carcinogen… (CNN) Tired of the high drug costs and shortages of life-saving generic drugs, major hospitals and hospital systems in the United States, including the Mayo Clinic, have come together to create Civica Rx, a not-for-profit generic drug company.

An ambitious project to cleanup the ocean’s plastic pollution got underway over the weekend as members of The Ocean Cleanup project began towing their system out to sea. If it works as expected, they’ll try to take a bite out of the Great Pacific Garbage Patch a huge collection of floating trash that’s three times the size of France, or about double the size of Texas.

The Great Pacific Garbage Patch is the nickname for an area between Hawaii and California, where plastic and other human-made litter and debris accumulate, according to the National Oceanic and Atmospheric Administration… (CNN) What is the extent of information to be disclosed in the consent?

The 3 Judges Constitution Bench of Hon’ble Supreme Court of India in the landmark judgment titled as “Samira Kohli versus Prabha Manchanda, AIR 2008 SC 1385” has held that: “32. We may now summarize principles relating to consent as follows: (ii) The ‘adequate information’ to be furnished by the doctor (or a member of his team) who treats the patient, should enable the patient to make a

IJCP Sutra 371: Ventilate your room regularly. TB spreads in small closed spaces. Put a fan in your window to blow out air that may contain bacteria.

Medical voice for policy change balanced judgment as to whether he should submit himself to the particular treatment as to whether he should submit himself to the particular treatment or not. This means that the Doctor should disclose (a) nature and procedure of the treatment and its purpose, benefits and effect; (b) alternatives if any available; (c) an outline of the substantial risks; and (d) adverse consequences of refusing treatment.

But there is no need to explain remote or theoretical risks involved, which may frighten or confuse a patient and result in refusal of consent for the necessary treatment. Similarly, there is no need to explain the remote or theoretical risks of refusal to take treatment which may persuade a patient to undergo a fanciful or unnecessary treatment. A balance should be achieved between the need for disclosing necessary and adequate information and at the same time avoid the possibility of the patient being deterred from agreeing to a necessary treatment or offering to undergo an unnecessary treatment.

(v) The nature and extent of information to be furnished by the doctor to the patient to secure the consent need not be of the stringent and high degree mentioned in Canterbury but should be of the extent which is accepted as normal and proper by a body of medical men skilled and experienced in the particular field. It will depend upon the physical and mental condition of the patient, the nature of treatment, and the risk and consequences attached to the treatment.”

Thus, the nature and extent of information to be furnished by the doctor should be of the extent which is normal for medical men skilled and experienced in the particular field.

The doctor is required to furnish such adequate information so as to enable the patient to make a balanced judgment about his/her treatment/surgery.

For this, the Doctor should disclose: ÂÂ

nature and procedure of the treatment and its purpose, benefits and effect;

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alternatives if any available;

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an outline of the substantial risks; and

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adverse consequences of refusing treatment.

Tobacco harm reduction: The London-based Royal College of Physicians states “Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this

figure” (Royal College of Physicians [London], Nicotine without smoke: tobacco harm reduction. 28 April 2016).

One in five men and one in six women worldwide, develop cancer during their lifetime, and one in eight men and one in 11 women die from it, IARC’s (International Agency for Research on Cancer) Global Cancer Observatory says, in its first report since 2012.

Doctors being asked to ditch Latin and use ‘plain English’: The Academy of Medical Royal Colleges says too often correspondence contains complex medical jargon rather than plain and simple English. Using the phrase “twice-daily” to explain the dosing of a medicine is better than the Latin abbreviation “bd”, for example. The Please Write to Me initiative, led by Dr Hugh Rayner, a kidney specialist, is aimed mainly at doctors working in outpatient clinics, although it is best practice for all clinicians who need to write clinical letters... (BBC UK) The best way to use food as energy is to pay attention to the glycemic index, which measures how quickly sugar from food is absorbed into your bloodstream. Refined carbs with a high glycemic index increase blood sugar levels to provide a quick jolt of energy. But the insulin pumped into the blood in order to control this sudden spike often leads to an equally sudden drop in blood sugar levels (sugar crash), which makes one feel even more tired. Eating foods with a low glycemic index can provide a slow and steady energy boost. The best choices are foods that rank from 0 to 69 on the glycemic index scale.

‘Napalm girl’ undergoes laser treatment: More than four decades after she suffered 3rd and 4th degree burns during a napalm attack carried out by South Vietnamese airplanes during the Vietnam War, the Vietnamese woman, aged 9 years then (1972), experienced significant improvement in her pain and burn scars after she underwent laser treatment. She suffered daily pain, which she rated 10 out of 10, due to scars which covered 40% of her body. After a series of laser treatments, she reported softening of the scars, increased range of motion, nerve regeneration and reduction in pain 3 out of 10. This case was published online September 5, 2018 in JAMA Dermatology.

ICMR will launch Malaria Elimination Research Alliance India (MERA INDIA) on November 15 to eliminate malaria from India by the year 2030. While major stakeholders of the alliance will be Union and State Health Ministries and National Programs, medical colleges, National Institute of Malaria Research (NIMR), World Health Organization (WHO), Medicines for

IJCP Sutra 372: Wash your hands with soap or use a hand sanitizer before handling the baby.

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Malaria Venture (MMV) and several Multinational Companies (MNCs) will also be made partners...

(The Pioneer, Sept. 15, 2018).

‘Swachhata Hi Seva’ Movement’ launched by the Prime Minister Shri Narendra Modi to boost nationwide public participation in the Swachh Bharat Abhiyan, and catalyze the fulfilment of Bapu’s dream of a Clean India. The movement is being organized in the run up to the fourth anniversary of the Swachh Bharat Mission, on October 2nd, 2018, which will also mark the commencement of the 150th year celebrations of Mahatma Gandhi.

The diagonal earlobe crease may be a marker of heart disease: As reported in ET Healthworld, September 16, 2018, Dr Himmatrao Bawaskar evaluated 888 patients; of these, 508 had diagonal earlobe crease. Of these 486 (95%) had ischemic heart disease, 264 (52%) had diabetes and 508 had high BP. Can a patient dictate as what all a doctor should write instead of following the protocol?

No, the patient cannot dictate any doctor as to what write and doctors have to follow their protocol. As per the provisions of Clause 7.7 of the Indian Medical Council Professional Conduct, Etiquette and Ethics Regulations, 2002, the name of the doctor will be deleted from the register of Medical Council, if he is found to have signed or given under his name any certificate, report, etc. which is untrue or misleading. The provisions of Clause 7.7 are reproduced hereunder: “7.7 Signing Professional Certificates, Reports and other Documents: Registered medical practitioners are in certain cases bound by law to give, or may from time to time be called upon or requested to give certificates, notification, reports and other documents of similar character signed by them in their professional capacity for subsequent use in the courts or for administrative purposes, etc. Such documents, among others, include the ones given at Appendix–4. Any registered practitioner who is shown to have signed or given under his name and authority any such certificate, notification, report or document of a similar character which is untrue, misleading or improper, is liable to have his name deleted from the Register.”

Thus, in view of the above Clause 7.7, if the doctor writes what is dictated by the patient without following the proper protocol, procedure and the same is untrue, misleading or improper then the Medical Council of India or the respective state medical council will delete his name from the Register of the respective Medical Council in which the doctor is registered. Accordingly, the doctor shall be debarred from practicing medicine.

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IJCP Sutra 373: Be careful to support the baby’s head and neck.

Recently, WHO said that there were 137 confirmed and probable cases of Ebola and 92 deaths in the latest outbreak in the eastern Democratic Republic of the Congo in Africa.

Poor progress has been made in reducing child stunting: According to the UN report, “The State of Food Security and Nutrition in the World 2018”. Nearly 151 million children aged under five are too short for their age due to malnutrition in 2017, compared to 165 million in 2012. Globally, Africa and Asia accounted for 39% and 55% of all stunted children, respectively.

Prevalence of child wasting remains extremely high in Asia where almost one in 10 children under five has low weight for their height, compared to just one in 100 in Latin America and the Caribbean.

Thirteen percent or 43 million Americans live in county with a primary care physician shortage, defined as less than one primary care physician per 2,000 people, according to a report from UnitedHealth Group. Americans in rural areas are nearly five times as likely to live in a county with a primary care physician shortage compared to urban and suburban Americans; 38% vs. 8%. Only 33% of active US physicians practice primary care (2,88,000 out of 8,69,000). The estimated primary care physician shortage could increase from 18,000 in 2018 to 49,000 by 2030 ... (Becker’s Hospital Review, Sept. 11, 2018) Scientists have found that kidney stones partially dissolve and regrow: The findings showed that kidney stones are built up in calcium-rich layers that resemble other mineralisations in nature, such as those forming coral reefs. This contradicts the widely held notion that kidney stones are homogenous rocks that never dissolve (Bruce Fouke, geology and microbiology professor at the University of Illinois).

People who feel younger than their actual age also may have brains that age more slowly, suggests a small study published online June 7, 2018, by Frontiers in Aging Neuroscience.

Foods that are like in properties with dosha (humor) or dhatu (tissue elements) or mala (excrement), increase that particular Dosha, Dhatu or Mala. Similarly, foods opposite in properties decrease that particular Dosha, Dhatu or Mala e.g., eating Mamsa increasing Mamsa dhatu.

Daily low-dose aspirin found to have no effect on healthy life span in older people in a large NIH-funded study, which examined outcomes in United States and Australia.

Medical voice for policy change Excerpts from NIH: In a large clinical trial to determine the risks and benefits of daily low-dose aspirin in healthy older adults without previous cardiovascular events, aspirin did not prolong healthy, independent living (life free of dementia or persistent physical disability). Risk of dying from a range of causes, including cancer and heart disease, varied and will require further analysis and additional follow-up of study participants. These initial findings from the ASPirin in Reducing Events in the Elderly (ASPREE) trial, partially supported by the National Institutes of Health (NIH), were published online on September 16, 2018 in three papers in The New England Journal of Medicine.

ASPREE is an international, randomized, double-blind, placebo-controlled trial that enrolled 19,114 older people (16,703 in Australia and 2,411 in the United States).

The study began in 2010 and enrolled participants aged 70 and older; 65 was the minimum age of entry for African-American and Hispanic individuals in the United States because of their higher risk for dementia and cardiovascular disease. At study enrollment, ASPREE participants could not have dementia or a physical disability and had to be free of medical conditions requiring aspirin use. They were followed for an average of 4.7 years to determine outcomes.

“Clinical guidelines note the benefits of aspirin for preventing heart attacks and strokes in persons with vascular conditions such as coronary artery disease,” said NIA Director Richard J. Hodes, M.D. “The concern has been uncertainty about whether aspirin is beneficial for otherwise healthy older people without those conditions. This study shows why it is so important to conduct this type of research, so that we can gain a fuller picture of aspirin’s benefits and risks among healthy older persons.”

In the total study population, treatment with 100 mg of low-dose aspirin per day did not affect survival free of dementia or disability. Among the people randomly assigned to take aspirin, 90.3% remained alive at the end of the treatment without persistent physical disability or dementia, compared with 90.5% of those taking a placebo. Rates of physical disability were similar, and rates of dementia were almost identical in both groups.

The group taking aspirin had an increased risk of death compared to the placebo group: 5.9% of participants taking aspirin and 5.2% taking placebo died during the study. This effect of aspirin has not been noted in previous studies; and caution is needed in interpreting this finding. The higher death rate in the aspirintreated group was due primarily to a higher rate of cancer deaths. A small increase in new cancer cases was

IJCP Sutra 374: Start breastfeeding within an hour of birth.

reported in the group taking aspirin but the difference could have been due to chance.

The researchers also analyzed the ASPREE results to determine whether cardiovascular events took place.

They found that the rates for major cardiovascular events—including coronary heart disease, nonfatal heart attacks and fatal and nonfatal ischemic stroke—were similar in the aspirin and the placebo groups. In the aspirin group, 448 people experienced cardiovascular events, compared with 474 people in the placebo group.

Significant bleeding—a known risk of regular aspirin use—was also measured. The investigators noted that aspirin was associated with a significantly increased risk of bleeding, primarily in the gastrointestinal tract and brain. Clinically significant bleeding—hemorrhagic stroke, bleeding in the brain, gastrointestinal hemorrhages or hemorrhages at other sites that required transfusion or hospitalization—occurred in 361 people (3.8%) on aspirin and in 265 (2.7%) taking the placebo.

As would be expected in an older adult population, cancer was a common cause of death, and 50% of the people who died in the trial had some type of cancer.

Heart disease and stroke accounted for 19% of the deaths and major bleeding for 5%.

CMAAO PENANG RESOLUTION on Universal Health Coverage: The right to health is now generally recognized as a fundamental Human Right by most countries. The Sustainable Development Goal (SDG) 3 mandates governments to “ensure healthy lives and promote well-being for all at all stages”. Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. (WHO) The basis of a universal health coverage is primary healthcare ideally provided by team of health professionals and healthcare workers led by a family physician with the health needs of their patients and communities at the center. This team should be supported by other specialists and provides access to secondary and tertiary care as well as technical and social services. The funding of such a system can be provided by different means; including tax financing, private or social insurance or health savings accounts, out of pocket expenses or combinations of the above.

Role of governments Governments should act on the Social Determinants of Health, by enabling a healthy start into life, decent

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living conditions, quality education, safe and healthy environments including access to healthy nutrition and safe workplaces and transportation.

Regardless of the methodology chosen, the government should ensure that the patients can access timely, competent and quality healthcare services whenever they need it and without any financial hardship.

The access to healthcare includes the coverage of essential diagnostics, medications and devices; access to rehabilitation and palliation. The patient should have freedom of choice in the access, especially when it comes to selecting the primary care physician.

While the financing mechanisms may between nations and over time, the government should ensure that a transparent health system is always in place. Such system must cover every member of society and must not discriminate against those with congenital or preexisting conditions. Payments and/or reimbursements to health institutions, health professionals and healthcare workers, must be fair and appropriate.

While disease patterns change from acute episodic illnesses to chronic processes, healthcare systems must not fall from one silo-structure to another. Universal Health Coverage requires a universal or holistic approach to patients understanding them as persons in their families, groups and communities.

an estimated $2.5 billion to settle thousands of lawsuits from affected patients. A petition has been filed by 52-year-old Jyoti Sharma, who moved the National Consumer Disputes Redressal Commission (NCDRC) in 2016 suing Johnson & Johnson for Rs. 2 crore in damages. Sharma underwent a hip replacement surgery in New Delhi in September 2006. She claims she visited the hospital on multiple occasions complaining of pain but wasn’t informed about the global recall.

Early 2011, when her doctor advised her to undergo tests to determine the cobalt-chromium level in the blood, they found that her cobalt levels were as high as 3.69 (the normal range is between 0.08 and 0.09).

She says she was first informed of the global recall in March 2012 after which, in June 2012, her implant was removed and she underwent a revision hip replacement surgery. When the pain persisted, she moved court.

Continuous calorie restriction group: 1200 to 1500 kcal a day (30% protein, 45% carbohydrate and 25% fat), for a total of 10,300 kcal a week.

Intermittent-fasting group: 500 to 600 kcal a day (including a minimum of 50 g of protein) on two consecutive or nonconsecutive days of the week, and to consume their usual diet on the other 5 days, for a total of 11,500 kcal a week.

Levels of immunosuppression associated with inflammatory bowel disease (IBD) treatment regimens

Thus, the role of the physicians extends to be an advocate for healthy living conditions, healthy lifestyles and wellness of all members of the communities. Attentions should be directed to the Social Determinants of Health as well as to identifiable causes of illness, injury and disease; and to general health promotion, health education and specific prevention.

High-level immunosuppression

Role of NMAs

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Glucocorticoids (prednisone >20 mg/day for at least 2 weeks and within 3 months of stopping therapy).

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6-mercaptopurine, azathioprine or methotrexate at doses higher than those associated with low-level immunosuppression or discontinuation within 3 months.

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Adalimumab, certolizumab pegol, golimumab, infliximab, natalizumab or vedolizumab, or discontinuation within 3 months.

NMAs should promote UHC by explaining to their physicians the benefit of UHC for their patients and communities and to encourage the leadership role their physicians should take to make this possible.

NMAs should analyze current and foreseeable health demands of the people and thereafter target appropriate educational programs for health professionals on prevention, health promotion and nutrition.

NMAs should reach out to politicians, the media and other influencers to advocate for Universal Health Care and to explain that expenditure for healthcare is not just a cost, but an investment in the future of every society.

The hip implant class action lawsuit against the pharma major Johnson and Johnson in the US, began in 2011: Two years later, in 2013, the firm agreed to pay

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Low-level immunosuppression: Lower daily doses of corticosteroids than those in high-level immunosuppression for more than 14 days: Methotrexate (0.4 mg/kg/week), azathioprine (<3.0 mg/kg/day), or mercaptopurine (<1.5 mg/kg/day).

Inactivated vaccines for patients with IBD ÂÂ

Influenza: All patients with IBD should be vaccinated seasonally with the intramuscular/ intradermal inactivated influenza vaccine prior to starting immunosuppressive therapy.

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Pneumococcal pneumonia: All patients with IBD should be vaccinated once with the PCV13

IJCP Sutra 375: Ensure that the baby is exclusively breastfed for the first 6 months.

Medical voice for policy change followed by the PPSV23 (first dose after 8 weeks if immunocompromised, or after ≥1 year if immunocompetent; second dose after 5 years; and third dose after 65 years of age). If previously vaccinated with the PPSV23, then the PCV13 should be administered at least 1 year after the PPSV23 in both immunocompromised and immunocompetent adults. ÂÂ

Hepatitis A: Check hepatitis A immune status at the patient’s initial visit. If nonimmune to hepatitis A, vaccinate the patient with a 2-dose series (0 months and 6-12 months).

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Hepatitis B: Check hepatitis B immune status at the patient’s initial visit. If nonimmune to hepatitis B, vaccinate the patient with a 3-dose series (0 months, and 1 and 6 months after first dose) and recheck titres 1 to 2 months after last vaccination. If the patient remains nonimmune, offer booster with a double dose of hepatitis B vaccine or offer combined hepatitis A/B vaccination.

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Human papilloma virus: All male and female IBD patients between the ages of 11 and 26 years should be vaccinated with the human papilloma virus vaccine.

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Meningococcal disease: Patients with IBD should be vaccinated with the meningococcal vaccine according to standard Advisory Committee on Immunization Practices (ACIP) recommendations for the general population.

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Tetanus, diphtheria, and pertussis: All patients with IBD should be vaccinated with Td every 10 years.

TDap should be substituted once for the Td vaccine to provide additional coverage for pertussis.

Live vaccinations for patients with IBD ÂÂ

Measles, mumps, rubella (MMR): Vaccinate all nonimmune patients with the MMR vaccine as long as they have not been on immunosuppressive therapy within the previous 3 months and there are no plans to start immunosuppressive therapy within the next 6 weeks.

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Varicella zoster: Vaccinate all nonimmune patients with the varicella zoster vaccine as long as they have not been on immunosuppressive therapy within the previous 3 months and there are no plans to start immunosuppressive therapy within the next 6 weeks.

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Herpes zoster: Vaccinate all patients over the age of 60 years with the herpes zoster vaccine. Vaccination is safe in patients on low-dose immunosuppression but contraindicated in patients on biologic therapy

IJCP Sutra 376: Child should be fed on demand or at least 8 times in 24 hours.

or on corticosteroids. Do not vaccinate patients on high-dose immunosuppressive therapy within the past 3 months or who plan to start high-dose immunosuppressive therapy within the next 6 weeks.

Depression is prevalent globally and now resistance exercises have been advised, if you have depression.

A study in published in the June issue of JAMA Psychiatry has found that people with mild-to-moderate depression who performed resistance training two or more days a week saw “significant” reductions in their symptoms, compared with people who did not. The findings also suggested that resistance exercises may be even more beneficial for those with more severe depressive symptoms.

There is good news for patients with polycystic kidney disease, one of the leading causes of kidney failure. So far, there has been no cure. But for the first time, there is hope: tolvaptan now has been approved by US FDA. It blocks the thirst hormone, vasopressin and blocks the cyst from forming more fluids.

Good news for grass root healthcare workers: The Cabinet Committee on Economic Affairs, chaired by the Prime Minister Shri Narendra Modi has approved enhancement of Honorarium to Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHs) and Performance Linked Incentive to AWHs Under Anganwadi Services (Umbrella ICDS Scheme).

Watch out for pollution news: Research focused on long-term health problems after exposure to pollution will be in the spotlight at the upcoming European Respiratory Society International Congress 2018.

Some tips for GPs: Botox can help people who have trouble speaking clearly after a stroke and the evidence does not support the use of aspirin as monotherapy for the prevention of thromboembolic events in patients with atrial fibrillation. A baby born in Southern Asia is 9 times more likely to die in the first month than a baby born in a high-income country.

Countries need to urgently accelerate their response to end tuberculosis (TB), including drug-resistant TB. Fewer people fell ill and died from TB last year but countries are still not doing enough to end TB by 2030, warns the WHO in its 2018 Global TB Report. Although global efforts have averted an estimated 54 million TB deaths since 2000, TB remains the world’s deadliest infectious disease.

Power cuts are common in many Asian countries. Do you know that if there is a power cut for >4 hours then all perishable foods including meat, poultry, fish,

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eggs and left overs in your refrigerator needs to be discarded. It may be one reason of high number of food poisoning cases seen in these countries.

Of note, the definition of “a drink” in this study was 10 g of alcohol - that’s 30% less than a standard drink in the US, but 25% more than a standard drink in the UK.

Asian medical professionals need to be concerned about Rabies, which is estimated to cause 59,000 human deaths annually in over 150 countries, with 95% of cases occurring in Africa and Asia. Due to widespread underreporting and uncertain estimates, it is likely that this number is a gross underestimate of the true burden of disease. Ninety-nine percent of rabies cases are dogmediated and the burden of disease is disproportionally borne by rural poor populations, with approximately half of cases attributable to children under 15.

Loneliness an epidemic of the modern age: Nearly half of Americans say that they feel lonely most or even all of the time, and it isn’t just a detriment to their social lives and happiness; loneliness is bad for their health. Large number of studies have found strong links between loneliness and disease from cardiovascular disease to stroke and even death on the whole.

How do we read the food labels and what do they mean in terms of sodium content?

Let us have a look at them. ÂÂ

Sodium-free or salt-free: Less than 5 mg sodium per serving.

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Very low sodium: Less than 35 mg sodium per serving.

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Low sodium: Less than 140 mg sodium per serving.

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Light in sodium: At least 50% less sodium than original product.

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Reduced sodium: At least 25% less sodium than original product.

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Too much salt: The average adult eats about 3,400 mg of sodium per day, which is far more than the recommended daily goal of 2,300 mg.

The Heart Care Foundation of India (HCFI) recommends an even lower goal: no more than 1,500 mg per day, especially for those with high BP or heart disease.

Many of us are on a low carb diet: For short-term, this is okay, but not in the long run. Dietary Guidelines for Americans recommends that carbohydrates make up 45-65% of total daily calories. I recommend fasting with a fruit diet once a week.

If you are an alcohol lover read this: In August of 2018, two larger studies examined the impact of alcohol.

The first one, published in The Lancet, included only people who drank at least some alcohol. It concluded that common recommendations regarding “moderate” drinking (one drink a day or less for women, and two drinks per day or less for men) might be too much.

The second study, also published in The Lancet, was even bigger. It examined data from hundreds of studies and other sources (including sales of alcohol, home-brewed alcoholic beverage consumption, and even estimates of tourist consumption) in 195 locations. It concluded that the best option for overall health was no drinking at all.

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Scientists have observed an uptick in activity and chaos in the amygdala, which regulates emotions and emotional responses. Similarly, the dorsal posterior insula, which regulates how painful something feels actually becomes more active when we are lonely, so injuries - which, incidentally, happen more often to people who are socially isolated - actually hurt more.

Cortisol is the fight or flee hormone. But our bodies are not designed to be under constant stress, and cortisol is known to disrupt nearly every biological process when our levels of it are too high. The antidote to high cortisol quotients is oxytocin. And oxytocin production ramps up to reward our social interactions specifically. Oxytocin is the social and the love hormone and is responsible for the pleasant ‘warm’ feelings we get from spending time around friends and loved ones. Maintaining a balance between the stress and social hormones is the key.

Another endocrine chemical, 'brain derived neurotrophic factor (BDNF)' helps the brain to remain plastic, or flexible, so that we can continue to hold on to past memories and create new ones.

Socially isolated people, however, have a shortage of this substance, too. If you don’t have one, make one friend today.

Good news - European Parliament adopts resolution to curb antimicrobial resistance: The growing threat posed by antibiotic-resistant bacteria can only be tackled through a holistic ‘One Health’ approach, Members of European Parliament (MEPs) have said. Many countries including India have done in the past.

Health Ministry has launched sputum sample transportation through Dept. of Post for diagnosis of TB. The pilot project starts in Karawal Nagar in Delhi.

Now more people can get tested followed by appropriate management and reduced disease transmission.

Scientists have identified at least four new distinct personality types - average, reserved, self-centred and role model - after sifting through data from over 1.5 million people across the globe. Which one are you?

(Nature Human Behaviour).

IJCP Sutra 377: Avoid feeding honey, water or things other than breast milk in lieu of a ritual as it can be a source of infection to a baby.

Conference Proceedings

55th National Conference of Indian Academy of Pediatrics (PEDICON 2018) Legal Issues in Adolescents

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Urine strip test is also a rapid test but has limitation of doing only glucose and albumin detection. Sugars and proteins other than albumin are not detected.

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These newer tools have wide clinical implications.

Dr Himabindu Singh, Hyderabad ÂÂ

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The rate of crime amongst youth has increased to 40% and almost 56% of the crimes are done by youngsters in the age group 16-25 years.

Creating awareness on medico-legal issues by parents, teachers and stake holders is important since it impacts the lives of adolescents.

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Knowledge about POCSO Act, Juvenile Justice Act, legal age of marriage and consent for sex, Narcotic drugs and Psychotropic Substances Act, Child Labour Act, Laws regarding pornography, Motor Vehicle Act, media literacy, etc., among adolescents needs to be enhanced.

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Teaching adolescents self-discipline is the way out.

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Good communication between parents and children helps develop a nurturing environment, helps in sharing concerns, gives scope for guidance and nonintrusive supervision.

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Monitoring their digital activities, peer groups and early detection of deviation which is likely to become a legal issue should be taken up by gatekeepers of adolescent health.

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Enhancing life skills is protective and avoids conflict with law.

Therapeutic hypothermia in neonates Dr Muktanshu Patil ÂÂ

Therapeutic hypothermia (deliberate lowering of the body temperature) aims to cool the brain soon after birth and for several days afterwards to prevent brain damage (Therapeutic hypothermia with intracorporeal temperature monitoring for hypoxic perinatal brain injury. Interventional Procedures Guidance; IPG347, 2010 May).

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The aim of intervention with hypothermia is to maintain a core temperature of 33.5°C for 72 hours, commencing as soon as possible after resuscitation.

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Current management of perinatal hypoxic-ischemic injury consists of maintaining physiological parameters within the normal range and treating seizures with anticonvulsants.

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The baby’s rectal and skin temperature is measured throughout.

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After cooling, the baby’s temperature is gradually returned to normal. The primary goal of rewarming is to slowly rewarm the baby over 6-12 hours.

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The management of cooled babies includes providing them with respiratory support; cardiovascular support and fluid, electrolytes and management of clotting abnormalities.

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There are no absolute contraindications to cooling infants who meet the criteria, except where there are other life-threatening congenital abnormalities present. Relative contraindications include >12 hours of age, with major congenital abnormalities, with severe coagulopathy, requiring inspired oxygen over 80%, ‘in extremis’ and not expected to survive.

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Cooling is concluded after 72 hours.

Rapid Diagnostic Tests in Infectious Diseases Dr Ketan Shah, Surat ÂÂ

Various rapid diagnostic tests are available now in India.

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Tests like BIOFIRE, which use a panel of tests, can give fast and accurate diagnosis. This test is used in respiratory, GIT and CSF specimens. It has been tried even in blood samples.

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Malaria, dengue, leptospirosis, chikungunya, typhoid can be diagnosed by rapid card tests.

However they need to be interpreted in view of clinical findings and need to be confirmed by other tests like blood culture or PCR, ELISAbased tests.

IJCP Sutra 378: Give the baby a sponge bath until the umbilical cord falls off and the navel heals completely (1-4 weeks).

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

Antivirals - When, How and Where?

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Dr Ritabrata Kundu, Kolkata ÂÂ

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The antiviral chemotherapy for the treatment of common viral infections is faced with many challenges such as intracellular replication of the virus, unavailability of phenotypic/genotypic assay for resistance, incomplete pharmacodynamics of antiviral drugs, outcome influenced by interplay between pathogen and host defences, and dependence of optimal therapy on specific and timely diagnosis of the disease.

The decision to start antiviral therapy in respiratory infections, such as flu, should not wait for lab confirmation.

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Antiviral treatment for patients with suspected or confirmed flu is only recommended in case of hospitalized patients, with severe, complicated or progressive illness and those with higher risk of complications.

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Antiviral therapy is not recommended in case of acute hepatitis while treatment is only recommended in immune active form of chronic hepatitis.

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In case of Herpes simplex encephalitis, 3 antiviral drugs are available in India: acyclovir, valacyclovir and famciclovir.

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In case of neonatal HSV, acyclovir use is recommended.

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As per the recommendation of AAP, uncomplicated varicella in a healthy child should not be given treatment. In immunocompetent persons at increased risk of moderate-to-severe varicella, acyclovir is recommended.

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Infants born to mother with varicella, preterm <28 weeks or <1 kg exposed to varicella should be treated with VZIG/IVIG.

Dermatological Manifestations of Infectious Diseases in Children

Neonatal Hypoglycemia Dr Ketan G Bharadva, Surat Healthy term newborns have great nutritional and metabolic adaptive capabilities. Early and exclusive breastfeeding meets their needs.

Usually severe or recurrent or prolonged clinical hyperinsulinemic hypoglycemia causes neurological insult and it occurs in at risk babies. So always segregate babies “at risk” of hypoglycemia and monitor them: ÂÂ

SGA: <10th percentile wt or clinically evident wasting; LBW; prematurity (<35 weeks, or late preterm infants with clinical signs or extremely poor feeding); discordant twin weight 10% < larger twin; all infants of diabetic mothers, especially if poorly controlled; LGA: >90th percentile for weight and macrosomic appearance.

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Perinatal stress: severe acidosis or hypoxia-ischemia; cold stress; suspected infection; respiratory distress.

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Maternal drug treatment (e.g., b-blockers, oral hypoglycemics).

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Polycythemia (venous Hct >70%)/hyperviscosity; erythroblastosis fetalis; Beckwith-Wiedemann syndrome; microphallus or midline defect; known or suspected inborn errors of metabolism or endocrine disorders.

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Infants displaying hypoglycemia.

Physical examination should include general appearance, vital signs, signs of toxicity.

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Types of rash - Erythematous; maculopapular; vesicular; bullous; petechio-purpuric; necroticogangrenous; erythema multiforme; erythema nodosum; urticarial; epidermo-necrolysis.

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There are 3 approach categories - 1) Serious disease needing urgent intervention; 2) Visibly identifiable viral syndromes; 3) Undifferentiated rash.

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Serious disease needing urgent intervention Blister, purpura, necrotic, mucosal, sandpaper rash.

484

signs

terbutaline,

associated

with

Rather than routine prelacteal formula or milk supplementation, give attention to general management recommendations for all term infants: ÂÂ

Act to support early (within 1st hour of birth); frequent (10-12 times/day in initial days); on demand cues; exclusive breastfeeding and promote skin-to-skin contact of mother with infant.

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Help mother to provide stimulation to the breasts by manual or mechanical expression with appropriate frequency (>8 times/day) until baby is latching and suckling well to protect milk supply.

Dr Ashok S Kapse, Surat ÂÂ

Roseola vs. Rubeola - Fever peaks with rash: Rubeola; fever defervesce with rash: Roseola.

Routine monitoring of blood sugar in term newborns without risk factors is unnecessary and may be harmful.

We should technically train ourselves and staff in how to support breastfeeding. When we irrationally sanction prelacteal milk or formulas instead of trained support to breastfeeding, a mother without a trained support is itself now a risk factor for breastfeeding success!

IJCP Sutra 379: Kangaroo Mother Care especially for low birth weight infants, wherein the baby is held in a special way stuck with the chest to provide skin-to-skin contact with the mother along with exclusive and frequent breastfeeding.

Around the Globe

News and Views Health Ministry Bans 328 FDCs with Immediate Effect The Ministry of Health and Family Welfare has prohibited the manufacture for sale, sale or distribution for human use of 328 Fixed Dose Combinations (FDCs) with immediate effect. It has also restricted the manufacture, sale or distribution of six FDCs subject to certain conditions.

Earlier, the Central Government had, through its notifications published on the 10th March, 2016 in the Gazette of India, prohibited the manufacture for sale, sale and distribution for human use of 344 FDCs under Section 26A of the Drugs and Cosmetics Act, 1940.

Subsequently, the Government had prohibited five more FDCs in addition to the 344 under the same provisions.

Accordingly, the Ministry of Health and Family Welfare has, in exercise of powers conferred by Section 26A of the Drugs and Cosmetics Act, 1940, prohibited the manufacture for sale, sale or distribution for human use of 328 FDCs through its gazette notifications dated 7th September 2018; it has also restricted the manufacture, sale or distribution of six FDCs subject to certain conditions. These notifications will take immediate effect. However, the matter was contested by the affected manufacturers in various High Courts and the Supreme Court of India. In compliance with the directions given by the Supreme Court of India in its judgment dated the 15th December, 2017, the matter was examined by the Drugs Technical Advisory Board constituted under Section 5 of the Drugs and Cosmetics Act, 1940, which furnished its report on these drugs to the Central Government.

The Drugs Technical Advisory Board recommended, amongst other things, that there is no therapeutic justification for the ingredients contained in 328 FDCs and that these FDCs may involve risk to human beings.

The Board recommended that it is necessary to prohibit the manufacture, sale or distribution of these FDCs under Section 26A of the Drugs and Cosmetics Act, 1940 in the larger public interest. With regard to six FDCs, the Board recommended that their manufacture, sale and distribution be restricted subject to certain conditions based on their therapeutic justification. Fifteen FDCs out of the 344 prohibited on the 10th March, 2016, which were claimed to be manufactured prior to 21st September,

IJCP Sutra 380: Substitute white salt with black salt wherever possible.

1988, have been kept out of the purview of current notifications… (Press Information Bureau, Ministry of Health and Family Welfare, September, 12, 2018)

Dairy Consumption Lowers Heart Disease and Mortality Rates Dairy consumption of around three servings per day is associated with lower rates of cardiovascular disease and mortality, compared to lower levels of consumption, according to data from the Prospective Urban Rural Epidemiological (PURE) global observational study of over 1,30,000 people in 21 countries, published September 10, 2018 in The Lancet. Those who consumed three servings of whole fat dairy per day had lower rates of mortality and cardiovascular disease versus those who consumed less than 0.5 serving of whole fat dairy in a day.

Amyotrophic Lateral Sclerosis also Affects the Mind A new study published online September 12, 2018 in the journal Neurology says that amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease, also affects the mind, especially later in the course of the disease.

These patients have problems with thinking skills and behavioral problems such as apathy, changes in eating behaviors and lack of inhibition even at the earliest stages and by the last stage of the disease, only very few people are free of these cognitive and behavioral problems. Hence, these patients should be routinely screened for these problems.

Gestational Diabetes Increases Maternal Risk of Type 2 Diabetes a Decade Later According to a study published September 11, 2018 in JAMA, high blood sugar during pregnancy, even if did not meet cut-off for diagnosis of gestational diabetes were significantly more likely to have developed type 2 diabetes a decade after pregnancy when compared to women who did not have high blood sugar during pregnancy. Children of mothers with high blood sugar were more likely to be obese.

Perception of Quality of Care Lower in Certain Dialysis Settings, Says Study For-profit operation, free-standing status and large dialysis organization designation were associated

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

with less favorable patient-reported experiences of care, according to a cross-sectional analysis of 2939 US dialysis facilities published online September 10, 2018 in JAMA Internal Medicine.

USPSTF Recommends Ocular Prophylaxis of Newborns to Prevent Gonococcal Ophthalmia Neonatorum The United States Preventive Services Task Force (USPSTF) recommends prophylactic ocular topical medication (with 0.5% erythromycin ophthalmic ointment) for all newborns to prevent gonococcal ophthalmia neonatorum (Grade A recommendation) in a draft recommendation statement on ocular prophylaxis for gonococcal ophthalmia neonatorum published on its website. The draft is open to public comment till October 9, 2018.

SC Issues Directions to End Stigma Attached to Leprosy Patients In a bid to remove centuries old stigma attached to leprosy patients, the Supreme Court recently directed the Centre to consider framing separate rules for issuing them disability certificates so that they can avail of reservation and various other welfare benefits. The apex court said that acceptability of leprosy patients in the society would go a long way in reducing the stigma attached to the disease and passed a slew of directions to the Centre and the State governments for launching massive awareness programs.

A bench comprising Chief Justice Dipak Misra and Justices AM Khanwilkar and DY Chandrachud said due attention must be paid to ensure that leprosy affected persons are issued Below Poverty Line cards, so they can avail of benefits under Antyodaya Anna Yojana and other similar schemes, which would enable them to secure their right to food.

The top court said: “The Union and the State Governments must pro-actively plan and formulate a comprehensive community based rehabilitation scheme, which shall cater to all basic facilities and needs of the leprosy affected persons and their families. The scheme shall be aimed at eliminating the stigma that is associated with persons afflicted with leprosy.

“The Union Government may consider framing separate rules for assessing the disability quotient of the leprosy affected persons for the purpose of issuing disability certificate in exercise of the power granted under the Rights of Persons with Disabilities Act, 2016.”

It further said that awareness campaigns must inform that a person affected by leprosy is not required to be sent

486

IJCP Sutra 381: Do not keep salt shaker on the table.

to any special clinic, hospital or sanatorium and should not be isolated from family members or the community.

It said that awareness campaigns should also inform that a person affected with leprosy can lead a “normal married life, can have children, can take part in social events and go to work or school as normal.”

“The Union and the State Governments must ensure that both private and public schools do not discriminate against children hailing from leprosy affected families.

Such children should not be turned away and attempt should be made to provide them free education,” it said.

Asking the agencies not to use frightening images of people hit by leprosy, the top court said the content and information in the awareness programs should use positive images of cured persons sharing their experiences of becoming healthy.

“The Union and the States are to ensure that drugs for management of leprosy and its complications including the multi-drug therapy (MDT) drugs are available free of cost and do not go out of stock at all Primary Health Centres or public health facilities in the country,” it said.

“All-year awareness campaigns should also be run, by the Union as well as the States, to inform the citizenry that under the National Leprosy Eradication Program cases diagnosed through general health care system including NGOs, treatment is provided free of cost to all leprosy,” it added.

Second Case of Monkeypox in the UK A second person has been diagnosed with the deadly monkeypox virus in England, just a few days after the first case was revealed. The patient, who had traveled to Nigeria, arrived at Blackpool Victoria Hospital with symptoms of the disease, Public Health England (PHE) said. They are now being treated at the Royal Liverpool University Hospital, a specialist center. The first case of the disease was recorded on Friday in a Nigerian national staying at a naval base in Cornwall. The patient was transferred to the expert infectious disease unit at the Royal Free Hospital in London. Dr Nick Phin, deputy director of PHE’s National Infection Service, said the two cases are not related but added that it was ‘unusual’ to see two cases in such a short space of time...

(Metro UK, Sept 12, 2018)

About Monkeypox (WHO) ÂÂ

Monkeypox is a rare viral zoonotic disease that occurs mainly in central and west Africa, near tropical rainforests.

Around the Globe ÂÂ

The monkeypox virus is similar to human smallpox. Although monkeypox is much milder than smallpox, it can be fatal.

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The case of human monkeypox was identified in 1970 in the Democratic Republic of Congo in a 9-year-old boy in a region where smallpox had been eliminated in 1968.

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Case fatality rate ranges from 1% to 10%.

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Infection of index cases results from direct contact with the blood, bodily fluids or cutaneous or mucosal lesions of infected animals.

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Human-to-human transmission can result from close contact with infected respiratory tract secretions, skin lesions of an infected person or objects recently contaminated by patient fluids or lesion materials.

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Incubation period ranges between 6 and 16 days.

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The infection can be divided into two periods:

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Invasion period (0-5 days): Fever, intense headache, lymphadenopathy, back pain, myalgia (and an intense asthenia)

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Skin eruption period (within 1-3 days after appearance of fever) in which rash appears on the body; face (in 95% of cases), and palms of the hands and soles of the feet (in 75% of cases) are most affected. Evolution of the rash from maculopapules to vesicles, pustules, followed by crusts occurs in about 10 days. Three weeks might be necessary before the complete disappearance of the crusts.

Differential diagnoses: Smallpox (even though it is eradicated), chickenpox, measles, bacterial skin infections, scabies, syphilis and medicationassociated allergies. Lymphadenopathy during the prodromal stage of illness can be a clinical feature to distinguish monkeypox from smallpox.

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Diagnosis: Identification of the monkeypox virus in lab.

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There are no specific treatment or vaccines available for monkeypox infection.

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Prevention is by educating the public about risk factors and who to reduce exposure to the virus; healthcare workers should strictly follow standard infection control precautions.

TAVR Associated with Shorter Duration of Hospitaliza­tion Than SAVR According to a new study published Sept. 14, 2018 in Circulation: Cardiovascular Interventions, a significantly

greater reduction in the average length of hospital stay was observed in patients who underwent transcatheter aortic valve replacement (TAVR) compared to those who underwent surgical aortic valve replacement (SAVR).

They were also significantly less likely to be transferred to a skilling nursing facility.

Biologics Increase Risk of Serious Infections in Patients with Refractory Atopic Dermatitis Treatment of a refractory atopic dermatitis with a biologic agent doubled the risk of hospitalization for a serious bacterial or opportunistic infection versus highpotency topical steroids or nonbiologic systemic therapy.

Infection risk also varied substantially among nonbiologic systemic agents, with cyclosporine posing the lowest risk and azathioprine and mycophenolate the greatest risk.

These findings were presented at the ongoing European Academy of Dermatology and Venereology congress in Paris.

18F-FDG

PET/CT Scan may Detect Early Coronary Artery Disease in Psoriasis Patients In this cross-sectional cohort study of patients with psoriasis assessed with 18F-FDG positron emission tomography/computed tomography (PET/ct) and coronary computed tomography angiography, aortic vascular inflammation was directly associated with quantitative burden of coronary artery disease, luminal stenosis severity within the coronary arteries, and the prevalence of high-risk coronary plaque beyond traditional cardiovascular risk factors. The study is reported in JAMA Cardiology online September 12, 2018.

Eating More Whole Grain Foods Lowers the risk of Type 2 Diabetes The study from the Danish Diet, Cancer, and Health Cohort published in the September 2018 issue of the Journal of Nutrition says that eating more whole grain foods such as rye bread, whole grain bread or oatmeal/ muesli significantly lowers the risk of developing type 2 diabetes among middle-aged men and women.

Pembrolizumab + Pemetrexed + Platinum Chemo­therapy Approved as First-line Treatment of Metastatic NSCLC Based on efficacy and safety data from the phase 3 KEYNOTE-189 trial in patients with advanced disease, the European Commission has approved the combination of pembrolizumab (Keytruda, Merck), pemetrexed (Alimta, Lilly) and platinum chemotherapy for the first-line treatment of metastatic non-small cell

IJCP Sutra 382: Do not add salt in your food except in pulses and cooked vegetables.

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Indian Journal of Clinical Practice, Vol. 29, No. 5, October 2018

lung cancer (NSCLC). The drug is restricted to patients whose tumors have no epidermal growth factor receptor (EGFR) or anaplastic large-cell lymphoma kinase (ALK) mutations.

NACO Releases HIV Estimations 2017 The National AIDS Control Organization (NACO) has released the report HIV Estimations 2017. It is the 14th round in the series of HIV Estimations under National AIDS Control Programme (NACP). The first round of HIV estimation in India was done in 1998, while the last round was done in 2015.

The report highlights the significant achievement of National AIDS response on prevention as well as on treatment front but has also indicated that there is no place for complacency as country move forward on ambitious goal of attaining the ‘End of AIDS’ by 2030.

As per the report, in 2017, India had around 21.40 lakh people living with HIV (PLHIV) with adult prevalence of 0.22%. Around 87.58 thousand new HIV infections and 69.11 thousand AIDS related deaths happened in 2017 while around 22,675 mothers needed antiretroviral therapy (ART) for prevention of mother-to-child transmission of HIV. HIV Estimations 2017 corroborate the previous rounds in terms of characteristic of the HIV epidemic in India i.e., national prevalence and incidence remains low, but the epidemic is high in some geographical regions and population group. The report has noted that the rate of decline in annual new HIV infections has been relatively slower in recent years.

The report concludes that, overall, the impact of the programme has been significant with more than 80% decline in estimated new infection from peak of epidemic in 1995. Similarly, estimated AIDS related death declined by 71% since its peak in 2005. As per UNAIDS 2018 report, the global average for decline in new infections and AIDS related deaths from peak has been 47% and 51% respectively... (Press Information Bureau, Ministry of Health and Family Welfare, September 14, 2018)

FDA Approves Device for Treatment of Acute Coronary Artery Perforations The US Food and Drug Administration (FDA) has approved a device intended to treat acute coronary artery perforations, or tears in the blood vessels of the heart. The PK Papyrus Covered Coronary Stent System is the first device approved by the FDA for this indication in 17 years.

488

IJCP Sutra 383: Do not add salt to salads.

Psoriasis Clearance Decreases as the Number of Comorbidities Increases A study of patients with moderate or severe plaque psoriasis presented at the European Academy of Dermatology and Venereology Congress in Paris reported that overall, 64% of patients had one or more comorbid conditions at the start of treatment, and some of the patients had new comorbid diagnoses during follow-up. The proportion of patients who achieved disease clearance decreased as the number of comorbidities increased.

People with Hangovers have Impaired Cognitive Functions People with hangovers demonstrate impairment in a variety of cognitive functions and everyday tasks, including driving, according to results of a systematic review and meta-analysis of 19 studies published online August 25 in Addiction. Various components of attention, memory and psychomotor performance were impaired during hangovers, including the ability to operate a vehicle

The Second CGRP Blocker Gets FDA Approval for Migraine Fremanezumab is the second calcitonin gene-related peptide (CGRP) blocker for preventing migraine to be approved by the US FDA. Fremanezumab is a fully humanized monoclonal antibody, which binds to the CGRP ligand and blocks its binding to the receptor.

Patients with Psoriatic Arthritis are at Increased Risk of Type 2 Diabetes The development of type 2 diabetes in an incident population of psoriatic arthritis (PsA) is significantly higher than in patients with psoriasis alone or in a general population, whereas the increased risk of cardiovascular disease in PsA and psoriasis is similar, says a study published online September 12, 2018 in the journal Rheumatology.

First AAP Policy Statement on Care for Transgender and Gender-diverse Children In a policy statement published September 17, 2018 online in the journal Pediatrics, the American Academy of Pediatrics (AAP) has urged support and care of transgender and gender-diverse children and adolescents and states “Transgender and gender-diverse children face many challenges in life, but, like all children, they can grow into happy and healthy adults when supported and loved throughout their development.” The statement

Around the Globe aims to help pediatricians and parents navigate health concerns of gender-diverse youth while advocating for ways to eliminate discrimination and stigma.

Topical Ruxolitinib Improves Atopic Dermatitis A topical formulation of the JAK1/2 inhibitor ruxolitinib (1.5%) administered twice-daily led to dose-dependent improvement of 71.6% in atopic dermatitis in a phase II randomized trial presented at the European Academy of Dermatology and Venereology congress in Paris.

Study Shows Fewer Relapses with Fingolimod vs Interferon beta-1a in Pediatric Multiple Sclerosis Among pediatric patients with relapsing multiple sclerosis, fingolimod was associated with a lower rate of relapse and less accumulation of lesions on magnetic resonance imaging (MRI) over a 2-year period than interferon beta-1a but was associated with a higher rate of serious adverse events.

New Guideline Recommends Weight Loss Strategies for Sleep Apnea Patients The American Thoracic Society (ATS) has published a clinical practice guideline for the role of weight management in the treatment of adult obstructive sleep apnea (OSA). The Expert Panel made a strong recommendation that patients with OSA who are overweight or obese be treated with comprehensive lifestyle intervention consisting of a reduced-calorie diet, exercise or increased physical activity and behavioral guidance.

Asthmatic Individuals More Likely to Develop Obesity A study presented at the European Respiratory Society International Congress in Paris, France has suggested that people with asthma are more likely to go on to become obese. Those who develop asthma as adults and those who have non-allergic asthma are at the greatest risk of obesity.

People Who Walk Just 35 Minutes a Day may have Less Severe Strokes People who participate in light-to-moderate physical activity, such as walking at least 4 hours a week or swimming 2 to 3 hours a week, were twice as likely to have a mild stroke rather than a moderate or severe stroke compared to people who are physically inactive, according to a study published online September 19, 2018 in Neurology.

IJCP Sutra 384: Avoid adding salt to foods at the table.

Infant Walkers are a Major Cause of Serious Injury Infant walkers remain a dangerous and preventable source of injury for children, despite a US mandatory safety standard, increased public awareness and fewer older walkers in the home, according to a study published online September 17, 2018. Majority of infant walker-related injuries occur when the child falls down the stairs in a walker, with most injuries to the head and neck. The American Academy of Pediatrics (AAP) has called for a ban on the manufacture and sale of infant walkers in the United States.

NIH Funds Study to Prevent, Treat HIV Among Adolescents in Poor Countries The National Institutes of Health (NIH) has awarded $7.5 million for an international research program to prevent and treat HIV infection among adolescents and young adults in seven African countries and Brazil. The study, called Prevention and Treatment through a Comprehensive Care Continuum for HIVaffected Adolescents in Resource Constrained Settings (PATC3H), will support research to develop strategies to identify youth at risk of HIV infection and those living with HIV and to enroll them into medical care programs.

Complications are Common in Neonates Born to Obese Women without Hypertension or Diabetes Maternal obesity, even in the absence of hypertensive disorders or diabetes, is an independent risk factor for significant neonatal morbidity and neurologic neonatal morbidity, as reported in a study published August 17, 2018 in Obstetrics & Gynecology. These neonates were more likely to have hypoxicâ&#x20AC;&#x201C;ischemic encephalopathy, hypothermia treatment and suspected sepsis.

ASCO Guidelines for Treatment of C. difficile Infection in Children with Cancer The American Society of Clinical Oncology (ASCO) has published a guideline for the prevention and treatment of Clostridium difficile infection (CDI) in children and adolescents with cancer and pediatric hematopoietic stem-cell transplantation recipients in the Journal of Clinical Oncology online September 14, 2018. The guideline strongly recommends either oral metronidazole or oral vancomycin for the initial treatment of nonsevere CDI and oral vancomycin for the initial treatment of severe CDI. Fidaxomicin may be considered in recurrent CDI.

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Nobel Prize in Physiology or Medicine 2018 Jointly Awarded to Cancer Researchers The Nobel Prize in Physiology or Medicine 2018 was awarded jointly to James P. Allison and Tasuku Honjo "for their discovery of cancer therapy by inhibition of negative immune regulation."

The Royal Swedish Academy of Sciences said, “by stimulating the inherent ability of our immune system to attack tumor cells this year’s Nobel Laureates have established an entirely new principle for cancer therapy.”

National Initiatives Launched in India Emblematic of Actions Needed to Achieve SDGs: UN Chief United Nations, India's ambitious programs such as 'Clean India' and "Educate the Girl Child, Save the Girl Child" are "emblematic" of the types of actions needed to achieve the Sustainable Development Goals (SDGs), UN Secretary General Antonio Guterres has said. Guterres, who begins a 3-day visit to India, said that while India still faces challenges, the country has a long history of innovation and leadership in developing programs to further social welfare and tackle inequalities.

"National initiatives such as those being launched in India are emblematic of the types of actions needed to achieve the SDGs, contributing to a common objective of more inclusive development," Guterres told PTI ahead of his first trip to India as the UN chief.

The SDGs, otherwise known as the Global Goals, are a universal call by the United Nations Development Programme (UNDP) for action to end poverty, protect the planet, improve health, education and ensuring that all people enjoy peace and prosperity by 2030. "The initiatives hold promise for expanding the availability of adequate sanitation, empowering women and girls, increasing access to quality education, and reducing inequality by shrinking the digital divide," Guterres said.

He said the various programs launched in India have already achieved impressive results. "I was very impressed to learn that, in the first 2.5 years of implementation, the Clean India campaign supported the construction of over 39 million household toilets working toward an open defecation free India by 2019,"

he said. On the Narendra Modi government's flagship Beti Bachao, Beti Padhao (Educate the Girl Child, Save the Girl Child) program, Guterres said the campaign has helped to substantially decrease school dropout rates among girls enhancing gender equality in education.

With the focus on digitisation, the UN chief said access to digital documents in India has never been higher with over 1.7 billion digitized, which can make the distribution of services like food ration cards much easier.

Risk of Subsequent Osteoporotic Fractures is Higher in Men Men had a three-fold higher risk of sustaining a second fracture within the first year after their index fracture compared with men without a previous fracture (hazard ratio [HR] 3.3, 95% confidence interval [CI] 2.6-4.1), whereas among women with an index fracture, the risk of a second fracture was elevated but to a lesser extent (HR 1.8, 95% CI 1.7-2), according to a study presented at the American Society for Bone and Mineral Research annual meeting.

High Variability of Cardiometabolic Parameters is a Predictor of Mortality High variability of fasting blood glucose and total cholesterol levels, systolic blood pressure and body mass index was an independent predictor of mortality and cardiovascular events according to a study of more than six million people with a follow-up period of a median of 5.5 years. The risk of outcomes increased significantly with the number of high-variability metabolic parameters. These findings are published October 1, 2018 in the journal Circulation.

A Limb Loss and Preservation Registry to be Established in the US A new database supported by the National Institutes of Health and the Department of Defense aims to establish the number of people in the United States living with limb loss and to provide insight on their challenges and needs. The Limb Loss and Preservation Registry, expected to be operational in 2020 will be the first national registry of people who have lost limbs and promises to collect data that will improve prevention, treatment and rehabilitation efforts for this population.

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490

IJCP Sutra 385: Take stock of the sources of salt in your diet, such as restaurant meals, salt-based condiments and convenience foods. Some of these are really loaded with salt.

Spiritual Update

Understanding the Gunas KK aggarwal

T

he mental state of a person in Vedic language is described in terms of gunas. The present state of mind of any person is a result of mixing of three gunas of nature called tamas, rajas and satoguna. In terms of states of mind they are called tamas, rajas and sattva and the nature of a person is called tamsik, rajsik and satwik.

Whether it is Vedas, Upanishads, Bhagwad Gita or the text of Ayurveda, all talk about these gunas. The Sankhya philosophy also says that a mixture of the three makes the cosmic mind as well as the human mind. Bhagwad Gita talks in great detail about the nature, yagna as well as diet depending upon these gunas.

A satwik diet is one, which makes a person full of satoguna and makes him or her with predominant satwik nature. The same is true for other two gunas.

According to Ayurvedic text and in Atharvaveda, any food, which comes from the roots or underground part of the tree, is tamsik in nature. Tamsik foods should not be eaten raw. They should either be slow cooked or soaked in water for hours before consumption.

Foods from the top part of the tree like coconut, fruits, leaves and flowers are satwik in nature and can be consumed fresh, as they are. Food which comes from the middle part of the tree is often rajsik in nature.

Group Editor-in-Chief, IJCP Group

Fresh, soaked, sprouted, natural food are often satwik, while old, leftover foods are tamsik in nature. Most satwik foods are naturally white.

Ramayana also has characters with different nature.

Kumbhakaran represents a person with tamsik nature, Meghnad and Ravana with rajsik nature and Vibhishan with satwik nature. One can see that the diet of Kumbhakaran was left over foods, onions, radish, carrots and nonvegetarian food, all are tamasik.

Shastras also teaches us about satwik food. In Vedic knowledge, God is represented by the consciousness and whatever is offered to God is the one, which is offered to consciousness and hence all offerings to God are soul healing and soul nurturing food items. Only satwik foods are offered to God as one can live on satwik food forever. Examples are dry fruits, fruits and milk. One cannot live on rajsik or tamsik food; hence, they have to be taken in moderation only.

The offerings to God include honey, milk, curd, fruits and vegetables, etc. Panchamrit offered in Puja is a mixture of milk, curd, ghee, honey and sugar is a classical example.

Yogashastra also talks about the role of satwik diet in great detail. It says people who eat less are yogis, people who eat in moderation are bhogis and people who eat a lot are rogis. The synonymous are tamsik for rogis, rajsik for bhogis and satwik for yogis.

In terms of proper diet one should eat dinner lighter than lunch, eat only natural food in the night and follow the principles of moderation and variety.

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Lifestyle Modifications Sodium intake <2 g/day sodium restriction in patients with symptomatic HF. Fluid restriction <2 L/day.

2 vaccines: Flu and pneumonia.

2 restrictions: Say no to smoking and tobacco.

Limit alcohol to <2 pegs per day.

NYHA class II patients can opt for cardiac rehab program.

IJCP Sutra 386: Read the labels when shopping.

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INSPIRATIONAL Story

Success Depends Upon Maturity!

M

aturity is many things. It is the ability to base a judgment on the big picture, the long haul. It means being able to resist the urge for immediate gratification and opt for the course of action that will pay off later.

One of the characteristics of the young is “I want it now.”

Grown-up people can wait. Maturity is perseverance– the ability to sweat out a project or a situation, in spite of heavy opposition and discouraging setbacks, and stick with it until it is finished. The adult who is constantly changing friends and changing mates is immature. He/ she cannot stick it out because he/she has not grown up.

Maturity is the ability to control anger and settle differences without violence or destruction. The mature person can face unpleasantness, frustration, discomfort and defeat without collapsing or complaining. He/she knows he cannot have everything his/her own way every time. He/she is able to defer to circumstances, to other people-and to time. He/she knows when to compromise and is not too proud to do so.

Maturity is humility. It is being big enough to say, “I was wrong.” And, when he/she is right, the mature person need not experience the satisfaction of saying, “I told you so.”

Maturity is the ability to live up to your responsibilities, and this means being dependable. It means keeping

your word. Dependability is the hallmark of integrity.

Do you mean what you say-and do you say what you mean? Unfortunately, the world is filled with people who cannot be counted on. When you need them most, they are among the missing. They never seem to come through in the clutches. They break promises and substitute alibis for performance.

They show up late or not at all. They are confused and disorganized. Their lives are a chaotic maze of broken promises, former friends, unfinished business and good intentions that somehow never materialize. They are always a day late and a dollar short.

Maturity is the ability to make a decision and stand by it. Immature people spend their lives exploring endless possibilities and then doing nothing. Action requires courage. Without courage, little is accomplished.

Maturity is the ability to harness your abilities and your energies and do more than is expected. The mature person refuses to settle for mediocrity. He/she would rather aim high and miss the mark than lowand make it.

Maturity is the art of living in peace with that which cannot be changed, the courage to change that which should be changed, no matter what it takes, and the wisdom to know the difference.

■■■■

492

IJCP Sutra 387: Look for lower sodium in cereals, crackers, pasta sauces, canned vegetables or any foods with low-salt options. Or, eat less processed and packaged foods.

Ind e ISS xed N 0 with 971 -08 IndME 76 D

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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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Asian Journal of Diabetology

Brachial Artery: Its Embryological Glucose Tolerance in Nondiabetic Patients after First Attack of Acute Myocardial Infarction and its Outcome

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A Case of Left Atrial Myxoma Presenting as Severe Pulmonary Hypertension

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Cornary Artery Air Embolism

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lighter reading

Signing Checks

Never be rude to anyone

Mr. Schwartz was the oldest of seven children, so he had to quit school and work to help support his younger brothers and sisters. He never learned to read, so when he married and started a checking account, he signed his checks simply “XX”. Eventually he started his own business, which immediately prospered.

He soon was a very rich man.

An American tourist asked a boat guy in Zanzibar, “Do you know Biology, Psychology, Geography, Geology or Criminology?”

One day, he got a call from his bank. “Mr. Schwartz,” said the banker, “I need to ask you about this check. We weren’t sure you had really signed it. All these years you’ve been signing your checks ‘XX’, but we just got one that was signed with three XXX’s…”

Mr. Schwartz answered, “No problem, my friend. It’s just that since I’ve become so wealthy, my wife thought I ought to have a middle name.”

Some answers ÂÂ

Antibody - One who hates his body

ÂÂ

Artery - Study of Fine Paintings

ÂÂ

Bacteria - Back door of a Cafeteria

ÂÂ

Coma - Punctuation Mark

ÂÂ

Gallbladder - Bladder of a Girl

ÂÂ

Genes - Blue Denim

ÂÂ

Labour Pain - Hurt at Work

ÂÂ

Liposuction - A French Kiss

ÂÂ

Ultrasound - Radical Sound

ÂÂ

Cardiology - Advanced Study of Playing Cards

The boat guy said, “No. I don’t know any of these.”

The tourist then said, “What the hell do you know on the face of this Earth? You will die of illiteracy!”

The boat guy said nothing. After a while the boat developed a fault and started sinking. The boatman then asked the tourist, “Do you know Swimology and Escapology from Crocodiology?”

The tourist said, “No!” The boat guy replied, “Well, today you will Drownology and Crocodiology will eat you. I will not Helpology and you will Dieology because of your Badmouthology.”

Dr. Good and Dr. Bad Situation: A 56-year-old female with type 2 diabetes who often complained of sleep disturbance recently mentioned fatigue and numbness in feet.

Sleep disturbance is not related to fatigue and numbness

It is related to both the conditions

© IJCP GROUP

HUMOR

Lighter Side of Medicine

A Happy Family Boy was introducing, “Hi, my father’s name is “Laughing” and my mother’s name is “Smiling”.

Girl was surprised, “Really? You must be Kidding!”

Boy defended, “No, no, that’s my brother’s name. I am ‘JOKING’.”

494

Lesson: A cross-sectional study suggested that diabetes-related

symptoms, including neuropathic pain and fatigue, are strongly related to sleep disturbance and sleep-related impairment in adults with type 2 diabetes, underscoring the need to include detailed assessments of neuropathic pain and fatigue when evaluating sleep.

IJCP Sutra 388: Ask about salt added to food, especially at restaurants. Most restaurant chefs will omit salt when requested.

Diabetes Care. 2018;41(1):156-62.

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ISSN number 0971-0876

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The Medical Council of India (UGC, ICI)

Indian Journal of Clinical Practice is published by the IJCP Group. A multispecialty journal, it provides clinicians with evidence-based updated information about a diverse range of common medical topics, including those frequently encountered by the Indian physician to make informed clinical decisions.

The journal has been published regularly every month since it was first launched in June 1990 as a monthly medical journal. It now has a circulation of more than 3 lakh doctors.

IJCP is a peer-reviewed journal that publishes original research, reviews, case reports, expert viewpoints, clinical practice changing guidelines, Medilaw, Medifinance, Lighter side of medicine and latest news and updates in medicine. The journal is available online (http://ebook.ijcpgroup.com/ Indian-Journal-of-Clinical-Practice-January-2018.aspx) and also in print. IJCP can now also be accessed on a mobile phone via App on Play Store (android phones) and App Store (iphone). Sign up after you download the IJCP App and browse through the journal.

IJCP is indexed with Indian Citation Index (ICI), IndMed (http://indmed.nic.in/) and is also listed with MedIND (http://medind.nic.in/), the online database of Indian biomedical journals. The journal is recognized by the University Grants Commission (20737/15554). The Medical Council of India (MCI) approves journals recognized by UGC and ICI. Our content is often quoted by newspapers.

The journal ISSN number is 0971-0876 and the RNI number is 50798/1990.

If you have any Views, Breaking news/article/research or a rare and interesting case report that you would like to share with more than 3 lakh doctors send us your article for publication in IJCP at editorial@ijcp.com.

Dr KK Aggarwal Padma Shri Awardee Group Editor-in-Chief, IJCP Group

IJCP Sutra 389: Remember the word ‘Na’, which is present in many drugs, soda, etc.

495

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,

496

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.

IJCP Sutra 390: Nothing can be preserved without adding salt to it, therefore beware of processed and frozen fruits.

Discussion –

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

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses).

At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution.

Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes.

Q. J. Expt. Physiol. 1955;40:89-111.

Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat.

– All photomicrographs should indicate the magnification of the print.

– Special features should be indicated by arrows or letters which contrast with the background.

– The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen.

– Color illustrations will be accepted if they make a contribution to the understanding of the article.

–

Do not use clips/staples on photographs and artwork.

–

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

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

Books

5. Special requests _____________________________

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

6. Suggestions for reviewers (name and postal address)

Articles in Books

2.____________ 2.________________

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

3.____________ 3.________________

4.____________ 4.________________

Tables –

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

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

–

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

IJCP Sutra 391: Many sweet food items have significant hidden salt in them.

Indian 1.____________Foreign 1.________________

7. All authors’ signatures________________________ 8.

Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

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

Dr KK Aggarwal

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

497

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