Medinews Oct 2011 by IJCP

Vol. 11, No. 10, October 2011

ISSN 0971-880X

Single Copy Rs. 100/-

Pages 12

Dr KK Aggarwal Gr. Editor-in-Chief, IJCP Group

Official Voice of Doctors of India

d i t o r i a l

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

Eating beetroot before any workout helps. Baked beetle root in one of the study at St. Louis University Chicago gave runners a modest edge in speed during a 5K run when they were close to the finish line. With the beetroot, they were 41 seconds faster at the finish.

A study from the UK also had shown that exercisers could work out longer if they drank beetroot juice. Other research has found that beetroot juice can help reduce blood pressure. Beetle root is rich in nitrates. Nitrates are converted into nitric oxide by the body. The nitric oxide dilates blood vessels. That results in improved oxygen delivery. The study included whole vegetable rather than the juice. In the study of 11 men and women, average age 25, each ate 200 grams of beetroot (500 mg of nitrates). After the beetroot, exercisers had overall times that were 3% faster compared to their times after eating cranberry relish, and 5% faster during the last mile, she found. In the study 200 g of beetle nut was baked at 350° for 90 minutes. The skin was peeled and rest added with a tablespoon of lemon juice, 1/8 teaspoon of cinnamon and 1/8 teaspoon of nutmeg to make it more palatable. It was consumed about 45 minutes before they jogged or can be eaten two and a half hours before an event. Make beetroot a part of any pre-workout diet; beetroot juice can help reduce blood pressure.

FDA Okays Novel Gel to Curb Bleeding during Surgery The FDA has approved a gel called LeGoo that temporarily stops blood flow during surgery. LeGoo is indicated for use in blood vessels below the neck and that are 4 mm or less in diameter. The gel stops blood from filling a surgical area without causing damage to the vessel, which often happens when clamps or elastic loops are used, an FDA statement said. LeGoo is temperature sensitive - liquid at room temperature and solid at a higher temperature. The gel plugs the vessel for upto 15 minutes, after which it dissolves. The plug can be dissolved sooner by cooling the vessel with an ice pack or cold saline, the statement said.

Nobel Prize 2011 Winners Physiology or Medicine: Bruce A Beutler and Jules A Hoffmann jointly “for their discoveries concerning the activation of innate immunity” and to Ralph M Steinman “for his discovery of the dendritic cell and its role in adaptive immunity. Peace: Ellen Johnson Sirleaf, Leymah Gbowee and Tawakkul Karman “for their nonviolent struggle for the safety of women and for women’s rights to full participation in peace-building work”. Physics: Saul Perlmutter, Brian P Schmidt and Adam G Riess “for the discovery of the accelerating expansion of the Universe through observations of distant supernovae”. Chemistry: Dan Shechtman “for the discovery of quasicrystals”. Literature: Poet Tomas Tranströmer.

Famous Quote “All that is necessary for evil to triumph is for good men to do nothing.” —Edmund Burke

Make Sure

During Medical Practice A patient intolerant to penicillin was denied rheumatic prophylaxis. Oh my God! Why was he not put on a sulfa drug?

©IJCP Academy

Member The Indian Newspaper Society

Make sure that patients who cannot tolerate penicillin are put on sulfadiazine or sulfisoxazole. This antibiotic class is effective for preventing group A streptococcal (GAS) infection although it cannot be used to achieve eradication. KK Aggarwal

Case Report

News & Views

Fitness Update

Photo Quiz

Legal Column

Expert’s Opinion

Research Review

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Case Report Giant Asymptomatic Cystic Dilatation in Dandy-Walker Malformation Amit Agrawal, Wardha

andy-Walker is a congenital abnormality characterized by a hindbrain abnormality associated with cystic dilatation of the fourth ventricle, hypoplasia of the vermis cerebelli, separation of the cerebellar hemispheres, dilatation of the aqueductus mesencephali and absence of the lateral and median apertures of the fourth ventricle, an enlarged or normal-sized posterior cranial fossa; in some patients there may be hydrocephalus.1,2 A 9-year-old male child underwent right ventriculoperitoneal shunt at the age of three months. He is doing well since

than except he is mentally-retarded (chronological age three years). There were no features of raised intracranial pressure. Recently, parents investigated the child with a CT scan to know the functioning of the shunt and it showed massive posterior fossa cyst and other features of DandyWalker malformation (DWM) and well-functioning shunt (Fig. 1). Classically, DWM is diagnosed when a cyst fills an enlarged posterior cranial fossa and separates rudimentary cerebellar hemispheres and can be associated with live-born mortality rates as high as 70%.3 The prognosis in patients with DWM is guarded and in survivors many children demonstrate significant disabilities on problems.4 In patients where Dandy-Walker syndrome is not complicated by hydrocephalus and consists of a large cyst communicating to the fourth ventricle early cystoperitoneal shunt surgery is recommended.5 In present case the patient is doing well after nine years of surgery and is not symptomatic for the malformation except mental retardation that is persisting. Conservative management and regular follow-up was advised for this child.

References 1. 2.

Figure 1. Typical features of Dandy-Walker malformation on CT scan with associated giant cyst in the posterior fossa, note the well functioning shunt.

Parents often Shun Recommended Childhood Vaccine Schedule An artificially low perceived risk for vaccine-preventable diseases, combined with an artificially high perceived risk for side effects potentially associated with vaccines, causes many parents to shun the recommended schedule for childhood vaccinations and adopt alternative schedules, according to the lead author of a report published online October 3 in Pediatrics. (Source: Medscape Medical News)

Dandy WE, Blackfan KD. Internal hydrocephalus: an experimental, clinical and pathological study. Am J Dis Child 1914;8:406-82. Kollias SS, Ball WS Jr, Prenger EC. Cystic malformations of the posterior fossa: differential diagnosis clarified through embryologic analysis. Radiographics 1993;13(6):1211-31. Nyberg DA, Mahony BS, Hegge FN, Hickok D, Luthy DA, Kapur R. Enlarged cisterna magna and the Dandy-Walker malformation: factors associated with chromosome abnormalities. Obstet Gynecol 1991;77(3):436-42. Chang MC, Russell SA, Callen PW, Filly RA, Goldstein RB. Sonographic detection of inferior vermian agenesis in Dandy-Walker malformations: prognostic implications. Radiology 1994;193(3): 765-70. Miyamori T, Okabe T, Hasegawa T, Takinami K, Matsumoto T. Dandy-Walker syndrome successfully treated with cystoperitoneal shunting - case report. Neurol Med Chir (Tokyo) 1999;39(11): 766-8.

Antihypertensives before Bed may Lower BP Taking antihypertensive medication at night may do a better job of controlling blood pressure than taking them in the morning, researchers found. In a review and metaanalysis, evening administration significantly lowered 24-hour mean systolic and diastolic blood pressures compared with morning dosing, Ping Zhao, MD, of Sichuan University in China, and colleagues reported online in Cochrane Reviews. (Source: Medpage Today)

News & Views Why are some susceptible to diabetes?

Thin Parents Produce Kids with Less Body Fat

Researchers at the University of Wisconsin-Madison, including one of an Indian-origin, have identified a gene that could explain why some people are more susceptible to diabetes.

Children whose parents are thin are thrice as likely to be lean than those with overweight parents, new research says. The study by University College London (UCL) is based on results from the Health Survey for England, in which data is collected annually from multiple households. From 2001 to 2006, trained interviewers recorded the height and weight of parents and upto two children in 7,000 families. They used this information to calculate their body mass index (BMI), a height to weight ratio, reports the journal Archives of Paediatrics & Adolescent Medicine. (Source: TOI, Oct. 4, 2011)

The gene, found in tests on obese mice, controls tomosyn-2 and acts as a brake on insulin secretion from the pancreas. “It’s too early for us to know how relevant this gene will be to human diabetes, but the concept of negative regulation is one of the most interesting things to come out of this study and that very likely applies to humans,” says lead researcher Alan Attie. The researchers found tomosyn-2 while searching for genes that contribute to diabetes susceptibility in obese mice. (Source: TOI, Oct. 7, 2011)

Higher HDL Lowers Cardiovascular Risk in Type 2 Diabetes Higher high-density lipoprotein (HDL) levels in patients with type 2 diabetes significantly reduced the odds of hospitalization related to cardiovascular disease, data from a large cohort study showed. Every 5 mg/dl increase in baseline HDL was associated with a 6% reduction in the CVD hospitalization risk. During a mean follow-up of 55.8 months, each 5 mg/dl increase in HDL was associated with a 4% lower risk. (Source: Medpage Today)

Restless Legs Tied to Hypertension Middle-age women with self-reported restless legs syndrome (RLS) were as much as 41% more likely to have hypertension as women who did not have the neurologic disorder, analysis of a cohort from the Nurses’ Health Study showed. Overall, women with RLS symptoms had a 20% higher prevalence of hypertension. The odds of hypertension increased with the frequency of symptoms, topping out at 41% among women who had 15 or more episodes per month. (Source: Medpage Today)

FDA Update Combo Pill for Diabetes, Cholesterol The FDA has approved a fixed-dose combination tablet that combines the diabetes drug sitagliptin with simvastatin, under the brand name Juvisync. It’s the first product with drugs for diabetes and high cholesterol in a single pill, the agency. Sitagliptin is a DPP-4 inhibitor sold as Januvia, first approved in 2006, as an adjunct to diet and exercise. Simvastatin (Zocor) is one of the most popular statin drugs for reducing total and LDL cholesterol. (Source: Medpage Today)

First Face Mask for Kids The FDA has cleared the first single-use face mask for preventing the spread of airborne pathogens that is made especially for children. The Kimberly-Clark Pediatric/Child Face Mask was designed to fit children from five to 12 years of age and does not resist air flow as strongly as an adult mask. “Children are not small adults. This pediatric face mask helps fill an unmet need for medical devices that are specifically designed for children’s unique anatomy and growing bodies,” Susan Cummins, MD, of the FDA’s Center for Devices and Radiological Health said in a statement. (Source: Medpage Today)

ED Drug for Enlarged Prostate Tadalafil (Cialis), currently marketed for erectile dysfunction, also may be used to treat benign prostatic hyperplasia (BPH), the FDA said. The newly approved indication includes both prostate enlargement by itself and when it occurs along with erectile dysfunction. Tadalafil is the first phosphodiesterase-5 inhibitor to be approved for BPH. Eight other drugs are currently available for the condition, all of which are either a-adrenergic blockers or 5-a-reductase inhibitors. (Source: Medpage Today)

Ease Way for Innovation The FDA has announced a new ‘blueprint’ to spur biomedical innovation, which contains a plan to make it easier for drugs and devices that are considered ‘personalized medicine’ to come to market. FDA Commissioner Margaret Hamburg told reporters on Wednesday that the overall plan - released as part of a sweeping report on improving innovation - addresses concerns about the long-term sustainability of the medical product development pipeline. Despite more money than ever being spent on research and development, the medical product pipeline is slowing. In 2010, the FDA had the lowest number of new product applications in its history, Hamburg said. (Source: Medpage Today)

Fitness Update Whey Protein Concentrate: A Brief Summary On average, high quality milk is 27% protein, 37% lactose (milk sugar) and 30% fat. The remaining 6% is calcium, other minerals, and ash. Thus, what is called ‘4% milk’ or ‘whole milk’ is a high-fat food, because the percentage determination includes the water, and milk is mainly water. Its label is largely a commercial fiction. It is not a prime food, especially when trying to increase muscle or to reduce body fat. What is called ‘2% milk’ still contains more fat and more lactose than protein. It is not a prime food either. Skim milk has near zero fat but still contains a high amount of lactose. Skim milk powder, which some people use in cooking and as a low-fat protein source, is the worst of milk, because more than half of it is lactose. Upto 30% of adults have varying degrees of allergic responses to lactose, because lactase, its digesting enzyme in the gut, declines rapidly during childhood. Humans and their pets are the only adult animals that drink milk.

Exercise Helps Prevent Heart Failure in Cancer Patients Cardiotoxicity, or treatment-induced heart failure, is a serious side effect of chemotherapy, a treatment given to cancer patients. The condition affects physical fitness, physical therapy and quality-of-life. While previous research shows that exercise can help heart failure patients and cancer survivors, no work has been done to test the effect of exercise in cancer survivors with treatment-induced heart failure. Researchers from Vanderbilt University and the University of Texas at San Antonio conducted a pilot study to test a small group of patients who were recovering from various forms of cancer, and who were diagnosed with cardiotoxicity. The patients underwent an exercise-based treatment program for 16 weeks, and researchers measured cardiovascular fitness. While patients were only able to perform a low amount of moderate activity at the beginning of the intervention, they were able to perform more and more exercise as time passed and physical fitness improved. Researchers measured quality-of-life and mental health (using questionnaires), and both were improved significantly as a result of the intervention. Study authors note that exercise programs for patients suffering from cancer or treatment-induced heart failure need to be designed by a professional.

Weakness in Heart Attack Therapy Identified

TB Cases Decline Worldwide for the First Time

Scientists didn’t have a plausible research-based answer until now, according to the UCSF researchers. In a paper published this month in the scientific journal Science Translational Medicine, researchers offer an explanation of why a gap exists been the success of human trials and rodent experiments. Researchers use bone marrow from young, healthy donor rodents to treat mice that had heart attacks. However, in humans, bone marrow cells came from the patients themselves - typically older - after they suffered heart attacks.

For the first time, the number of people infected with tuberculosis (TB) each year is declining, according to Mario Raviglione, MD, director of the World Health Organization (WHO)’s Stop TB program. He spoke here on October 11, during a press conference to release Global Tuberculosis Control 2011, WHO’s 16th annual report on TB, which summarizes advances made and challenges ahead. The report features data on TB in nearly 200 countries with treatment results and financing trends. In a numbers-heavy talk, Dr Raviglione highlighted a mix of positive and sobering news from the report. Among achievements, he noted that:

“It’s very important to consider the disease, whenever you think about treatments that involve returning cells into the same person from whom they were taken,” said the paper’s senior author Matt Springer, PhD, associate professor of medicine in the UCSF Division of Cardiology and UCSF Cardiovascular Research Institute. “The very disease you’re trying to treat might actually cause a problem for those cells, and that seems to be the case here. “Heart attacks are very complicated, and are hard to treat even with pharmacology and interventional therapies,” said Xiaoyin Wang, MD, lead author and an associate research specialist at the UCSF Cardiovascular Research Institute. “It’s difficult to get reasonable and realistic results to heal heart attacks. —Rajat Bhatnagar, International Sports & Fitness Distribution, LLC, http://www.isfdistribution.com

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The number of people who were infected with TB decreased to 8.8 million in 2010, after peaking at nine million in 2005. In 2010, TB deaths declined to the lowest level in a decade, to 1.4 million deaths, after reaching 1.8 million deaths in 2003. The TB death rate dropped 40% between 1990 and 2010. All regions except Africa are on track to achieve a 50% decline in mortality by 2015.

In 2009, 87% of patients treated were cured, bringing the total successfully treated to 46 million cured and seven million lives saved under WHO guidelines since 1995. “It’s a major achievement,” he said. (Source: Medscape Medical News)

Photo Quiz Persistent Rash in a Child

six-year-old girl presented with a rash on her right arm that her mother first noticed one month earlier. The rash began on her shoulder and grew distally down her arm in a linear pattern (Figure 1). It measured 1 cm × 35 cm and was hypopigmented and papular (Figure 2). The rash was nonpruritic. Application of antibiotic ointment and hydrating lotion had no effect. The patient was otherwise healthy, and her vaccinations were up to date. There were no other rashes on the patient or her family members, and there had been no change in her environment or exposures.

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

Figure 1.

Figure 2.

A. Lichen planus. B. Lichen striatus. C. Psoriasis. D. Tinea corporis. (For Answer and Discussion, see page 10...)

An Inspirational Story Temper Control There once was a little boy who had a bad temper. His father gave him a bag of nails and told him that every time he lost his temper, he must hammer a nail into the fence. The first day the boy had driven 37 nails into the fence. Over the next few weeks as he learned to control his anger, the number of nails hammered daily, gradually dwindled down. He discovered it was easier to hold his temper than to drive those nails into the fence. Finally the day came when the boy didn’t lose his temper at all. He told his father about it and the father suggested that the boy now pull out one nail for each day that he was able to hold his temper. The days passed and the young boy was finally able to tell his father that all the nails were gone. The father took his son by the hand and led him to the fence. He said “you have done well, my son, but look at the holes in the fence. The fence will never be the same. When you say things in anger, they leave a scar just like this one. You can put a knife in a man and draw it out. It won’t matter how many times you say I’m sorry, the wound is still there.”

The Consultant was doing a hospital round. He stopped at the bedside of one gloomy-looking patient and examined the chart and case notes, nodding wisely. “You are progressing very well indeed, my man,” he announced at last. “I see that your neck is still very swollen, but I’m not too worried about that…” “I dare say you’re not!” burst out the patient. “And if yours was swollen don’t kid yourself that I’d be shedding any tears either!”

Mind Teaser

Make sure you control your temper the next time you are tempted to say something you will regret later.

How much dirt is there in a hole that measures two feet by three feet by four feet?

—Ms. Ritu Sinha

Answer: There is no dirt in a hole.

Laugh a While!

Legal Column What is a Grievous Hurt-Indian Penal Code? It is very difficult to draw a line between those bodily hurts which are serious and those which are slight. To make out the offense of voluntarily causing grievous hurt, there must be some specific hurt, voluntarily inflicted and coming within the scope of following as per law. According to Indian Penal Code Section 320, the following kinds of hurt are designated as ‘grievous’.  Emasculation: It means depriving a male of masculine power.  Permanent privation of sight of either eye: The gravity lies in the permanency because it deprives a person the use of the organ of sight.  Permanent privation of the hearing of either ear: It deprives a man of his sense of hearing. Injury to the tympanum or auditory nerve or by thrusting something into the ear which causes deafness.  Privation of any member or joint: The term ‘member’ means an organ or a limb being part of man capable of performing a distinct function. It includes, nose, mouth, hands, feet, phalanges, etc.  Destruction or permanent impairing of the powers of any member or joint: The use of limbs and joints of body are essential to the discharge of the normal functions of the body. Their deprivation causes lifelong crippling and makes the person defenseless and miserable.  Permanent disfiguration of the head or face: The word ‘disfigure’ means to cause some external injuries which detracts from personal appearance but does not weaken a person.

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Fracture or dislocation of a bone or tooth: It is not necessary that a bone should be cut through and through; cut should be upto the medulla. If there is a break by cutting or splintering of the bone or there is a rupture or fissure in it, it would amount to a fracture but the doctor must document the dimension of fracture and duration/age correlation with age of injury. Dislocation means displacement. Mere looseness of teeth will not amount to dislocation. It has to be proven that the tooth was originally not loose and that there was fracture or dislocation by the injury. Any hurt which endangers life or which causes the victim to be in severe bodily pain or unable to follow his ordinary pursuits for a period of 20 days: A wound may cause intense pain, prolonged disease or long-lasting body injury but does not fall under any of the seven clauses. A body injury/beating may not mutilate the sufferer or fracture his bones but may be so harsh and painful and may even cause death. The eighth clause provides for such hurts. This includes three different types of hurt. These are:  

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Any hurt which endangers life Any hurt which causes the victim to be in severe bodily pain for a period of 20 days Any hurt which prevents the victim from following his ordinary pursuits for a period of 20 days. —Dr Sudhir Gupta, Additional Professor, Forensic Medicine & Toxicology, AIIMS.

Legal Question A patient was brought to a private hospital. The hospital recorded the case as ‘Brought dead’. No police information, MLC or autopsy were done and the body was handed over to the relatives. The relatives demand that the hospital should issue a death certificate for their legal requirements pertaining to bank accounts and other money matters. My question is: “Is it the duty of the hospital in this case to issue a death certificate and to send the information about death to the Registrar of Births and Deaths?” 

It was wrong on the part of the hospital not to inform the police and, having informed the police, not to register it as an MLC.

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Even otherwise, if a patient is brought dead to the hospital and the police is not informed and an MLC is not prepared for whatsoever reason, the hospital should maintain proper record of the case almost on the same lines as an MLC so that if at some time in future legal issues crop up and the hospital gets a notice in this regard, it should be able to give a proper and satisfactory reply.

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The hospital is not legally competent to issue a death certificate unless it is so authorized in terms of Section 10 (1) (iii) of the Registration of Births and Deaths Act, 1969. Section 10 (1) is reproduced below: “10. (1) It shall be the duty of:  The midwife or any other medical or health attendant at a birth or death  The keeper or the owner of a place set apart for the disposal of dead bodies or any person required by a local authority to be present at such place  Any other person whom the State Government may specify in this behalf by his designation, to notify every birth or death or both at which he or she attended or was present, or which occurred in such areas as may be prescribed, to the Registrar within such time and in such manner as may be prescribed.” Whether the hospital is thus empowered or not should be known to the hospital. If the hospital is not sure about this position, it should make necessary inquiry from the state health directorate to get a realistic official answer. (Cont’d on page 10...)

Expert’s Opinion Malaria Update What is the treatment of uncomplicated malaria as per National Guidelines? All fever cases diagnosed as malaria by rapid diagnostic test (RDT) or microscopy and should promptly be given effective treatment. Following decision rules are followed based on method of diagnosis: If, even after the full treatment and with no history of vomiting and diarrhea, the patient does not respond within 72 hours, then you should suspect resistance, clinically. Such cases not responding to ACT (Artesunate 3 days + sulfadoxinepyrimethamine 1 day), should be treated with oral quinine with tetracycline/doxycycline. These instances should be reported to concerned District Malaria/State Malaria Officer/ROHFW for initiation of therapeutic efficacy studies. —AC Dhariwal, Hitendrasinh G Thakor, Directorate of NVBDCP, New Delhi

Lab Update Porphyrin Test: Indications When a patient has symptoms that suggest an acute neurologic/psychiatric porphyria, such as abdominal pain, tingling in hands or feet, and/or confusion or hallucinations, or that suggest a cutaneous porphyria, such as reddening, blistering, or scarring on sun–exposed skin. —Dr Arpan Gandhi and Dr Navin Dang

Medicine Update What is the treatment of Wilson’s disease? Pharmacological therapy: Initial treatment for symptomatic patients should include a chelating agent (D-penicillamine or trientine). Trientine may be better tolerated.  Penicillamine: It is a general chelator and induces cupruria. Maximum dose is 20 mg/kg/day. Side effects are fever, rash, proteinuria, lupus-like reaction, aplastic anemia, leukopenia, thrombocytopenia, nephrotic syndrome, degenerative changes in skin, elastosis perforans serpingosa, serous retinitis and hepatotoxicity.  Trientine: It is a general chelator and induces cupruria. Maximum dose is 20 mg/kg/day. Side effects are gastritis, aplastic anemia and sideroblastic anemia.  Zinc: It is a metallothionein inducer and blocks intestinal absorption of copper. Usual dose in adults is 50 mg elemental zinc thrice-daily. Side effects are gastritis and biochemical pancreatitis.  Tetrathiomolybdate: It is a chelator which blocks copper absorption. Side effects are anemia, neutropenia and hepatotoxicity. Dietary: Patients should avoid intake of foods and water with high concentrations of copper, especially during the first year of treatment. Treatment of presymptomatic patients can be accomplished with a chelating agent or with zinc. Trientine may be better tolerated. —Dr Neelam Mohan, Director, Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta - The Medicity

Conference Calendar 89th Annual Fall Clinical Conference November 3-5, 2011 Venue: Overland Park, KS, United States Website: http://kcswcs.org/FC2011/FC2011.html Contraceptive Technology: Quest for Excellence November 3-5, 2011 Venue: Atlanta, GA, United States Website: http://contemporaryforums.com/Live-CEConferences/Contraceptive-Technology-Quest-ForExcellence/ Keystone Symposia: Malnutrition, Gut-Microbial Interactions and Mucosal Immunity to Vaccines November 7-11, 2011 Venue: New Delhi, India Website: http://www.keystonesymposia.org/11T1

Current Issues of Endocrinology and Endocrine Surgery November 17-18, 2011 Venue: Congress Hall, Kiev, Ukraine Website: http://www.nbscience.com/31.html International Conference on Integrated Preventive Cardiology November 24-25, 2011 Venue: Madhavbaug Ayurvedic Cardiac Rehabilitation Centre, Mumbai, Maharashtra, India Website: http://cardiac-conference.in/ Breast Cancer Controversies 2011 November 29-30, 2011 Venue: London, United Kingdom Website: http://www.breastcancermeeting.co.uk

Research Review Mycobacterium tuberculosis Lipolytic Enzymes as Potential Biomarkers for the Diagnosis of Active Tuberculosis Background: New diagnosis tests are urgently needed to address the global tuberculosis (TB) burden and to improve control programs especially in resource-limited settings. An effective in vitro diagnostic of TB based on serological methods would be regarded as an attractive progress because immunoassays are simple, rapid, inexpensive and may offer the possibility to detect cases missed by standard sputum smear microscopy. However, currently available serology tests for TB are highly variable in sensitivity and specificity. Lipolytic enzymes have recently emerged as key factors in lipid metabolization during dormancy and/or exit of the nonreplicating growth phase, a prerequisite step of TB reactivation. The focus of this study was to analyze and compare the potential of four Mycobacterium tuberculosis lipolytic enzymes (LipY, Rv0183, Rv1984c and Rv3452) as new markers in the serodiagnosis of active TB. Methods: Recombinant proteins were produced and used in optimized ELISA aimed to detect IgG and IgM serum antibodies against the four lipolytic enzymes. The capacity of the assays to identify infection was evaluated in patients with either active TB or latent TB and compared with two distinct control groups consisting of BCG-vaccinated blood donors and hospitalized non-TB individuals. Results: A robust humoral response was detected in patients with active TB, whereas antibodies against lipolytic enzymes were infrequently detected in either uninfected groups or in subjects with latent infection. High specifity levels, ranging from 93.9% to 97.5%, were obtained for all four antigens with sensitivity values ranging from 73.4% to 90.5%, with Rv3452 displaying the highest performances. Patients with active TB usually exhibited strong IgG responses but poor IgM responses. Conclusion: These results clearly indicate that the lipolytic enzymes tested are strongly immunogenic allowing to distinguish active from latent TB infections. They appear as potent biomarkers providing high sensitivity and specificity levels for the immunodiagnosis of active TB. Source: Brust B, Lecoufle M, Tuaillon E, et al. PLoS One 2011;6(9):e25078.

Endoscopic Appearance and Clinicopathological Character of Breast Cancer Background: The Japanese Association of Mammary Ductoscopy proposed a classification system based on the objective endoscopic appearance of intraductal lesions. This system includes four categories: Solitary polypoid, multiple polypoid, superficial and combined type. However, previous studies did not adequately compare endoscopic findings with histological findings and the prognosis. Patients and methods: One hundred ten patients with nipple discharge who had intraductal tumors were identified by mammary ductoscopy, and 25 breast cancer patients were identified from our database of records between 2001 and 2008. The clinicopathological data and outcomes of these patients were then reviewed. Results: Lesions in 25 breast cancer patients comprised 12 polypoid solitary type, 3 polypoid multiple type, 5 superficial type and 5 combined type. Polypoid type showed a low sensitivity on cytological analysis (5 malignant and 10 benign). On the contrary, superficial or combined type showed a high sensitivity (4 malignant and 1 benign). Furthermore, invasive ductal carcinoma was frequently found in the solitary polypoid type. Actuarial disease-free survival (DFS) for all patients at 10 years was 78%. The estrogen/progesterone receptor status and endoscopic appearance did not significantly affect DFS, while there was a significant difference in DFS between ductal carcinoma in situ and invasive ductal carcinoma. Conclusion: Ductoscopy is a useful procedure for guiding subsequent breast surgery in the treatment of nipple discharge, and the appearance may be essential in treating breast cancer patients with nipple discharge. Source: Yamamoto D, Tsubota Y, Yoshida H, et al. Anticancer Res 2011;31(10):3517-20.

(...Cont’d from page 6)

Discussion

Summary Table

The answer is B: lichen striatus.

Condition

Characteristics

Lichen planus

Pruritic, shiny, flat, violaceous papules that may have Wickham striae; commonly affects the mouth, extremities, or trunk; can be associated with immunosuppression, especially from hepatitis C

Lichen striatus

Asymptomatic, linear rash that expands distally down the extremity; occurs along Blaschko lines; typically affects children and resolves without treatment within two years

Psoriasis

Erythematous plaques covered with a silver scale, usually on the elbows, knees, and lower back; can be accompanied by arthritis or nail changes; thought to be immune-mediated; associated with inflammatory bowel disease

Tinea corporis

Mildly pruritic, round lesions with a scaly border and central clearing; can occur on any part of the body; diagnosis confirmed with a potassium hydroxide preparation or fungal culture

Lichen striatus is an asymptomatic, papular rash with a sudden onset (full disease develops within weeks). The eruptions usually appear as a linear rash that expands distally down the extremities, but rarely can appear on the trunk or face. They are usually 2 mm to 2 cm in width, and the length can vary from a few centimeters to the entire length of a limb. Few cases of multiple bands have been reported.1 The rash occurs most often in childhood and is seldom reported in adults.2 It typically resolves without intervention within two years.2 Nail involvement is rare, but when it occurs it affects a single nail. Nail changes (e.g., ridging, splitting, fraying, onycholysis) can be observed before, during, or after the skin eruption.3 Lichen striatus occurs along the Blaschko lines (a linear and sometimes curved pattern of skin lesions on the body following the lines of embryogenesis), suggesting a somatic mutation in the keratinocytes.1 Microscopic findings include epidermal hyperkeratosis and focal parakeratosis in the epidermis. The CD8 cell infiltrate surrounds the sweat glands, a finding that distinguishes lichen striatus from lichen planus.2 Lichen planus manifests as pruritic, shiny, flat, violaceous papules that may have Wickham striae (a white, lacelike pattern on the surface). The condition usually occurs in middle-aged adults and may have a short or chronic course. The rash typically affects the mouth, extremities, or trunk. Involvement of the buccal mucosa is common, occurring in up to 70 percent of patients.4 Lichen planus can also affect the nails, causing ridging. It can be associated with immunosuppression, especially from hepatitis C. Psoriasis is a chronic skin condition causing plaques with silver scale surrounded by erythema, usually occurring on the elbows, knees, and lower back. It is thought to be an immune-mediated disease and is associated with inflammatory bowel disease. The typical age of onset is biphasic, with the first peak between 20 and 30 years of age, and the second peak between 50 and 60 years of age.5 Arthritis or nail changes can develop.

Tinea corporis is a fungal infection that presents as a mildly pruritic, round, scaly patch. It extends centrifugally and has a raised, erythematous border with central clearing. This annular rash can be found on any body part. Diagnosis is confirmed with a potassium hydroxide preparation or fungal culture. Outbreaks can occur as a result of skin-toskin contact.6

References 1.

2. 3. 4. 5. 6.

Eczema, lichen simplex, erythroderma and prurigo. In: Rook AJ, Wilkinson DS, Ebling FJG, Champion RH, Burton JL. Textbook of Dermatology. 4th ed. Oxford, United Kingdom: Blackwell; 1986: 414-415. Charles CR, Johnson BL, Robinson TA. Lichen striatus: a clinical, histologic and electron microscopic study of an unusual case. J Cutan Pathol. 1974;1(6):265-274. Toda K, Okamoto H, Horio T. Lichen striatus. Int J Dermatol. 1986;25(9):584-585. Thompson DF, Skaehill PA. Drug-induced lichen planus. Pharmacotherapy. 1994;14(5):561-571. Farber EM, Nall ML. The natural history of psoriasis in 5,600 patients. Dermatologica. 1974;148(1):1-18. Shiraki Y, Hiruma M, Hirose N, Sugita T, Ikeda S. A nationwide survey of Trichophyton tonsurans infection among combat sport club members in Japan using a questionnaire form and the hairbrush method. J Am Acad Dermatol. 2006;54(4):622-626. Source: Adapted from Am Fam Physician. 2011;84(5):563-564.

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The position can vary from state to state because “Vital statistics including registration of births and deaths” is, by virtue of entry 30, a subject included in list III (Concurrent list) of Schedule 7 of the Constitution. 

The relatives’ demand is without basis. They are trying to avoid their legal duty cast upon them in terms of Section 8 (1) (a) of the Registration of Births and Deaths Act, 1969. Section 8 (1) (a) is reproduced below: “8. (1) It shall be the duty of the persons specified below to give or cause to be given, either orally or in writing, according to the best of their knowledge and belief, within such time as may be prescribed, information to the Registrar of the several

particulars required to be entered in the forms prescribed by the State Government under sub-section (1) of Section 16 (a) in respect of births and deaths in a house, whether residential or nonresidential, not being any place referred to in clauses (b) to (e), the head of the house or, in case more than one household live in the house, the head of the household, the head being the person, who is so recognized by the house or the house-hold, and if he is not present in the house at any time during the period within which the birth or death has to be reported, the nearest relative of the head present in the house, and in the absence of any such person, the oldest adult male person present therein during the said period;” —Dr MC Gupta, Advocate

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