Indexed with IndMED
ISSN 0971-0876
www.ijcpgroup.com
Volume 25, Number 3
August 2014, Pages 201–300
Peer Reviewed Journal
zz American Family Physician zz Anesthesiology zz Cardiology zz Community Medicine zz Dentistry zz Dermatology zz ENT zz Internal Medicine zz Obstetrics and Gynecology
an i c i ys ians
zz Pediatrics
Phly Physic y l mi ami
zz Respiratory Infections
Fademy of F n ica Aca
zz Surgery
er merican m A eA
zz Expert View
ingurnal of th t a or d Jo
zz Medilaw
rp-reviewe o c In eer AP
Full text online: http://ebook.ijcpgroup.com/ijcp/
Single Copy Rs. 300/-
Online Submission
IJCP Group of Publications Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor
Volume 25, Number 3, August 2014 from the desk of THE group editor-in-chief
205 Ebola Virus a New Terror Agent: Dengue-like Illness with Rabies-like Mortality
Dr Deepak Chopra Chief Editorial Advisor Padma Shri, Dr BC Roy National & DST National Science Communication Awardee
Dr KK Aggarwal Group Editor-in-Chief
Dr Veena Aggarwal MD, Group Executive Editor
IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma, Dr Kamala Selvaraj Cardiology Dr Praveen Chandra, Dr SK Parashar Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty ENT Dr Jasveer Singh Dr Chanchal Pal Dentistry Dr KMK Masthan Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar Dr Rajiv Khosla Dermatology Dr Hasmukh J Shroff Dr Pasricha Dr Koushik Lahiri Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan Dr Vineet Suri Journal of Applied Medicine & Surgery Dr SM Rajendran, Dr Jayakar Thomas Orthopedics Dr J Maheshwari
Anand Gopal Bhatnagar Editorial Anchor Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions
This journal is indexed in IndMED (http://indmed.nic.in) and full-text of articles are included in medIND databases (http://mednic.in) hosted by National Informatics Centre, New Delhi.
KK Aggarwal
American Family Physician
207 Parathyroid Disorders
Thomas C. Michels, Kevin M. Kelly
216 Practice Guidelines 218 Photo Quiz Anesthesiology
220 Perioperative Laryngospasm in Children
Sudivya Sharma
226 Anesthetic Challenges in a Patient with Ludwig’s Angina
Presenting with Septic Shock and Acute Renal Failure: A Case Report
Abhimanyu Bhatia, Anumeha Jain, Meenaxi Sharma, Nitin Johar, Ayush Sharma
CARDIOLOGY
232 Complete Heart Block in Rheumatoid Arthritis
Kavina Marian Fernandes, Vivek GC
Community Medicine
235 Women’s and Providers’ Experiences with Injectable
Contraceptives (Depo-Provera): A View from Vadodara, India
Prakash V Kotecha, Sangita V Patel, Rajendra K Baxi, Shagufa Kapadia, Kedar Mehta
Dentistry
240 Extrusion of Fractured Anterior Tooth: An Invisible Approach
RV Murali, L Rajashekhar, S Rajalingam
244 Follicular Adenomatoid Odontogenic Tumor
S Loganathan, H Srinvasan, R Veerakumar, M Arul Pari
Dermatology
247 Generalized Granuloma Annulare in a Diabetic Patient
Amrita Chauhan, Hemanta Kumar Kar
ENT
252 A Rare Case of Type II First Branchial Cleft Sinus Managed by Complete Excision
DR Nageswaran
Internal medicine
256 Hemophagocytic Lymphohistiocytosis: A Case Report
Debaprasad Chakrabarti, Avik Chakraborty, Anindya Sundar Trivedi Amrit Kr Bhattacharyya
259 Significance of Peripheral Blood Smear in Diagnosis of Blood Parasitic Infection
Gopal Raval, Devang Patvari, D Kothari, P Joshi, M Pandya
Obstetrics and Gynecology Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com
262 Nonpuerperal Uterine Inversion: A Rare Presentation
Sonia Luthra, AD Dwivedi
265 Grade 3 Placenta at 24 Weeks Gestation: A Rare Finding
DP Gupta, Hem Prabha Gupta, S Bhadury, DK Saxena, Ratna Prabha Gupta
Printed at New Edge Communications Pvt. Ltd., New Delhi E-mail: edgecommunication@gmail.com
268 A Case of Fibrothecoma of Ovary
© Copyright 2014 IJCP Publications Ltd. All rights reserved.
271 Uterine Rupture: A 5-year Review
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.
Jyotsna Potdar, Avinash Joshi, Snehal Tate
Nalini Sharma, Anshu Khamsera, JK Goel
274 Postpartum Posterior Reversible Encephalopathy: A Diagnostic Dilemma
Ridhi Kathuria, MC Bansal
Pediatrics
Editorial Policies
278 Mesenteric Cystic Teratoma in an 1-year-old Child: A Case Report
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.
Sana Aboosalih, Leena Dennis Joseph, Prakash A, CN Sai Shalini, Rajendiran S
Respiratory Infections
281 Polyvalent Mechanical Bacterial Lysate: A Polyvalent Respiratory Vaccine
Jyoti Yadav
Surgery
284 A Rare Case of Intrathyroid Dermoid Cyst in a Middle-aged Female
Raxith S Ragavendra, Narayan I Hebsur, Narayan Y Kabadi
AROUND THE GLOBE
287 News and Views Expert View
291 Do β-blockers Cause Sexual Dysfunction?
KK Aggarwal
mediLAW
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.
293 How Applicable are Consent Laws in India?
KK Aggarwal
LIGHTER READING
296 Lighter Side of Medicine
IJCP’s Editorial & Business Offices Delhi
Mumbai
Kolkata
Bangalore
Chennai
Hyderabad
Dr Veena Aggarwal 9811036687 E - 219, Greater Kailash, Part - I, New Delhi - 110 048 Cont.: 011-40587513 editorial@ijcp.com drveenaijcp@gmail.com Subscription Dinesh: 9891272006 subscribe@ijcp.com Ritu: 09831363901 ritu@ijcp.com
Mr. Nilesh Aggarwal 9818421222 Mr. Pravin Dhakne 8655611025, 24452066
Ritu Saigal Sr. BM 9831363901
H Chandrashekar GM Sales & Marketing 9845232974
Chitra Mohan Sr. BM 9841213823 40A, Ganapathypuram Main Road Radhanagar Chromepet Chennai - 600 044 Cont.: 22650144 chitra@ijcp.com
Venugopal GM Sales & Marketing 9849083558
Unit No: 210, 2nd Floor, Shreepal Complex Suren Road, Near Cine Magic Cinema Andheri (East)
7E, Merlin Jabakusum 28A, SN Roy Road Kolkata - 700 038 Cont.: 24452066 ritu@ijcp.com
Mumbai - 400 093 nilesh.ijcp@gmail.com
Sr.: Senior; BM: Business Manager; GM: General Manager
Arora Business Centre, 111/1 & 111/2, Dickenson Road (Near Manipal Centre) Bangalore - 560 042 Cont.: 25586337 chandra@ijcp.com
H. No. 16-2-751/A/70 First Floor Karan Bagh Gaddiannaram Dil Sukh Nagar Hyderabad 500 059 Cont.: 65454254 venu@ijcp.com
from the desk of THE group editor-in-chief Dr KK Aggarwal
Padma Shri, Dr BC Roy National & DST National Science Communication Awardee Sr. Physician and Cardiologist, Moolchand Medcity President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS National Senior Vice President, IMA Member, Ethics Committee, MCI Chairman, Ethics 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)
Ebola Virus a New Terror Agent: Dengue-like Illness with Rabies-like Mortality ÂÂ The filoviruses, Marburg and Ebola, are among the most virulent human pathogens. ÂÂ Case fatality rates are 80-90%. ÂÂ Ebola viruses are also classified as 'hemorrhagic fever (HF) viruses' based on their clinical manifestations,
which include coagulation defects, a capillary leak syndrome and shock.
ÂÂ Other types of viral HF include rift valley fever, Crimean-Congo HF, lassa fever, yellow fever and dengue HF. ÂÂ The filoviruses, Marburg and Ebola, causes severe HF that resembles fulminant septic shock. ÂÂ Person-to-person transmission requires direct contact with blood or other virus-containing body fluids. ÂÂ The reservoir host of the filoviruses is not known. ÂÂ Various bat species may serve as a source of infection for both humans and wild primates. ÂÂ Flavi viruses cause extensive tissue damage. ÂÂ They also induce a systemic inflammatory syndrome by causing the release of cytokines, chemokines and other
proinflammatory mediators from infected macrophages.
ÂÂ The incubation period is usually 5-7 days, but may exceed 2 weeks. ÂÂ Patients usually have an abrupt onset of nonspecific symptoms, such as fever, malaise and myalgias. ÂÂ As the illness progresses, patients develop worsening prostration, stupor and hypotension. ÂÂ Signs of impaired coagulation generally remain limited to conjunctival hemorrhages, easy bruising and failure
of venipuncture sites to clot.
ÂÂ Due to their virulence, stability as aerosols and high infectivity, Marburg and Ebola viruses are classified as
Category A bioterror agents.
ÂÂ The occurrence of even a single human infection outside of Africa is therefore a public health emergency
requiring immediate investigation, since it could represent the leading edge of an impending outbreak.
ÂÂ Rapid diagnostic tests for Marburg and Ebola virus infection have been developed, based on the detection
of viral antigens by enzyme-linked immunosorbent assay (ELISA) or specific RNA sequences by reversetranscription polymerase chain reaction (RT-PCR) in blood or other body fluids. The diagnosis is confirmed through cell culture.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
205
from the desk of THE group editor-in-chief Bioterrorism The CDC has identified a number of pathogens that could be used in biological terrorism and have ranked them into various categories based on their overall potential to cause harm. High-priority agents include organisms that: ÂÂ Can be easily disseminated or transmitted person-to-person ÂÂ Cause high mortality ÂÂ Might cause public panic and social disruption ÂÂ Require special action for public health preparedness ÂÂ The highest priority agents (Category A) include anthrax and smallpox. These agents are of particular concern
because they can be grown easily in large quantities and are sturdy organisms, resistant to destruction. They are also particularly well-suited to airborne dissemination, thereby infecting large numbers of people.
ÂÂ Second highest priority agents (Category B) include those that are moderately easy to spread and generally
cause less morbidity and mortality than Category A, but may require enhanced diagnostic capacity or surveillance techniques. Examples include agents of Q fever or brucellosis.
ÂÂ Category C agents include pathogens that could be engineered for mass dissemination either because of
ready availability, or ease of production and transport. They are usually agents of significant potential morbidity and/or mortality. Examples include hantavirus or multidrug-resistant tuberculosis.
Because of their virulence, stability and high infectivity as small-particle aerosols, Marburg and Ebola virus are classified as Category A bioterror agents by the CDC and the National Institute of Allergy and Infectious Diseases (NIAIDs). The occurrence of even a single human infection outside of Africa is therefore a public health emergency requiring immediate investigation, since it could represent the leading edge of an impending outbreak. Marburg and Ebola HF occur naturally only in Central Africa.
ÂÂ No specific therapy is available for patients who have developed Ebola or Marburg HF; care is supportive. ÂÂ Healthcare workers should employ isolation and barrier procedures recommended by the Centers for Disease
Control and Prevention (CDC) the World Health Organization (WHO) when caring for patients with suspected or known filovirus infection.
ÂÂ Platelets count may fall and serum glutamic-oxaloacetic transaminase (SGOT) may be more than serum
glutamic-pyruvic transaminase (SGPT) as seen in dengue fever. ■■■■
206
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
American Family Physician
Parathyroid Disorders THOMAS C. MICHELS, KEVIN M. KELLY
Abstract Disorders of the parathyroid glands most commonly present with abnormalities of serum calcium. Patients with primary hyperparathyroidism, the most common cause of hypercalcemia in outpatients, are often asymptomatic or may have bone disease, nephrolithiasis, or neuromuscular symptoms. Patients with chronic kidney disease may develop secondary hyperparathyroidism with resultant chronic kidney disease-mineral and bone disorder. Hypoparathyroidism most often occurs after neck surgery; it can also be caused by autoimmune destruction of the glands and other less common problems. Evaluation of patients with abnormal serum calcium levels includes a history and physical examination; repeat measurement of serum calcium level; and measurement of creatinine, magnesium, vitamin D, and parathyroid hormone levels. The treatment for symptomatic primary hyperparathyroidism is parathyroidectomy. Management of asymptomatic primary hyperparathyroidism includes monitoring symptoms; serum calcium and creatinine levels; and bone mineral density. Patients with hypoparathyroidism require close monitoring and vitamin D (e.g., calcitriol) replacement.
Keywords: Parathyroid glands, serum calcium, hyperparathyroidism, hypoparathyroidism, parathyroidectomy
T
he four parathyroid glands, located posterior to the thyroid gland, regulate calcium homeostasis through release of parathyroid hormone (PTH). Because most parathyroid disorders present with abnormalities of serum calcium, they commonly appear in differential diagnoses. Therefore, understanding the presentation and principles of evaluation of parathyroid disorders is important in primary care. Pathophysiology
The parathyroid glands respond to low serum calcium levels by releasing PTH, which is an 84-amino acid peptide. PTH increases serum calcium levels through direct action on bone and the kidneys. It stimulates osteoclasts to resorb bone and mobilize calcium into the blood. In the kidneys, PTH acts to reduce calcium clearance and stimulates synthesis of 1,25-dihydroxyvitamin D, which stimulates calcium absorption in the gastrointestinal tract (Figure 1).1,2 In their normal state, the glands function to keep serum calcium levels within a consistent and tightly con trolled range. The glands synthesize and store the PTH, THOMAS C. MICHELS, MD, MPH, is a faculty member in the Madigan Family Medicine Residency Program in the Department of Family Medicine at Madigan Army Medical Center in Tacoma, Wash. KEVIN M. KELLY, MD, MBA, is the director of the Darnall Family Medicine Residency Program at Carl R. Darnall Army Community Hospital, Fort Hood, Tex. At the time this article was written, he was the faculty development fellow with the Madigan Family Medicine Residency Program in the Department of Family Medicine at Madigan Army Medical Center. Source: Adapted from Am Fam Physician. 2013;88(4):249-257.
allowing it to respond within minutes of hypocalcemia. Sustained hypo calcemia leads to cellular replication and increased mass of the glands. Calcium and 1,25-dihydroxyvitamin D provide negative feedback at the parathyroid glands to inhibit PTH release. One normal gland is sufficient for adequate secretion of PTH to maintain normal calcium levels.1,3,4 Parathyroid disorders most commonly present with serum calcium abnormalities. Rarely, patients can present with a neck mass or for evaluation of a family history of para thyroid or related disorders. The estimated incidence of primary hyperparathyroidism is approximately 25 cases per 100,000 persons per year in outpatients of Western countries,5-7 with a prevalence of one to four per 1,000 persons.8 Hypoparathyroidism most commonly occurs after inadvertent damage or removal of parathyroid glands during neck surgery; estimates for the occurrence of this surgical complication range from 0.5% to 6.6%, with higher rates after repeat neck surgery.1,9 Multiple endocrine neoplasia type 1 (MEN-1) and type 2 (MEN-2), which often include parathyroid neoplasia, each occur in about two per 100,000 persons per year.10 Parathyroid cancer is rare, with an incidence of approximately four per 10 million persons per year.11 Hyperparathyroidism
Primary Primary hyperparathyroidism, the most common cause of hypercalcemia in outpatients, is often discovered
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
207
American Family Physician Table 1. Symptoms Associated with Hypercalcemia Organ system
Most common symptoms and possible diagnoses
Cardiovascular
Angina, dyspnea, palpitations, syncope Possible diagnoses: diastolic dysfunction, dysrhythmias, hypertension, left ventricular hypertrophy, vascular calcification
Decreased serum calcium
Gastrointestinal Anorexia, constipation, epigastric pain, nausea, vomiting Possible diagnoses: pancreatitis, peptic ulcer disease
Increased serum calcium
Neuromuscular
Parathyroid glands Bone
Possible diagnoses: corneal calcification, delirium, mild cognitive impairment
Parathyroid hormone
Kidney
Renal
Increased bone resorption
Skeletal
Positive feedback/ stimulation
Information from references 4, 12, and 13.
Increased calcium absorption in the gastrointestinal tract
Figure 1. Control of mineral metabolism by parathyroid hormone (PTH). Calcium-sensing receptors of parathyroid cells respond to serum calcium level and change with increased release (hypocalcemia) or suppression (hypercalcemia) of PTH. PTH stimulates bone resorption, which increases serum calcium and phosphorus. In the kidney, PTH stimulates reabsorption of calcium and promotes phos phorus excretion. PTH also helps convert 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D in the kidneys, which then increases intestinal transport of calcium and phosphorus. Information from references 1 and 2.
incidentally during evaluation of serum electrolyte levels. Before the easily available measurement of serum calcium levels, patients presented with a spectrum of symptoms (Table 1).4,12,13 Most patients today are asymptomatic, with nephrolithiasis occurring in up to 15% of patients, bone disease (formerly osteitis fibrosa cystica) occurring in 2% of patients, and neuromuscular
208
Arthralgia, bone pain, fractures Possible diagnoses: bone disease, insufficiency fractures, osteomalacia, osteoporosis
Intestine
Negative feedback/ decreased activity
Polydipsia, polyuria, renal colic Possible diagnoses: nephrocalcinosis, nephrolithiasis, nephrogenic diabetes insipidus
Increased calcium reabsorption
25-hydroxyvitamin D to 1,25-dihydroxyvitamin D
Anxiety, confusion, depression, fatigue, forgetfulness, impaired vision, insomnia, lethargy, weakness
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
symptoms occurring rarely.3,14,15 Although marked symptoms are uncommon in Western countries, it is important to be aware that subtle and nonspecific symptoms may be present.14-16 Other causes of hypercalcemia are listed in Table 2.3,5,8,17,18 Overall, 85% of patients with primary hyperparathyroidism have a single adenoma. Risk factors for primary hyperparathyroid ism include a history of neck radiation, age older than 50 years, and female sex; women are twice as likely as men to develop primary hyperparathyroidism. Multiglandular hyperplasia accounts for 10% to 15% of patients with primary hyperparathyroidism, and carcinoma accounts for 1% or less. There are also uncommon familial causes, such as MEN-1 and MEN-2A; persons with these conditions may have parathyroid adenomas or asymmetric hyperplasia.8,19
Secondary Secondary hyperparathyroidism most com monly occurs because of decreased levels of 1,25-dihydroxyvitamin D, hyperphosphatemia, and hypocalcemia in the setting of chronic kidney
American Family Physician Table 2. Causes of Hypercalcemia
Evaluation
Parathyroid hormone–dependent
Primary hyperparathyroidism is diagnosed when the serum calcium level is elevated, with an increased or inappropriately normal serum PTH level. An algorithm for the evaluation of patients with suggestive symptoms or asymptomatic hypercalcemia is shown in Figure 2.2,4,8,10,21-23 Hypercalcemia should be verified, and vitamin D levels should be measured and determined to be adequate before parathyroid disorder is considered.18 In patients with hypercalcemia, the PTH level distinguishes PTH-mediated from non– PTH-mediated hypercalcemia. A physical examination is important to identify subtle features consistent with hyperparathyroidism and to assist in the differential diagnosis (Table 3).1,4,8,24
Primary hyperparathyroidism Familial hypocalciuric hypercalcemia Lithium-associated Tertiary hyperparathyroidism Genetic disorders (e.g., multiple endocrine neoplasia type 1 or type 2A, familial hyperparathyroidism) Parathyroid hormone–independent Renal failure, acute or chronic* Neoplasms Parathyroid hormone–related protein dependent Osteolytic metastases and multiple myeloma Other humoral syndromes Excess vitamin D Ingested or topical vitamin D analogues Granulomatous disease Williams syndrome Other endocrine diseases: thyrotoxicosis, adrenal insufficiency Drugs: vitamin A intoxication, milk-alkali syndrome, thiazide diuretics, theophylline Other: immobilization, Jansen disease Note: Causes are listed in order of clinical importance. *Renal failure is typically associated with hypocalcemia unless patients with acute kidney injury have concomitant rhabdomyolysis, and unless patients with chronic kidney disease develop tertiary hyperparathyroidism. Information from references 3, 5, 8, 17, and 18.
disease. Other causes include vitamin D deficiency secondary to low dietary intake, lack of sun exposure, malabsorption, liver disease, and other chronic illness.20 In some patients with advanced renal failure, hypercalcemia is due to progres sion from appropriate parathyroid hyperplasia to autonomous overproduction of PTH, a disorder termed tertiary hyperparathyroidism.12,20 Patients with normocalcemic hyperparathyroidism may present with low bone density, osteoporosis, or a fragility fracture. Many of these patients will probably evolve into having hyperparathyroidism, although the exact natural history is not known. It is important to exclude vitamin D deficiency and chronic kidney disease before making this diagnosis.8,15
Other tests listed in Figure 2 should identify patients with primary hyperparathyroidism.2,4,8,10,21-23 Familial hypocalciuric hypercalcemia results from an inactivating mutation of the calcium-sensing receptor gene, and patients with this disorder require a higher level of calcium to suppress PTH secretion; they may present with high calcium levels, normal or elevated PTH levels, and low urinary calcium secretion.8 Referral to an endocrinologist (or other specialist if an eti ology for hypercalcemia other than primary hyperparathyroidism is found) is often indicated after this stepwise evaluation.
Indications for Surgery Patients with primary hyperparathyroidism and symptoms or signs should undergo surgical removal of their parathyroid gland(s).25,26 In some patients, medical comorbidities may preclude surgery, and controlling hypercal cemia alone may be the goal. In this situation, the calcimimetic cinacalcet (Sensipar) effectively lowers serum calcium levels, but does not affect bone density.27,28 Age alone should not preclude parathyroidectomy.29 The role of surgery in patients with asymptomatic primary hyperparathyroidism is not as clear. Younger patients and patients at risk of progression to symptomatic disease are the best candidates for parathyroidectomy. Recommendations from the Third International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism include performing parathyroidectomy in asymptomatic persons with primary hyperparathyroidism and any one of the following26: ÂÂ Serum calcium level greater than 1.0 mg per dL
(0.25 mmol per L) above the upper limit of normal
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
209
American Family Physician Evaluation of Hypercalcemia Symptoms*
Incidental laboratory finding
Hypercalcemia Serum albumin, ionized calcium, corrected calcium levels† Verified hypercalcemia
Immediate treatment if severe‡
History and physical examination§ Measure vitamin D||, magnesium, creatinine, PTH levels
Specific cause identified, such as chronic kidney disease-mineral and bone disorder¶, medications**
PTH level normal or high (PTHdependent hypercalcemia) Calcium/creatinine ratio with 24-hour urine collection
Elevated ratio ( > 0.01)
Low ratio (≤ 0.01)
PTH level low (< 20 pg per mL [20 ng per L]; PTH-independent hypercalcemia) Measure PTHrp, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D levels
Primary hyperparathyroidism Familial hypocalciuric Risk factors for multiple endocrine hypercalcemia †† neoplasia, carcinoma? Yes
No
Gene analysis, other hormone evaluation Localization studies, bone mineral density measurement, renal ultrasonography‡‡
Elevated PTHrp level Obtain history and perform physical examination if not done Perform common laboratory testing (e.g., complete blood count, liver profile); chest radiography; mammography; abdominal and chest computed tomography; serum/urine immunoelectrophoresis; bone scan Elevated 1,25-dihydroxyvitamin D level Chest radiography (e.g., lymphoma, sarcoid)
Elevated 25-hydroxyvitamin D level Check medications, including vitamins and herbal medications (e.g., vitamin D toxicity) Normal PTHrp and vitamin D levels Perform other tests, such as serum protein electrophoresis; urine protein electrophoresis; measurement of thyroid-stimulating hormone, vitamin A, or cortisol levels Possible causes include immobilization, vitamin A toxicity, milk-alkali syndrome
Figure 2. Algorithm for evaluating patients with hypercalcemia. PTH = Parathyroid hormone; PTHrp: Parathyroid hormone–related peptide. *See Table 1. †Ideal laboratory testing should be performed with the patient fasting and with minimal venous occlusion. Corrected serum calcium = measured serum calcium + 0.8(4 – measured serum albumin); calcium is measured in mg per dL, and albumin is measured in g per dL. ‡Management of parathyroid crisis or severe hypercalcemia (calcium level > 14 mg per dL [3.50 mmol per L]) includes volume repletion with normal saline (usually 2 to 4 L per day) and bisphosphonates (usually intravenous pamidronate). Calcitonin and other agents can be used, but they are not first-line therapy. §See Table 3. ||Vitamin D deficiency: 25-hydroxyvitamin D level < 20 ng per mL (50 nmol per L). ¶Includes renal osteodystrophy and other disorders of mineralization. **Most commonly thiazide diuretics and lithium. Thiazide diuretic–related hypercalcemia is typically mild and may take two weeks to resolve. For a review of the effects of lithium, see: Saunders BD, Saunders EF, Gauger PG. Lithium therapy and hyperparathyroidism: an evidence-based assessment. World J Surg. 2009;33(11):2314-2323. Vitamin D deficiency (25-hydroxyvitamin D level < 20 ng per mL) and hypomagnesemia should be corrected. ††Risk factors for multiple endocrine neoplasia are positive family history, prior pancreatic or pituitary tumor in the index patient, multiple or recurrent parathyroid tumors, male sex, and younger age. Patients with parathyroid carcinoma usually present with symptoms from marked hypercalcemia and very high PTH levels; these patients may have a neck mass. ‡‡Choice of localization studies is institution-specific; sestamibi scans and ultrasonography are most commonly used. Renal imaging with plain radiography or ultrasonography is indicated only when nephrolithiasis is suspected. Information from references 2, 4, 8, 10, and 21 through 23.
210
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
American Family Physician Table 3. Physical Examination Findings in Persons with Parathyroid Disorders System
Finding
Possible cause(s)
Abdominal
Flank pain, tenderness
Nephrolithiasis from hypercalcemia
Epigastric pain, tenderness
Pancreatitis from hypercalcemia, or causing hypocalcemia
Hypotension
Hypocalcemia
Hypertension
Hypercalcemia
Irregular heartbeat
Dysthymia from hypo- or hypercalcemia
Rales, edema, third heart sound
Congestive heart failure or systolic or diastolic dysfunction from hypo- or hypercalcemia
Dry, puffy skin
Hypocalcemia
Dry, brittle hair
Hypocalcemia
Candidiasis
Polyglandular autoimmune syndrome with hypoparathyroidism
Chvostek sign
Hypocalcemia
Trousseau sign
Hypocalcemia
Emotional instability, anxiety, depression
Hypo- or hypercalcemia
Cognitive dysfunction, dementia
Hypo- or hypercalcemia
Lethargy, delirium, coma
Hypercalcemia
Muscle weakness
Hypercalcemia
Movement disorders, parkinsonism
Hypocalcemia
Other: head, ears, eyes, nose, and throat
Neck mass or lymphadenopathy
Granulomatous disease, parathyroid cancer, large parathyroid adenoma
Other: ophthalmologic
Cataract
Hypocalcemia
Band keratopathy
Hypercalcemia
Cardiovascular
Dermatologic
Neuromuscular
Information from references 1, 4, 8, and 24.
ÂÂ Creatinine clearance less than 60 mL per minute
per 1.73
m2
(1 mL per second per
m2)
ÂÂ Bone mineral density T-score of less than –2.5 at
any one of three sites (i.e., hip, spine, or wrist) and/or any previous fragility fracture (z scores should be used in premenopausal women and in men younger than 50 years)
ÂÂ Age younger than 50 years
In one study, 15% of asymptomatic patients developed an indication for surgery over an average of 4.7 years.6 Asymptomatic persons with primary hyperpara thyroidism and osteoporosis or osteopenia are candi dates for parathyroidectomy because bone density and fracture risk improve after surgery. Bone density, but not fracture risk, has also been shown to improve after bisphosphonate therapy and hormone therapy in these patients.27 The relationship between neurocognitive function and primary hyperparathyroidism is
somewhat controversial, but some studies show improvement in neurocognitive function after parathyroidectomy.16,27,30,31 Other reviews conclude that surgery and medical management improve bone density; however, there were no differences in quality of life.32,33 If patients with primary hyperparathyroidism do not undergo parathyroidectomy, they should be closely monitored for the development of symptoms or other indications for surgery. These patients should have serum calcium and creatinine levels measured annually, and three-site (i.e., hip, spine, and forearm) bone density measurement every one to two years (PTH has a catabolic effect on cortical bone, and this change may only be evident in the distal forearm).15,26 The management of secondary hyperparathyroidism in chronic kidney disease usually involves consultation with a nephrologist. Protein restriction and calcium
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
211
American Family Physician
Evaluation of Hypocalcemia Symptoms*
Laboratory evaluation done for other reasons
Hypocalcemia
Serum magnesium, albumin, ionized calcium, corrected calcium levels†
Correct hypo- or hypermagnesemia
Immediate treatment if symptomatic‡
Verified hypocalcemia
Serum phosphorus, creatinine, PTH, 25-hydroxyvitamin D levels§
Patient and family history, physical examination||
Suspect underlying cause¶
Elevated creatinine level
PTH level elevated
PTH level normal or low
Chronic kidney diseasemineral and bone disorder** Phosphorus level low or Phosphorus level high or lower limit of normal upper limit of normal Low vitamin D level
Vitamin D deficiency
Pseudohypoparathyroidism
Calcium/creatinine ratio with 24-hour urine collection
High
Calcium-sensing receptor abnormality
Low Hypoparathyroidism
Figure 3. Algorithm for evaluating patients with hypocalcemia. PTH = Parathyroid hormone *See Table 6. †Ideal
laboratory testing should be performed with the patient fasting and with minimal venous occlusion. Corrected serum calcium = measured serum calcium + 0.8(4 – measured serum albumin); calcium is measured in mg per dL, and albumin is measured in g per dL. ‡Calcium
gluconate, 1 to 2 g intravenously slowly over 10 minutes, with clinical and electrocardiographic monitoring, followed by slow infusion (10 g of calcium gluconate in 1 L of dextrose 5% at 1 to 3 mg per kg per hour). §See
Table 7.
||See ¶See
Table 3.
Table 5.
**Includes renal osteodystrophy and other disorders of mineralization. Information from references 1 through 4, and 24.
212
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
American Family Physician supplementation have been shown to decrease the development of this complication, with a reduction in death from renal causes. Vitamin D supplements and calcimimetics, which inhibit PTH secretion, have been shown to improve biochemical markers (without patient-oriented outcomes). There are several evidencebased reviews for managing chronic kidney diseasemineral and bone disorder; full discussion of these guidelines is beyond the scope of this article and is available from this referenced source.34 Hypoparathyroidism Hypoparathyroidism most commonly occurs after inadvertent damage or removal of parathyroid glands during neck surgery. It can occur years after neck surgery.1 Most head and neck surgeons carefully track this complication with intra- and postoperative monitoring of calcium and PTH levels.31 Autoimmune parathyroid destruction, either isolated or as part of a multiple endocrine deficiency syndrome, is another important cause of hypoparathyroidism. Rarely, there is tissue resistance to the actions of PTH, which results in a picture of hypoparathyroidism but with elevated PTH levels. This is termed pseudohypoparathyroidism, and it is a genetically heterogeneous condition.1,24 These and other causes of hypoparathyroidism are listed in Table 4.1,3,24
Table 4. Causes of Hypoparathyroidism Mechanism Comment Destruction of parathyroid tissue Postsurgical Most common form of hypoparathyroidism Postradiation Rare complication Autoimmune May be associated with other endocrine insufficiencies Metastatic infiltration Case reports Heavy metal deposition Iron deposition in 10% of persons with thalassemia Reversible impairment in parathyroid hormone secretion or action Hypomagnesemia Chronic illness, drugs, acidosis Hypermagnesemia Tocolytic therapy, magnesium supplementation Resistance to parathyroid hormone action Pseudohypoparathyroidism — Genetic disorders of parathyroid hormone synthesis Note: Causes are listed in order of clinical importance. Information from references 1, 3, and 24.
Most patients with hypoparathyroidism present with hypocalcemia. Figure 3 is an algorithm for evaluating patients with symptomatic or incidentally discovered hypocalcemia.1-4,24 In some patients, such as those with acute pancreatitis, sepsis, or other critical illness, the cause of hypocalcemia is apparent, and treatment without full evaluation is warranted. Table 5 lists causes of hypocalcemia based on clinical clues.1,24 Symptoms associated with hypocalcemia depend on the severity, duration, and rate of development; com mon symptoms are listed in Table 6.1,3,24 Physical find ings are listed in Table 3.1,4,8,24 It is important to ensure repletion to normal levels of vitamin D and magnesium
Table 5. Causes of Hypocalcemia Based on Clinical Clues Cause Acute illness: pancreatitis, tumor lysis, severe illness Autoimmune disease Family history of hypocalcemia Limited ultraviolet light exposure or poor dietary intake Malabsorption syndrome Neck surgery Renal disease
Result Secondary hyperparathyroidism from low circulating calcium levels Autoimmune parathyroid gland destruction Genetic defects in calcium-sensing receptor or parathyroid hormone secretion Vitamin D deficiency
Vitamin D deficiency Low or absent parathyroid hormone with parathyroid gland removal Secondary hyperparathyroidism
Information from references 1 and 24.
Table 6. Symptoms Associated with Hypocalcemia Organ system Cardiovascular
Neurologic
Neuromuscular
Most common symptoms and possible diagnoses Dyspnea, edema, palpitations, syncope Possible diagnoses: dysrhythmia, prolonged corrected QT interval, systolic dysfunction Headache, impaired vision, neuropsychiatric symptoms Possible diagnoses: premature cataracts, pseudotumor cerebri Circumoral numbness and paresthesias; cramping, muscle twitching, spasms; seizures Possible diagnosis: carpopedal spasm
Information from references 1, 3, and 24.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
213
American Family Physician Table 7. Laboratory Evaluation of Hypocalcemia Condition
Level Parathyroid hormone
Phosphorus
25-hydroxyvitamin D 1,25-dihydroxyvitamin D
Low
Elevated
Normal
Normal or low
Calcium-sensing receptor activating mutation Normal or low
Elevated
Normal
Normal
Parathyroid hormone resistance (pseudohypoparathyroidism)
Elevated
Elevated
Normal
Normal
Vitamin D deficiency
Elevated
Low or normal
Low
Normal or elevated
Chronic kidney disease
Elevated
Elevated
Normal
Low
Hypoparathyroidism
Information from reference 22.
in these patients. Serum levels of PTH, phosphorus, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D can help differentiate between disorders causing hypocalcemia (Table 7).22 Figure 3 provides brief recommendations for the immediate treatment of severe hypocalcemia1-4,24; a detailed discussion is beyond the scope of this article. Long-term management of hypoparathyroidism should include at least initial involvement of an endocrinolo gist. Vitamin D analogues are essential (e.g., calcitriol), and thiazide diuretics and dietary modification are typically used as well. PTH therapy has been studied, but data are limited and PTH preparations are not approved by the U.S. Food and Drug Administration for this purpose.1,35 Other Parathyroid Disorders Some patients present to their physician after a family member has been diagnosed with MEN. MEN-1 includes neoplasias of the parathyroid, pancreas, pituitary, and adrenal glands. MEN-2 includes neoplasias of the thy roid, adrenal, and parathyroid glands. MEN-2A involves medullary thyroid carcinoma, pheochromocytoma, and parathyroid tumors. The issue of screening family mem bers for MEN-1 is controversial because presymptomatic detection has not been shown to reduce morbidity or mortality. Because hyperparathyroidism is common in persons with MEN-1 (80% to 100%), it is reasonable to screen with measurement of serum calcium levels alone. Others advocate screening with measurement of calcium and PTH levels annually, starting at eight years of age.19 A discussion with the affected patient and family about screening is warranted. In a family with a history of MEN-2, a sample from one patient already affected should be tested to determine the
214
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
specific genetic mutation for that family. When a mutation is found, all persons of unknown status in that family should then be definitively genotyped.10,21 Rarely, patients with parathyroid disorders may present with a neck mass, either self-reported or as an incidental finding on examination. Parathyroid cancer, hyperplasia, adenomas, and cysts could all present in this way. Other neck tumors, including primary or metastatic cancers, are more common than parathyroid causes. Ultrasonography, computed tomography, and biopsy are typically required to determine the diagnosis.36 REFERENCES 1. Shoback D. Clinical practice. Hypoparathyroidism. N Engl J Med. 2008;359(4):391-403. 2. Stack BC, Randolph G. Parathyroid disease: Investigations. In: Arora A, Tolley NS, Tuttle RM, eds. A Practical Manual of Thyroid and Parathyroid Disease. Chichester, UK: Wiley-Blackwell; 2010:164-73. 3. Bringhurst FR, Demay MB, Kronenberg HM. Hormones and disorders of mineral metabolism. In: Larsen PR, Kronenberg HM, Melmed S, Polonsky KS, eds. Williams Textbook of Endocrinology. 10th ed. Philadelphia, Pa.: Saunders; 2003:1303-1348. 4. Stearns M, Cox J. Parathyroid disease: symptoms, differential diagnosis, and management. In: Arora A, Tolley NS, Tuttle RM, eds. A Practical Manual of Thyroid and Parathyroid Disease. Chichester, UK: WileyBlackwell; 2010:145-163. 5. Suliburk JW, Perrier ND. Primary hyperparathyroidism. Oncologist. 2007;12(6):644-653. 6. Yu N, Leese GP, Smith D, Donnan PT. The natural history of treated and untreated primary hyperparathyroidism: the parathyroid epidemiology and audit research study. QJM. 2011;104(6):513-521. 7. Wermers RA, Khosla S, Atkinson EJ, Hodgson SF, O’Fallon WM, Melton LJ III. The rise and fall of primary hyperparathyroidism: a population-based study in Rochester, Minnesota, 1965-1992. Ann Intern Med. 1997; 126(6):433-440.
American Family Physician 8. Pallan S, Khan A. Primary hyperparathyroidism: Update on presentation, diagnosis, and management in primary care. Can Fam Physician. 2011;57(2):184-189. 9. McGinn JD. Prevention of complications in revision endocrine surgery of the head & neck. Otolaryngol Clin North Am. 2008;41(6):1219-1230, xi. 10. Brandi ML, Gagel RF, Angeli A, et al. Guidelines for diagnosis and therapy of MEN type 1 and type 2. J Clin Endocrinol Metab. 2001;86(12): 5658-5671. 11. Sharretts JM, Kebebew E, Simonds WF. Parathyroid cancer. Semin Oncol. 2010;37(6):580-590. 12. Taniegra ED. Hyperparathyroidism. Am Fam Physician. 2004;69(2):333-339. 13. Silverberg SJ, Bilezikian JP. The diagnosis and management of asymp tomatic primary hyperparathyroidism. Nat Clin Pract Endocrinol Metab. 2006;2(9):494-503. 14. Lendel I, Horwith M. An update from the latest workshop on asymp tomatic primary hyperparathyroidism. Otolaryngol Clin North Am. 2004;37(4):737-749, viii. 15. Marcocci C, Cetani F. Clinical practice. Primary hyperparathyroidism [published correction appears in N Engl J Med. 2012;366(22):2138]. N Engl J Med. 2011;365 (25):2389-2397. 16. Mikhail N. Clinical significance of vitamin D deficiency in primary hyperparathyroidism, and safety of vitamin D therapy. South Med J. 2011;104(1):29-33. 17. Eastell R, Arnold A, Brandi ML, et al. Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab. 2009;94(2):340-350. 18. Sharma B, Misicko NE, Hitchcock K, Neher JO. Clinical inquiries. How should you evaluate elevated calcium in an asymptomatic patient? J Fam Pract. 2008;57(4):267-269. 19. Malone JP, Srivastava A, Khardori R. Hyperparathyroidism and multiple endocrine neoplasia. Otolaryngol Clin North Am. 2004;37(4):715-736, viii. 20. Ahmad R, Hammond JM. Primary, secondary, and tertiary hyperparathyroidism. Otolaryngol Clin North Am. 2004;37(4):701-713, vii-viii. 21. Marsh DJ, Gimm O. Multiple endocrine neoplasia: types 1 and 2. Adv Otorhinolaryngol. 2011;70:84-90. 22. Fuleihan GE, Silverberg SJ. Diagnosis and differential diagnosis of primary hyperparathyroidism. UpToDate. February 11, 2011. http://www.uptodate.com/contents/ diagnosis-and-differential-diagnosis-of-primaryhyperparathyroidism [subscirption required]. Accessed May 4, 2012. 23. Cheung K, Wang T, Farrokhyar F, Roman S, Sosa J. A meta-analysis of preoperative localization techniques for patients with primary hyperparathyroidism. Ann Surg Oncol. 2012;19(2):577-583.
24. Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia [published correction appears in BMJ. 2008;336(7659). http://www.bmj.com/content/ 336/7659/0.2. Accessed August 2, 2012]. BMJ. 2008; 336(7656):1298-1302. 25. Khan AA, Bilezikian JP, Potts JT Jr.; Guest Editors for the Third International Workshop on Asymptomatic Primary Hyperparathyroidism. The diagnosis and management of asymptomatic primary hyperparathyroidism revisited. J Clin Endocrinol Metab. 2009;94(2): 333-334. 26. Bilezikian JP, Khan AA, Potts JT Jr.; Third International Workshop on the Management of Asymptomatic Primary Hyperthyroidism. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. J Clin Endocrinol Metab. 2009;94(2):335-339. 27. Khan A, Grey A, Shoback D. Medical management of asymptomatic primary hyperparathyroidism: proceedings of the Third International Workshop. J Clin Endocrinol Metab. 2009;94(2):373-381. 28. Dillon ML, Frazee LA. Cinacalcet for the treatment of primary hyperparathyroidism. Am J Ther. 2011;18(4): 313-322. 29. Stechman MJ, Weisters M, Gleeson FV, Sadler GP, Mihai R. Parathyroidectomy is safe and improves symptoms in elderly patients with primary hyperparathyroidism (PHPT). Clin Endocrinol (Oxf). 2009;71(6):787-791. 30. Velasco PJ, Manshadi M, Breen K, Lippmann S. Psychiatric aspects of parathyroid disease. Psychosomatics. 1999;40(6):486-490. 31. Udelsman R, Pasieka JL, Sturgeon C, Young JE, Clark OH. Surgery for asymptomatic primary hyperparathyroidism: proceedings of the Third International Workshop. J Clin Endocrinol Metab. 2009;94(2):366-372. 32. Bollerslev J, Jansson S, Mollerup CL, et al. Medical observation, compared with parathyroidectomy, for asymptomatic primary hyperparathyroidism: a prospective, randomized trial. J Clin Endocrinol Metab. 2007;92(5):1687-1692. 33. Sankaran S, Gamble G, Bolland M, Reid IR, Grey A. Skeletal effects of interventions in mild primary hyperparathyroidism: a meta-analysis. J Clin Endocrinol Metab. 2010;95(4):1653-1662. 34. Brancaccio D, Cozzolino M. CKD-MBD: an endless story. J Nephrol. 2011;24(suppl 18):S42-S48. 35. Waldegger L, Cranney A, Adachi JD, Tugwell P, Wells G. Human parathyroid hormone for the treatment of osteoporosis in post-menopausal women. Cochrane Database Syst Rev. 2001;(2):CD003111. 36. Schwetschenau E, Kelley DJ. The adult neck mass. Am Fam Physician. 2002;66(5):831-838.
■■■■
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
215
American Family Physician
Practice Guidelines ACS Releases Updated Guidelines on Cancer Screening The American Cancer Society (ACS) has released its annual update of guidelines for cancer screening, with recommendations covering cancers of the breast, cervix, colon and rectum, and prostate. For each cancer site, the guidelines address the affected population, associated tests or procedures, and the appropriate frequency of screening for average-risk, asymptomatic persons.
Breast Cancer Early detection of breast cancer in average-risk women includes a combination of regular clinical breast exami nation and counseling, and mammography. Women between 20 and 39 years of age should undergo clinical breast examination every three years, and then annu ally beginning at 40 years of age. During clinical breast examination, physicians should discuss with patients the importance of recognizing breast changes. This is also an opportunity to emphasize an awareness of any family history of breast or ovarian cancers in firstand second-degree relatives. Physicians should discuss breast self-examination with patients, and explain the potential benefits, limitations, and harms associated with it. Breast self-examination may be performed regularly, occasionally, or not at all. If women choose to perform breast self-examination, physicians should instruct them on the proper technique. Annual mammography should begin at 40 years of age in average-risk women. Physicians should inform patients about the benefits of detecting breast cancer before symptoms develop, and that the balance of ben efits to harms supports regular mammography. Benefits include a reduction in the risk of dying from breast cancer and, if cancer is detected early, less aggressive surgery (i.e., lumpectomy versus mastectomy), less aggressive adjuvant therapy, and more treatment options. The limitations of mammography include the inability to detect all cancers and that some cancers detected will have a poor prognosis. Possible harms from breast cancer screening include false-positive results, the need for biopsy, and the detection of
Source: Adapted from Am Fam Physician. 2012;86(6):571-576.
216
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
cancer that is not progressive (i.e., the cancer would not have been detected in the patient’s lifetime). Mammography should be continued as long as the patient is in good health and would be a candidate for breast cancer treatment. The decision to stop screening should be based on the individual patient; there is no definite upper age at which mammography should be discontinued.
Cervical Cancer Screening for cervical cancer depends on a woman’s age, screening history, risk factors, and choice of screening tests. Women at average risk should begin screening by 21 years of age or approximately three years after first vaginal intercourse, regardless of whether they have received the human papillomavirus (HPV) vaccination. Annual screening with conventional cytology or biennial screening with liquid-based cytology is recommended until 30 years of age. Women older than 30 years who have had three consecutive normal screening test results may choose to be screened every two to three years with conventional or liquid-based cytology, or to be screened every three years with combination HPV DNA testing and conventional or liquid-based cytology. Physicians should explain to patients who undergo HPV DNA testing that HPV infection usually is not detectable or harmful; infection is common in most persons who have had sexual intercourse; a positive result does not indicate the presence of cancer; and many women with HPV infection will not develop advanced cervical neoplasia. Screening should continue in women with an intact cervix until 70 years of age, but may be stopped if test results have been normal in the previous 10 years, and if there is documentation of three consecutive normal Papanicolaou test results.
Colorectal Cancer Average-risk adults should undergo colorectal cancer screening beginning at 50 years of age using one of the following options: (1) annual high-sensitivity guaiac fecal occult blood testing (FOBT) or fecal immuno chemical testing, (2) testing stool for exfoliated cell DNA (screening interval is uncertain), (3) flexible sigmoidoscopy every five years, (4) colonoscopy every 10 years, (5) double-contrast barium enema every five
American Family Physician years, or (6) computed tomography colonography every five years. The first two screening options detect cancer, whereas the other four options detect cancer and advanced adenomas. Another acceptable option is annual testing with guaiac FOBT or fecal immunochemical testing with flexible sigmoidoscopy every five years. In-office single-panel guaiac FOBT using a stool sample collected during digital rectal examination is not recommended because of its low sensitivity for advanced adenomas and cancer. The newer, high-sensitivity guaiac FOBT (e.g., Hemoccult SENSA) or fecal immunochemical testing should replace older, lower-sensitivity versions of the guaiac test (e.g., Hemoccult II). Physicians should emphasize that at-home testing with guaiac FOBT or fecal immu nochemical testing requires a commitment to following the manufacturer’s instructions for specimen collection. When performed correctly, these methods can reduce the risk of developing and dying from colorectal cancer, with effectiveness similar to colonoscopy.
Prostate Cancer Screening for prostate cancer should not be performed without an informed decision-making process. Men who have at least a 10-year life expectancy should have a discussion with their physician about the benefits, risks, and uncertainties of prostate cancer screening with digital rectal examination and prostate-specific antigen (PSA) testing. Men at average risk should be informed about their screening options beginning at 50 years of age, whereas men at higher risk (e.g., blacks, men with a family history of prostate cancer before 65 years of age) should be informed beginning at 45 years of age. Men with multiple family members diagnosed with prostate cancer before 65 years of age should be informed beginning at 40 years of age. If a patient cannot decide whether to be tested, the physician can make the decision based on his or her knowledge of the patient’s preferences and values. Prostate cancer screening should not be offered to asymptomatic men who have a life expectancy of less than 10 years based on age and health status. For men who choose to be screened, PSA testing is recommended, with or without a digital rectal
examination. Men with a PSA level less than 2.5 ng per mL (2.5 mcg per L) may be screened every two years, whereas men with a PSA level of 2.5 ng per mL or greater should be screened annually. A PSA level of 4.0 ng per mL (4.0 mcg per L) or greater has been used to refer patients for further evaluation or biopsy, which is reasonable in men at average risk of prostate cancer. In patients with a PSA level between 2.5 and 4.0 ng per mL, physicians should use an individualized risk assessment to determine the next step.
Endometrial, Lung, and Ovarian Cancers There is insufficient evidence to recommend screening for endometrial cancer in women at average risk. At the time of menopause, women at average risk should be informed about the risks and symptoms (e.g., unexpected bleeding and spotting). Women who experience these symptoms should be encouraged to report them to their physician. Several organizations are in the process of reviewing evidence to determine the potential benefits and harms of screening for lung cancer with low-dose computed tomography. There is insufficient evidence to indicate whether screening for early ovarian cancer detection is effective using any of the following methods: pelvic examination, cancer antigen 125 as a tumor marker, transvaginal ultrasonography, or multimarker panels and bioinfor matics analysis of proteomic patterns.
Cancer-Related Checkup In men and women 20 years and older, a preventive health examination provides an opportunity for physicians to screen for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin. This is also an opportunity for physicians to educate patients about self-examination techniques or increased awareness of the signs and symptoms of skin, breast, and testicular cancers. Additional counseling may be given on smoking cessation, sun exposure, diet and nutrition, physical activity, sexual practices, and environmental and occupational exposures.
■■■■
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
217
American Family Physician
Photo Quiz Spontaneous Hematomas A 61-year-old woman presented with easy bruising that had progressed to spontaneous development of painful bruises covering approximately 10 percent of her body. The symptoms began one month earlier. She had a history of depression, migraines, coronary artery disease, and two transient ischemic attacks. She had been taking the same regimens of butalbital/ aspirin/caffeine, prescribed and over-the-counter aspirin, and clopidogrel for years, but had recently started desvenlafaxine for refractory depression. She did not have recent illness, fevers, or other pain. Physical examination revealed large, diffuse hematomas on all aspects of her body (Figures 1 and 2). The hematomas appeared spontaneously and rapidly with minimal pressure. Complete blood count was unremarkable.
Figure 1.
Question Based on the patient’s history and physical examination findings, which one of the following is the most likely diagnosis? A. Hemophilia. B. Iatrogenic coagulopathy. C. Physical abuse. D. Senile purpura. E. Thrombocytopenic purpura.
Figure 2.
SEE THE FOLLOWING PAGE FOR DISCUSSION.
Source: Adapted from Am Fam Physician. 2013;87(5):371-372.
218
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
American Family Physician Discussion The answer is B: iatrogenic coagulopathy. Coagulopathy with clopidogrel and aspirin is well described.1,2 Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) may increase bleeding in patients who are on concurrent antiplatelet therapy.3 Newer formulations of SSRIs and SNRIs have been developed to reduce adverse effects and drug-drug interactions,4 but they may not reduce the bleeding risk. As the use of these medications increases, it is important to recognize their potential interactions with antiplatelet medications. Patients should be monitored closely for bleeding risk, particularly at initiation and dosage changes. Treatment is the discontinuation of one of the medications. Hemophilia is a group of genetic disorders associated with decreased coagulation.5 The spectrum of hemophilia runs from mild (typically occurs only after surgery or trauma) to severe (often evident at birth). Moderate disease can present later in life with spontaneous bleeding, but this is rare. Hemophilia typically leads to hemarthrosis, causing pain in weightbearing joints. Physical abuse of older persons is common, and can present as unexplained bruises or welts.6 Other signs
Summary Table Condition
Characteristics
Hemophilia
Onset at birth or after surgery or trauma; typically leads to hemarthrosis, causing pain in weight-bearing joints
Iatrogenic coagulopathy
May occur with therapeutic dose of any antiplatelet therapy; more common with changes in dosage or addition of interactive medications; selective serotonin reuptake inhibitors should be considered as etiology of platelet dysfunction
Physical abuse
Unexplained bruises, often with malnutrition, open sores, dehydration, sudden patchy hair loss, or unexplained fractures
Senile purpura
Dark, irregularly shaped hemorrhagic areas; typically limited to extensor surfaces of hands and arms in older persons
Thrombocytopenic purpura
Acute idiopathic form typically presents in children and adolescents after a viral illness; thrombotic form often is associated with other symptoms, including neurologic findings, decreased renal function, and fever
include malnutrition, open sores, dehydration, sudden patchy hair loss, and unexplained fractures.7 Other clinical signs and spontaneous bruising would not be present. Senile purpura appears as dark, irregularly shaped hemorrhagic areas caused by abnormal skin elasticity and mobility that lead to tearing of small, superficial blood vessels.8 These hemorrhagic areas are typically limited to the extensor surfaces of the hands and arms. The condition is associated with aging because of gradual atrophy of the perivascular connective tissue on the extensor surfaces of the hands and arms. Thrombocytopenic purpura can be idiopathic or have a thrombotic etiology.9,10 Both types are characterized by thrombocytopenia, and patients may have a history of recent viral infection, upper respiratory tract illness, malignancy, or use of antiplatelet drugs. The acute idiopathic type is rare in adults, and the thrombotic type typically is accompanied by other clinical signs, including neurologic findings, decreased renal function, and fever. Diagnosis can be excluded with a normal platelet count or possibly the absence of supporting clinical evidence. REFERENCES 1. Plavix (clopidogrel bisulfate) tablets [prescribing information]. Bridgewater, N.J.: Bristol-Myers Squibb/ Sanofi Pharmaceuticals Partnership; 2011. http://products. sanofi-aventis.us/plavix/plavix.html. Accessed April 26, 2011. 2. McQuaid KR, Laine L. Systematic review and metaanalysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Am J Med. 2006;119(8):624-638. 3. Reeves RR, Wise PM, Cox SK. SSRIs & the risk of abnormal bleeding. J Psychosoc Nurs Ment Health Serv. 2007;45(4):15-21. 4. Kamath J, Handratta V. Desvenlafaxine succinate for major depressive disorder: a critical review of the evidence. Expert Rev Neurother. 2008;8(12):1787-1797. 5. Franchini M, Favaloro EJ, Lippi G. Mild hemophilia A. J Thromb Haemost. 2010;8(3):421-432. 6. Swagerty DL Jr, Takahashi PY, Evans JM. Elder mistreatment. Am Fam Physician. 1999;59(10):2804-2808. 7. Administration on Aging; National Center on Elder Abuse. http://www.ncea.aoa.gov. Accessed April 26, 2011. 8. Harrison TR. Harrison’s Principles of Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005:680. 9. Aster RH, Bougie DW. Drug-induced immune thrombocytopenia. N Engl J Med. 2007;357(6):580-587. 10. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med. 2002;346(13):995-1008.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
219
anesthesiology
Perioperative Laryngospasm in Children Sudivya Sharma
Abstract Pediatric laryngospasm is an anesthetic emergency. The incidence is twice that of adults in older children and three times that of adults in younger children. It is a protective reflex closure of the glottis as a result of abnormal stimulus. Risk factors for laryngospasm can be classified into three categories: Patient-related, surgery-related and anesthesia-related. A high-degree of ‘situation awareness’ on the part of the anesthetist facilitates the early diagnosis of laryngospasm. It occurs during anesthesia for two reasons: Firstly, a lack of inhibition of glottic reflexes because of inadequate central nervous system depression and secondly increased stimuli. It presents as inspiratory stridor, airway obstruction, increased inspiratory efforts, tracheal tug, paradoxical chest and abdominal movements, desaturation, bradycardia and/or central cyanosis. Persistent laryngospasm can lead to negative pressure pulmonary edema and pulmonary aspiration. We discuss the diagnosis, management and prevention of laryngospasm. In addition, we talk about the controversy of deep versus awake extubation and its implication in postoperative respiratory complications.
Keywords: Laryngospasm, extubation, stridor, edema, aspiration, anesthesia
L
aryngospasm is a protective reflex closure of the glottis as a result of abnormal stimulus.1 Most of the time, the resulting hypoxia abolishes the reflex and the spasm tends to be self-limited.2-4 However, in rare occasions, serious morbidity such as cardiac arrest, arrhythmia, pulmonary edema, bronchospasm or aspiration may ensue.4-7 The incidence of laryngospasm in pediatric population ranges from 0.04 to 14%. It occurs more commonly in pediatric anesthetic practice than in adults. The incidence is twice that of adults in older children and three times that of adults in younger children.4 Pediatric laryngospasm is an anesthetic emergency. True laryngospasm is ‘complete closure of the larynx caused by external stimulation’. Here the ventricular cords (false vocal cords) are tightly occluded, the paraglottis (intralaryngeal part of the epiglottis) moves posteriorly and the arytenoid cartilages both perform a ventral movement thus effectively sealing the larynx.8 There is chest movement but silent with no bag movement and no ventilation possible. Partial laryngospasm involves chest movement but stridulous noise with a mismatch between the patients’ respiratory effort and the small
Registrar Dept. of Pediatric Anesthesia BJ Wadia Hospital for Children, Mumbai, Maharashtra Address for correspondence Dr Sudivya Sharma Flat No.: 77-B, Mahavir Krupa Building TJ Road, Sewri (West), Mumbai - 400 015 E-mail: drsudivyasharma@gmail.com
220
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
amount of bag movement. In partial spasm, both vocal cords are firmly pressed against each other, leaving a small lumen open at the posterior commissure, which allows minimal ventilation by an anesthetist. A characteristic crowing noise may be heard in partial laryngospasm but will be absent in complete laryngospasm.9 Risk factors and Presentation Risk factors for laryngospasm can be classified into three categories: Patient-related, surgery-related and anesthesia-related factors.10 Patient-related risk factors include young age, upper respiratory tract infections, reactive airway, the American Society of Anesthesiologist (ASA) Grade 4, ex-premature infants, obstructive sleep apnea, obesity, gastroesophageal reflux disease, airway anomaly, low magnesium or calcium. Surgical procedures involving airway procedures, hypospadias, tonsillectomy, appendicectomy, bronchoscopy, esophagoscopy, anal surgery, etc, have high incidence of laryngospasm. Other influencing factors are use of mouth gag, duration of surgery, amount of bleeding, use of throat pack, cuffed or uncuffed tube, trauma at intubation, change of head and neck position during surgery, tight fitting tube, etc. A high-degree of ‘situation awareness’ on the part of the anesthetist facilitates the early diagnosis of laryngospasm. Anesthesia-related factors include light
anesthesiology plane of anesthesia; vocal cord stimulation with volatile anesthetics, secretions, mucus, blood, laryngoscope blade, suction catheter; multiple attempts of intubation and laryngeal mask airway (LMA) insertion. In intubated patients, it occurs mostly during emergence and recovery, whereas in patients with LMA or face mask, it occurs during induction and maintenance. The use of thiopentone is associated with a greater risk than propofol and ketamine. Similarly, desflurane and isoflurane are irritants to the airway. The use of LMA is risky if upper respiratory tract infection is present or if laryngospasm is anticipated. Most laryngeal reflexes are elicited by stimulation of the afferent fibers contained in the internal branch of the superior laryngeal nerve. These reflexes control the laryngeal muscle contractions, which protect the airway during swallowing. Laryngospasm may occur secondary to loss of inhibition of the laryngeal closure reflex as a result of abnormal excitation. It presents as inspiratory stridor, airway obstruction, increased inspiratory efforts, tracheal tug, paradoxical chest and abdominal movements, desaturation, bradycardia and/or central cyanosis. Complications Persistent laryngospasm can lead to negative pressure pulmonary edema and pulmonary aspiration. The development of marked negative intrathoracic pressures due to airway obstruction is believed to be the primary pathological event in the development of pulmonary edema in this situation. It is not clear how best to prevent the problem at extubation, some advocating extubation using a ‘no touch’ technique when patients are awake while others advocate extubation under deep anesthesia. Management Laryngospasm once detected, the stimulation should be ceased, be it surgery, suctioning or airway instrumentation, etc. Hundred percent oxygen should be administered with face mask. The chin lift and jaw thrust should be tried. Larson’s maneuver breaks laryngospasm by vagal stimulation. Deepen the plane of anesthesia with intravenous induction agent like propofol (20% of the induction dose). The airway should be visualized and cleared. Continuous intermittent positive pressure or intermittent positive pressure is applied, it helps open the glottis by force, or when the glottis opens momentarily, it splints and keeps it patent. If the above measures fail, succinylcholine is administered intravenously or
intramuscularly or intralingual along with atropine. Persistent spasm should be dealt with intubation and mechanical ventilation. Superior laryngeal nerve, a branch of vagus nerve can be blocked to treat laryngospasm. Transtracheal lidocaine injection through the cricothyroid membrane can also break the spasm. Once laryngospasm is relieved, humidified oxygen can be administered to decrease laryngeal irritation. Patients who experienced severe laryngospasm should be observed for 2-3 hour to ensure that pulmonary complications are not overlooked.
Deep versus Awake Extubation Many controversies exist among anesthesiologists about the best technique of tracheal extubation, which reduces the incidence of laryngospasm. Both awake and anesthetized extubation have advantages and disadvantages. The advantage of deep tracheal extubation over awake extubation in children undergoing tonsillectomy is that patients are less likely to cough and strain which can cause bleeding from the tonsillar bed and consequently increase the risk of laryngospasm. On the other hand, awake tracheal extubation offers the advantage of protecting the airway against aspiration during this vulnerable period. Deep extubation is performed to avoid adverse reflexes caused by the presence of the tracheal tube and its removal, at the price of a higher risk of hypoventilation and upper airway obstruction. The ‘No Touch’ technique was initially described by Lee. It is virtually an awake tracheal extubation. This technique consists of suctioning of the blood and secretions from the pharynx, turning the patient to the lateral position while anesthetized, discontinuing the volatile anesthetics and avoiding any stimulation until the patients open their eyes and spontaneously wake-up to be followed by tracheal extubation. Concerning tracheal extubation, Lee suggested that the tracheal tube be removed, while the lungs are inflated by positive pressure; this technique decreases the adductor response of the laryngeal muscles and reduces the incidence of layngospasm. Also, positive pressure inflation of the lungs before tracheal extubation is followed by forced exhalation ‘artificial cough’ after extubation, which expels any secretions or blood and this in turn decreases vocal cord irritation and laryngospasm.10-13 Prevention The use of fentanyl, lidocaine, dexmedetomidine before extubation decreases the incidence of laryngospasm.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
221
anesthesiology The respiratory complications are less with less use of opioids (i.e., multimodal analgesia). Intracuff local anesthetic application or spray can be used for smooth emergence. The patient position during extubation is significant; lateral position or head down is associated with lower incidences of pulmonary aspiration, whereas semi-upright or lateral position is chosen for patients with obstructive sleep apnea. The mean threshold for glottis closure is increased during inspiration, hence extubation should be timed at end inspiration. The filling of cuff of the tube with liquid can prevent throat irritation caused by its expansion with N20.14 Few anesthesiologists in modern practice would use 5% carbon dioxide (CO2) for preventing laryngospasm. The mechanism is that the respiratory drive to exhale the CO2 overrides the laryngospasm reflex.15 Premedication with anticholinergic agents to prevent larygospasm is controversial. However, they decrease secretions which play a role in triggering laryngospasm. Also, premedication with an oral benzodiazepine decreases upper airway reflexes and thus may decrease laryngospasm during induction of anesthesia. Koc et al have also reported that 2% topical lidocaine sprayed to the glottis at 4 mg/kg or 2% intravenous lidocaine given at 1 mg/kg 5 min before extubation are fairly effective in preventing laryngospasm following tonsillectomy and 16 adenoidectomy. Conclusion While laryngospasm occurs relatively frequently and is nearly always easily recognized and handled, it has the potential to cause morbidity and mortality, especially if managed poorly. Laryngospasm occasionally presents atypically and may be precipitated by factors which are not immediately recognized, increasing the potential for patient harm and further complications such as pulmonary aspiration and post-obstructive pulmonary edema. A structured approach is recommended. Identifying the risk factors and taking the necessary precautions are the key points in prevention of laryngospasm. Finally, it is important that a full explanation of what happened be given to the patient and the problem clearly documented in the anesthetic record. If a particular precipitating event was significant, or a particular action was useful in resolving the crisis, this should be clearly explained and documented.
Also, anesthesia administered by a pediatric anesthesiologist is associated with lower incidence of laryngospasm. References 1. Van der Walt J. Laryngospasm. In: Pediatric anesthesia: principles and practice. Bissonnette B, Dalens B (Eds.), McGraw-Hill: New York 2002:p.644. 2. Fink BR. The etiology and treatment of laryngeal spasm. Anesthesiology 1956;17(4):569-77. 3. Suzuki M, Sasaki CT. Laryngospasm: a neurophysiologic redefinition. Anesthesia for eye, ear, nose and throat surgery. In: Miller’s Anesthesia. 6th edition, Miller RD (Eds.), Elsevier Churchill Livingstone: Philadelphia 2005:p.2538. 4. Olsson GL, Hallen B. Laryngospasm during anaesthesia. A computer-aided incidence study in 136,929 patients. Acta Anaesthesiol Scand 1984;28(5):567-75. 5. Green SM, Klooster M, Harris T, Lynch EL, Rothrock SG. Ketamine sedation for pediatric gastroenterology procedures. J Pediatr Gastroenterol Nutr 2001;32(1):26-33. Erratum in: J Pediatr Gastroenterol Nutr 2001;32(2):234. 6. Roy WL, Lerman J. Laryngospasm in paediatric anaesthesia. Can J Anaesth 1988;35(1):93-8. 7. Mulkey Z, Yarbrough S, Guerra D, Roongsritong C, Nugent K, Phy MP. Postextubation pulmonary edema: a case series and review. Respir Med 2008;102(11):1659-62. 8. Sumner E, Hatch D (Eds.). Paediatric Anaesthesia. 2nd edition, Arnold: London, 1999. 9. Hampson-Evans D, Morgan P, Farrar M. Pediatric laryngospasm. Paediatr Anaesth 2008;18(4):303-7. 10. Al-alami AA, Zestos MM, Baraka AS. Pediatric laryngospasm: prevention and treatment. Curr Opin Anaesthesiol 2009;22(3):388-95. 11. Murray-Calderon P, Connolly MA. Laryngospasm and noncardiogenic pulmonary edema. J Perianesth Nurs 1997;12(2):89-94. 12. Roy WL, Lerman J. Laryngospasm in paediatric anaesthesia. Can J Anaesth 1988;35(1):93-8. 13. Lee KW, Downes JJ. Pulmonary edema secondary to laryngospasm in children. Anesthesiology 1983;59(4):347-9. 14. Kamarkar S, Varshney S. Tracheal extubation. Contin Educ Anaesth Crit Care Pain 2008;8(6):214-20. 15. Nishino T, Yonezawa T, Honda Y. Modification of laryngospasm in response to changes in PaCO2 and PaO2 in the cat. Anesthesiology 1981;55(3):286-91. 16. Koç C, Kocaman F, Aygenç E, Ozdem C, Cekiç A. The use of preoperative lidocaine to prevent stridor and laryngospasm after tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998;118(6):880-2.
■■■■
222
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Anesthesiology
Anesthetic Challenges in a Patient with Ludwig’s Angina Presenting with Septic Shock and Acute Renal Failure: A Case Report Abhimanyu Bhatia*, Anumeha Jain†, Meenaxi Sharma‡, Nitin Johar*, Ayush Sharma$
Abstract Ludwig’s angina is a rapidly progressive, potentially fulminant cellulitis that involves the sublingual and submandibular spaces and that typically originates from an infected or recently extracted tooth. Airway management is a critical part of anesthesia practice, especially in patients with deep neck infections. The presence of swelling in the neck, elevation of the tongue, trismus or pharyngeal and glottic edema create formidable problems. A cause of death in these patients with difficult intubation is the acute loss of the airway during interventions to control it. The American Association of Anesthesiologists (ASA) developed guidelines for the management of the difficult airway focus on strategies for intubation as well as alternative airway techniques that can be used in such patients. We report a case of Ludwig’s angina where the situation was further complicated by patient presenting with septic shock and acute renal failure.
Keywords: Ludwig’s angina, fulminant cellulitis, septic shock, renal failure, anesthetic challenge
L
udwig’s angina is a rapidly progressive, potentially fulminant cellulitis that involves the sublingual and submandibular spaces and that typically originates from an infected or recently extracted tooth, most commonly the lower second and third molars.1
Airway management is a critical part of anesthesia practice, especially in patients with deep neck infections. A cause of death in these patients with difficult intubation is the acute loss of the airway during interventions to control it.2 Deep neck infections are formed from the untreated dental caries. Infection spreads in the bone and submandibular, submental, retropharyngeal or lateral pharyngeal spaces. Advanced cases of abscess formations lead to restricted temporomandibular joint mobility with trismus and pharyngeal, laryngeal edema causing narrowing and eventually loss of the airways.3
*Resident †Professor ‡Professor and Head Dept. of Anesthesia NIMS Medical College, Jaipur, Rajasthan $Intern Dr DY Patil Medical College and Hospital, Navi Mumbai, Maharashtra Address for correspondence Dr Abhimanyu Bhatia C-3, Bali Nagar, Shivaji Marg, New Delhi - 110 015 E-mail: dr.abhimanyu@yahoo.co.uk
226
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
The American Association of Anesthesiologists (ASA) developed guidelines for the management of the difficult airway focus on strategies for intubation as well as alternative airway techniques that can be used when a patient with a difficult airway is encountered.4,5 The presence of swelling in the neck, elevation of the tongue, trismus or pharyngeal and glottic edema create formidable problems.6 We herewith report a case of Ludwig’s angina where the situation was further complicated by patient presenting with septic shock and acute renal failure. Case Report A 38-year-old female patient was referred to NIMS Medical College and Superspecialty Hospital, Jaipur, which is a tertiary referral hospital for oral and maxillofacial surgeries and intensive care medicine, with complaints of continuously advancing facial swelling on left lateral part of the neck, high-grade fever, decreased mouth opening, extreme pain and redness with severe dysphagia and dysphonia since 8 days. The patient had history of 3 episodes of loss of consciousness over past 2 days and anuria since 1 day before reporting to the hospital. History of toothache since 15 days. She was a known hypertensive and was on tablet amlodipine 5 mg (irregularly) for the past 18 months.
Anesthesiology
She had past history of appendicectomy 3 years back under general anesthesia at Jaipur, which was uneventful.
Routine investigations: Hb = 8.8 g/dL, total leukocyte count = 34,000/mm3, platelet count = 86,000/mm3, blood sugar = 56 mg/dL.
There was no history of other medical or surgical illnesses, food or drug allergy, addictions.
The kidney function tests showed serum creatinine at 4.71 mg/dL and blood urea of 116 mg/dL.
On general examination patient was semiconscious and disoriented to time, place, person. On general examination, her axillary temperature was 102°F, pulse rate 110/min, regular and low volume and blood pressure of 72/58 mmHg, respiratory rate of 25/min. Her weight was 96 kg, height 160 cm body mass index (BMI) of 37.5 kg/m2.
There was no rhythm abnormality on ECG and her chest X-ray was also normal. Soft tissue neck X-ray revealed exaggerated submandibular space.
She had severe pallor. No icterus, clubbing, cyanosis, edema or lymphadenopathy. In systemic examination, cardiothoracic, gastrointestinal systems were normal. Bilateral air entry was equal. Local oral examination revealed halitosis, trismus and a submandibular swelling which was diffuse and tender. Both the nares were not patent and filled with copious secretions and pus. Airway examination revealed restricted mouth opening of one finger with very less interincisor gap with short neck. Thyromental distance was 5.8 cm with painful but adequate neck movements. Mallampati grading could not be performed due to decreased mouth opening.
Therefore a diagnosis of Ludwigâ&#x20AC;&#x2122;s angina with septicemia and acute renal failure was made and patient was scheduled for emergency drainage surgery after initial stabilization. For initial stabilization, dextrose (25%) 200 mL intravenous (IV) was infused stat and blood sugar was maintained between 140-180 mg/dL with hourly glucose monitoring. Central venous pressure (CVP) was measured with right subclavian central venous cannulation (CVC). To begin with, it was 6 mmHg. Thus, 1,000 mL bolus crystalloid solution was infused but the mean arterial pressure (MAP) failed to rise above 58 mmHg. So, norepinephrine in titrating doses was started and MAP was brought to 70 mmHg and maintained. Keeping in mind the early goal directive therapy for surviving sepsis campaign, antibiotics were started within half hour of admission. Injection
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
227
Anesthesiology cefoperazone + sulbactam 1.5 gm IV b.i.d., injection linezolid 600 mg IV b.i.d., injection clindamycin 600 mg IV stat, then o.d. After airway examination and looking at the obesity, decision for fiberoptically guided orotracheal intubation with backup as emergency tracheostomy was made. Written informed consent was taken for the procedure and postoperative ventilator support. Preoperative preparation was done giving injection ranitidine 150 mg IV, injection metoclopramide 10 mg IV, 15 minutes before the scheduled operation. Vital monitoring with ECG, pulse-oximetry, noninvasive blood pressure (NIBP) and blood glucose was started. After explaining the procedure to the patient, pharynx was anesthetised by topical aerosol spray of lignocaine 10% (6-8 puffs). Preparation for tracheal anesthesia was done by cricothyroid injection of 3 mL 4% lignocaine. For preoperative medication injection glycopyrrolate 0.2 mg IV with fentanyl 50 µg slow IV was given. Portex endotracheal tube was railroaded on lubricated karl storz fiberscope. When the scope passed through the larynx it was advanced into the larynx till the carina was seen and than endotracheal tube was placed, bronchoscope was taken out, endotracheal tube inside the trachea was confirmed by ETCO2 and air entry equalization was done by auscultation of breath sounds. Induction was done with injection ketamine 100 mg. Muscle relaxation was done with atracurium 0.5 mg/kg. Analgesia was maintained by titrating fentanyl while blood pressure was maintained by titrating noradrenaline. Subsequent anesthesia was maintained by using isoflurane and nitrous oxide in oxygen. During the surgery stab incisions were given at lower border of mandible, left submandibular and submental regions and drainage was done. An impacted tooth was excavated, drain was placed and skin sutured in layers. After the surgery the respiratory effort was minimal with anuria so the decision for further ventilatory support was taken. Patient was shifted to surgical intensive care unit (ICU), was put on A/C volume control mode with tidal volume set at 450 mL and respiratory rate set at 16/min with PEEP of 5.
0.3 µg/kg/hr and meanwhile vasoconstrictor was tapered. Another session of hemodialysis was done. Six-hourly ABG’s were done. Blood glucose charting was maintained. Antibiotic coverage was continued with injection imipenem, injection linezolid and injection clindamycin. Three units whole blood (crossmatched) were transfused over 36 hours.
Postoperative Recovery The patient started passing urine after 24 hours, white blood cell (WBC) counts also came down to 12,000/mm3. After this no metabolic disturbances were present in the serial ABG’s so dexmedetomidine was tapered and weaning from ventilator was done. Patient was successfully extubated on post-op Day 3. The patient was under observation for further 48 hours in the ICU and was discharged on the ninth postoperative day. DISCUSSION Ludwig’s angina was first described by Wilhem Fredrich Von Ludwig 18367 and is defined as potentially lethal, rapidly spreading cellulitis, that involves sublingual and submandibular spaces, which is manifested by a brawny suprahyoid induration, tender swelling in the floor of the mouth, elevation and posterior displacement of the tongue.8 Predisposing factors include dental caries, recent dental treatment, sickle cell disease, a compromised immune system, trauma, tongue piercing and may occur in children without any precipitating cause.9,10 The signs and symptoms are severe pain, neck swelling, fever, toothache, malaise, dysphagia and halitosis.11 Swelling of the floor of the mouth, trismus, edema and abscess formation lead to the narrowing and ultimate loss of the airway.12 Streptococci and anaerobes are frequent causative organisms. In the preantibiotic era, the reported mortality was as high as 54%. In the present scenario, where patients are treated with antibiotics, it varies between 0-8.5%.12 The treatment modality includes maintenance of the airway, second- and third-generation antibiotics and surgical incision and drainage.
Immediately a femoral high flow dialysis catheter of 11.5 F (dual lumen Dura-Flow) was inserted, hemodialysis was started and 850 mL of ultrafiltrate was taken out.
Medical management with antibiotics, improved dental care and dexamethasone in the early stages of the disease has minimized the need for surgical intervention to control the airway.2,3,13 But, if swelling is too big and spreading fast then surgical incision and drainage is the modality of choice.
Patient was kept on ventilator for approximately 36 hours. Sedation was maintained by dexmedetomidine
The airway management for surgical incision and drainage in Ludwig’s angina patient is a big challenge
228
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Anesthesiology for the anesthetist and there is no clear consensus or guidelines for management and it varies with patient’s condition and anesthetist’s comfort level. The suggested methods include tracheostomy, conventional laryngoscopy and intubation (after administration of muscle relaxant), awake blind nasal intubation and awake fiberoptic intubation.2 Decompression of Ludwig’s angina under cervical block has also been reported.14
exchange. Traditional intermittent hemodialysis remains the old therapy in ARF with patients with good metabolic control but with a poor hemodynamic tolerance, especially in septic patients.20 In septic shock, hemofiltration is more often used, considering a better hemodynamic tolerance and it is argued that hemofiltration can reverse the sepsis-related inflammatory response, even in the absence of ARF.21
Tracheostomy is generally the gold standard and is kept as a back up as the airway gets compromised very often and very quickly. Elective awake tracheostomy has been suggested for all patients with deep neck infections in order to avoid the dangers of emergency tracheostomy in a severely compromised airway.
Conclusion
Distorted airway anatomy, tissue immobility and limited access to the mouth make orotracheal intubation by direct laryngoscopy difficult. In advanced cases, induction of general anesthesia is dangerous because this may precipitate complete airway closure and make mask ventilation and intubation impossible.15 Therefore fiberoptic intubation is the safest option. Although distorted anatomy, edema and secretions may contribute to difficulty with fiberoptic intubation, in skilled and experienced hands, flexible fiberoptic nasal intubation is the preferred method of airway management16 and has a high rate of success.2 The presence of septic shock with Ludwig’s angina makes the management more complicated and tedious as the patient can deteriorate at a much faster rate than anticipated. The management of the sepsis in this patient was done by early goal directed therapy which is a cornerstone for surviving sepsis campaign (SSC). After the insertion of subclavian CVC and measurement of CVP and MAP patient was given appropriate fluids and a vasopressor, norepinephrine was started without further delay. There is compelling data on the use of early, broadspectrum antibiotics and their potential impact on outcomes.17 The surviving sepsis campaign (SSC) suggests that antibiotics should be given within 1 hour of the diagnosis of severe sepsis or septic shock.18 Gaieski et al19 have demonstrated that patients who received antibiotics in <1 hour from either triage or qualification for early goal-directed therapy had a lower odds ratio for mortality. There is consensus that patients with severe acute renal failure (ARF) and sepsis require some form of dialysis. Among such patients, some with refractory septic shock may benefit from high volume plasma
It is important to diagnose Ludwig’s angina at early stages and if the need for surgical drainage arises then initial stabilization of the patient along with airway management should be given the prime importance. Fibreoptic intubation under topical anesthesia is emerging as the preferred option and tracheostomy should always be kept as a backup. Sound clinical judgment is critical for timing and for selecting the method for airway intervention. Management of septic shock and acute renal failure should be started at the earliest keeping in mind the latest approved guidelines. In our patient, the key to success was meticulous preoperative stabilization of the patient’s shock and adequate preoperative planning of the anesthesia, excellent airway management and adequate postoperative intensive care, which lead to reversal of shock and renal failure.
Competing Interests The authors declare that they have no competing interests.
Authors’ contributions All the authors were involved in the management of the case and they were involved in the process of editing, correcting and finalizing the manuscript. All authors have read and approved the final manuscript.
Consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Acknowledgments We thank the patient and patient party for giving us consent for the publication of the case report. We also thank the surgical team for their willingness to provide photographs and other related information for the publication of this case report.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
229
Anesthesiology References 1. Fauci A, Braunwald E, Kasper D, Hauser S, Longo D. Harrison’s Principles of Internal Medicine. 17th edition, McGraw-Hill Companies 2008:pg.212. 2. Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg 2005;100(2):585-9. 3. Raval C, Rashiduddin M. Nasal endotracheal intubation under fibreoptic endoscopic control in difficult oral intubation, two pediatric cases of submandibular abscess. Oman Med J 2009;24(1):51-3. 4. Berkow LC. Strategies for airway management. Best Pract Res Clin Anaesthesiol 2004;18(4):531-48. 5. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98(5):1269-77. 6. Allen D, Loughnan TE, Ord RA. A re-evaluation of the role of tracheostomy in Ludwig’s angina. J Oral Maxillofac Surg 1985;43(6):436-9. 7. Loughnan TE, Allen DE. Ludwig’s angina. The anaesthetic management of nine cases. Anaesthesia 1985;40(3):295-7. 8. Patterson HC, Kelly JH, Strome M. Ludwig’s angina: an update. Laryngoscope 1982;92(4):370-8. 9. Perkins CS, Meisner J, Harrison JM. A complication of tongue piercing. Br Dent J 1997;182(4):147-8. 10. Kurien M, Mathew J, Job A, Zachariah N. Ludwig’s angina. Clin Otolaryngeal 1994;108:138-43. 11. Sethi DS, Stanley RE. Deep neck abscesses - changing trends. J Laryngol Otol 1994;108(2):138-43. 12. Neff SP, Merry AF, Anderson B. Airway management in Ludwig’s angina. Anaesth Intensive Care 1999;27(6):659-61. 13. Kulkarni AH, Pai SD, Bhattarai B, Rao ST, Ambareesha M. Ludwig’s angina and airway considerations: a case report. Cases J 2008;1(1):19.
14. Mehrotra M, Mehrotra S. Decompression of Ludwig angina under cervical block. Anesthesiology 2002;97(6):1625-6. 15. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 2001;110(11):1051-4. 16. Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J 2004;21(2):242-3. 17. Tannehill D. Treating Severe Sepsis & Septic Shock in 2012. J Blood Disord Transfus 2012;S4:002. 18. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al; International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; Canadian Critical Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Japanese Association for Acute Medicine; Japanese Society of Intensive Care Medicine; Society of Critical Care Medicine; Society of Hospital Medicine; Surgical Infection Society; World Federation of Societies of Intensive and Critical Care Medicine. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36(1):296-327. Erratum in: Crit Care Med 2008;36(4):1394-6. 19. Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010;38(4):1045-53. 20. Rouby JJ, Rottembourg J, Durande JP, Basset JY, Degoulet P, Glaser P, et al. Hemodynamic changes induced by regular hemodialysis and sequential ultrafiltration hemodialysis: A comparative study. Kidney Int 1980;17(6):801-10. 21. Hoffmann JN, Hartl WH, Deppisch R, Faist E, Jochum M, Inthorn D. Effect of hemofiltration on hemodynamics and systemic concentrations of anaphylatoxins and cytokines in human sepsis. Intensive Care Med 1996;22(12):1360-7.
■■■■
230
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Cardiology
Complete Heart Block in Rheumatoid Arthritis KAVINA MARIAN FERNANDES*, VIVEK GC*
Abstract Rheumatoid arthritis (RA) can affect all parts of the heart. The pericardium, endocardium, valves, myocardium and the conduction system can get involved separately or in combination. However, complete heart block is very uncommon. We describe a case of a 65-year-old lady with RA presenting with complete heart block because of its rarity and unusual feature like negative rheumatoid factor.
Keywords: Rheumatoid arthritis, complete heart block, conduction disturbances, sudden cardiac death
R
hythm and conduction disturbances and sudden cardiac death (SCD) are important manifestations of cardiac involvement in autoimmune rheumatic diseases (ARDs). Complete heart block (CHB) is a rare complication of rheumatoid arthritis (RA) with an approximate incidence of 1 in 1,000 patients with RA.1 CHB in RA occurs generally in patients with established erosive RA.2 It can develop suddenly, being discovered after syncope or found unexpectedly on routine physical and electrocardiographic examination.2 In patients with high activity of RA, the decrease of heart rate variability reflects severity of inflammation. Decreased heart rate variability in degree I-II RA activity, is predictor for ventricular arrhythmias, SCD and acute myocardial infarction (MI). Antibodies to cardiac conducting tissue were found significantly more often in these patients than in those without conduction abnormalities.
attacks, chest pain and palpitation. She had been on ayurvedic treatment. There was no history of oral ulcers, photosensitive rash, hair loss or abortions. She did not suffer from hypertension, diabetes mellitus or ischemic heart disease. There was no family history of autoimmune disorders. On examination, she was afebrile, pulse rate was 40/min, regular, blood pressure of 100/70 mmHg and respiratory rate of 14/min, jugular venous pressure (JVP) was raised and showed cannon a waves and SaO2 was 98% at room air. She had pallor and bilateral pitting pedal edema. There was no icterus, clubbing, lymphadenopathy or goiter. She had Boutonnieres deformity, swan neck deformity of index finger, ring finger of both hands, z-deformity of thumb, ulnar deviation of wrist and hallux valgus (Fig. 1). Trophic ulcers were present in the sole of the right and left foot. No nodules were palpable. Systemic examination was otherwise normal.
CASE PRESENTATION A 65-year-old female presented to our department with low-grade fever and fatigue on exertion (Class III New York Heart Association [NYHA]) of 2-week duration. She also had deforming polyarthritis since 20 years. She had stiffness in joints on getting up in the morning, which would last till late morning. The patient did not complain of giddiness, syncopal
*Dept. of General Medicine Vijayanagar Institute of Medical Sciences Bellary, Karnataka Address for correspondence Dr Vivek GC No. 210, 7th A Main, Vijayanagar 2nd Stage Bangalore - 560 104 E-mail: gc.vivek@gmail.com
232
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Figure 1. Picture showing the Boutonnieres deformity, swan neck deformity of index finger, ring finger of both hands, z-deformity of thumb, ulnar deviation of wrist and hallux valgus.
Cardiology
Figure 2. ECG showing complete heart block.
Investigations revealed hemoglobin - 8 g/dL, total leukocyte count (TLC) - 14,300 cells/mm3; differential leukocyte count (DLC) was polymorphs - 69%, lymphocytes - 13%, eosinophils - 12%, monocytes - 6%. Erythrocyte sedimentation rate (ESR) was 65 mm/hour, platelet count - 3.17 lac/mm3; liver function tests (SGOT - 33 IU/L, SGPT - 30 IU/L), renal function tests (urea - 25 mg/dL, creatinine - 1.2 mg/dL, sodium - 140 mEq/L, potassium - 4.2 mEq/L, chloride - 102 mEq/L), blood glucose (RBS - 94 mg/dL), uric acid and thyroid function tests were normal. Urine routine showed traces of albumin. ECG showed CHB (Fig. 2). 2-D echocardiography showed LA - 3.37 cm, AO - 2.27 cm, dilated RA and RV, mild mitral regurgitation (probably functional as there was no thickening of leaflets or chordae), left ventricular ejection fraction (LVEF) - 40%, no regional wall motion abnormality. Right ventricle systolic pressure (RVSP) by tricuspid regurgitation jet 45 mmHg, and no evidence of clot, vegetation or pericardial effusion. X-ray of both wrists anteroposterior (AP) view showed juxta articular osteopenia, Boutonnieres deformity at 4th distal interphalangeal (DIP) joint and narrowing of radiocarpal, intercarpal joint spaces. Left wrist X-ray also showed hitch hikers thumb, swan neck deformity of 2nd finger, Boutonnieres deformity in 4th finger (Fig. 3).
Figure 3. X-ray of both hand and wrist (AP view) showing Boutonnieres deformity at 4th DIP joint, left wrist X-ray also showed hitch hikers thumb, swan neck deformity of 2nd finger.
X-ray of bilateral feet (AP/oblique view) showed diffuse osteopenia of the bones, narrowing of joint spaces involving tarsometatarsal joint and intertarsal joint, medial deviation of 2nd to 5th toes, lateral deviation of great toe (Fig. 4). Chest X-ray was normal. Troponin I - 0.011 ng/mL (negative), rheumatoid factor/ RA test - 18 IU/mL (negative) CRP - 150.8 mg/L (raised), anti-CCP antibodies - 0.60 U/mL (negative), ANA >125 U (strongly positive); SS-A 3+, RO-52 3+, centromere B 3+.
Figure 4. X-ray of right foot (AP/oblique) showing narrowing of joint spaces involving tarsometatarsal joint and intertarsal joint, medial deviation of 2nd to 5th toes, lateral deviation of great toe.
Arterial Doppler study of both lower limbs was normal, venous Doppler did not show any signs of deep venous thrombosis (DVT). The patient was administered injection atropine 0.6 mg intravenous (IV) initially and repeated 3 times. However, there was no change in the rhythm or heart rate. The patient has undergone a pacemaker implantation and continues to be well. The patient was started on methotrexate (10 mg/ week)and hydroxychloroquine (400 mg/day) along with anti-inflammatory drugs.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
233
Cardiology DISCUSSION RA is a chronic inflammatory disease of unknown etiology marked by a symmetric, peripheral polyarthritis. It is the most common form of chronic inflammatory arthritis and often results in joint damage and physical disability. Because it is a systemic disease, RA may result in a variety of extra-articular manifestations, including fatigue, subcutaneous nodules, lung involvement, pericarditis, peripheral neuropathy, vasculitis and hematologic abnormalities.4 The clinical diagnosis of RA is largely based on signs and symptoms of a chronic inflammatory arthritis, with laboratory and radiographic results providing important supplemental information. In 2010, a collaborative effort between the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) revised the 1987 ACR classification criteria for RA in an effort to improve early diagnosis.4 The most frequent site of cardiac involvement in RA is the pericardium. Cardiomyopathy, another clinically important manifestation of RA, may result from necrotizing or granulomatous myocarditis, coronary artery disease or diastolic dysfunction. Mitral regurgitation is the most common valvular abnormality in RA, occurring at a higher frequency than the general population.2 Right bundle branch block (RBBB), hemiblocks or AV blocks of any degree could occur. CHB is a rare complication of RA.1 Connective tissue diseases are responsible for <2% of cases of CHB. The transition from sinus rhythm to CHB usually appears to be sudden and permanent. However, there may be progression from first-degree heart block or blocks of the bundles or their fascicles to second-degree heart block and finally CHB. The conduction disturbances are usually mild, asymptomatic and incidentally diagnosed by electrocardiography. There is a female preponderance. In addition to standard 12-lead ECG, 24-hour Holter monitoring is most widely applied for evaluation of patients with arrhythmias and conduction abnormalities. The mean duration of RA prior to the development of the block is 10-12 years. In the case series published by Ahern et al,5 the average age for development of CHB was about 60 years, which matches our case. CHB can be due to following mechanisms: 1) Direct involvement of conducting system with granuloma; 2) extension of the inflammatory process from base of aorta to mitral valve to conduction pathways; 3) amyloidosis; 4) hemorrhage into rheumatoid nodule; 5) coronary arteritis causing ischemia of the conduction tissue; 6) focal myocarditis
234
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
due to RA and 7) premature coronary artery disease due to accelerated atherosclerosis in patients with RA.6 Conduction blocks once established in the disease do not respond to anti-inflammatory treatment.6 If patient is symptomatic pacemaker implantation helps improve.7 CONCLUSION CHB is a rare complication of RA. It usually occurs in patients with established erosive nodular rheumatoid disease and in rheumatoid factor positive cases but can also occur in those who are seronegative although rarely. CHB usually suggests active disease though it can occur in patients with well-controlled disease.8 The transition from sinus rhythm to CHB usually appears to be sudden and permanent. Spontaneous recovery is possible, but extremely rare. If patient is symptomatic, pacemaker implantation helps improve symptoms and prognosis. The indications for a permanent pacemaker are the same as any patient of CHB without RA. Once a pacemaker has been installed, the prognosis is good in the absence of other cardiac complications such as congestive cardiac failure. REFERENCES 1. Seferović PM, Ristić AD, Maksimović R, Simeunović DS, Ristić GG, Radovanović G, et al. Cardiac arrhythmias and conduction disturbances in autoimmune rheumatic diseases. Rheumatology (Oxford) 2006;45 Suppl 4:iv39-42. 2. Harris M. Rheumatoid heart disease with complete heart block. J Clin Pathol 1970;23(7):623-6. 3. Parnes EIa, Krasnosel’skiĭ MIa, Tsurko VV, Striuk RI. Long-term prognosis in patients with rheumatoid arthritis depending on baseline variability of cardiac rhythm. Ter Arkh 2005;77(9):77-80. 4. Shah Ankoor E. William St. Clair. Rheumatoid arthritis. In: Harrison’s Principles of Internal Medicine. 18th edition, Vol. 2, Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J (Eds.), McGraw-Hill Company: 2012:p.2738-52. 5. Ahern M, Lever JV, Cosh J. Complete heart block in rheumatoid arthritis. Ann Rheum Dis 1983;42(4):389-97. 6. Mandell BF, Villa-Forte A. Rheumatic diseases and the cardiovascular system. In: Heart Disease: A Text Book of Cardiovascular Medicine. 9th edition, Braunwald E, Zipes DP, Libby P (Eds.), WB Saunders Company p.1876-904. 7. Spragg D, Tomaselli GF. The bradyarrythmias. In: Harrison’s Principles of Internal Medicine. 18th edition, Vol. 2, Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J (Eds.), McGraw-Hill Company 2012:p.1867-70. 8. David-Chaussé J, Blanchot P, Warin J, Dehais J, Bullier R, Texier JM. Atrioventricular blocks and rheumatoid arthritis. Rev Rhum Mal Osteoartic 1976;43(3):177-83.
Community Medicine
Women’s and Providers’ Experiences with Injectable Contraceptives (Depo-Provera): A View from Vadodara, India Prakash V Kotecha*, Sangita V Patel†, Rajendra K Baxi‡, Shagufa Kapadia#, Kedar Mehta$
Abstract Objective: To compare users’ and providers’ perspectives on injectable contraceptives (IC). Methods: This qualitative study employed semi-structured in-depth interview technique. Sixty women with experience of using IC and 10 doctors involved in providing IC were selected. Telephonic interviews of doctors were also conducted. Results: Over 50% of the women had side effects and had discontinued use within 1 year. The most common ‘likes’ according to women included ease of use, being tension free for 3 months and being effective and those of the providers were that it reduced anemia, privacy could be maintained, noncontraceptive benefits, good substitute, not to be taken daily like pills, safe and effective. The most common ‘dislikes’ reported by providers and clients were excessive bleeding, amenorrhea, irregular periods, spotting, weight gain and frequent pregnancy tests. Conclusion: Although certain distinct advantages of IC have been expressed, the associated problems are equally significant and therefore IC should not be an over-the-counter contraceptive.
Keywords: Clients’ and providers’ perspectives, depo-provera, injectable contraceptives, India, qualitative study
C
hoice of contraceptive methods is a key element of family planning that benefits both women and providers. Offering client’s choices can help increase contraceptive prevalence rates. Data from 36 developing countries indicate that making one additional modern method widely available could increase contraceptive prevalence by about 12%.1 Hence, there is a need to expand contraceptive choices. Progestin-only injectable contraceptives (POIC) i.e., Depo-medroxyprogesterone acetate (DMPA) and Norethisterone enanthate (NETEN) are newer contraceptives.
*Technical Advisor Academy for Educational Development, New Delhi †Associate Professor ‡Professor Dept. of Preventive and Social Medicine Medical College-Baroda, Vadodara, Gujarat #Professor and Head Dept. of Human Development and Family Studies Faculty of Home Science, MS University, Vadodara, Gujarat $Assistant Professor Dept. of Preventive and Social Medicine GMERS Medical College, Gotri, Vadodara, Gujarat Address for correspondence Dr Sangita V Patel Associate Professor Dept. of Preventive and Social Medicine Medical College-Baroda, Vadodara - 390 001, Gujarat E-mail: sangita_psm@yahoo.co.in
Awareness about POIC is low in India (19%) with near-zero usage for contraception.2 Early attempts for clinical trials of DMPA by the Indian Council of Medical Research (ICMR) in the 1970s were abandoned due to unacceptable high rates of bleeding disorders in DMPA users. After the US Food and Drug Administration (FDA) approval of DMPA for contraceptive use in 1992, the Drug Controller of India licensed NETEN (1986) and DMPA (1993) for restricted use in the private sector with a condition that the manufacturers carry out post-marketing surveillance amongst Indian women.3 The present study, thus was undertaken to compare women’s and providers’ perspectives on IC and to identify whether to include IC in our National Family Welfare Program or not as policy making decisions. Material and methods
Sample Selection Women, who had experience of using IC either at the time of study or in the past, were selected for the study from the list provided by IC providers. The providers comprised of doctors involved in providing IC, many of them were involved with IC projects. Telephonic interviews were also conducted and information was elicited from different gynecologists of the city, irrespective of whether they prescribe IC to their clients at present or not.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
235
Community Medicine Enrollment
Reasons for Using IC
Obstetrics and Gynecology specialists who prescribed IC were asked to give their voluntary consent for participation after taking consent from their clients. A total of 10 doctors who prescribed IC to their clients and 60 women were studied. To ensure that, we get total picture of users’ perspective we enrolled both types of users - current and past and to assure positive recall adequately we decided to take them in the ratio of 3:1 as far as possible and obtained them from government and private practitioners. While interviewing the doctors who prescribed IC, it was realized that how many doctors prefer use of IC as contraceptive method, would not be possible to find out from interviewing only those doctors who prescribed IC. Thus in an effort to have a quick data on these aspects, a telephonic interview was attempted by picking up telephone numbers of all obstetricians from doctor’s directory. For the telephonic interviews, 85 doctors irrespective of whether they prescribed the injection or not, were interviewed. Five doctors refused to give consent for telephonic interview.
The influence of the doctor was evident in the responses of 23% of the women who reported ‘no other option left’ as one of the reasons for using IC. It was interesting to see that 78% of the women had negative perceptions about one or more contraceptive methods without ever using them! About three-fourths of the women did not want to use Copper T. There were many women who admitted that it would be difficult for them to remember taking pills daily and hence had found IC as a suitable alternative.
Study Tools Women who consented were assured of confidentiality and interviewed by co-investigators using semistructured in-depth interview technique. Similarly, semi-structured interviews of 10 providers who prescribed IC to their clients were conducted by the senior investigator. The research staff noted down the interviews and later translated them into English after reviewing for accuracy. Transcripts were content analyzed using the technique of open coding to discover conceptual patterns or themes, in the text. Themes found to be both salient and repeated in the text were defined and used as codes to organize the text into categories. The quantitative study was done by telephonic interview. Results
Demographic Profile of IC Users Of the 60 women interviewed, 16 were those who had taken IC in the past and were no longer continuing it, whereas 44 were those who were currently taking IC. Most of the women belonged to the age group of 25-29 years. Four out of the 60 women were nonliterate. Most of the women (45%) had at least secondary education. More than three-fourths of the women were housewives. Majority (53%) of women using IC belonged to relatively better socioeconomic class.
236
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
A 29-year-old woman with one child reasoned, “Taking pills everyday is a problem, and on top of it I feel uneasy, have nausea and headache”. Another woman explained, “We both are not comfortable using condoms, there was white discharge due to Copper T and by using pills I used to get excessive bleeding. So, I had to take injections”.
Women’s Likes ‘Likes’ about IC were reported by 97% of the women, understandably more current than past users. Voices of IC Users “There is no tension for 3 months and only some people suffer from side effects while others may not”. “It is better than taking pills daily. IC is simple and convenient”. “It is good that after taking the injection I don’t get periods so I get more time to worship God”.
What Doctors Like About IC Majority of the doctors viewed IC as a better option as compared to pills or Copper T. More than half reported “not having to take the pains of remembering it daily like in case of oral contraceptive (OC) pills” as the major point in favor of IC. Almost half of the doctors pointed out that irregular menstruation perceived as a problem by the IC users, was in a way advantageous to them. A senior lady gynecologist observed, “Since menorrhagic patients lose so much blood, amenorrhea due to IC could be beneficial to them”. Some doctors believed that the use of IC is gradually increasing. One of the prominent lady gynecologists practicing since more than two decades stated, “IC gives 100% safety and assurance. I advise my clients to try IC first before going to OC pills or Copper T”.
Community Medicine Majority of them preferred giving IC to post-delivery cases. As mentioned by one of the lady gynecologists, “During the lactation period, clients do not mind amenorrhea due to IC, as they are mentally prepared for amenorrhea. They are happy about it, as their main concern is that they should not get pregnant”.
Dislikes and Problems When asked regarding their dislikes 57% of the total women reported having dislikes about IC, which were more in past users than current users. A school teacher troubled with the problem of spotting said, “I am scared, what if something happens when I am at the school?” A 23-year-old woman, who did not get periods for a year, explained: “If we do not get our periods then the uterus may get infected, tumor or cancer of uterus may also occur.” A woman fed-up of excessive bleeding said, “Husband wife’s relation gets disturbed due to continuous bleeding.” Frequent visits to doctor due to continuous bleeding were also a matter of concern. The prevalence of problems was almost the same in both current and past users. The problems reported were the side effects of IC experienced by the women. A woman with three children, who had continuous excessive bleeding for 16-17 days retorted, “It would be alright even if I would have conceived again, but at least I would have not faced such problems”. A woman, who discontinued taking IC, reasoned, “I felt there is no guarantee of the injection. I did not get periods for 2-3 months so, I felt as if I have conceived”. The side effects of IC were the major cause of concern for the doctors as well. Menstrual irregularity was reported as the most common complaint by their clients. According to some of the doctors, amenorrhea due to IC is quite stressful for their clients as they are always in confusion whether amenorrhea is just a side effect of IC or is it because they have conceived.
Return of fertility was also a concern mentioned. One doctor emphasized this saying, “Return of fertility is the most important research aspect of IC and it should be done”.
Perceptions of Providers Obtained by Quantitative Survey Out of the 83 doctors who were interviewed on phone, about 16% never prescribed IC, while 84% had prescribed IC at some time during their practice and 41% were currently prescribing IC. Only about onefifth of the doctors reported positive qualities regarding IC (20.4%). Positive qualities were reportedly higher in case of doctors who currently prescribe the injection (35.3%) as compared to those who used to prescribe IC in the past (14%) and those who have never prescribed IC to their clients till now (7.7%). However, negative qualities were reported by a majority of the doctors (94%) and among them the percentage of doctors who used to prescribe IC in the past was the highest (36/36) as compared to those who presently prescribe IC (31/34). Among the 13 doctors who had never prescribed IC in the past, 11 of them had negative perceptions regarding IC. This might be one of the reasons for not prescribing IC to their clients. A doctor who had never prescribed IC said, “I know that due to injection side effects are obvious then why should it be given and why should one try”. Some doctors were in favor of IC even though they were aware of the side effects that it caused. As can be expected, most of the doctors who currently prescribed IC reported these qualities as compared to those who had stopped prescribing IC. According to a senior lady gynecologist, “IC is good as there is no fear of getting pregnant for 3 months. Although I am willing to give, my clients hesitate because of side effects”.
A senior lady doctor said, “If I just examine and say that they have not conceived, they do not believe it. I have to do a pregnancy test. So, there is an additional expense”.
Even though some doctors mentioned the favorable points, most of them expressed their dissatisfaction regarding IC due to its side effects, which is similar to our findings from the in-depth interviews. Out of the 83 doctors interviewed, 78 of them had negative perceptions about IC-based on the problems faced by their clients after using it. Amenorrhea and irregular bleeding were the two major complaints of the clients, as reported by most doctors.
Apart from this, the doctors also highlighted the socio-cultural impact and psychological stress of menstrual irregularity and amenorrhea in particular.
This was followed by substantial dissatisfaction of the clients due to various side effects of IC for which they blamed the doctors.
“In our society it is strongly believed that menstrual cycle should be regular”.
As one lady doctor who prescribed IC in the past puts it, “Clients with amenorrhea which did not even get cured by
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
237
Community Medicine
Women’s likes yy Good for those who cannot swallow pills yy No monthly tension of periods yy No botheration in doing routine work yy Simple and comfortable
Common likes yy Effective in preventing pregnancy yy Not to be taken daily like pills but just once in 3 months yy Good substitute when other contraceptives give problem
Doctors’ likes yy Reduces anemia yy Good for menorrhagic patients yy Privacy can be maintained yy Noncontraceptive benefits
Women’s dislikes yy Severe backache and headache yy Possibility of damage to uterus yy Problem in going to religious places yy Mental tension due to problems in menstrual cycle
Common dislikes
Doctors’ dislikes
yy Excessive bleeding yy Amenorrhea yy Irregular periods yy Scanty bleeding yy Spotting yy Weight gain yy Frequent pregnancy tests
yy Break through bleeding yy Delayed fertility and lack of data related to that
Figure 1. Likes and dislikes of IC according to women and doctors.
medicines, used to come and complain about it and blame me for it. It was such a headache. This was the main reason for me to stop prescribing IC”. Psychosocial stress associated with menstrual irregularity was another important concern with the clients. Referring to this, one of the doctors endorsed this view, “Every woman wants 1 monthly cycle. If they do not get periods, they are always in a dilemma whether they are pregnant or not”. Discussion The ‘likes’ reported by clients for using IC were being tension free after having taken it, simple, comfortable and no botheration in doing routine work. The most common likes by providers and clients were that of the convenience of having to take the injection only once in 3 months, effective in preventing pregnancy and good substitute when other contraceptives give problem. However, the side effects or problems due to IC were the major cause of concern for all the doctors, even though they acknowledged the benefits of IC. One study showed likes of DMPA are independent of
238
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
intercourse and also independent of the user’s memory (and thus of continuing motivation).4 Higher percentage of past users had ‘dislikes’ than current users implying that for the past users these dislikes were perhaps the reasons for having discontinued IC. Over 50% of the women reported some or the other complaints. The problems presented were mainly the side effects of IC experienced by the women. The most common dislikes reported both by women and providers were excessive bleeding, amenorrhea, irregular periods, scanty bleeding, spotting, weight gain and frequent pregnancy tests as shown in Figure 1. Psychological stress due to problems in menstrual cycle, religious restrictions, severe backache and possibility of damage to uterus were mentioned as dislikes particularly by women. While for the doctors delayed fertility and lack of data related to it was a major concern. Over half of the doctors from quantitative survey had stopped prescribing IC as their clients had adverse problems out of proportion to the possible advantages that they could perceive. Three different studies reported irregular bleeding, spotting and amenorrhea as the common side effects.5-7
Community Medicine However, rising popularity of injectable contraceptives in Sub-Saharan Africa has also been documented.8 The most commonly reported reasons for method discontinuation are side effects, primarily menstrual irregularities and weight gain.6,9 DPMA carries a higher risk of amenorrhea than NETEN and may be recommended to women who prefer minimal menstrual bleeding.10 Dr C Sathyamala in her monograph articulates that it is not suitable for nulliparous women, adolescents, breast-feeding women.11 Studies thus far have not shown any serious longterm effects of DMPA or NETEN. However, both have been used for a relatively short time and the potential long-term effects (over >15 years) are not yet known.12 Hence, counseling provided by the doctors plays an important role in the acceptance of IC as a reliable and convenient method. Inadequate counseling leading to lack of knowledge regarding possible side effects of IC brings about substantial dissatisfaction among IC users and hence is likely to affect its continuation rate. Doctors were not in favor of making IC ‘over the counter’ available to women and believed that it was suitable only for a particular group of clients and IC should be given to the clients only under their supervision. A large number of providers also believe that IC is very unsafe and is a banned contraceptive and should not be used. Based on the complaints of side effects by the clients, quite a few of those who started prescribing with enthusiasm have now backed out from their routine prescription. This study was only carried out in one region of India and is thus not necessarily representative of all of India.
Acknowledgments We express sincere thanks to ÂÂ
UNFPA, New Delhi office in general and Dr Dinesh Agrawal in particular for financial and technical assistance for this study.
ÂÂ
And practicing gynecologists, doctors and their clients whose support and co-operation made this study a reality.
References 1. Ross JA. Management strategies for family planning programs. Centre for Population and Family Health, School of Public Health, Columbia University, New York, 1989. 2. National Family Health Survey. International Institute for Population Science. Mumbai, India, 1993. 3. SAMA. Unveiled reality: a study on women’s experiences with Depo-Provera, an injectable contraceptive. SAMA, Delhi, 2000. 4. Bigrigg A, Evans M, Gbolade B, Newton J, Pollard L, Szarewski A, et al. Depo Provera. Position paper on clinical use, effectiveness and side effects. Br J Fam Plann 1999;25(2):69-76. 5. Hirve S. Injectables as a choice - evidence-based lessons. Indian J Med Ethics 2005;2(1). 6. Polaneczky M, Guarnaccia M, Alon J, Wiley J. Early experience with the contraceptive use of depot medroxyprogesterone acetate in an inner-city clinic population. Fam Plann Perspect 1996;28(4):174-8. 7. Sarojini NB, Murthy L. Why women’s groups oppose injectable contraceptives. Indian J Med Ethics 2005;2(1). 8. Adetunji J. Rising popularity of injectable contraceptives in Sub-Saharan Africa. Population Association of America, Los Angeles, Office of Population and Reproductive Health, Bureau for Global Health, US Agency for International Development (USAID). 2006 Mar. 30–Apr.1. 9. Sangi-Haghpeykar H, Poindexter AN 3rd, Bateman L, Ditmore JR. Experiences of injectable contraceptive users in an urban setting. Obstet Gynecol 1996;88(2):227-33. 10. Draper BH, Morroni C, Hoffman M, Smit J, Beksinska M, Hapgood J, et al. Depot medroxyprogesterone versus norethisterone oenanthate for long-acting progestogenic contraception. Cochrane Database Syst Rev 2006;(3):CD005214. 11. Sathyamala C. An Epidemiological Review of the Injectable Contraceptive Depo-Provera. Medico Friend Circle and Forum for Women’s Health. Mumbai, 2000 and 2001. 12. Facts about injectable contraceptives: memorandum from a WHO meeting. Bull World Health Organ 1982;60(2):199-210.
■■■■
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
239
DENTISTRY
Extrusion of Fractured Anterior Tooth: An Invisible Approach RV Murali*, L Rajashekhar†, S Rajalingam‡
Abstract Case report: The management of patients with traumatic injuries to their dentition is an integral part of general dental practice. The purpose of this paper is to discuss the immediate endodontic and orthodontic (lingual) management of traumatized anterior teeth with fracture at the subgingival level, which otherwise would have gone for extraction. History and clinical finding: A 24-year-old male reported with fractured left central incisor following road traffic accident. On clinical examination, it was observed that the upper left central incisor had a horizontal fracture at the cervical one-third level with the fracture line extending subgingivally on palatal side. The traumatized tooth was first treated endodontically, and then referred to our department for orthodontic extrusion before permanent crown placement. Treatment plan: Treatment plan was to extrude the fractured anterior tooth in order to keep the restorative margin supragingival. This was to be followed by a metal cast post and metal free ceramic crown to complete the restoration of tooth. Invisible approach (lingual orthodontics) was used as the patient was insistent upon the braces not being seen outside during the course of the treatment. Conclusion: Tooth extrusion techniques offer excellent treatment option for subgingival fractures. It is a well-documented clinical method for altering the relation between a nonrestorable tooth and its attachment apparatus, extruding sound tooth material from within the alveolar socket by light forces. The use of the lingual technique for forced eruption enhances acceptance of orthodontic treatment by adult patients.
Keywords: Traumatic injuries, dentition, central incisor, tooth extrusion, subgingival fractures, lingual technique
T
ooth traction (extrusion) was first described by Heithersay in 1973.1 Orthodontic extrusion is a conservative procedure that allows retention of a tooth without extraction. Inability to keep the restorative margin at supragingival level leads to the ultimate failure of restoration. Orthodontic tooth movement can modify and improve the periodontal anatomy of the hard and soft tissue morphology as also periodontally damaged or fractured teeth. Extrusion is a tooth movement that occurs in the direction of the normal eruptive process; forced orthodontic extrusion is movement of vertical translation (in a coronal direction) obtained through the application of light continuous forces.2,3
*Professor and Head †Senior Lecturer ‡Postgraduate Student Dept. of Orthodontics and Dentofacial Orthopedics Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu Address for correspondence Dr RV Murali Professor and Head Dept. of Orthodontics and Dentofacial Orthopedics Sree Balaji Dental College and Hospital, Chennai, Tamil Nadu
240
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
The indications and contraindications for orthodontic extrusion were discussed by Bach et al (2001).4 Indications for the treatment include - subgingival or infraosseous lesion of the tooth between the cementoenamel junction and the coronal third of the root; restoration impinging on the biological width; reduction of angular bone defects and isolated periodontal pockets; to maintain the integrity of an alveolar ridge for implant placement, tooth extrusion is done prior to extraction to grow alveolar bone in the extraction socket for future implant placement; for treatment of trauma or impacted teeth (for e.g. canines). The contraindications4 are - ankylosis, hypercementosis, vertical root fracture, root proximity, short roots, insufficient prosthetic space and exposure of the furcation. Extrusion is not recommended in cases where it will not be possible to achieve a 1:1 crown root ratio after final restoration. Extrusion is the easiest orthodontic movement to achieve because it closely resembles natural tooth eruption. Normally 0.2-0.3 Newton of force is required for the forced eruption of a single rooted tooth.5 A 3-4 mm distance from the alveolar crest to the restorative margin has been recommended for optimal periodontal health.6
DENTISTRY Traditional methods for orthodontic extrusion have been the use of labial appliances. This technique may be unacceptable to patients with serious esthetic concerns or needs. In such situations, lingual appliances may be an option for the patient. Lingual orthodontics in the current state, was first introduced by Alexander et al7 and Fujita.8 Although, this technique can be used to treat all kinds of malocclusion, it is preferred mostly by adult patients. This technique has changed the way of treating interdisciplinary cases with esthetic concerns, not only after treatment but even during the course of treatment. Case Report A 24-year-old male was referred to the Dept. of Orthodontics and Dentofacial Orthopedics, Sree Balaji Dental College and Hospital, Chennai, with a fractured upper left central incisor (21) subsequent to an injury. On clinical examination, it was observed that the upper right central incisor had a horizontal fracture at the
cervical one-third level (Figs. 1 and 2) with the fracture line extending subgingivally on palatal side. There were no other injuries reported. The traumatized tooth was first treated endodontically (Fig. 3), and then referred to our department for orthodontic extrusion before permanent crown placement. The patient was co-operative, and presented no contraindications for orthodontic treatment. As he was getting married, he preferred that the braces be put lingually and not labially. The lingual brackets (STb Brackets*) were positioned on the upper cast and a transfer tray made from glue gun** was fabricated (Fig. 4). After complete oral prophylaxis, etching with 37% orthophosphoric acid was done and the brackets were bonded on to the upper teeth (Fig. 5). A lingual button was bonded on 21 and tied with 0.012â&#x20AC;? NiTi lingual arch wire (Fig. 6). To avoid the lingual button and arch-wire
Figure 3. The traumatized tooth-treated endodontically.
Figures 1 and 2. Horizontal fracture of upper right central incisor with the fracture line extending subgingivally on palatal side.
Figure 4. Transfer tray made from glue gun.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
241
DENTISTRY
Figure 5. STb brackets bonded to the upper arch.
Figure 8. Postextrusion radiograph.
Figure 6. Lingual button bonded on 21 and was tied with 0.012â&#x20AC;? NiTi lingual arch wire.
Figure 9. Gingivectomy done to contour the gingival line.
Figure 7. Incisal margin of composite veneer margin kept 2 mm short to help in assessing the extrusion process.
Figure 10. Post and core on fractured (21).
being seen through the fractured incisor, a composite veneer was added to the fractured incisor. However, the margin was kept 2 mm short to help in assessing the extrusion process (Fig. 7). The patient was recalled once weekly to check the extrusion. The necessary
movement of the tooth (approximately 3 mm) to recover the biologic width had been attained in a period of 2 months. This was very much evident on the radiograph (Fig. 8). Once the required extrusion was achieved, the arch-wire was removed, and the lingual button
242
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
DENTISTRY Conclusion A multidisciplinary approach is necessary for the restoration of tooth fractured at subgingival level, because the margin of restoration should ideally be supragingival. In this clinical report, a treatment modality for forced eruption therapy that minimizes esthetic impairment was described. The use of the lingual technique for forced eruption may enhance acceptance of orthodontic treatment by adult patients who wish to avoid unnecessary esthetic compromises while undergoing the treatment of fractured tooth. References
Figure 11. Metal free ceramic cemented.
was debonded. After the procedure of orthodontic extrusion, the circumferential supracrestal fiberotomy around the exposed tooth was done to cut the stretched periodontal fibers to avoid reverse movement of the root intrusion to the earlier position.9-11 Following supracrestal fiberotomy procedure, gingivectomy was done to contour the gingival line (Fig. 9). Upon debonding, a metal free ceramic crown was given in 21 after post and core (Figs. 10 and 11). *Ormco Corporation, 1717 West Collins, Orange, CA 92867. **Bosch PKP 18E Glue Gun, Robert Bosch Gmg H, P.O. Box 106050, Stuttgart, Germany.
Discussion The restoration of fractured incisor with a subgingival fracture line has been managed over the years with the comprehensive multidisciplinary approach, in various ways. The method of tooth extrusion, first described by Hiethersay,1 uses the simple physiologic process of normal tooth eruption and applies it clinically to increase the clinical length of the crown. Tooth extrusion has been achieved by different methods including labial fixed appliances, modified arch-wires, mini implants and recently lingual bracket systems. Many adults now prefer the use of lingual brackets to labial appliances for esthetic reasons. In this case, the patient showed willingness for the treatment only after the option of lingual appliances was given. In this case report, a multidisciplinary approach of the fractured tooth using lingual orthodontics has been highlighted.
1. Heithersay GS. Combined endodontic-orthodontic treatment of transverse root fractures in the region of the alveolar crest. Oral Surg Oral Med Oral Pathol 1973;36(3):404-15. 2. Ingber JS. Forced eruption: part II. A method of treating nonrestorable teeth - Periodontal and restorative considerations. J Periodontol 1976;47(4):203-16. 3. Gianelly A, Goldman HM. Biologic Basis of Orthodontics. Lea and Febiger: Philadelphia, PA 1971:p.154-7. 4. Bach N, Baylard J, Voyer R. Orthodontic extrusion: periodontal considerations and applications. J Can Dent Assoc 2004;70(11):775-80. 5. Biggerstaff RH, Sinks JH, Carazola JL. Orthodontic extrusion and biologic width realignment procedures: methods for reclaiming nonrestorable teeth. J Am Dent Assoc 1986;112(2):345-8. 6. Postashnick SR, Rosenberg ES. Forced eruption: principles and restorative dentistry. J Prosthet Dent 1982;48(2):141-8. 7. Alexander CM, Alexander RG, Gorman JC, Hilgers JJ, Kurz C, Scholz RP, et al. Lingual orthodontics. A status report. J Clin Orthod 1982;16(4):255-62. 8. Fujita K. Multilingual-bracket and mushroom arch wire technique. A clinical report. Am J Orthod 1982;82(2):120-40. 9. Brown GJ, Welburry RR. Root extrusion, a practical solution in complicated crown-root incisor fractures. Br Dent J 2000;189(9):477-8. 10. Arhun N, Arman A, Ungor M, Erkut S. A conservative multidisciplinary approach for improved aesthetic results with traumatized anterior teeth. Br Dent J 2006;201(8):509‑12. 11. JI J, Luo XP, Lu W, Shi YJ, Wu L, Shu CJ. Esthetics restoration after rapid orthodontic extrusion of subgingivally fractured incisor: a case report. Hua Xi Kou Qiang Yi Xue Za Zhi 2007;25(2):206-7.
■■■■
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
243
DENTISTRY
Follicular Adenomatoid Odontogenic Tumor S Loganathan*, H Srinvasan†, R Veerakumar‡, M Arul Pari#
Abstract Adenomatoid odontogenic tumor is an uncommon odontogenic lesion, composed of odontogenic epithelium, characterized histologically by duct like structures with amyloid like deposits, noninvasive lesion with slow but progressive growth. Here, we are reporting a case of adenomatoid odontogenic tumor in a 16-year-old female patient in the maxillary region. This paper throws light on the controversies regarding its origin and management in light of recent findings, clinical, radiographic, histopathologic and therapeutic features of the adenomatoid odontogenic tumor.
Keywords: Adenomatoid odontogenic tumor, odontogenic epithelium, duct like structures, amyloid like deposits, maxillary region, excisional biopsy
A
denomatoid odontogenic tumor, is an uncommon benign epithelial lesion of odontogenic origin, accounting for 3-7% of odontogenic tumors, and was first described by Drieibaldt in 1907.1 According to the second edition of the World Health Organization (WHO) “Histological typing of odontogenic tumors”,2 adenomatoid odontogenic tumor is defined as “A tumor of odontogenic epithelium with duct-like structures and with varying degrees of inductive change in the connective tissue. The tumor may be partly cystic, and in some cases the solid lesion may be present only as masses in the wall of a large cyst.” The epithelial lining of the odontogenic cyst may transform into an odontogenic neoplasm like ameloblastoma. There are three variants of adenomatoid odontogenic tumor, follicular variant (73%), which has a central lesion associated with an embedded tooth, the extrafollicular variant (24%), which has a central lesion and no connection with the tooth and the peripheral variety (3%).3 The report describes an intraosseous
*Senior Lecturer Dept. of Oral and Maxillofacial Surgery †Reader Dept. of Oral Surgery ‡Reader #Senior Lecturer Dept. of Pedodontia Priyadarshini Dental College, Pandur, Thiruvallur, Tamil Nadu Address for correspondence Dr S Loganathan Senior Lecturer Dept. of Oral and Maxillofacial Surgery Priyadarshini Dental College, Pandur, Thiruvallur, Tamil Nadu E-mail: drloganathans@gmail.com, srini11@hotmail.com
244
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
follicular adenomatoid odontogenic tumor in the maxilla illustrating the clinical, histopathological and biological features of the tumor and emphasizes the importance of the relation between the dental follicle and the tumor tissue. Case Report A 16-year-old female patient reported with a chief complaint of unerupted tooth and pain in the upper anterior left maxillary region. The medical history was insignificant. Intraoral examination disclosed a nontender, expansible lesion of the left maxilla, surrounded by normal mucosa and retained deciduous canine and missing left permanent canine (Fig. 1). Orthopantomogram (OPG) and maxillary
Figure 1. Intraoral picture showing asymmetry on the left maxillary region and missing left permanent canine, retained deciduous canine and malpositioned left lateral incisor.
DENTISTRY canine (Figs. 2 and 3). According to the clinical and radiological findings, the lesion was diagnosed as an adenomatoid odontogenic tumor. Under local anesthesia, excisional biopsy was performed with excavation of upper left canine (Fig. 4). The differential diagnosis was dentigerous cyst, calcified epithelial odontogenic tumor and odontogenic keratocyst.
Histopathological Features Figure 2. Panoramic radiograph reveals radiolucency surrounding the impacted left permanent canine, retained deciduous canine and displaced lateral incisor.
Odontogenic epithelium was arranged in the form of sheets, rods and few odontogenic cells, arranged in duct like structures with eosinophilic material in the center. A well-defined firm thick fibrous tissue capsule was seen at the periphery, which confirmed the diagnosis of adenomatoid odontogenic tumor. Discussion
Figure 3. Occlusal radiograph reveals radiolucency surrounding the impacted left permanent canine, retained deciduous canine and displaced lateral incisor.
Figure 4. Picture showing the tumor and the impacted canine.
occlusal view revealed the presence of a significant unilocular radiolucent area with well-defined sclerotic borders, involving an impacted upper left permanent
Adenomatoid odontogenic tumor is a slow growing lesion, constituting only 3% of all odontogenic tumors with a predilection for the anterior maxilla (ratio 2:1).4 Rick et al have reported adenomatoid odontogenic tumor to occur with many types of cysts and neoplasms including dentigerous cyst, calcifying odontogenic cyst, odontoma and ameloblastoma, etc.5 In relation with a dentigerous cyst, the adenomatoid odontogenic tumor may demonstrate, grossly and microscopically, one or more associated cystic cavities. Some of these cysts are lined by nonkeratinized stratified squamous epithelium, which is similar to the lining of the dentigerous cyst or lined by less structured membrane that may demonstrate bud like extensions into the connective tissue. In our case, a moderate amount of the inflammatory component was evident in the sections, which could cause the cystic epithelium to lose its characteristic features and hence restrict the typing to an odontogenic cyst alone. Odontogenesis is a complex process wherein neoplastic or hamartomatous lesions can occur at any stage of odontogenesis. The secondary development of an ameloblastic proliferation, whether hyperplastic or neoplastic is well-known, but remains controversial. In the present case, the multifocal cellular proliferation had the structure of an AOT although larger lesions reported in the literature are usually in the dimensions of 2-3 cm. Radiographically, they usually appear as or without root resorption.6,7 This appearance must be differentiated from various types of disease, such as calcifying odontogenic tumor or cysts.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
245
DENTISTRY The differential diagnosis can also be made with ameloblastoma, ameloblastic fibroma and ameloblastic fibro-odontoma. The tumor is well-encapsulated and shows an identical benign behavior. Therefore, conservative surgical enucleation produces excellent outcome without recurrence.8,9 Our patient has been under follow-up for 8 months. Conclusion Our case report supports the general description of adenomatoid odontogenic tumor in the previous studies. We conclude that the rarity of adenomatoid odontogenic tumor may be associated with its slowly growing pattern and symptomless behavior. Therefore, it should be distinguished from more common lesions of odontogenic origin in routine dental examinations. References 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. In: Odontogenic Cysts and Tumors. Warldon CA (Ed.), WB Saunders: Philadelphia, Pa, USA 2002:p.589-642. 2. Jing W, Xuan M, Lin Y, Wu L, Liu L, Zheng X, et al. Odontogenic tumours: a retrospective study of 1642
cases in a Chinese population. Int J Oral Maxillofac Surg 2007;36(1):20-5. 3. Bravo M, White D, Miles L, Cotton R. Adenomatoid odontogenic tumor mimicking a dentigerous cyst. Int J Pediatr Otorhinolaryngol 2005;69(12):1685-8. 4. Swasdison S, Dhanuthai K, Jainkittivong A, et al. Adenomatoid odontogenic tumors: an analysis of 67 cases in a Thai population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105(2):210-5. 5. Nigam S, Gupta SK, Chaturvedi KU. Adenomatoid odontogenic tumor: a rare cause of jaw swelling. Braz Dent J 2005;16(3):251-3. 6. Larsson A, Swartz K, Heikinheimo K. A case of multiple AOT-like jawbone lesions in a young patient - a new odontogenic entity? J Oral Pathol Med 2003;32(1): 55-62. 7. Dayi E, Gürbüz G, Bilge OM, Ciftcioğlu MA. Adenomatoid odontogenic tumour (adenoameloblastoma). Case report and review of the literature. Aust Dent J 1997;42(5): 315-8. 8. Philipsen HP, Reichart PA, Nikai H. The adenomatoid odontogenic tumor (AOT): an update. J Oral Pathol Med 1997;2:55-60. 9. Motamedi MH, Shafeie HA, Azizi T. Salvage of an impacted canine associated with an adenomatoid odontogenic tumour: a case report. Br Dent J 2005;199(2):89-90.
■■■■
Dental Treatment by Pediatricians Effective for Kids Primary care physicians can reduce tooth decay in indigent children by providing them with fluoride treatment, oral health education, exams and referrals, a new study shows. “Programs targeting vulnerable populations through medical offices can reduce disparities in oral health among preschool- aged populations,” Leo N. Achembong, BDS, MPH, from the North Carolina Department of Health and Human Services in Raleigh and colleagues write. The researchers published their results online March 31 in Pediatrics. Many children do not see dentists regularly, and lack of oral care is particularly common among children younger than 3 years - and even more so among those whose families cannot afford private dentistry. In effort to address the gap, 46 state Medicaid programs in the United States reimburse physicians for some preventive dental services, the researchers write. Most of these programs started after 2006. North Carolina launched its Into the Mouth of Babes Program (IMBP), in 2000. The program trains physicians to paint fluoride varnish on the teeth of their youngest patients, to examine the health of the children’s mouths, to teach the children and their caregivers about caring for the kids’ mouths, and to refer them to dentists to treat decayed teeth and other oral disease. The program provides services to children enrolled in Medicaid from the time of the first tooth eruption until age 42 months. It has expanded steadily, reaching about 80,000 children in 2011. To measure its effectiveness, Dr. Achembong and colleagues counted the number of decayed, missing and filled teeth (DMFT) among 920,505 5-year-old children. They found that the rate increased from 1.53 DMFT per child in 1998 to 1.84 in 2004 and then dropped back to 1.59 in 2009.
246
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Dermatology
Generalized Granuloma Annulare in a Diabetic Patient Amrita Chauhan*, Hemanta Kumar Kar*
Abstract Granuloma annulare (GA) is a transient, benign, cutaneous inflammatory disorder that is pathologically characterized by necrobiotic collagen associated with an infiltration of histiocytes and lymphocytes. The lesions of classical GA consist of localized, small, firm, asymptomatic papules that are flesh-colored or pale red; they are grouped in a ring-like or circinate fashion. Generalized GA (GGA) has been defined as lesions that occur on the trunk and on both sets of extremities or on either the upper or lower extremities. We present the case of a 50-year-old female suffering from diabetes and hypertension since last 4 years, who complained of appearance of mildly pruritic red raised lesions and ring-shaped lesions of 7-month duration over anterior neck, upper back, back, forearms, dorsum of hands and feet. A diagnosis of GGA was made and was confirmed histopathologically.
Keywords: Granuloma annulare, cutaneous inflammatory disorder, necrobiotic collagen, histiocytes, lymphocytes, diabetes, hypertension
G
ranuloma annulare (GA) is a benign granulomatous disease of unknown etiology characterized by multiple erythematous and annular plaques with histopathological features of necrobiosis and palisading granulomas. Colcott Fox first described it in 1895; in 1902, Radcliffe-Crocker labeled it as GA. The unusual variants of GA include generalized, perforating, patch and subcutaneous. These various types of GA share similar pathological findings. There are four pathological structural patterns of GA: Palisading, interstitial, perforating and subcutaneous. The most common clinical form is localized GA, which accounts for approximately 75% of all cases. The lesions are usually found on the hands, feet, wrists and ankles but can potentially occur anywhere on the body. Generalized GA (GGA) has been defined as lesions occurring on at least the trunk and either upper or lower, or both, extremities. While localized variants of GA are typically self-limited, disseminated GA tends to be chronic. GGA is differentiated from the localized form (classical GA) by a later age of onset, wider distribution of lesions, protracted course with only rare spontaneous resolution and poor response with therapy. In addition, the interstitial pattern is reported to be predominant in the annular type of GGA. Because it is a rare variant of GA, the clinicopathological correlations of GGA have not yet been clearly established.
*Dept. of Dermatology STD and Leprosy Dr RML Hospital and PGIMER Baba Kharak Singh Marg, New Delhi
Case Report A 50-year-old female, resident of Delhi, presented to Dr Ram Manohar Lohia Hospital with complaints of mildly pruritic red raised lesions and ring-shaped lesions for the last 7 months over anterior neck, upper back, back, forearms, dorsum of hands and feet. There was a history of spontaneous resolution after 1 month of topical corticosteroid preparation. However, the lesions recurred after 2 months of stopping therapy. The patient is a known case of diabetes mellitus (DM) and hypertension (HT) for the last 4 years; she is on regular oral hypoglycemic therapy and antihypertensive therapy (metformin, glimepiride, amlodipine, metoprolol, telmisartan). There was no history of recent change in the medications preceding the skin eruption. On examination, there were multiple well-defined, erythematous papules as well as annular plaques that were 0.5-2 cm in size, round to oval in shape, distributed over the neck, upper back, back, forearms and dorsum of hands and feet. On skin biopsy, the dermis showed focal perivascular mononuclear infiltrate. Occasional giant cells were also seen along with a few scattered histiocytes in between the collagen fibers. The collagen was degenerated or necrobiotic, consistent with the diagnosis of GA (interstitial pattern). Other investigations like complete hemogram, blood sugar (fasting and postprandial), liver function test (LFT), kidney function test (KFT), urine (routine and microscopic examination), serum calcium, serum angiotensin-
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
247
Dermatology
Figure 1. Erythematous papular as well as smooth, nonscaly annular lesions over upper limbs, trunk and lower limbs.
A
B
C
D
Figure 2. (A) Perivascular mononuclear infiltrate, (B) histiocytes in between collagen bundles, (C) giant cell and (D) degenerated/ necrobiotic collagen thus suggestive of GA (interstitial pattern).
248
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Dermatology converting enzyme (ACE) levels, chest X-ray, thyroid profile were within normal limits. Mantoux test was 7 mm. Serum Venereal Disease Research Laboratory (VDRL), enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) 1 and 2, hepatitis B surface antigen (HbsAg) and anti-HCV (hepatitis C virus) were negative. Thus, a diagnosis of GGA was made. Discussion Annular lesions are extremely common and striking in appearance but can also be misleading. The term ‘annular’ stems from the Latin word ‘annulus’, meaning ringed. The lesions appear as circular or ovoid macules or patches with an erythematous periphery and central clearing. The most common diagnosis of such lesions in an outpatient setting is dermatophytosis. However, other differentials to be considered depending upon the clinical presentation include cutaneous sarcoidosis, erythema multiforme, GA, subacute cutaneous lupus erythematosus and Sweet’s syndrome among others. GA is a benign, usually selflimited dermatosis of unknown cause. It is widely believed to be an immunologicallymediated reaction in which inflammation surrounds blood vessels and alters collagen and elastic tissues. It is characterized by localized, pruritic, erythematous or flesh-colored, annular plaques that usually occur on the extremities. The disease is idiopathic and often resolves within 2 years. Although, the pathogenesis of GA has not been fully elucidated, the presence of activated T cells in the lymphocytic infiltrate of GA has been demonstrated, suggesting there is a cell-mediated immune response to various precipitating factors. Several precipitating factors have been proposed, which include sun exposure, insect bites, viral infections, thyroiditis, tuberculin skin tests and trauma. GGA is a subset of the disease that causes a wide distribution of more than 10 lesions. Several investigators have attempted to demonstrate a relationship between GGA and other systemic diseases, most notably DM, though the association between the two is not yet clearly established. Studies that looked for carbohydrate intolerance by performing glucose tolerance testing or assessing the hemoglobin A1C
values failed to find an increased prevalence of altered carbohydrate metabolism in patients with GA. However, Studer et al noted that 10 of 84 adult patients (12%) with GA (localized or generalized) had DM, as opposed to the 5% prevalence of DM among the regional population. Thus, a work-up for DM is warranted in a patient presenting with GGA. Our patient was already a diagnosed case of DM and was on regular oral hypoglycemic therapy. Generally, treatment for classical GA is unnecessary because spontaneous resolution is expected. However, GGA was reported to be different from classical GA by exhibiting a protracted course with only rare spontaneous resolution and a poor response to therapy. A variety of treatment modalities for GGA have been used, but they have shown only partial responses. These include topical application of vitamin E, cryotherapy, laser destruction and topical or intralesional injection of corticosteroids. Systemic trials of PUVA, dapsone, hydroxychloroquine, niacinamide, chlorambucil, isotretinoin and potassium iodide have been reported, but the observed efficacy was limited and the side effects most often outweighed the benefits. Our patient is responding to topical steroid and oral antihistamine therapy and is under our follow-up. Conclusion GGA is an uncommon benign disorder. A work-up for DM is required, especially in those over 40 years of age. Although GGA may be resistant to therapy, topical and or intralesional corticosteroids are the safest options when benefits are compared with the risks. Suggested Reading 1. Granuloma annulare. In: Weedon’s Skin Pathology. Weedon D (Ed.), 2nd edition, Churchill-Livingstone: London 2002:p.200-2. 2. Dabski K, Winkelmann RK. Generalized granuloma annulare: histopathology and immunopathology. Systematic review of 100 cases and comparison with localized granuloma annulare. J Am Acad Dermatol 1989;20(1):28-39. 3. Studer EM, Calza AM, Saurat JH. Precipitating factors and associated diseases in 84 patients with granuloma annulare: a retrospective study. Dermatology 1996;193(4):364-8.
■■■■
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
249
Every citizen of India should have the right to accessible, affordable, quality and safe heart care irrespective of his/her economical background
Sameer Malik Heart Care Foundation Fund An Initiative of Heart Care Foundation of India
E-219, Greater Kailash, Part I, New Delhi - 110048 E-mail: heartcarefoundationfund@gmail.com Helpline Number: +91 - 9958771177
“No one should die of heart disease just because he/she cannot afford it” About Sameer Malik Heart Care Foundation Fund
Who is Eligible?
“Sameer Malik Heart Care Foundation Fund” it is an initiative of the Heart Care Foundation of India created with an objective to cater to the heart care needs of people.
Objectives Assist heart patients belonging to economically weaker sections of the society in getting affordable and quality treatment. Raise awareness about the fundamental right of individuals to medical treatment irrespective of their religion or economical background. Sensitize the central and state government about the need for a National Cardiovascular Disease Control Program. Encourage and involve key stakeholders such as other NGOs, private institutions and individual to help reduce the number of deaths due to heart disease in the country. To promote heart care research in India.
All heart patients who need pacemakers, valve replacement, bypass surgery, surgery for congenital heart diseases, etc. are eligible to apply for assistance from the Fund. The Application form can be downloaded from the website of the Fund. http://heartcarefoundationfund.heartcarefoundation. org and submitted in the HCFI Fund office.
Important Notes The patient must be a citizen of India with valid Voter ID Card/ Aadhaar Card/Driving License. The patient must be needy and underprivileged, to be assessed by Fund Committee. The HCFI Fund reserves the right to accept/reject any application for financial assistance without assigning any reasons thereof. The review of applications may take 4-6 weeks. All applications are judged on merit by a Medical Advisory Board who meet every Tuesday and decide on the acceptance/rejection of applications. The HCFI Fund is not responsible for failure of treatment/death of patient during or after the treatment has been rendered to the patient at designated hospitals.
To promote and train hands-only CPR.
Activities of the Fund Financial Assistance
The HCFI Fund reserves the right to advise/direct the beneficiary to the designated hospital for the treatment.
Financial assistance is given to eligible non emergent heart patients. Apart from its own resources, the fund raises money through donations, aid from individuals, organizations, professional bodies, associations and other philanthropic organizations, etc.
The financial assistance granted will be given directly to the treating hospital/medical center.
After the sanction of grant, the fund members facilitate the patient in getting his/her heart intervention done at state of art heart hospitals in Delhi NCR like Medanta – The Medicity, National Heart Institute, All India Institute of Medical Sciences (AIIMS), RML Hospital, GB Pant Hospital, Jaipur Golden Hospital, etc. The money is transferred directly to the concerned hospital where surgery is to be done.
Drug Subsidy
The HCFI Fund has the right to print/publish/webcast/web post details of the patient including photos, and other details. (Under taking needs to be given to the HCFI Fund to publish the medical details so that more people can be benefitted). The HCFI Fund does not provide assistance for any emergent heart interventions.
Check List of Documents to be Submitted with Application Form Passport size photo of the patient and the family A copy of medical records Identity proof with proof of residence Income proof (preferably given by SDM)
The HCFI Fund has tied up with Helpline Pharmacy in Delhi to facilitate
BPL Card (If Card holder)
patients with medicines at highly discounted rates (up to 50%) post surgery.
Details of financial assistance taken/applied from other sources (Prime Minister’s Relief Fund, National Illness Assistance Fund Ministry of Health Govt of India, Rotary Relief Fund, Delhi Arogya Kosh, Delhi Arogya Nidhi), etc., if anyone.
The HCFI Fund has also tied up for providing up to 50% discount on imaging (CT, MR, CT angiography, etc.)
Free Diagnostic Facility
Free Education and Employment Facility
The Fund has installed the latest State-of-the-Art 3 D Color Doppler EPIQ 7C Philips at E – 219, Greater Kailash, Part 1, New Delhi.
HCFI has tied up with a leading educational institution and an export house in Delhi NCR to adopt and to provide free education and employment opportunities to needy heart patients post surgery. Girls and women will be preferred.
This machine is used to screen children and adult patients for any heart disease.
Laboratory Subsidy HCFI has also tied up with leading laboratories in Delhi to give up to 50% discounts on all pathological lab tests.
About Heart Care Foundation of India
Help Us to Save Lives The Foundation seeks support, donations and contributions from individuals, organizations and establishments both private and governmental in its endeavor to reduce the number of deaths due to heart disease in the country. All donations made towards the Heart Care Foundation Fund are exempted from tax under Section 80 G of the IT Act (1961) within India. The Fund is also eligible for overseas donations under FCRA Registration (Reg. No 231650979). The objectives and activities of the trust are charitable within the meaning of 2 (15) of the IT Act 1961.
Heart Care Foundation of India was founded in 1986 as a National Charitable Trust with the basic objective of creating awareness about all aspects of health for people from all walks of life incorporating all pathies using low-cost infotainment modules under one roof. HCFI is the only NGO in the country on whose community-based health awareness events, the Government of India has released two commemorative national stamps (Rs 1 in 1991 on Run For The Heart and Rs 6.50 in 1993 on Heart Care Festival- First Perfect Health Mela). In February 2012, Government of Rajasthan also released one Cancellation stamp for organizing the first mega health camp at Ajmer.
Objectives Preventive Health Care Education Perfect Health Mela Providing Financial Support for Heart Care Interventions Reversal of Sudden Cardiac Death Through CPR-10 Training Workshops Research in Heart Care
Donate Now... Heart Care Foundation Blood Donation Camps The Heart Care Foundation organizes regular blood donation camps. The blood collected is used for patients undergoing heart surgeries in various institutions across Delhi.
Committee Members
Chief Patron
President
Raghu Kataria
Dr KK Aggarwal
Entrepreneur
Padma Shri, Dr BC Roy National & DST National Science Communication Awardee
Governing Council Members Sumi Malik Vivek Kumar Karna Chopra Dr Veena Aggarwal Veena Jaju Naina Aggarwal Nilesh Aggarwal H M Bangur
Advisors Mukul Rohtagi Ashok Chakradhar
Executive Council Members Deep Malik Geeta Anand Dr Uday Kakroo Harish Malik Aarti Upadhyay Raj Kumar Daga Shalin Kataria Anisha Kataria Vishnu Sureka
This Fund is dedicated to the memory of Sameer Malik who was an unfortunate victim of sudden cardiac death at a young age.
Rishab Soni
HCFI has associated with Shree Cement Ltd. for newspaper and outdoor publicity campaign HCFI also provides Free ambulance services for adopted heart patients HCFI has also tied up with Manav Ashray to provide free/highly subsidized accommodation to heart patients & their families visiting Delhi for treatment.
http://heartcarefoundationfund.heartcarefoundation.org
ENT
A Rare Case of Type II First Branchial Cleft Sinus Managed by Complete Excision DR NAGESWARAN
Abstract First branchial cleft anomalies account for <8% of all branchial abnormalities. Their rarity and disease presentations have frequently led to misdiagnosis and inappropriate treatment. The first branchial cleft anomalies with their varied clinical manifestations may present to an otologist, a pediatrician or maxillofacial and general surgery practice. There is a need to highlight the clinical features, which can aid in accurate diagnosis. Here we present a rare case of type II first branchial cleft sinus, which was excised totally.
Keywords: Abscess, congenital defects, ear, sinus, neck CASE REPORT A 30-year-old female patient presented to ENT OPD with complaints of right ear discharge since childhood. On examination, the tympanic membrane was found to be intact. On pressing the right side of neck, there was discharge from the floor of external auditory canal. There was a history of incision and drainage of pus in the right submandibular region in her childhood. Magnetic resonance imaging (MRI) showed a sinus tract (Fig. 1) extending from the floor of the external auditory canal into the parotid and up to the neck. Based on the history, clinical examination and imaging a diagnosis of first branchial cleft sinus was made. Since, the sinus tract was extending into the parotid we planned to do a superficial parotidectomy and then to trace the sinus tract, so as to preserve all branches of facial nerve.
from the floor of external auditory canal was also excised. Biopsy was reported as a sinus tract with covering of cartilage.
Figure 1. MRI showing the sinus tract.
A routine parotidectomy incision was made and extended into the neck. A superficial parotidectomy was performed after preserving all branches of facial nerve. The sinus tract covered with cartilage ran beneath the facial nerve into the parotid and up to the neck, which was excised totally. An eclipse of skin
Senior Consultant Dept. of ENT Meenakshi Mission Hospital and Research Centre, Madurai, Tamil Nadu Address for correspondence Dr DR Nageswaran Senior Consultant Dept. of ENT Meenakshi Mission Hospital and Research Centre, Madurai - 625 107, Tamil Nadu E-mail: nageswaranent@hotmail.com
252
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Figure 2. After complete removal of sinus tract.
ENT
Figure 3. Intraoperative photo with facial nerve and its branches.
cartilaginous junction or at the cartilaginous portion. Type I lesion can be removed while still keeping the epidermal skin of the meatus intact via retroauricular incision while for type II lesion early identification of the facial nerve at stylomastoid foramen is recommended. Should the skin fistula opening involve the external auditory canal it is removed with skin and cartilage. Primary closure is normally possible, but if more than 30% of the circumference of the external auditory canal is denuded split thickness skin grafting and stenting are recommended. Recurrence after first surgery is low. Generally, the complications include recurrence 12.5%, infection 7.7%, facial palsy 2.9%, ear canal stenosis 0.96% and keloid formation. Conclusion
dISCUSSION During the 4th week of human embryological development, six pairs of branchial arches appear, which will form the lower face and neck and they disappear by 7th week. First branchial cleft anomalies are the result of incomplete closure of the cleft. The chance of malformations occurring nearer the ear and parotid is greater than that occurring at the hyoid region, as obliteration proceeds from ventral to dorsal. There are two types: 1) Type I ectodermal origin, it can have a tract running medial and parallel to the external auditory canal superior to the facial nerve and ending in a cul-de-sac on a bony plate at the level of mesotympanum. 2) Type II ectodermal and mesodermal in origin, can present as a sinus, fistula or a combination of both. They are associated with a sinus or fistula opening in the region of submental triangle, extend superiorly towards the floor of external auditory canal at the level of bony
Although the external ear is derived from the first branchial cleft, the clinical manifestations of its duplication anomalies are not necessarily confined to otology, its rarity and diverse presentations have frequently led to misdiagnosis and inappropriate treatment. The clinician must be familiar with the specific otologic and head and neck features. Surgical expertise must be available to remove the lesion completely and preserve all branches of facial nerve and perform otologic reconstructive surgery if necessary. REFERENCES 1. McRae RG, Lee KJ, Goertzen E. First branchial cleft anomalies and the facial nerve. Otolaryngol Head Neck Surg 1983;91(2):197-202. 2. Aronsohn RS, Batsakis JG, Rice DH, Work WP. Anomalies of the first branchial cleft. Arch Otolaryngol 1976;102(12):737-40.
■■■■
Caloric vestibular stimulation (CVS), a test commonly used by ENT specialists and audiologists to test patients’ balance, could transiently enhance illness awareness in patients with schizophrenia, reports a pilot proof-ofconcept study presented at the American Society of Clinical Psychopharmacology (ASCP) 2014 Annual Meeting.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
253
Internal medicine
Hemophagocytic Lymphohistiocytosis: A Case Report Debaprasad Chakrabarti*, Avik Chakraborty*, Anindya Sundar Trivedi†, Amrit Kr Bhattacharyya‡
Abstract Hemophagocytosis lymphohistiocytosis (HLH) is a potentially lethal disorder due to an uncontrolled immune response to a triggering agent. Active pulmonary tuberculosis is an uncommon the immunological trigger for HLH. Herein we present this case to raise the awareness amongst physicians regarding the uncommon manifestation of a common disease.
Keywords: Hemophagocytosis lymphohistiocytosis, immune response, active pulmonary tuberculosis
H
emophagocytic lymphohistiocytosis (HLH) is a potentially fatal condition, characterized by multisystem inflammation: A reactive process resulting from prolonged and excessive activation of immune cells, in particular natural killer (NK) cells and CD8+ cytotoxic and antigen presenting cells. Hemophagocytosis, which is mediated through CD163 heme scavenging receptor, is a hallmark of activated macrophages/histiocytes and is a characteristic finding after which the disorder was named. It is helpful to think HLH as the severe end of the spectrum of hyperinflammatory disorders when immune system starts to damage host cells.1 Common triggers include infection, malignancies, autoimmune disease or metabolic condition. In our case, the inciting stimulus was disseminated tuberculosis, an uncommon cause for HLH. CASE REPORT A 35-year-old gentleman was admitted to our hospital with chief complaints of intermittent fever and pain in multiple large and medium joints for last 6 months. He also noticed weight loss of 10 kg approximately. There was no history of cough; hemoptysis or rash. He denied any history of sexual promiscuity.
*Associate Professor †Postgraduate Trainee ‡Professor and Head Dept. of Medicine Tripura Medical College and Dr BRAM Teaching Hospital Hapania, Agartala, Tripura Address for correspondence Dr Debaprasad Chakrabarti Associate Professor Dept. of Medicine Tripura Medical College and Dr BRAM Teaching Hospital Hapania, Agartala, Tripura (West) - 799 014 E-mail: drdebaprasad2007@rediffmail.com
256
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Since, last 1 month, he developed high-grade fever associated with mild abdominal distension and pedal swelling. He was a chronic alcoholic consuming 40 g of alcohol since past 10 years. In his family, his brother was treated for pulmonary tuberculosis 2 years back. During hospital stay, he developed an abscess over left thigh and underwent incision and drainage, fasciotomy and debridement. On examination, he was febrile, anemic and icteric. There was ankle edema and few nonmatted neck nodes, largest measuring 2 x 2 cm. Vitals were stable. Reduced breath sound, on right base, hepatosplenomegaly and ascites were noted on systemic examination. On investigation, hemoglobin (Hb) - 6.8 g/dL, total leukocyte count (TLC) - 1,500, differential leukocyte count (DLC) - P80,L15,M5,E0,B0 and platelet count 98,000, erythrocyte sedimentation rate (ESR) - 110 mm/hr. Peripheral blood smear suggestive of normocytic normochromic picture with pancytopenia. Blood culture was sterile. Liver function test (LFT) revealed bilirubin - 0.7 mg/dL, alanine transaminase/aspartate transaminase (ALT/AST) - 64/78 IU. Protein - 5.6 g/dL, albumin - 2.5, prothrombin time - 19 sec (INR-1.9). Viral and autoimmune markers were negative. Ascitic fluid analysis revealed protein - 1.8 g/dL, cell count 100/mm3 with lymphocytes 95%. Acid-fast bacilli (AFB) stain was negative and adenosine deaminase (ADA) was normal. Chest X-ray showed right pleural effusion and ultrasonography (USG) revealed hepatosplenomegaly and ascites. Computed tomography (CT) abdomen showed multiple pre-, para-aortic and retrocaval nodes (Figs. 1 and 2). Bone marrow aspiration cytology and biopsy showed normocellular marrow with trilineage hematopoiesis and hemophagocytosis (Figs. 3 and 4). There was also moderate plasmacytosis and increased megakaryopoiesis. In presence of pancytopenia and hemophagocytosis on marrow a possibility of HLH
Internal medicine
Multiple enlarged lymph nodes
Ivc is displaced anteriorly
Figure 1. CT showing pre- and para-aortic lymphadenopathy.
Figure 2. CT showing retrocaval lymphadenopathy with areas of necrosis.
Figure 3. Phocomicrograph of bone marrow aspirate showing a large hemophagocyte with an engulfed myelocyte (Giemsa x 1,000).
Figure 4. Phocomicrograph of bone marrow aspirate showing a large hemophagocyte with engulfed megakaryocytic fragment with platelet and erythroid cells (Giemsa x 1,000).
was considered and he was further investigated. Serum ferritin was raised (1,088 ng/dL), serum triglyceride was also elevated (310 mg/dL) and serum fibrinogen was normal. Neck node biopsy was suggestive of necrotizing granulomatous lymphadenitis and Gene-Xpert of bone marrow aspirate was positive for Mycobacterium tuberculosis. Considering the clinical and laboratory profile, a final diagnosis of disseminated tuberculosis with hemophagocytosis was made based on HLH 2009 criteria and he was put on ATT (HRZE). Seen on last follow-up, there was significant clinical improvement. DISCUSSION HLH is a potentially fatal hyperinflammatory condition caused by highly stimulated but ineffective immune response.1 Incidence is 1.2 cases per million
individuals per year. Broadly HLH can be classified into two categories either primary (genetic) or secondary (acquired). Primary variety occurs due to mutation in genes important in cytolytic pathway that cause perforin and granzymes to induce apoptosis in target cells.2 Though primary variety presents usually by the age of 2 years, it can occur throughout life including presentation in prenatal period to as late as seventh decade of life.3 Epstein-Barr virus is the most common infectious etiology implicated in secondary hemophagocytic syndrome, but the syndrome has been associated with a variety of viral, bacterial and parasitic pathogens. Secondary form can also occur in association with malignancies and rheumatological disease.4 HLH is a multisystem inflammatory disorder caused by prolonged and excessive activation of immune cells, in particular NK cells and CD8 + cytotoxic
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
257
Internal medicine Table 1. HLH Diagnostic Criteria 2009 Molecular diagnosis of HLH or X-linked lymphoproliferative syndrome (XLP) Or at least 3 of 4 yy Fever yy Splenomegaly yy Cytopenias (minimum 2 cell lines reduced) yy Hepatitis And at least 1 of 4 yy Hemophagocytosis yy ↑ Ferritin yy ↑ sIL2ra (age based) yy Absent or very decreased NK function Other results supportive of HLH diagnosis yy Hypertriglyceridemia yy Hypofibrinogenemia yy Hyponatremia
‘T’ cells (CTL). Dysfunctional NK cells and CTL are believed to be ineffective in controlling the infection. In addition, there is a failure of regulatory pathways responsible for contraction or termination of immune response. As a result of both, there is continuous stimulation of immune cells leading to overproduction of proinflammatory cytokines like tumor necrosis-a (TNF-a), interleukin (IL)-6, IL-10 and interferon-g (IFN-g), which in turn hyperstimulates the tissue macrophages. This cytokine storm is primarily responsible for varied clinical picture.5 Dysregulated activation and proliferation of macrophages lead to uncontrolled phagocytosis of platelets, erythrocyte and lymphocytes and their precursors throughout the reticuloendothelial system. HLH clinically manifests with fever, lymphadenopathy, jaundice, hepatosplenomegaly and bleeding tendency or multiorgan failure. Diagnostic criteria6 of HLH is shown in Table 1. HLH can be rapidly fatal without specific intervention. Effective treatment designed for primary HLH and severe forms of secondary cases include therapies that target activated macrophages/histiocytosis (etoposide, steroids, high-dose IV IgG) and/or activated T cells (steroids, cyclosporine A, antithymocyte globulins, 2 CdA, Campath 1H.)7 After initial treatment bone marrow transplantation is indicated in primary disease and severe secondary persistent HLH. Tuberculosis is an uncommon but important cause of secondary HLH accounting for 3% of all cases affecting all age groups.8 Elderly population is more at risk for developing tuberculosis associated HLH. It confers a
258
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
high overall mortality (44-80%), which is mainly due to under recognition of the condition. Though, the exact pathogenesis of tuberculosis associated HLH is not clearly known, it is likely the phenomenon is related to immune dysregulation. Culture of the bone marrow appears to be a more sensitive test than peripheral blood culture (38% vs 8%) first-line ATT can be appropriate. The duration may need to be prolonged beyond 6 months. Besides ATT, other therapeutic option includes glucocorticoids to control the intense immune reaction. However, given the limited number of case reports the optimum dose and duration of steroid therapy as well as its exact place in tuberculosis associated HLH treatment regimen remains unclear.9 In presence of active tuberculosis, hemophagocytosis syndrome is rare but serious; hence physicians should actively seek out tuberculosis in any given case of HLH to avoid missing a common diagnosis. Importantly hemophagocytosis may not be obvious on bone marrow biopsy early in course of disease. Early diagnosis and treatment is essential for better outcome. REFERENCES 1. Janka G. Hemophagocytic lymphohistiocytosis: when the immune system runs amok. Klin Padiatr 2009;221(5):278-85. 2. Stepp SE, Dufourcq-Lagelouse R, Le Deist F, Bhawan S, Certain S, Mathew PA, et al. Perforin gene defects in familial hemophagocytic lymphohistiocytosis. Science 1999;286(5446):1957-9. 3. Malloy CA, Polinski C, Alkan S, Manera R, Challapalli M. Hemophagocytic lymphohistiocytosis presenting with nonimmune hydrops fetalis. J Perinatol 2004;24(7):458-60. 4. Janka GE. Hemophagocytic syndromes. Blood Rev 2007;21(5):245-53. 5. Brastianos PK, Swanson JW, Torbenson M, Sperati J, Karakousis PC. Tuberculosis-associated haemophagocytic syndrome. Lancet Infect Dis 2006;6(7):447-54. 6. Filipovich AH. Hemophagocytic lymphohistiocytosis (HLH) and related disorders. Hematology Am Soc Hematol Educ Program 2009:127-31. 7. Henter JI, Horne A, Aricó M, Egeler RM, Filipovich AH, Imashuku S, et al. HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2007;48(2):124-31. 8. Créput C, Galicier L, Buyse S, Azoulay E. Understanding organ dysfunction in hemophagocytic lymphohistiocytosis. Intensive Care Med 2008;34(7):1177-87. 9. Shea YF, Chan JF, Kwok WC, Hwang YY, Chan TC, Ni MY, et al. Haemophagocytic lymphohistiocytosis: an uncommon clinical presentation of tuberculosis. Hong Kong Med J 2012;18(6):517-25.
Internal medicine
Significance of Peripheral Blood Smear in Diagnosis of Blood Parasitic Infection Gopal Raval, Devang Patvari, D Kothari, P Joshi, M Pandya
Abstract Bancroftian filariasis is a tropical and subtropical disease caused by Wuchereria bancrofti and transmitted by the Culex mosquitoes. It is conventionally diagnosed made by demonstrating microfilariae in the peripheral blood smear. Microfilariae and adult filarial worm have been incidentally detected in the blood. We here report an unusual case of Bancroftian microfilariasis in a 28-year-old male coming from endemic area with history of fever since 1 month. Patient had history of yellowish discoloration of skin and sclera.
Keywords: Microfilaria, Plasmodium falciparum, jaundice
F
ilariasis is caused by slender thread-like nematodes belonging to super family Filarioidea. Filariasis is endemic in India and South-East Asia. Present estimate suggest that over 120 million people in 80 countries are affected by filariasis and more than 1.1 billion people live in areas where there is risk of infection.1,2 Individuals having circulating microfilariae are outwardly healthy but have the ability to transmit the infection to others through mosquito bites. Those with chronic filarial infection suffer severely from the disease but no longer transmit the infection. Diagnosis of filarial infection is frequently made on clinical grounds in endemic areas, but demonstration of microfilariae in circulating blood is the only means by which one can make definitive diagnosis.2,3
1 month before. He stayed there for 15 days. After returning to Ahmedabad, he had developed all these complaints. Patient had no any other sign and symptom suggestive of filariasis like swelling, enlargement of limb except traveling and staying at an endemic area. So, when patient came with this complaint to Dr Jivraj Mehta Hospital, blood investigation was advised in form of complete blood count (CBC), peripheral smear for malaria parasite (PSMP), liver function test (LFT) and renal function test (RFT).
Peripheral Smear Findings Blood sample collected at routine time (no night blood sample). Blood smear examination of patient revealed the trophozoite of Plasmodium falciparum and
CASE REPORT A 28-years-old male patient presented at Dr Jivraj Mehta Hospital with complaint of fever on and off since 1 month. Fever was associated with chills, and highgrade in nature. Patient also had a history of yellowish discoloration of skin and sclera since 1 month. Patient had past history of traveling to Madhya Pradesh
*Nephrology, Pulmonary and Research Department Dr Jivraj Mehta Smarak Health Foundation, Bakeri Medical Research Center Ratubhai Adani Arogyadham, Ahmedabad, Gujarat Address for correspondence Consulting Nephrologist Dr Jivraj Mehta Smarak Health Foundation Bakeri Medical Research Centre Ratubhai Adani Arogyadham Dr Jivraj Mehta Marg, Ahmedabad - 380 007, Gujarat E-mail: research@jivrajhealthcare.org
Figure 1. Microfilaria of W. bancrofti. Note the cephalic and tail tip free from nuclei (Fields stain, 40x).
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
259
Internal medicine Table 1. Other Laboratory Findings Lab investigations
Result
Differential count Neutrophils
77%
Lymphocytes
21%
Eosinophils
01%
Monocyte
2%
Platelets counts
1,55,000/mm3
Serum bilirubin Total Figure 2. Trophozoites of P. falcipraum (oil immersion field 100x Fields stain).
7.91 mg%
Direct
6.17 mg%
Indirect
1.74 mg%
SGPT
451 IU/L
Parasites
Trophozoite of P. falciparum Grade II and microfilaria of W. bancrofti are seen
Onchocerca volvulus and Loa loa are most common organisms reported in former and W. bancrofti and Brugia malayi are the two most common species in latter..4
Figure 3. Trphozoites of P. falciparum and microfilaria of W. bancrofti (oil immersion field 100x Fields stain).
scattered microfilariae in background of lymphocytes, neutrophils and eosinophils (Figs. 1 and 2). Morphologically the microfilaria showed presence of hyaline sheath (Fig. 1), cephalic space length: breath ratio of 1:1. Nuclei were spherical, regularly placed, appeared in row, well-separated without any overlapping (Figs. 2 and 3) and absent at cephalic end and tail tip (Figs. 1 and 2). The results of laboratory findings are summarized in Table 1. DISCUSSION Filariasis is a major public problem in tropical countries, especially India, China, Indonesia and parts of Africa. Clinically, filariasis can be of two major categories: ÂÂ
Filariasis of skin and subcutaneous tissue
ÂÂ
Lymphatic filariasis.
260
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
The life cycle of W. bancrofti is found in two hosts. Man is definitive host and mosquito is an intermediate host. Adult worm resides in lymph nodes where the gravid female releases a large numbers of microfilariae. These larvae pass through the thoracic duct and pulmonary capillaries to the peripheral circulation.5 Our case, W. bancrofti infection (filariasis) associated with P. falciparum infection. P. falciparum and W. bancrofti are transmitted by the same mosquito vector, Anopheles gambiae and interaction between the two species in the vector may have important implications for transmission of these two infections.6 Patient also had raised serum glutamic-pyruvic transaminase (SGPT) and eosinophil counts were within normal range, which has also been reported by Varghese et al.7As in this case, patient had no other history suggestive of filarial infection except traveling and staying at an endemic area, this case would have been missed if peripheral smear was not properly examined. So, if a patient has any history of traveling and staying at an endemic area peripheral smear should be carefully examined for filarial infection. Patient was referred to physician and given falcigo 120 mg IV stat as loading dose on the first day followed by 60 mg IV twicedaily for 5 days and diethylcarbamazine (6 mg/kg) for 21 days. Patient was advised to come for follow-up after 21 days. Patient improved with the above treatment.
Internal medicine CONCLUSION The main purpose of this case report is to raise the awareness that in tropical countries like India where filariasis is endemic, it should always be considered as a differential diagnosis of fever with history of traveling and staying at an endemic area. As patient also had an infection of P. falciparum, filarial infection would have been easily missed if the smear had not been examined properly. Careful examination of peripheral smears is very important in prompt recognition of the disease and institution of specific treatment especially in unsuspected cases.
2. Park K. Textbook of Preventive and Social Medicine. 18th edition, M/S Banarsidas Bhanot Publisher: Jabalpur, India 2005:p.211-6. 3. Rawat V, Rizvi G, Sharma N, Pandey H. An unusual presentation of Wuchereria bancrofti infection. Indian J Med Microbiol 2009;27(4):382-3. 4. Mallick MG, Sengupta S, Bandyopadhyay A, Chakraborty J, Ray S, Guha D. Cytodiagnosis of filarial infections from an endemic area. Acta Cytol 2007;51(6):843-9. 5. Kishore B, Khare P, Gupta RJ, Bisht SP. Microfilaria of Wuchereria bancrofti in cytologic smears: a report of 5 cases with unusual presentations. Acta Cytol 2008;52(6):710-2.
REFERENCES
6. Marsh K, Kinyanjui S. Immune effector mechanisms in malaria. Parasite Immunol 2006;28(1-2):51-60.
1. Sivakumar S. Role of fine needle aspiration cytology in detection of microfilariae: report of 2 cases. Acta Cytol 2007;51(5):803-6.
7. Varghese R, Raghuveer CV, Pai MR, Bansal R. Microfilariae in cytologic smears: a report of six cases. Acta Cytol 1996;40(2):299-301.
■■■■
First Aid for Poisonous Bites and Stings People often panic if they have been bitten or stung. You should tell the patient that many snakes, spiders, insects and sea creatures are harmless and that even the bites and stings of dangerous animals often do not cause poisoning. Keep the patient calm and still. Moving the bitten or stung limb speeds up the spread of venom to the rest of the body. Fear and excitement also make the patient worse. The patient should be told not to use the limb and to keep it still and below the level of the heart. The limb may swell after a while, so take off the patient’s rings, watch, bracelets, anklets and shoes as soon as possible. A splint and a sling may help to keep the limb still. Avoid doing the following: ÂÂ Do not cut into the wound or cut it out. ÂÂ Do not suck venom out of the wound. ÂÂ Do not use a tourniquet or tight bandage. ÂÂ Do not put chemicals or medicines on the wound or inject them into the wound (for e.g., potassium permanganate crystals). ÂÂ Do not put ice packs on the wound. ÂÂ Do not use proprietary snake bite kits. The patient should lie on one side in the recovery position so that the airway is clear, in case or vomiting or fainting. Do not give the patient anything by mouth - no food, alcohol, medicines or drinks. However, if it is likely to be a long time before the patient gets medical care, give the patient water to drink to stop dehydration. Try to identify the animal, but do not try to catch it or keep it if this will put you, the patient or others at risk. If the animal is dead take it to hospital with the patient, but handle it very carefully, because even dead animals can sometimes inject venom. As soon as possible, take the patient to a hospital, medical dispensary or clinic where medical care can be given. The patient should not walk but should keep as still as possible. If there is no ambulance or car, carry the patient on a stretcher or trestle, or on the crossbar of a bicycle. Antivenom should only be given in a hospital or medical center where resuscitation can be given, because the patient may have an allergic reaction. If available, antivenom should be used if there is evidence of severe poisoning. It should not be used when there are no signs of poisoning.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
261
Obstetrics and gynecology
Nonpuerperal Uterine Inversion: A Rare Presentation Sonia Luthra*, AD Dwivedi†
Abstract A nonpuerperal uterine inversion is a rare condition. Many gynecologists might not see any in their entire practice. Prolapsed fibroids tend to be the most common inciting factor with few reports of inversion associated with uterine neoplasm and endometrial polyps. We report a case of nonpuerperal uterine inversion due to a benign submucous leiomyoma. A 45-yearold lady presented with history of menometrorrhagia and urinary retention. On examination, a large, firm mass with a thick base found in vagina. Uterine inversion (stage 1) noted on laparotomy. Total abdominal hysterectomy with bilateral sapingooophorectomy was done after removal of myoma through vagina. Uterine inversion frequently goes undetected until surgery. It is often diagnosed during operation. Its management is a challenge, even for an experienced gynecologist.
Keywords: Nonpuerperal uterine inversion, prolapsed fibroids, uterine neoplasm, endometrial polyps, total abdominal hysterectomy, salpingo-oophorectomy
U
terine inversion is a rare complication of delivery. A nonpuerperal uterine inversion is even more uncommon, but how really rare it is, has not been defined.1-5 However, the fact that many gynecologists might not see any in their entire practice gives a clue as to its infrequent nature. “In puerperium it is an emergency, while in gynecology it is a diagnostic dilemma”.6 Prolapsed fibroids tend to be the most common inciting factor with few reports of inversion associated with uterine neoplasm and endometrial polyps.1-4 We report a case of nonpuerperal uterine inversion due to a benign submucous leiomyoma.
Case Report A 45-year-old multiparous (P7+0) woman presented with heavy bleeding per vaginum since 1 month. She had history of menometrorrhagia and blood mixed discharge since 1 year. She was catheterized for acute urinary retention 10 days back. Pelvic examination revealed the presence of a large, firm, infected, grayishwhite round mass, measuring approximately 10 cm in diameter, filling whole of the vagina (Fig. 1). Mass
*Assistant Professor †Professor Dept. of Obstetrics and Gynecology, Hind Institute of Medical Sciences Barabanki, Lucknow, Uttar Pradesh Address for correspondence Dr Sonia Luthra Assistant Professor Dept. of Obstetrics and Gynecology, Hind Institute of Medical Sciences Safedabad, Barabanki, Uttar Pradesh E-mail: meetsonialuthra@rediffmail.com
262
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
was firm, hemorrhagic and was protruding from the cervix with a wide and thick base. The preoperative ultrasound demonstrated a uterus with heterogeneous echogenic image within a thickened endometrial cavity measuring 13.5 × 21.8 mm. Laboratory tests showed severe anemia with hemoglobin level of 4.8 g/dL. With these findings, we interpreted the mass as a prolapsed submucous myoma with very thick pedicle. In view of this findings decision to have abdomino-perineal approach for abdominal hysterectomy with bilateral salpingo-oophorectomy was taken. On laparotomy, inversion of uterus (stage 1) was noted. Figure 2 is showing an abdominal view of an inverted uterus with bilateral round ligaments and uteroovarian ligaments drawn into the cup of approximately
Figure 1. Myomatous polyp on vaginal examination before surgery.
Obstetrics and gynecology
Figure 2. On laparotomy, inversion of uterus (stage 1) seen.
3 cm in diameter. Huntington and Haultain are commonly used abdominal approaches to reinvert the uterus. Huntington procedure was tried, which involved grasping the round ligaments and the uterus below the area of inversion and slowly pulling up to make the uterus reinverted but it failed. Prolapsed big myoma did not allow cup to be reinverted. Opening up the uterine cavity to separate myoma from its base at this stage would have caused undue hemorrhage, so hysterectomy was started and continued till the ligation of uterine vessels. Then a vertical midline incision on the anterior uterine wall was given and fibroid was resected at its base, which was attached directly at the fundus with no pedicle (Fig. 3). The tumor was extracted through vagina, which weighed 500 g with maximum diameter of 10 cm. Uterus was reinverted (Fig. 4) and hysterectomy was completed in usual manner without excessive blood loss. The postoperative period was uneventful and the patient was discharged from the hospital 5 days after the surgery. The final histopathological report revealed a benign submucous leiomyoma. Discussion
Figure 3. After resection of myoma from its base.
Figure 4. After reinversion of uterus.
Two types of uterine inversions have been reported; puerperal or obstetric and nonpuerperal or gynecologic.5 Nonpuerperal uterine inversion is an extremely rare condition accounting for only one-sixth of all cases of inversion.5 Gomez-Lobo et al4 reported 150 cases of nonpuerperal uterine inversions documented from 1887 to 2006. It is mostly related to benign myomas and seldom associated with malignancies. Malignancy commonly found is leiomyosarcoma, or less commonly found are endometrial carcinoma, rhabdomyosarcoma, malignant mixed m端llerian tumor or endometrial stromal sarcoma.1-5,7-11 Takano et al summarized 88 reported cases of nonpuerperal uterine inversion; 71.6% of them were associated with leiomyomas and 20% were malignant.8 Mwinyoglee et al in their review report stated that 97.4% were associated with tumors; out of which 20% were malignant.9 This emphasizes the need to perform biopsies prior to definitive treatment. Uterine inversion is suspected when a tumor is palpable in vagina or seen at vulva but uterine fundus is not palpable on pelvic examination.7 In our case, extruded tumor was observed in vagina but pelvic examination failed to identify uterine inversion. It indicates that the diagnosis of inversion may be difficult to make during clinical examination. Imaging procedures such
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
263
Obstetrics and gynecology as ultrasound and magnetic resonance imaging (MRI) can contribute to the diagnosis. Preoperative evaluation with MRI has been described by Lewin et al.12 Sagittal views demonstrate a U-shaped endometrial cavity, while axial images show a bull’s eye configuration. The etiology of uterine inversion is not clearly defined. Possible explanations could be a thin uterine wall, rapid growth of the tumor, tumor size, attachment of the tumor at fundus, dilatation of the cervix by distension of the uterine cavity and sudden expulsion of the tumor.3,5 As the tumor with its pedicle attached to uterine fundus increases in size, the uterine wall becomes thinner and the uterine muscle becomes progressively relaxed at a point where the pedicle had attached. Then as the cervix further dilates, the tumor extrudes into the vagina, thus resulting in uterine inversion.8 However, our case had no pedicle still tumor extruded into the vagina and caused uterine inversion. A classification of genital inversion has been described:10 ÂÂ
Stage 1: Inversion of the uterus is intrauterine or incomplete. The fundus remains within the cavity.
ÂÂ
Stage 2: Complete inversion of the uterine fundus through the fibromuscular cervix.
ÂÂ
Stage 3: Total inversion, whereby the fundus protrudes through the vulva.
ÂÂ
Stage 4: The vagina is also involved with complete inversion through the vulva along with an inverted uterus.
Nonpuerperal uterine inversion is often chronic, although Das11 has reported 8.6% of the inversion as sudden. The main symptoms of nonpuerperal uterine inversions are anemia caused by irregular vaginal bleeding, vaginal discharge, lower abdominal and/or pelvic pain, a protruding mass in the vagina and in some cases obstruction of the urethra. Patients with this condition are less likely to suffer shock.8 Unfortunately, because of the rare nature of the disorder, uterine inversion frequently goes undetected until surgery unless a high index of suspicion is maintained. It is often diagnosed during operation as it happened in our case. Many surgical techniques have been described but they need to be tailored accordingly. Its management is a challenge, even for an experienced gynecologist.
reported because of its rarity. Most gynecologists will never encounter such a case and thus has to be managed based upon little or no previous experience. It is often found during operation as preoperative diagnosis is difficult. Its presence should be suspected whenever a large prolapsed fibroid is encountered. Radiological evaluation may help in making the correct diagnosis preoperatively. Biopsy of the mass is prudent given its association with uterine malignancy. References 1. da Silva BB, Dos Santos AR, Bosco Parentes-Vieira J, Lopes-Costa PV, Pires CG. Embryonal rhabdomyosarcoma of the uterus associated with uterine inversion in an adolescent: a case report and published work review. J Obstet Gynaecol Res 2008;34(4 Pt 2):735-8. 2. Ueda K, Okamoto A, Yamada K, Saito M, Takakura S, Tanaka T, et al. Nonpuerperal inversion of the uterus associated with endometrial cancer: a case report. Int J Clin Oncol 2006;11(2):153-5. 3. Lupovitch A, England ER, Chen R. Non-puerperal uterine inversion in association with uterine sarcoma: case report in a 26-year-old and review of the literature. Gynecol Oncol 2005;97(3):938-41. 4. Gomez-Lobo V, Burch W, Khanna PC. Nonpuerperal uterine inversion associated with an immature teratoma of the uterus in an adolescent. Obstet Gynecol 2007;110(2 Pt 2):491-3. 5. Krenning RA, Dörr PJ, de Groot WH, de Goey WB. Nonpuerperal uterine inversion. Case report. Br J Obstet Gynaecol 1982;89(3):247-9. 6. Hing Ling Yi, Deshmukh S. Bombay Hosp J 2009;51: 490-1. 7. Ehrlich CE, Bonaventura LM. Nonpuerperal inversion of the uterus by endometrial stromal sarcoma of the uterine fundus. South Med J 1977;70(7):872-3. 8. Takano K, Ichikawa Y, Tsunoda H, Nishida M. Uterine inversion caused by uterine sarcoma: a case report. Jpn J Clin Oncol 2001;31(1):39-42. 9. Mwinyoglee J, Simelela N, Marivate M. Non-puerperal uterine inversions. A two case report and review of literature. Cent Afr J Med 1997;43(9):268-71. 10. Skinner GN, Louden KA. Non-puerperal uterine inversion associated with an atypical leiomyoma. Aust N Z J Obstet Gynaecol 2001;41(1):100-1.
Conclusion
11. Das P. Inversion of the uterus. J Obstet Gynaecol Br Emp 1940;47:527-48.
A case of nonpuerperal uterine inversion due to a sessile fundal benign submucous myoma has been
12. Lewin JS, Bryan PJ. MR imaging of uterine inversion. J Comput Assist Tomogr 1989;13(2):357-9.
■■■■
264
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Obstetrics and gynecology
Grade 3 Placenta at 24 Weeks Gestation: A Rare Finding DP Gupta*, Hem Prabha Gupta†, S Bhadury‡, DK SAXENA#, Ratna Prabha Gupta$
Abstract Grade 1 placenta is commonly found at 24 weeks of gestation. We present a rare case of Grade 3 placenta at 24 weeks of gestation in a young primipara with no associated maternal or fetal complication. This grade of maturity at 24 weeks of gestation is not reported in literature.
Keywords: Placental grading, gestational age
T
Placental Grading
he placenta is dedicated to the survival of the fetus and the appearance and structure of the placenta changes progressively as the pregnancy advances. The speed at which changes occur in the placenta also varies from one pregnancy to another. The placenta guards the fetus against poor maternal environment (e.g., when the mother is malnourished, diseased, smokes or is an addict) and can often compensate by becoming more efficient.1
The changes in the maturing placenta have been commonly referred to as placental grading. The maturity of the placenta depends upon a variety of factors (e.g., parity, maternal age).2 Maternal diseases such as diabetes, hypertension and Rhesus (Rh) incompatibility may affect the maturation process. Premature aging of the placenta (Grade 3 placenta before 34 weeks) may indicate an impending complication such as intrauterine growth restriction (IUGR) or pre-eclampsia, whereas it is common to see immature placenta in patients with gestational diabetes or Rh incompatibility.3
*Associate Professor Dept. of Radiology †Professor Dept. of Obstetrics and Gynecology ‡Professor and Head #Assistant Professor Dept. of Radiology Era’s Lucknow Medical College, Lucknow, Uttar Pradesh $Consultant Pathologist New X-ray and Pathology, Thakurganj, Lucknow, Uttar Pradesh Address for correspondence Dr DP Gupta MIG-2, Napier Road, Part II, LDA Colony, Thakurganj Lucknow - 226 003, Uttar Pradesh E-mail: dp_gupta2007@yahoo.co.in
Grade 0
Grade 1
Grade 2
Grade 3
Figure 1. Four grade of placental aging.
Grannum et al first described four grades (Grade 0-3) of placental aging (Fig. 1).4 ÂÂ
Grade 0: Placental body is homogenous, occurs in first trimester to early second trimester.
ÂÂ
Grade 1: Placental body shows few echogenic densities ranging from 2 to 4 mm in diameter. Chorionic plate shows small indentations. Changes are seen in mid second trimester to early third trimester (18-29 weeks).
ÂÂ
Grade 2: Chorionic plate shows marked indentations creating comma like densities that extend into the placental substance but do not reach the basal plate. The basal layer becomes punctuated with linear echoes, which are enlarged
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
265
Obstetrics and gynecology Rh-positive (anti-D), hepatitis C virus (HCV), human immunodeficiency virus (HIV), hepatitis B surface antigen (HBsAg) nonreactive, serum calcium 8.3 mg%. Fasting blood glucose 80.0 mg/dL, postprandial (2 hours) 100 mg/dL. Complete and microscopic urine examination was normal. Gestational age according to last menstrual period (LMP) was 23.6 weeks, which corresponded to cost-utility analysis (CUA) 24.6 weeks. All the biometric measurements were in accordance with the normal values at this gestational age. They were: BPD 59.6 mm (24.2 weeks ± 15 days), HC 241 mm (26.2 weeks ± 14 days), AC 205 mm (25.1 weeks ± 15 days), FL 46.3 mm (25.3 weeks ± 15 days). The CUA was calculated to be 24.6 weeks. The fetal weight was 789 ± 118 g, which was also in normal range. There was no obvious deformity. The placenta shows complete indentations of chorionic plate reaching the basal plate, dividing the placenta into cotyledons with fall out areas. This picture corresponds to Grade 3 placenta as described by Grannum (Fig. 2). The case was followed up to her delivery. She had full-term normal delivery. A healthy baby weighing 2,650 g with no obvious complication was delivered. Figure 2. Ultrasound of the patient showing Grade 3 placenta.
with their long axis parallel to the basal layer (late third trimester to delivery). Grade 3: This is the highest grade of the placenta. The comma like densities reach the basal plate as the placental septae are deposited with calcium, which surrounds the placental lobes (cotyledons) resulting in complete circles of calcium. Echo-spared areas may be found in the center, with highly echogenic basal echoes that may produce acoustic shadow. Case report Mrs. ‘X’ aged about 19 years, came to the Dept. of Obstetrics and Gynecology, Era’s Lucknow Medical College, Lucknow, for routine check-up. She was sent to the radiology department for routine USG for the well-being of the fetus. This was her first pregnancy. She belonged to poor socioeconomic status. She was a nonsmoker, nonaddict and was not suffering from any disease. Her weight was 40 kg. Routine blood investigations were: Hemoglobin (Hb) 9.5 g/dL,
266
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Discussion Grade 3 placenta has been found by various workers in third trimester of pregnancy. Shweni and Moodley5 found in 18.9% cases Grade 3 placenta in 38 weeks of pregnancy. They found 75.7% Grade 2 placenta to be more common at this stage of pregnancy. Rogozzino et al6 and Golde et al7 also found Grade 3 placenta at a wide range of gestational age (31-44 weeks). Proud2 also found 15% cases of Grade 3 at 34-36 weeks. All workers have reported Grade 3 placenta at a later period of third trimester and that Grade 3 placenta at an early period has not been mentioned. Spirt and Gordon8 have found that placental calcification is influenced by maternal serum calcium levels, parity and maternal age. There are studies that have confirmed the association between early placental maturation and problem in labor, poor condition at birth and low birth weight.2 In our case, the patient was very young, 19 years (low maternal age), primipara (low parity), anemic with low serum calcium levels 8.3 mg% (malnourished), normotensive, nondiabetic all findings affecting the premature maturation of placenta. On ultrasonographic examination, the placenta was Grade 3, finding which is rare at 24 weeks of gestation.
Obstetrics and gynecology Inspite of the maturity of placenta she delivered normally at full-term and the baby was of normal weight with no obvious complications. There was no IUGR. Premature aging of the placenta before 34 weeks may indicate impending complications such as IUGR or pre-eclampsia. In our case, the fetus had normal parameters. There were no maternal complications. Proud2 has suggested that finding Grade 3 placenta at early gestational period should lead to increased surveillance of fetal well-being rather than to more definite obstetric intervention. Our case is in accordance with the suggestion that Proud has made with regards to being more vigilant, rather than doing obstetric intervention. References 1. Kliman HJ. Behind every healthy baby is a healthy placenta. Online: http://info.med.yale.edu/obgyn/kliman/ placenta/behind.html. 2. Proud J, Grant AM. Third trimester placental grading by ultrasonography as a test of fetal well being. Br Med J (Clin Res Ed) 1987;294(6588):1641-4.
3. Hobbins JC, Winsberg F, Berkowitz RL. The placenta. In: Ultrasonography in Obstetric and Gynecology. 2nd edition, Hobbins JC, Winsberg F, Berkowitz RL (Eds.), Willams & Wilkins: Baltimore, 1983. 4. Grannum PA, Berkowitz RL, Hobbins JC. The ultrasonic changes in the maturing placenta and their relation to fetal pulmonic maturity. Am J Obstet Gynecol 1979;133(8): 915-22. 5. Shweni PM, Moodley SC. Placental grading by ultrasonography as an index of fetal maturity. Its application to the problem of elective caesarean section. S Afr Med J 1986;70(9):525-8. 6. Ragozzino MW, Hill LM, Breckle R, Ellefson RD, Smith RC. The relationship of placental grade by ultrasound to markers of fetal lung maturity. Radiology 1983;148(3): 805-7. 7. Golde SH, Platt LD. The use of ultrasound in the diagnosis of fetal lung maturity. Clin Obstet Gynecol 1984;27(2): 391-401. 8. Spirt BA, Gordon LP. The placenta as an indicator of fetal maturity: fact and fancy. Semin Ultrasound CT MR 1984;5:290-7.
■■■■
More Mothers Depressed at 4 Years than Shortly after Births Maternal depression is more common at 4 years postpartum than at any time during the first 12 months, especially among women who do not have another child during that 4 years. The study, published online May 21 in BJOG, sheds new light on how long women are subject to depression risk after childbirth and on whether having 1 or more children is a factor. Hannah Woolhouse, DPsych, from the Murdoch Children’s Research Institute and Royal Children’s Hospital, Parkville, Victoria, Australia, and colleagues conducted a prospective cohort study of nulliparous women who gave birth in 6 public hospitals in Melbourne, Australia, between April 1, 2003, and December 31, 2005.A total of 1507 women participated in the study, with a mean gestation of 15 weeks at enrollment. The mean maternal age at birth was 30.9 years, with a range of 18-50 years of age. Most women were Australianborn and living with their partners. The authors compared the cohort with routinely collected perinatal data for all nulliparous women older than 18 years who gave birth at Victoria public hospitals during the recruitment period and found that the study cohort had fewer women aged 18-24 years and fewer women born overseas of non-English-speaking backgrounds.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
267
Obstetrics and gynecology
A Case of Fibrothecoma of Ovary Jyotsna Potdar*, Avinash joshi†, Snehal Tate‡
Abstract Fibrothecomas are mesenchymal tumors derived from the ovarian stroma and consist of theca-like elements and fibrous tissue. The term ‘fibrothecoma’ has been used for neoplasms, which are intermediate between theca cell tumor and fibroma. The vast majority of fibrothecomas behave in a benign fashion and malignant variants are exceedingly rare. We report a case of fibrothecoma of ovary in a 59-year-old postmenopausal woman.
Keywords: Fibrothecoma, postmenopausal bleeding
P
ostmenopausal bleeding should not only raise the suspicion of cancer of endometrium. One must also think of ovarian tumors like fibrothecomas, which are rare, but can cause endometrial thickening and consequent bleeding. We report a case of fibrothecoma of ovary in a 59-year-old postmenopausal woman.
CASE REPORT A 59-year-old woman came to our Gynecology Outpatient Clinic with complaints of pain in abdomen since 6 months and distension of abdomen since 3 months. She was a known case of diabetes since 1 month and was on injection actrapid. Menstrual history: Attained menopause 12 years back. Obstetric history: She has two daughters and a son. Personal and family histories are noncontributory. General examination was normal. On per abdominal examination, a nontender, mobile, irregular mass of 20 × 15 cm was palpable in lower abdomen. *Associate Professor Dept. of Obstetrics and Gynecology †Professor and Head Dept. of Pathology ‡Junior Resident Dept. of Obstetrics and Gynecology Shrimati Kashibai Navale Medical College and General Hospital Narhe, Pune, Maharashtra Address for correspondence Dr Jyotsna Potdar Dept. of Obstetrics and Gynecology Shrimati Kashibai Navale Medical College and General Hospital Narhe, Pune, Maharashtra - 411 030 E-mail: jspobgn@gmail.com
268
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
On per vaginal examination, a solid irregular mass of 15 × 10 cm was felt in right fornix. A notch was felt between mass and uterus. Mass did not move with movement of cervix. USG findings reveal a large solid-cystic lesion arising from right adnexa measuring about 14 × 16 cm showing neovascularization. It was not seen separate from right ovary. It is suggestive of neoplastic etiology Uterus was bulky and shows thick endometrium. The endometrium was heterogenous thickened at fundus. There was minimal ascitic fluid. CT scan findings reveal a solid-cystic mass of 15 × 12 × 16 cm dimension with neovascularization arising from right adnexa. The mass was not seen separate from right ovary and caused mass effect on bowels displacing those laterally. There was minimal ascitic fluid. Left ovary was normal. Laboratory findings: Routine relevant investigations including analysis of tumor markers such as cancer antigen (CA)-125, CA-19-9, squamous cell carcinoma related antigens were normal. On laparotomy, we found a round well-circumscribed mass measuring 20 × 20 cm on right ovary (Fig. 1). The left ovary, uterus, pelvic lymph nodes and omentum were unremarkable. Frozen section revealed a sex cord tumor. The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy. Postoperative period was uneventful. On gross examination, a well-circumscribed ovarian mass, 20 × 20 cm in size, was seen which was composed of yellow-grey matter with myxoid changes. Histopathological report showed a well-circumscribed tumor composed of spindle cells having oval
Obstetrics and gynecology Incidence The reported incidence is between 0.4% and 8.0% of all ovarian tumors, and this wide variability can be attributed to the difficulty in differentiating fibrothecoma from ovarian fibromas or hyperplastic stromal nodules. Clinical presentation is usually nonspecific with pelvic pain and menorrhagia. Clinical examination reveals a solid regular mobile mass. Figure 1. A well-circumscribed ovarian mass (20 x 20 cm), which is composed of yellow-gray solid firm mass with focal myxoid change.
Endocrine manifestations are seen in hormonally active tumors. Diagnosis of fibrothecoma is primarily histological. Nevertheless, ultrasound, CT scan and pelvic magnetic resonance imaging (MRI) can guide towards the diagnosis.4 Ultrasound5 Initial imaging modality of choice, though sonographic features are generally nonspecific2 a the coma may manifest as: ÂÂ
An echogenic mass with distal acoustic attenuation
ÂÂ
A well-defined hypo-echoic mass
ÂÂ
An anechoic lesion with good through-transmission.
Secondary features of hyperestrogenism, such as endometrial thickening, also may be seen. Figure 2. A well-circumscribed tumor composed of spindle cells having oval nuclei arranged in fascicles and bundles. Extensive cystic degeneration is seen in the center.
nuclei arranged in fascicles and bundles. Extensive cystic degeneration was seen in the center (Fig. 2). Histopathologist’s opinion- fibrothecoma. DISCUSSION Fibrothecomas are mesenchymal tumors derived from the ovarian stroma and consist of theca-like elements and fibrous tissue. The term ‘fibrothecoma’ has been used for neoplasms, which are intermediate between theca cell tumor and fibroma. The vast majority of fibrothecomas behave in a benign fashion and malignant variants are exceedingly rare.1,2
Epidemiology They typically present in older women with over 80% presenting in the postmenopausal period.3
CT Scan Typically appear as unilateral, solid ovarian masses. Pelvic MRI T2: Reveals, a tumor with hyperintense (often from edema and cystic degeneration) areas and may mimic more common malignant ovarian tumors. However, the signal characteristics at T2-weighted imaging may vary in the presence of edema or cystic degeneration. Chemical shift: Intratumoral lipid may give a chemical shift artefact. Dynamic contrast imaging: The degree of contrast enhancement varies with the amount of fibrous tissue within the tumor. While theca cells in the normal ovary are highly vascularized, the fibrous tissue is known for delayed weak enhancement at dynamic contrast-enhanced imaging. If the tumor has significant fibroma component (i.e., fibrothecoma) the abundant fibrous tissue may produce predominantly low-signal intensity on both T1- and T2-weighted sequences.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
269
Obstetrics and gynecology Secondary features of hyperestrogenism, such as endometrial thickening, also may again be seen.
Laboratory Investigations CA-125 serum levels are usually normal. Rarely, high levels are noted, and those become normal after the removal of tumor.
Histopathology Findings5-7 Depending on the prevalence of cells or fibrous tissue, these tumors are pathologically classified as pure the coma, fibrothecoma and predominantly fibrous fibrothecoma.5 Fibrothecomas show large rounded ill-defined theca cells with moderate-to-abundant pale, sometimes vacuolated cytoplasm, which usually contains lipid. A fibromatous component separates sheets and nests of theca cells. Hyaline plaques are characteristics and sometimes a conspicuous feature. In some cases, there are large confluent zones of hyalinization and occasionally there is a myxoid background. Some tumors are more cellular than usual and are descriptively designated as cellular ‘fibrothecomas’. Though, they may show appreciable mitotic activity, they are clinically benign. Nevertheless, occasionally such a tumor may recur many years after surgery. The tumors which are >10 cm in diameter are associated with ascitis in 40% of cases and Meigs syndrome (ascitis and pleural effusion) in about 1% of cases. The cystic areas (if present) in these tumors lack epithelial lining. TREATMENT The treatment of these tumors is complete resection of the mass or en bloc resection with adjacent or infiltrated organs and structures. For all the patients with a potentially resectable tumor, the surgical access we prefer is a long midline ventral incision with the patient in supine position. An additional transverse incision was sometimes adopted in huge tumors in order to provide maximum exposure.
Prognosis A large tumor size, especially that with involvement of critical abdominal vessels as vena cava, aorta and
mesenteric vessels is considered to be a negative prognostic factor. The status of gross surgical margins is the most important factor influencing prognosis. If the adjacent organs, such as stomach, intestines, pancreas, kidney, liver, spleen or adrenal gland are infiltrated, en bloc resection with the involved organ is mandatory. If the surgeon achieves safe tumor resection without microscopic residual disease, patient may expect long-term survival. Few Important Points
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
More than 4 mitotic figures per 10 high power fields plus presence of abnormal mitotic figures indicate malignancy.
ÂÂ
Benign tumors sometimes give implants in peritoneal cavity, which should not be labeled as metastasis.
REFERENCES 1. Waxman M, Vuletin JC, Urcuyo R, Belling CG. Ovarian low-grade stromal sarcoma with thecomatous features: a critical reappraisal of the so-called “malignant thecoma”. Cancer 1979;44(6):2206-17. 2. Stage AH, Grafton WD. Thecomas and granulosa-theca cell tumors of the ovary: an analysis of 51 tumors. Obstet Gynecol 1977;50(1):21-7. 3. Mawad NM, Hassanein OM. Ovarian fibro-thecoma in a 19 years old Sudanese girl. Gynaecological case report. Clin Exp Obstet Gynecol 1994;21(4):243-5. 4. Dockerty MB, Masson JC. Ovarian fibromas: clinical and pathologic study of 283 cases. Am J Obstet Gynecol 1944:47:741-52. 5. Irving JA, Alkushi A, Young RH, Clement PB. Cellular fibromas of the ovary: a study of 75 cases including 40 mitotically active tumors emphasizing their distinction from fibrosarcoma. Am J Surg Pathol 2006;30(8):929-38. 6. Conte M, Guariglia L, Benedetti Panici P, Scambia G, Rabitti C, et al. Ovarian fibrothecoma: sonographic and histologic findings. Gynecol Obstet Invest 1991;32(1): 51-4. 7. Sivanesaratnam V, Dutta R, Jayalakshmi P. Ovarian fibroma - clinical and histopathological characteristics. Int J Gynaecol Obstet 1990;33(3):243-7.
■■■■
270
ÂÂ
Obstetrics and gynecology
Uterine Rupture: A 5-year Review Nalini Sharma*, Anshu Khamsera*, JK Goel*
Abstract Ruptured uterus is a serious obstetrics emergency with high maternal and fetal mortality and morbidity in developing countries. Aims and objectives: To find out the incidence of ruptured uterus possible etiological factors and fetomaternal outcome. To analyze the avoidable factors and to find out the measures required to decrease the incidence of this preventable condition. Material and methods: This is a retrospective study of cases of ruptured uterus for a period of 5 years from 2006 to 2010, which were managed in a medical college hospital in Western Uttar Pradesh, which caters to about 50 lacs population. Results: There were 6,275 deliveries during this time period, 19 women suffered from uterine rupture during this time, a incidence of 1 in 330 deliveries (0.3%). Maximum cases are below 30 years (mean age - 27.5 years) of age. About 63.5% cases had previous lowersegment cesarean section. Most of the women were unbooked multigravida 89.47% women received blood transfusion; 47.36% patients had hysterectomy. Maternal mortality and fetal mortality were 5.26% and 73.68%, respectively. Conclusion: Ruptured uterus is a preventable condition. Most cases of ruptured uterus can be prevented with good antenatal and intrapartum care and proper identification of high-risk cases.
Keywords: Spontaneous rupture, scarred uterus, VBAC, lower-segment cesarean section
R
uptured uterus is a serious obstetric emergency with high maternal and fetal morbidity and mortality. It is a preventable condition and rare in developed countries. Its incidence is still high in developing countries due to ignorance, quackery, illiteracy and maldistribution of health services.
January 2006 to 2010. These patients were identified from operation theater records. Details were obtained regarding etiological factors, clinical presentation, type of surgery, maternal and fetal morbidity and mortality.
Aims and Objectives
There were 6,275 deliveries at SRMSIMS during this period, 19 women with ruptured uterus were managed. The incidence of ruptured uterus was found to be 0.3% (1 in 330 birth). Of these 19 cases, >93% had not received antenatal care and were admitted as emergency cases. The ages of women ranged from 20 to 40 years (Fig. 1). Sixty-eight percent women were under 30 years. One (5.26%) was nullipara (Fig. 2). In maximum number (73%) of women parity was between p2-p4. Only 21.05% were grand multipara. Although many women were uncertain about their menstrual date but 57.89% had reached 37 weeks or more. Most cases (84%) came directly from home to SRMSIMS.
ÂÂ
To find out the incidence of ruptured uterus, possible etiologic factors and fetomaternal outcome after admission.
ÂÂ
To analyze the avoidable factors and to find out the measures required to decrease the incidence of this preventable complication.
Material and methods This is a retrospective study of all cases of ruptured uterus managed in the Dept. of Obstetrics and Gynecology, Shri Ram Murti Smarak Institute of Medical Sciences (SRMSIMS), Bareilly, a medical college hospital in Western Uttar Pradesh over a 5-year period from
*Dept. of Obstetrics and Gynecology Shri Ram Murti Smarak Institute of Medical Sciences Bareilly, Uttar Pradesh Address for correspondence Dr Nalini Sharma B1D, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalyaya E-mail: nalinisharma100@rediffmail.com
RESULTs
Of the 19 patients with ruptured uterus, 12 (63.15%) had previous cesarean section (Fig. 3). Out of 19 patients, 52.63% (n = 10) were in labor, of these 3 (15.78%) gave history of induction or augmentation of labor outside. These three cases considered of one case (5.26%) each of twin pregnancy with cesarean section, obstructed labor and prolonged labor. In one case (5.26%) of previous cesarean section there was history of repair of uterine rupture in second
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
271
Obstetrics and gynecology Table 1. Showing Age Distribution
Table 5. Types of Operative Treatment
Age of the patient
Treatment
Number of women (%)
Number of women (%)
20-25
5 (26.31)
Repair
7 (36.8)
26-30
8 (42.10)
31-35
5 (26.31)
Repair with bilateral tubal ligation
8 (42.10)
36-40
1 (5.26)
Subtotal hysterectomy Total hysterectomy Extraction of fetus and placenta from abdomen
Table 2. Showing Rupture in Relation to Parity Parity
1 (5.26) 1 (5.26)
1 (5.26)
Number of women (%)
0
1 (5.26)
1-2
14 (73.68)
3-4
1 (5.26)
>4
3 (15.78)
Table 3. Condition of Uterus associated with Rupture Condition of uterus
Number of women (%)
Scarred (LSCS)
12 (63.15)
Unscarred
6 (31.57)
Previous dilatation and curettage (D&C)
1 (15.26)
Table 4. Location of Uterine Rupture Main site of rupture
Number of women (%)
Lower-segment
9 (47.36)
Upper-segment
4 (21.05)
Both segment
3 (15.78)
Lateral wall
2 (10.52)
Extension into vagina
2 (10.52)
Broad ligament
1 (5.26)
Abdominal wall rupture
1 (5.26)
Unknown (went LAMA)
1 (5.26)
pregnancy. Two women (10.52%) had history of medical termination of pregnancy (MTP). Two patients (10.52%) were managed for their whole labor in SRMSIMS, both had vaginal birth after cesarean section (VBAC) but had postpartum hemorrhage (PPH). Most (89.47%) patients came with pain
272
LAMA
1 (5.26)
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
abdomen. Only one (5.26%) woman presented in shock of state, whereas rest of the patients were stable. Nine women (47.36%) had rupture in lower uterine segment, in 3 (15.78%) both segments were involved. Three patients (15.78%) had vaginal and lateral wall extension. The site and extension of uterine rupture are shown in Table 4. Eight cases (42.10%) had repair of rupture out of which bilateral tubal ligation was done in one woman. Nine (47.36%) women had hysterectomy, out of which 8 (42.10%) had subtotal hysterectomy. One patient (5.26%) went LAMA before any intervention due to personal reasons. One patient (5.26%) had abdominal wall rupture along with uterine rupture, placenta and fetus were removed from the abdominal wound. Same patient died due to septicemia. Major complications were febrile morbidity (15.78%), need for blood transfusion (89.47%), ICU admissions (31.57%), ventilatory support (5.26%), inotropic support 2 (10.52%). Ten (52.26%) women received 3 or more than 3 units of blood transfusion. Fetal outcome was very poor, 73.68% had fetal death. Maternal mortality was 5.26%, (5.26%) had developed uterovaginal fistula. Discussion The total incidence of rupture uterus in this study was 1 in 330 (0.3%). This can be compared with 0.33% and 0.09% reported from two studies by Mishra et al1 and Padhey et al.2 Roohi et al3 reported the incidence of rupture uterus 0.89% from a Pakistani teaching hospital Ezechi et al4 reported incidence of rupture uterus, 1 in 273 patients. Nagarkatti et al5 had reported incidence of 1 in 730 during (1970-1979) and 1 in 865 during (1980-1989) in his 20-year review. The mean maternal age was 27.5 years with the majority of the cases under 30 years. Padhye et al2 reported the mean
Obstetrics and gynecology maternal age 28.7 years. Roohi et al3 found similar result 75% patient of ruptured uterus were under 35-year. Many patients may have to sacrifice their uterus in young age, while managing these patients. In this study, about 93% women never seeked any medical advice. Our findings were consistent with other studies like Mishra et al1 (92.3%), in Padhye (69%), in Roohi et al3 (83%), in Ezechi et al4 (75.4%) patients were unbooked in his study. In our series, maximum number of women (73%) were multiparous. Only 21.05% were grand multipara. Roohi et al3 have reported 48.57% of grand multipara, Mishra et al1 reported about 20% patients who were grand multipara. Nulliparous women are usually considered to be immune to uterine rupture but in this study rupture was seen in a nullipara, when she was not in labor at 32 weeks. No cause could be found unlike Padhye et al2 who reported two primipara in whom cause was present (i.e., road traffic accident and history of oxytocin and fundal pressure). In our study 12 cases (63.15%) of uterine rupture had previous cesarean delivery. Other causes were obstructed labor, twin pregnancy history of MTP, history of induction and augmentation. With increasing cesarean section rates this figure was expected. Mishra et al1 reported only 19.2% had a previous cesarean section. Padhye et al reported, there were 62/150 shoulder presentations. The location of uterine rupture was extremely varied. Nine (47.36%) had rupture in lower uterine segment. In 3 cases of previous cesarean section scar was intact, rent was present in upper segment, lateral wall and fundus, respectively. The operative treatment given were repair 42.10% (n = 8). Repair with bilateral tubal ligation was done in one case. Nine (47.36%) had hysterectomy out of which eight had subtotal hysterectomy. Padhye et al2 had reported repair in 84% and hysterectomy only in 10% of cases. The choice of surgical procedure depends on the type, extent and location of rupture as well as the patient
condition and desire to preserve her childbearing capacity. Fetal outcome was very poor in this study, 73.68% (n = 14) of the fetus were stillborn. Maternal mortality was 5.06%. Padhye et al2 found 7.9% of maternal mortality and perinatal mortality was and 75%. Conclusion About 63.15% of patient had previous lower-segment cesarean section so we should avoid primary cesarean section as much as possible without increasing perinatal mortality and morbidity. All patients with previous lower-segment cesarean section should be made aware of the importance of the antenatal care in all subsequent pregnancies. They also require careful prenatal supervision, proper selection of cases for vaginal delivery in well-equipped hospital, early hospital admission and close supervision in labor, where early diagnosis and prompt intervention will further help to reduce mortality and morbidity to both mother and foetus. Although rupture in nullipara is rare but nullipara are not immune to rupture. We should keep this in mind while managing the nulliparous patient. Thus, in conclusion most cases of uterine rupture are preventable with good antenatal and intrapartum care and proper identification of high risk cases. References 1. Mishra SK, Morris N, Uprety DK. Uterine rupture: preventable obstetric tragedies? Aust N Z J Obstet Gynaecol 2006;46(6):541-5. 2. Padhye SM. Rupture of the pregnant uterus - a 20 year review. Kathmandu Univ Med J (KUMJ) 2005;3(3):234-8. 3. Roohi M, Sajida C. Incidence of rupture uterus at DHQ Hospital, Faisalabad. The Professional 1994;1:1-11. 4. Ezechi OC, Mabayoje P, Obiesie LO. Ruptured uterus in South Western Nigeria: a reappraisal. Singapore Med J 2004:45(3):113-6. 5. Nagarkatti RS, Ambiye VR, Vaidya PR. Rupture uterus: changing trends in etiology and management. J Postgrad Med 1991;37(3):136-9.
■■■■
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
273
Obstetrics and gynecology
Postpartum Posterior Reversible Encephalopathy: A Diagnostic Dilemma Ridhi Kathuria*, MC Bansal†
Abstract The disease entity described as posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological diagnosis. Clinical characters include variety of nonspecific symptoms viz, headache, delirium or confusion, visual disturbances, auditory difficulties and most important, seizures. Vasogenic edema, mostly in the posterior cerebral hemispheres, is thought to be the main cause of the radiological findings. Both the findings and symptoms are largely reversible if appropriate treatment in offered in time. Here is reporting of a case of PRES diagnosed postpartum based on clinical signs and findings on magnetic resonance imaging (MRI) scan. This was following an uneventful lower segment cesarean section in a marginally hypertensive patient. The patient was successfully treated with antihypertensives, anticonvulsants and supportive therapy. The differential diagnosis of convulsions in the postpartum period is discussed herein.
Keywords: PRES, clinicoradiological, vasogenic edema, postpartum, hypertensive, MRI
A
lthough posterior reversible encephalopathy syndrome (PRES) has gained substantial recognition since its initial description by Hinchey et al1 in 1996, both its clinical spectrum and underlying pathophysiology remain poorly defined. A clinical diagnosis of PRES includes the presence of headache, seizures, encephalopathy and visual disturbances, as well as radiologic findings of focal reversible vasogenic edema, best seen on magnetic resonance imaging (MRI) of the brain. The syndrome is most commonly encountered in association with acute hypertension, pre-eclampsia or eclampsia, renal disease, sepsis and exposure to immunosuppressants.2-8 It has been less commonly described in the setting of autoimmune disease.9-13 The distinctive role of autoimmune disease in the pathophysiology of PRES is often clouded by concurrent hypertension, renal disease and/or the use of immunosuppressants. Despite the syndrome’s name, radiographic lesions in PRES are rarely isolated to the ‘posterior’ parieto-occipital white matter and instead often involve the cortex, frontal
*Resident †Professor Dept. of Obstetrics and Gynecology National Institute of Medical Sciences, Jaipur, Rajasthan Address for correspondence Dr Ridhi Kathuria C/o - Vijay Nursing Home, F - 24/25, Sector -3, Rohini, New Delhi - 110 085 E-mail: ridhi.kathuria@yahoo.com
274
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
lobes, basal ganglia and brainstem.14,15 No conclusive evidence supports a clear relationship between clinical conditions and specific imaging findings of severity or location of edema,16 although some studies have suggested correlations such as greater vasogenic edema in normotensive patients5 and a trend for basal ganglia involvement in patients with pre-eclampsia or eclampsia.16 The underlying pathophysiology of PRES remains elusive. Several theories have been proposed, the most widely accepted of which states that rapidly developing hypertension leads to a breakdown in cerebral autoregulation, particularly in the posterior head region (where there is a relative lack of sympathetic innervation). Hyperperfusion ensues with protein and fluid extravasation, producing focal vasogenic edema.1,10,17 An alternative theory, which has been best characterized in pre-eclampsia, eclampsia and sepsis, implicates endothelial dysfunction.18,19 A third theory proposes that vasospasm with subsequent ischemia may be responsible. CASE REPORT A 27-year-old G3P1L1A1 patient was a booked case with antenatal care being taken at regular intervals. Her BP was recorded in the range of 120-140 mmHg (SBP) and 80-90 mmHg (DBP) throughout her antenatal care coverage (ANC) period.
Obstetrics and gynecology She underwent an elective lower segment cesarean section under spinal anesthesia. Her blood pressure (BP) remained within normal limits through the surgery and in the postoperative recovery period until discharge on the 5th postoperative day. She reported back to out patient department (OPD) on postoperative Day 9 with complaints of - bilateral frontoparietal and occipital headache, moderate to severe in nature, remaining throughout the day. Her BP at presentation was 180/110 mmHg. She was admitted for observation and investigatory work up. Meanwhile, antihypertensive therapy was started injection labetalol 20 mg IV bolus dose, followed by titrated doses based on BP), along with routine supportive therapy and good hydration, to combat post-spinal headache, which although was unlikely. On the 10th postoperative day, her BP was recorded at 170/110 mmHg, and she complained of severe constricting headache with 1 episode of generalized tonic-clonic seizures (GTSC) recorded lasting for few seconds. Promptly, treatment on the lines of postpartum eclampsia was started, including, injection magnesium sulphate, following the Pritchard regimen. Her specific investigations included coagulation profile, renal and liver function tests, serum calcium, serum electrolytes. Investigations for proteinuria were negative. Her serum uric acid was found elevated (7.5 mg/dL), serum creatinine was 2.6 mg/dL and blood urea 72 mg/dL. Fundoscopy did not reveal any papilloedema. CT brain and MRI venogram were normal. MRI-brain (T2 weighted axial image) revealed hyperintense areas within the cerebellar hemispheres, gray and white matter of bilateral frontal, parietal, occipital regions, suggesting the likelihood of PRES. Her treatment was changed accordingly and she was started on anticonvulsants, antihypertensives (calcium channel blockers), antiedema measures, supportive therapy-proton pump inhibitors and antibiotics. The patient was stabilized by the second day of treatment. Her neurological symptoms completely resolved by the 8th day. She was discharged on antihypertensive and anticonvulsive medications. She complied well with the therapy offered. She was followed up for 2 years and was free of neurological symptoms.
DISCUSSION The myriad of differential diagnosis for convulsions in the late postpartum period include - eclampsia, thromboembolic events, intracerebral hemorrhage, subarachnoid hemorrhage, intracranial SOL, head trauma, idiopathic epilepsy, infection (meningoencephalitis), amniotic fluid embolism, postpartum angiopathy.20,21 There was no past history of epilepsy or head injury. Infection due to dural puncture at the time of spinal anesthesia could be a possibility, but the total leukocyte count (TLC) within range of 7,900-9,000 cells/mm3 on various reports, largely rules it out. Postdural puncture spinal headache usually presents within 24-48 hours and adequate hydration generally aids the same. Amniotic fluid embolism generally occurs within 48 hours postpartum and symptoms of cardiopulmonary collapse and coagulopathy predominate, which was not seen in the present case. Any intracranial bleed, ischemia due to thromboembolism, vasospasm or SOL was ruled out with brain MRI with venogram. One shall consider the possibility of postpartum angiopathy in a postpartum patient with hypertension and headache without proteinuria. Postpartum angiopathy is a form of reversible cerebral segmental vasoconstriction characterized by severe 'thunderclap' headaches, seizures, focal neurological deficits and segmental narrowing and dilatation of large and medium sized arteries. Typically, scanning reveals ischemic lesions.20 PRES mostly secondary to late postpartum eclampsia was suggested as she presented with headache, followed by seizures, with raised serum uric acid levels, raised blood urea due to hypertension most likely but without protienuria. The clinical confusion arises in diagnosis whether the diagnosis should be eclampsia or hypertensive encephalopathy due to other reasons? What should be the correct treatment? With multidisciplinary approach we were able to scale down the differential diagnosis. MRI was typically consistent with vasogenic edema, involving typical areas - bilateral occipital, parietal, frontal and cerebellar region. PRES is mostly an under diagnosed and hence untreated condition. The incidence in the peripartum setting is still not known.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
275
Obstetrics and gynecology Literature reports an incidence of PRES in both males and females. Mostly it affects the hypertensive group of patients, followed by patients of metabolic syndrome. A few rare cases of normotensive female patients being affected is also reported.22-24 The newer age literature defines eclampsia as a form of PRES.
7. Small SL, Fukui MB, Bramblett GT, Eidelman BH. Immunosuppression-induced leukoencephalopathy from tacrolimus (FK506). Ann Neurol 1996;40(4):575-80.
Although it is seizure that defines eclampsia, some neurologic symptoms can precede the onset of seizure, such as persistent headaches, blurred vision, photophobia and altered mental status. These also define the hallmarks of PRES. The uncertainty also increases because imaging findings of eclampsia have shown varying degrees of hemorrhage, cerebral edema and vasculopathy.25
9. Kur JK, Esdaile JM. Posterior reversible encephalopathy syndrome - an underrecognized manifestation of systemic lupus erythematosus. J Rheumatol 2006;33(11):2178-83.
However, the reversibility of clinical neurologic signs and neuroradiologic lesions within a few days or weeks postpartum in most cases argues against the existence of true cerebral ischemic necrosis. In fact, the clinical and neuroimaging findings are more consistent with edema.25 This supports the diagnosis of PRES and eclampsia being a subset of PRES itself. PRES following an uneventful pregnancy is a very rare clinical entity. Recognition at the earliest and prompt initiation of the supportive measures can prevent permanent neurologic damage and thereby the associated morbidity. Multidisciplinary care forms the corner stone to achieve a safe motherhood in these women. REFERENCES 1. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334(8):494-500. 2. Hauser RA, Lacey DM, Knight MR. Hypertensive encephalopathy. Magnetic resonance imaging demonstration of reversible cortical and white matter lesions. Arch Neurol 1988;45(10):1078-83. 3. Schwaighofer BW, Hesselink JR, Healy ME. MR demonstration of reversible brain abnormalities in eclampsia. J Comput Assist Tomogr 1989;13(2):310-2. 4. Raroque HG Jr, Orrison WW, Rosenberg GA. Neurologic involvement in toxemia of pregnancy: reversible MRI lesions. Neurology 1990;40(1):167-9.
8. Appignani BA, Bhadelia RA, Blacklow SC, Wang AK, Roland SF, Freeman RB Jr. Neuroimaging findings in patients on immunosuppressive therapy: experience with tacrolimus toxicity. AJR Am J Roentgenol 1996;166(3):683-8.
10. Primavera A, Audenino D, Mavilio N, Cocito L. Reversible posterior leucoencephalopathy syndrome in systemic lupus and vasculitis. Ann Rheum Dis 2001;60(5):534-7. 11. Pozo-Rosich P, Villoslada P, Canton A, Simo R, Rovira A, Montalban X. Reversible white matter alterations in encephalopathy associated with autoimmune thyroid disease. J Neurol 2002;249(8):1063-5. 12. Tateishi Y, Iguchi Y, Kimura K, Aoki J, Uemura J, Shibazaki K. A case of autoimmune thyroid disease presenting posterior reversible encephalopathy syndrome. J Neurol Sci 2008;271(1-2):203-6. 13. Bohnen NI, Parnell KJ, Harper CM. Reversible MRI findings in a patient with Hashimoto's encephalopathy. Neurology 1997;49(1):246-7. 14. Lee VH, Wijdicks EF, Manno EM, Rabinstein AA. Clinical spectrum of reversible posterior leukoencephalopathy syndrome. Arch Neurol 2008;65(2):205-10. 15. Bartynski WS, Boardman JF. Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol 2007;28(7):1320-7. 16. Mueller-Mang C, Mang T, Pirker A, Klein K, Prchla C, Prayer D. Posterior reversible encephalopathy syndrome: do predisposing risk factors make a difference in MRI appearance? Neuroradiology 2009;51(6):373-83. 17. Schwartz RB, Jones KM, Kalina P, Bajakian RL, Mantello MT, Garada B, Holman BL. Hypertensive encephalopathy: findings on CT, MR imaging, and SPECT imaging in 14 cases. AJR Am J Roentgenol 1992;159(2):379-83. 18. Dekker GA, Sibai BM. Etiology and pathogenesis of preeclampsia: current concepts. Am J Obstet Gynecol 1998;179(5):1359-75. 19. Aird WC. The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome. Blood 2003;101(10):3765-77. 20. Prout RE, Tuckey JP, Giffen NJ. Reversible posterior leucoencephalopathy syndrome in a peripartum patient. Int J Obstet Anesth 2007;16(1):74-6.
5. Bartynski WS, Boardman JF, Zeigler ZR, Shadduck RK, Lister J. Posterior reversible encephalopathy syndrome in infection, sepsis, and shock. AJNR Am J Neuroradiol 2006;27(10):2179-90.
21. Krishnamoorthy U, Sarkar PK, Nakhuda Y, Mullins PD. Posterior reversible encephalopathy syndrome (PRES) in pregnancy: a diagnostic challenge to obstetricians. J Obstet Gynaecol 2009;29(3):192-4.
6. Furukawa M, Terae S, Chu BC, Kaneko K, Kamada H, Miyasaka K. MRI in seven cases of tacrolimus (FK-506) encephalopathy: utility of FLAIR and diffusion-weighted imaging. Neuroradiology 2001;43(8):615-21.
22. Servillo G, Striano P, Striano S, Tortora F, Boccella P, De Robertis E, et al. Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients. Intensive Care Med 2003;29(12):2323-6.
276
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Obstetrics and gynecology 23. Jamie MN, Shervin E. Late postpartum eclampsia with posterior reversible encephalopathy syndrome. Hospital Physician June 2007:p.45-9.
accompanying late postpartum eclampsia or hypertensive encephalopathy - a clinical dilemma. Online J Health Allied Sci 2012;11(1):20.
24. Shakuntala PN, Isaac P, Rashmi, Appaiah N, Thomas M. A rare case of reversible encephalopathy syndrome
25. Cipolla MJ. Cerebrovascular function in pregnancy and eclampsia. Hypertension 2007;50(1):14-24.
■■■■
Teenage Cancer Patients at Risk for Severe Menstrual Bleeding Cancer treatment can put teenage girls at a high-risk for heavy menstrual bleeding, and their care requires the collaborative involvement of oncologists and gynecologists, according to new guidelines issued by the Committee on Adolescent Health Care at the American College of Obstetricians and Gynecologists, and published in the August issue of Obstetrics and Gynecology. The guidelines describe options for the prevention and management of heavy menstrual bleeding in adolescents undergoing treatment for cancer. The committee notes that gynecologists can be consulted on strategies for menstrual suppression either before cancer therapy is initiated or during an episode of severe heavy bleeding.
Stress Urinary Incontinence – New ACOG Guidelines The American College of Obstetricians and Gynecologists has issued first-time guidelines regarding the evaluation of uncomplicated stress urinary incontinence (SUI) before surgical treatment in women. "SUI is a condition of involuntary loss of urine on effort, physical exertion, sneezing or coughing that is often bothersome to the patient and frequently affects quality of life," the committee writes in an opinion published in the June issue of Obstetrics and Gynecology. "It is estimated to affect 15.7% of adult women. Among women with SUI, 77.5% report their symptoms to be bothersome, and of this group 28.8% report their symptoms to be moderately to extremely bothersome; the degree of bother is associated with the severity of SUI." Conservative treatment options for SUI include pelvic muscle exercises prescribed alone or with physical therapy, behavioral modification, continence-support pessaries and urethral inserts. Surgical options to treat incontinence include retropubic urethropexies, autologous fascial slings, urethral bulking agents and synthetic midurethral slings.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
277
PEDIATRICS
Mesenteric Cystic Teratoma in an 1-year-old Child: A Case Report Sana Aboosalih*, Leena Dennis Joseph†, Prakash A‡, CN Sai Shalini†, Rajendiran S†
Abstract Extragonadal, intraperitoneal teratomas especially those arising from the mesentery and the mesocolon, are very rare in infants and children. Mesenteric teratoma is a tumor arising from totipotential primordial cells, and displays a mixture of tissues of tridermal or bidermal origin. The biologic behavior of teratomas depend on various interdependent epidemiologic and clinical variables such as the age at diagnosis, sex, tumor site, histology which all correlate to different cytogenetic and molecular biologic aberrations. Even though such cases are rare, cases presenting as abdominal distension, lump in the abdomen, features of intestinal obstruction, etc. must raise suspicion of this condition. In this case report, we describe a case of mesenteric teratoma in an 1-year-old female child who presented with bilious vomiting of 1-day duration. The mass was surgically resected and following microscopic examination revealed to be a mature teratoma.
Keywords: Mass, abdomen, mesenteric, teratoma
E
xtragonadal, intraperitoneal teratomas especially arising from the mesentery and mesocolon are very rare. Only a few cases have been reported, mostly ones in gastric, hepatic, mesocolic, mesosigmoid and mesenteric locations. Complete surgical excision is the treatment of choice for intra-abdominal teratoma. Complete tumor resection is sufficient for cure in benign teratomas. Mesenteric teratomas are rare in infants and children, but must be suspected if calcification is found by radiological investigation.
Case Report An 1-year-old female child presented with bilious vomiting of 1-day duration. The vomiting was intermittent, 4-6 times and mainly following feeds. The child did not pass stools for 1 day and the parents complained of abdominal discomfort and tenderness in the baby. No history of fever or any chronic illness was noted. No history of rheumatic heart disease, jaundice or seizure disorders was present. Birth history and
*Final Year MBBS Student †Dept. of Pathology ‡Dept. of Pediatric Surgery Sri Ramachandra Medical College and Research Institute, Porur Chennai, Tamil Nadu Address for correspondence Dr Leena Dennis Joseph Dept. of Pathology Sri Ramachandra Medical College and Research Institute Chennai ,Tamil Nadu - 600 116 E-mail: leenadj@gmail.com
278
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
developmental milestones were normal. The child was immunized as per schedule. On physical examination, all the vital parameters were within normal limits. Per abdomen examination revealed a vague mass palpable in the right hypochondriac, epigastric and umbilical region. The mass was firm in consistency and was mobile. Ultrasonogram of the abdomen also showed a huge mass measuring 10 × 10 cm. A diagnostic laparoscopy was followed by laparotomy with resection, and anastomosis of jejunum. The mesenteric tumor was excised and sent for histopathology. Per operative, there was a huge mass of size 10 × 10 cm in size, which was adherent to the jejunum. There was no free fluid, rest of the bowel was normal. Grossly the mass was greyish yellow with adherent bowel loops. The cut surface of
a
b
Figure 1. Histopathology showing bone and cartilage (a) and epidermis with cartilage (H&E x 100) (b).
PEDIATRICS cystic teratoma (dermoid cysts) and 6) pseudocysts (infectious and traumatic cysts).5 The World Health Organization (WHO) classification of germ cell tumors distinguishes mature and immature teratomas as well as teratomas with malignant transformation.3
a
b
Figure 2. Histopathology showing glandular epithelium (H&E x 200) (a) and small intestinal mucosa (H&E x 40) (b).
the soft tissue mass was soft with greyish white areas. On microscopic examination, the mass was a mature teratoma composed of bone, cartilage, glandular epithelium, muscle, skin and intestinal mucosa (Figs. 1 and 2). Extensive sampling did not reveal any immature or primitive components. The patient was discharged with antibiotics and advised follow-up. On follow-up, the baby is doing well and is regular with treatment. Discussion Teratomas are neoplasms that originate in pluripotent cells and are composed of a wide variety of tissue foreign to the origin or anatomic site in which they arise.1 They often occur in a paraxial or midline location, anywhere from the brain to the sacrum or they may arise in gonads. The most frequent tumor sites (in descending order) are: The sacrococcygeal region (33.8%), the ovaries (31.2%) and the testes (10.5%). Rare localizations include the mediastinum, the retroperitoneum, the head and neck region as well as the central nervous system.2 Extragonadal, intraperitoneal teratomas especially those arising from the mesentery and the mesocolon, are very rare in infants and children.3 There are very few mesenteric cysts reported in medical literature; due to their rarity there is lack of information and difficulty in classification. Now a new classification for mesenteric cysts, based essentially on histopathological features include the six following groups: 1) Cysts of lymphatic origin (simple lymphatic cyst and lymphangioma); 2) cysts of mesothelial origin (simple mesothelial cyst, benign cystic mesothelioma and malignant cystic mesothelioma); 3) cysts of enteric origin (enteric cyst and enteric duplication cyst); 4) cysts of urogenital origin; 5) mature
There are about 20 cases of mesenteric teratomas that have been reported so far. Teratomas have no pathognomonic signs or symptoms, and their clinical manifestation depends greatly on the size and location of the growth. The anatomy of the mesentery usually offers sufficient space for considerable growth before symptoms can appear, particularly when the lesion is located near the root. The symptoms may develop early if the lesion is localized at the periphery of the mesentery i.e., near the gut lumen. They present frequently, with a palpable mass or an increasing abdominal girth. Nausea, vomiting or constipation is the result of intestinal compression by the mass. An intractable chronic diarrhea as a manifestation has also been described.6-10 Complete surgical excision is the mainstay of management of intra-abdominal teratoma. Complete tumor resection is sufficient for cure in benign teratomas. Most of the abdominal teratomas are benign in nature and are composed of mature cells; however, 20-25% of these may also contain immature elements.6 Immature teratomas may contain variable quantities of immature neural tissue resembling embryonic components and these may coexist along with mature tissue. The presence of immature tissue in the histology of the excised tumor warrants the need for chemotherapy and regular follow-up. Serum a-fetoprotein assay is a reliable method for detecting the recurrence in teratomas. Mesenteric teratomas are rare in infants and children, but must be suspected if calcification is found by radiological investigation.7 References 1. Al-Arfaj AA, El-Shawarby MA, Al-Mulhim FA, Lardhi AA. Mesenteric cystic teratoma in children. Saudi Med J 2003;24(12):1388-90. 2. Harms D, Zahn S, GĂśbel U, Schneider DT. Pathology and molecular biology of teratomas in childhood and adolescence. Klin Padiatr 2006;218(6):296-302. 3. de Perrot M, BrĂźndler M, TĂśtsch M, Mentha G, Morel P. Mesenteric cysts. Toward less confusion? Dig Surg 2000;17(4):323-8. 4. Rattan KN, Ratan SK, Jhanwar A, Kaushik V, Magu S. Immature mesenteric teratoma causing intestinal obstruction. Indian J Pediatr 2007;74(2):207-8.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
279
PEDIATRICS 5. Srivastava J, RK Ghritlaharey. Immature mesenteric teratoma in an infant: a case report. J Clin Diagn Res 2010;4:3581-4. 6. Göbel U, Calaminus G, Engert J, Kaatsch P, Gadner H, Bökkerink JP, et al. Teratomas in infancy and childhood. Med Pediatr Oncol 1998;31(1):8-15. 7. Chiba T, Iwami D, Kikuchi Y. Mesenteric teratoma in an 8-month-old girl. J Pediatr Surg 1995;30(1):120.
8. Upadhyaya M, Rogers T, Thyagrajan MS. Infected mesenteric ileocaecal dermoid cyst in a child. JSCR 2010;10:5. 9. Raychaudhari C, Prajapati H, Shah HK. Two cases of immature mesenteric teratoma. Indian J Radiol Imaging 2006;16:567-70. 10. Singh M, Ratan K, Rani B, Kadian Y, Hasija S. Infected mature teratoma of mesentery in a child. APSP J Case Rep 2013;4(2):18.
■■■■
Childhood Reading Skills Linked to ‘Higher Intelligence’ in Young Adults A new study published in the journal Child Development finds that having strong reading skills as a child is a predictor for higher intelligence levels as a young adult. In previous studies, reading ability has been associated with improved health, education, socioeconomic status and creativity. The ability to read well can directly improve some of these factors. An example is that by being able to extract information from texts, individuals are better able to gain educational qualifications. Early reading ability was not just associated with improved vocabulary and general knowledge, but also with improved nonverbal intelligence. But some researchers have suggested that the act of reading has “a causal effect on more general cognitive abilities” that are associated with better life outcomes. In short: reading itself may boost intelligence. Other studies, however, suggest that there may instead be a shared genetic basis for reading and cognition. It is also possible that keen reading in children may reflect knowledge-seeking behavior rather than necessarily reading skill in itself, which could confound results. To investigate the issue further, researchers from the University of Edinburgh and King’s College London, both in the UK, compared the results of reading and intelligence tests from nearly 2,000 pairs of identical twins who were part of the Twins Early Development Study.
280
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
respiratory infections
Polyvalent Mechanical Bacterial Lysate: A Polyvalent Respiratory Vaccine JYOTI YADAV
Abstract Polyvalent mechanical bacterial lysate (PMBL) is a mixture of antigens derived from 13 strains of inactivated pathogenic bacteria. PMBL exerts therapeutic as well as preventive effects in acute and recurrent respiratory infections by activating and enhancing both immunoglobulin (Ig)M memory B cells and interleukin (IL)-2 receptor expressing T lymphocytes. PMBL is active as an immunomodulating agent and is used in acute, subacute, recurrent and chronic infections. It reduces number and intensity of episodes. It can be combined with antibiotics and mucolytic agents to get very good results.
Keywords: Polyvalent mechanical bacterial lysate, antigens, inactivated pathogenic bacteria, chronic obstructive pulmonary disease
P
olyvalent mechanical bacterial lysate (PMBL) is a mixture of antigens derived from 13 strains of inactivated pathogenic bacteria. These strains include Staphylococcus aureus, Streptococcus pyogenes, Streptococcus viridans, Klebsiella pneumoniae, Klebsiella ozaenae, Haemophilus influenzae B, Neisseria catarrhalis and Streptococcus pneumoniae (type 1, 2, 3, 5, 8 and 47). These 13 strains are commonly occurring pathogens, which cause respiratory tract infections. Although most of the upper respiratory tract infections are due to viruses, nevertheless epiglottis and laryngotracheitis are due to H. influenzae and majority of the bacterial pharyngitis is due to S. pyogenes.
Composition Total concentration of active ingredient is 50 mg out of which 7 mg is bacterial fraction (each strain concentrated at 6 billion) and 43 mg of glycoll, which acts as a support of freeze drying. Excipients present in PMBL include colloidal hydrated silica, microcrystalline cellulose, calcium hydrogen phosphate dehydrate, magnesium stearate, ammonium glycyrrhizate and essence of mint powder.
Professor Dept. of Physiology Pt. BD Sharma PGIMS, Rohtak, Haryana Address for correspondence Dr Jyoti Yadav 30/9J, Medical Enclave Pt. BD Sharma PGIMS, Rohtak, Haryana E-mail: drjyotiyadav2008@yahoo.com
Actions PMBL acts both on innate as well as adaptive immunity.1 Braido et al demonstrated that bacterial lysates have protective effect in respiratory tract infections.2 Cazzola et al observed that PMBL exerts therapeutic as well as preventive effects in acute and recurrent respiratory infections by activating and enhancing both immunoglobulin (Ig)M memory B cells and interleukin (IL)-2 receptor expressing T lymphocytes.3 PMBL stimulates both T and B lymphocytes.4,5 Chronic obstructive pulmonary diseases (COPD) patients having acute exacerbations of S. pneumoniae, N. catarrhalis and H. influenzae show beneficial effect when treated with PMBL.6 PMBL is active as an immunomodulating agent and is used in acute, subacute, recurrent and chronic infections. It reduces number and intensity of episodes. It can be combined with antibiotics and mucolytic agents to get very good results. It can easily be given from 3 years age onwards. PMBL is recommended for prevention when given in combination with inhaled corticosteroids and longacting β2 agonists. PMBL strengthens immune system, increases all subsets of natural killer cells, which play major role in destruction of cells infected by viruses. It also induces production of opsonizing immunoglobulins, which destroy pathogenic bacteria through granulocytes.7,8 PMBL is found to be effective in post-tubercular as well as COPD patients in reduction of exacerbation rate and lower the risk of development of concomitant respiratory infections in tuberculosis.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
281
respiratory infections Dosage and Local Action PMBL is recommended for first 10 days of the month for 3 consecutive months to have an efficient protection during winter and it’s use is extended during followup of 9 months in COPD patients. PMBL tablets do not have lifelong effect, as immunoglobulins have very short half-life between 6-21 days. PMBL tablets allow production of secretory IgA at application site resulting in mucosal protection against bacterial infections.9 PMBL intake increases IgA, IgM and IgG. On swallowing, PMBL tablet acts on gastrointestinal mucosa through gut associated lymphoid tissue and via systemic circulation of immunoglobulins and cytokines it treats respiratory tract infections. PMBL tablets can be given sublingually, which cause loco-regional action of antigens present in PMBL with immunocytes. The time of complete disintegration of PMBL tablet in oral cavity is 1.5-2 minutes. Sublingual route allows direct contact of antigens with mucosal immunocytes of mouth and larynx, thus inducing loco-regional activation of immune system. PMBL tablets act on all actors of immunological cascade to stimulate both innate and adaptive immunity. PMBL tablets should be taken before meals and should not exceed recommended dose. PMBL tablet is superior to it’s chemical lysates. PMBL offers protection starting from first week of intake and provides protection for an additional 3 months after the end of 3 months treatment.10-12
been tried but theoretically, it may prove beneficial in these patients. It has not yet been used in autoimmune diseases.
Side Effects There are very minimal side effects except laryngitis; however, more trials need to be done to ascertain other side effects.
Contraindications PMBL should be avoided in first 3 months of pregnancy. Cost of Vaccination Retail price of one 50 mg tablet is ` 40, thus cost of vaccination of 3 consecutive months will be about ` 1,200. If it is as effective as claimed, vaccination is cost-effective. References 1. Palmieri G. Prophylaxis of airways viral infections: role of the enhancement of the immune defenses. Giorn It Mal Tor 2003;57:46-51. 2. Braido F, Tarantini F, Ghiglione V, Melioli G, Canonica GW. Bacterial lysate in the prevention of acute exacerbation of COPD and in respiratory recurrent infections. Int J Chron Obstruct Pulmon Dis 2007;2(3):335-45. 3. Cazzola M, Rogliani P, Curradi G. Bacterial extracts for the prevention of acute exacerbations in chronic obstructive pulmonary disease: a point of view. Respir Med 2008;102(3):321-7.
Morandi et al observed that PMBL activates both circulating as well as plasmacytoid dendritic cells.7 Braido et al found that PMBL activates natural killer cells, which play important role in destruction of cells infected by viruses.8 PMBL activates dendritic cells and also increases the secretion of efficient IgA.1,13
4. Lanzilli G, Falchetti R, Tricarico M, Ungheri D, Fuggetta MP. In vitro effects of an immunostimulating bacterial lysate on human lymphocyte function. Int J Immunopathol Pharmacol 2005;18(2):245-54.
Therapeutic Uses
6. Cazzola M. A new bacterial lysate protects by reducing infectious exacerbations in moderate to very severe COPD: a double-blind, randomized, placebo-controlled trial. Trends in Med 2006;6:191-9.
Most of the seasonal flu vaccines like flu vaccine are trivalent vaccines, while PMBL vaccine is polyvalent having 13 various inactivated strains, thus it prevents most commonly occurring pathogens of upper and lower respiratory tract infections. PMBL’s mechanical lysis ensures attainment of particulate antigens which is 10-100 times more immunogenic than soluble antigens. PMBL is also found effective in community-acquired polymicrobial pneumonia in intensive care unit patients.14 PMBL when used in immunocompromised patients was found to be useful with no safety concern.15 Potential activity of PMBL in other therapeutic areas like allergies or cancer immunotherapy has not yet
282
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
5. Lanzilli G, Falchetti R, Cottarelli A, Macchi A, Ungheri D, Fuggetta MP. In vivo effect of an immunostimulating bacterial lysate on human B lymphocytes. Int J Immunopathol Pharmacol 2006;19(3):551-9.
7. Morandi B, Agazzi A, D’Agostino A, Antonini F, Costa G, Sabatini F, et al. A mixture of bacterial mechanical lysates is more efficient than single strain lysate and of bacterial-derived soluble products for the induction of an activating phenotype in human dendritic cells. Immunol Lett 2011;138(1):86-91. 8. Braido F, et al. Polyvalent mechanical bacterial lysate treatment in COPD: new immunological evidence. IV World Asthma and COPD Forum, 2011. 9. Braido F, et al. A good clinical outcome following therapy with a polyvalent mechanical bacterial lysate (PMBL) correlates with the capacity of inducing a specific loco
respiratory infections regional immunoresponse in patients with recurrent upper respiratory tract infections. XXVII Congress of the European Academy of Allergology and Clinical Immunology, 2008. 10. Tricarico D, Varricchio A, D’Ambrosio S, Ascione E, Motta G. Prevention of recurrent upper respiratory tract infections in a community of cloistered nuns using a new immunostimulating bacterial lysate. A randomized, double-blind clinical trial. Arzneimittelforschung 2004;54(1):57-63. 11. Boris VM. Prophylaxis of episodes of winter airways infection with a sublingual antibacterial vaccine obtained by mechanical lysis PMBL (ISMIGEN Zambon): clinical trial in patients with a case history of tuberculosis. Giorn It Mal Tor 2003;57:210e5. 12. Macchi A, Vecchia LD. Open comparative, randomized controlled clinical study of a new immunostimulating
bacterial lysate in the prophylaxis of upper respiratory tract infections. Arzneimittelforschung 2005;55(5):276-81. 13. Rossi GA, Peri C, Raynal ME, Defilippi AC, Risso FM, Schenone G, et al. Naturally occurring immune response against bacteria commonly involved in upper respiratory tract infections: analysis of the antigen-specific salivary IgA levels. Immunol Lett 2003;86(1):85-91. 14. Cillóniz C, Ewig S, Ferrer M, Polverino E, Gabarrús A, Puig de la Bellacasa J, et al. Community-acquired polymicrobial pneumonia in the intensive care unit: aetiology and prognosis. Crit Care 2011;15(5):R209. 15. Petrunov B, Nenkov P, Shekerdjiisky R. The role of immunostimulants in immunotherapy and immunoprophylaxis. Biotechnol and Biotechnol Eq 2007;21(7):454-8.
■■■■
Too Many Antibiotics, Too Few Antivirals for Influenza Antiviral medications may have been underprescribed for patients presenting to outpatient clinics with influenza during the 2012-2013 influenza season, according to an article published online July 17 in Clinical Infectious Diseases. In contrast, the authors find that antibiotic medications were overprescribed, despite repeated calls for more appropriate use. Fiona Havers, MD, MHS, from the Influenza Division, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and colleagues from the CDC and other institutions analyzed data from 5 geographically diverse sites in the US Influenza Vaccine Effectiveness Network Study. Outpatients were 6 months of age or older with acute respiratory illness (ARI) of less than 7 days.
‘Insufficient’ Progress on Noncommunicable Diseases: WHO Progress on controlling noncommunicable diseases (NCDs) worldwide has been “insufficient and highly uneven” since 2011, according to a new report from the World Health Organization (WHO). Although many countries have made progress in tackling the “epidemic” of NCDs, current global mortality from NCDs remains “unacceptably high and is increasing,” the report says. “Bolder measures are urgent to accelerate efforts to address NCDs and mitigate their impacts.” According to the WHO, 38 million people die each year from NCDs (28 million in developing countries), mainly from cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. More than 14 million deaths from NCDs occur in people between 30 and 70 years old, of which 85% are in developing countries.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
283
Surgery
A Rare Case of Intrathyroid Dermoid Cyst in a Middle-aged Female Raxith S Ragavendra*, Narayan I Hebsur†, Narayan Y Kabadi‡
Abstract Introduction: The term ‘dermoid cyst’ describes a cystic lesion comprising of stratified squamous epithelium with epidermal appendages. Presentation of case: A dermoid cyst arising in the left lobe of the thyroid gland in a 35-year-old female was managed with a left hemithyroidectomy. Discussion: While congenital lesions feature frequently in the differential diagnosis of childhood neck masses, dermoid cysts presenting as a unilateral neck mass are rare. Conclusion: When dermoid cysts are found within the thyroid, their pathogenesis may be explained by a disruption of normal thyroid development. Excision appears the treatment of choice.
Keywords: Dermoid cyst, stratified squamous epithelium, thyroid gland, congenital lesions, excision
T
he term ‘dermoid cyst’ describes a cystic lesion comprising of stratified squamous epithelium with epidermal appendages. DeMello referred to midline cervical lesions of the above morphology, originally classified as thyroglossal duct cysts, as dermoids. This classification remains controversial, but true midline dermoids in the cervical region are not uncommon. Clearly, these lesions remain clinically distinct from cervical teratoma which represents a tumor of germ cell origin containing all three layers of the trilaminar embryo. Dermoids located within or immediately adjacent to the thyroid gland appear rare. A dermoid cyst presenting as a midline, cold thyroid nodule in a 9-year-old girl has been previously reported. We describe an intrathyroid dermoid cyst presenting as a solitary thyroid nodule in a middle-aged female. CASE PRESENTATION A 35-year-old female presented with a left-sided neck mass. She noticed a swelling 1 year back. It had been gradually increasing in size since then. There were no
*Senior Resident †Associate Professor ‡Assistant Professor Dept. of General Surgery Karnataka Institute of Medical Sciences, Hubli, Karnataka Address for correspondence Dr Raxith S Ragavendra MS General Surgeon JSS Medical College, Mysore, Karnataka E-mail: raxith25@gmail.com
284
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
other symptoms or signs suggestive of thyroid disease. There was no history of dysphagia, hoarseness of voice or additional neck masses. Obstetric history, she was married with two children and tubectomized 4 years back, menstrual cycles were regular. There was no past history of irradiation or iodides. The family history was unremarkable, although her mother had an excision of nonfunctioning thyroid nodules several years earlier. Examination revealed a 3 × 2 cm oval-shaped, firm to hard mass left of the midline, medial and anterior to the sternocleidomastoid muscle (Fig. 1). It did not extend into the mediastinum and moved on swallowing but not on protrusion of the tongue. There was no cervical lymphadenopathy.
Investigation An ultrasound revealed a 3.4 × 1.9 cm hypoechoic nodule arising from within the left lobe of the thyroid (Fig. 2). Color duplex revealed no blood flow within the nodule. Thyroid function tests were within normal limits. Chest radiography was normal. Fine needle aspiration cytology (FNAC) was performed, which revealed few inflammatory cells.
Operative Findings A large smooth whitish color cystic mass was seen within and adherent to the left lobe of the thyroid gland (Fig. 3). There was evidence of a chronic inflammatory reaction around the mass. A left hemithyroidectomy was performed.
Surgery
Figure 1. Patient with solitary thyroid nodule.
Figure 2. Ultrasound of intrathyroid lesion.
Figure 3. Showing operative intrathyroid cyst.
Figure 4. Histopathology of dermoid cyst with adjacent thyroid tissue.
Histopathological Examination
majority of the gland but receives lateral contributions from the fourth ultimobranchial bodies that form the calcitonin-producing C cells.
The microscopic examination showed a dermoid cyst. The wall consisted of stratified squamous epithelium with few associated sebaceous glands. There were focal areas of rupture with an associated foreign bodytype giant cell-reaction around keratin. Histologically, the adjacent thyroid was unremarkable and the cyst appeared attached to it (Fig. 4). The postoperative recovery was uneventful. Repeated thyroid function tests 6 weeks postoperatively were normal. DISCUSSION The thyroid gland develops during the 3rd week of gestation, as a midline diverticulum from the ventral surface of the pharynx. Elongation of the embryo with growth of the pharynx and tongue leaves the thyroid caudal to its point of origin. The diverticulum forms the
A palpable neck mass is a commonly encountered clinical problem. Meticulous clinical history and physical examination may suggest the clinical diagnosis. Imaging is increasingly performed to confirm the clinical diagnosis and assesses the anatomical extent of involvement before any form of treatment. Apart from its location, the distinction between solid and cystic or cyst-like neck masses helps in the definitive diagnosis or to narrow the differential diagnoses. Cystic masses of the neck include a wide range of congenital and acquired lesions. The vast majority of cystic lesions in infants and children are congenital or developmental in origin, whereas inflammatory and neoplastic diseases constitute the majority of cystic or cyst-like neck masses in adults.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
285
Surgery An asymptomatic left-sided mass evident low in the anterior cervical triangle may represent lymphadenopathy in the pre-tracheal lymphatic chain with a single predominant node. A congenital anomaly such as a true cervical dermoid or third or fourth branchial cleft cyst must be considered as these, together, comprise 55% of cervical neck masses in children. Thymic cysts may occasionally present just lateral to the midline but are very rare. Lymphatic malformations such as cystic hygromas occur predominantly in the posterior triangle but may present in this manner. They are usually fluctuant and brilliantly translucent. A thyroglossal duct cyst would tend to present as a midline mass that elevates on tongue protrusion. A dermoid cyst is the most common of the teratomatous lesions in the head and neck region, approximately 7% occur of all dermoids occurring in this region. Histologically, it contains two germ cell layers and skin appendages (e.g., hair follicles and sebaceous glands). An epidermoid cyst is less common in the neck as compared to a dermoid cyst and is comprised solely of ectoderm. In this case, the nodule appeared to move with swallowing but did not elevate with protrusion of the tongue. The ultrasound scan suggested an intrathyroid mass and radionuclide scanning confirmed the presence of normal-appearing functioning thyroid tissue surrounding the mass. The mass was therefore thought to arise from the left hemithyroid. The intrathyroid location of the lesion is of particular interest with regard to the etiology of dermoids in the head and neck. A hypothesis for this entity is entrapment of cells within disparate layers during embryogenesis. This explains the appearance of components of ectoderm within a predominantly endodermal organ such as the thyroid. Yet another explanation has been the traumatic implantation of ectodermal cells within deeper tissues. This applies in the context of dermoid cysts identified around surgical incisions or near scars but would not be applicable to our patient.
CONCLUSION Dermoid cysts should be included in the differential diagnosis of a lateral neck mass in adults, even when apparently within the thyroid gland. Given the rarity of this lesion, the true diagnosis may only be made at operation. Because of the risk of infection and progressive enlargement, excision remains the treatment of choice. Suggested Reading 1. Cox CA, Nguyen DL, Medina J, Leonard JC. Dermoid cyst presenting as a “cold” thyroid nodule. Clin Nucl Med 1996;21(5):395. 2. deMello DE, Lima JA, Liapis H. Midline cervical cysts in children. Thyroglossal anomalies. Arch Otolaryngol Head Neck Surg 1987;113(4):418-20. 3. De Ponte FS, Brunelli A, Marchetti E, Bottini DJ. Sublingual epidermoid cyst. J Craniofac Surg 2002;13(2):308-10. 4. Mahmood S, Moody H. Dermoid, teratoma or choristoma? A rare lesion of the tongue in an adult. Br J Oral Maxillofac Surg 2003;41(2):117-9. 5. Mazzaferri EL. Management of a solitary thyroid nodule. N Engl J Med 1993;328(8):553-9. 6. Raab SS, Silverman JF, Elsheikh TM, Thomas PA, Wakely PE. Pediatric thyroid nodules: disease demographics and clinical management as determined by fine needle aspiration biopsy. Pediatrics 1995;95(1):46-9. 7. Skandalakis JE, Gray SW. Embryology for surgeons (Chapter 2). In: The Pharynx and its Derivatives. 2nd edition, Williams and Wilkins: Baltimore, 1994. 8. Tapper D, Sawin R, O’Neill JA Jr, Rowe MI, Grosfeld JL, Fronkalsrud EW, et al. Teratomas Andother Germ Cell Tumours Pediatric Surgery. 5th edition, Chapter 29, Mosby: St. Louis; 1998. 9. Thompson NW, Geiger JD, O’Neill JA Jr, Rowe MI, GrosfeldJL, Fronkalsrud EW, et al. Thyroid/Parathyroid Pediatric Surgery. 5th edition, Chapter 48, Mosby: St. Louis, 1998. 10. Torsiglieri AJ Jr, Tom LW, Ross AJ 3rd, Wetmore RF, Handler SD, Potsic WP. Pediatric neck masses: guidelines for evaluation. Int J Pediatr Otorhinolaryngol 1988;16(3):199-210.
■■■■
286
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Around the Globe
News and Views ÂÂ
ÂÂ
ÂÂ
ÂÂ
A new study has revealed that HIV infection does not affect kidney transplant graft or patient outcomes but hepatitis C virus (HCV) infection exerts a negative impact on both. Thus, pretransplant HCV eradication should be a priority to improve outcomes in this population. The data was presented at the 2014 World Transplant Congress in San Francisco. A new research presented at the 20th International AIDS conference has found no link between hormonal contraceptives and a woman’s risk for HIV after 17 years of follow-up in a Zambian cohort of HIV-discordant couple. However, a large metaanalysis revealed an increased risk for HIV with the use of depot medroxyprogesterone acetate only. The US Food and Drug Administration has approved the once-daily bronchodilator inhalation spray olodaterol for the long-term treatment of airflow obstruction in patients with chronic obstructive pulmonary disease, including chronic bronchitis and/or emphysema. A new study has revealed that anticholinergic drugs used to treat several conditions including asthma, high blood pressure, insomnia, dizziness and diarrhea, could impair physical functions in elderly patients such as eating and getting dressed. The findings were published in Age and Ageing, a Journal of the British Geriatrics Society.
ÂÂ
Greater preoperative pain and depression have been found to be associated with diminished improvement in quality of life (QOL) after lumbar surgery and posterior cervical fusion, suggest two studies published this month in The Spine Journal.
ÂÂ
A study presented at the ACS NSQIP National Conference has pointed that evidence-based measures along with an interdisciplinary team approach reduces surgical site infection rates in a high-risk patient population. Infection at the surgical site after open heart surgery was reduced by 77% at a Canadian hospital through its participation in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®).
ÂÂ
A research published July 31 in PLOS Pathogens has put forward a mechanism by which early infection
with type B coxsackie virus (CVB) impairs the heart’s ability to tolerate stress at later stages of life. ÂÂ
Using behavioral interventions to treat children and adolescents with attention-deficit/hyperactivity disorder (ADHD) has the potential to improve both child and parent functioning, suggests a new metaanalysis. The study was published in the August issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
ÂÂ
Scientists have identified the key role a protein named Yap plays in triggering a rare childhood muscle cancer, called Rhabdomyosarcoma (RMS). The findings were published July 31 in Cancer Cell.
ÂÂ
A phase 1 pilot trial of subcutaneous injections of PD01A in patients with parkinson’s disease (PD) has shown that the vaccine is well tolerated and safe, induces an immune response and the immune response appears to improve function.
ÂÂ
Researchers at the Johns Hopkins University School of Medicine have identified alterations in a gene linked to stress reactions that may help identify patients at increased risk for suicidal behavior, including attempts, possibly through a simple blood test. The findings were published July 30 in the American Journal of Psychiatry.
ÂÂ
An advisory committee to the US Food and Drug Administration has concluded that the benefit of Baxter International Inc’s experimental immune deficiency therapy, HyQvia, outweighs the risks. Data shows a favorable benefit-to-risk ratio for the drug designed to treat primary immunodeficiency diseases.
ÂÂ
The US Food and Drug Administration (FDA) has approved the glucose-reducing drug empagliflozin after the drug maker corrected manufacturing problems that caused the agency to reject the drug in March. The drug is indicated for improving glycemic control in adults with type 2 diabetes in association with diet and exercise.
ÂÂ
Expert pathology panels are better than community pathologists at diagnosing low-grade dysplasia (LGD) in association with Barrett’s esophagus, suggests a report from the Netherlands. In the study, amongst the 293 patients referred with a community diagnosis of LGD, revised diagnoses
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
287
Around the Globe of the expert panel left only 79 patients with a diagnosis of LGD. The study was published online in Gut. ÂÂ
ÂÂ
ÂÂ
The European Society of Cardiology and European Society of Anesthesiology (ESC/ESA) have published new recommendations for the cardiovascular management of patients undergoing noncardiac surgery. The new recommendations advice against the use of b-blockers in patients without clinical risk factors since the drugs do not decrease the risk of cardiac complications and may even increase this risk. The guidelines appear August 1 in the European Heart Journal. A new minimally invasive technique for repairing the most common cardiac birth defect in newborns, a hole in the heart, has been used successfully to fix the condition in six premature infants without resorting to open-heart surgery. The technique for repairing the condition, patent ductus arteriosus, was published online in the journal Catheterization and Cardiovascular Interventions. Researchers at UC San Francisco have noted that children with sensory processing disorders (SPD) exhibit decreased structural brain connections in specific sensory regions different than those in autism. This backs the fact that SPD is a clinically important neurodevelopmental disorder. The research was published in the journal PLOS ONE.
ÂÂ
A new study has suggested that trauma in abused children has lasting effects on mental and physical health and that experiences can alter gene activity. The study was published online in the journal Child Development.
ÂÂ
A single dose of a new oral fixed-dose drug combination NEPA appears to prevent nausea and vomiting in cancer patients undergoing chemotherapy. NEPA is a combination of the tachykinin NK1 receptor antagonist netupitant 300 mg and the 5-hydroxytryptamine 3 receptor antagonist palonosetron 0.5 mg. The data was published in Annals of Oncology.
ÂÂ
ÂÂ
288
A new study has shown that stimulation with a lowstrength electromagnetic field device immediately improves mood in patients with major depressive disorder (MDD) and bipolar disorder (BPD). The study was published in the August 1 issue of Biological Psychiatry. New guidelines issued by the Committee on Adolescent Health Care at the American College of Obstetricians and Gynecologists and published in the August issue of Obstetrics and Gynecology have stated that teenage girls undergoing cancer
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
ÂÂ
ÂÂ
ÂÂ
ÂÂ
ÂÂ
ÂÂ
ÂÂ
treatment are at a high risk for heavy menstrual bleeding, and their care requires the joint efforts of oncologists and gynecologists. Researchers at the Boston University School of Medicine have noted in their new study that recurrent gout attacks are twice as likely to strike on hot days when humidity is low. Study authors noted that the risk of gout attacks was also high under hot, humid conditions compared to moderate temperature and relative humidity, but to a lesser degree. The findings were published online in the American Journal of Epidemiology. The US Food and Drug Administration (FDA) has approved aflibercept injection to treat visual impairment caused by diabetic macular edema (DME). The agent decreases the abnormal growth of blood vessels as well as leakage and edema in the retina as it blocks vascular endothelial growth factor (VEGF) A. In a recent survey conducted by researchers from University of Ottawa Heart Institute, half of the patients said they were unaware that replacing their ICD generator was “optional,” and of these, more than one in four said they would have considered nonreplacement. This raises concerns regarding patients’ awareness of the legalities of treatment refusal and their right to decision making. A new meta-analysis conducted at the Harvard School of Public Health has identified the number of fruits and vegetables a person needs to eat per day in order to reduce the risk of early death, particularly cardiovascular mortality, and concludes that five daily portions seem enough. A clear dose–response relationship existed that continued up to five servings a day, after which there was no further reduction in risk. According to a study published online in the July 31 issue of the New England Journal of Medicine, infants with severe combined immune deficiency (SCID) who are diagnosed and receive hematopoietic cell transplant by age 3.5 months have a 94% probability of survival. Furthermore, older infants who receive a transplant before the onset of a first infection have a 90% survival rate. A Swedish national cohort study has revealed that low gestational age at birth is associated with an increased likelihood of venous thromboembolism in infancy, early childhood, and young adulthood. The study was published online July 28 in Pediatrics. A report published online July 28 in Pediatrics has revealed that children who undergo adenotonsillectomy for obstructive sleep apnea (OSA) may be at risk for weight gain.
Around the Globe ÂÂ
Use of a strict protocol to treat neonatal narcotic abstinence syndrome possibly reduces the duration of opioid exposure as well as the length of hospital stay, suggests a new study. The benefits of a stringent protocol are significant, irrespective of the opioid used. The study is published online July 28 in Pediatrics.
ÂÂ
A study presented at the Alzheimer’s Association International Conference (AAIC) 2014 has suggested that long-term use of the diabetes drug pioglitazone may protect against dementia.
ÂÂ
The European Union’s regulatory body, Coordination Group for Mutual Recognition and Decentralized Procedures – Human (CMDh), has endorsed the suspension of marketing authorization of methadone oral solutions that contain high molecular weights of the additive povidone until the product can be reformulated. High-molecular-weight povidone (K90) accumulates inside the cells of vital organs leading to tissue damage and even death.
ÂÂ
ÂÂ
ÂÂ
ÂÂ
ÂÂ
The Paracetamol for Low-Back Pain Study (PACE), published online July 24 in The Lancet, has revealed that the drug has no effect on speed of recovery, pain, or many other factors associated with the condition. The US Food and Drug Administration (FDA) has approved an abuse-deterrent extendedrelease formulation of oxycodone, a combination of oxycodone hydrochloride and naloxone hydrochloride to treat severe pain that requires daily, around-the-clock, long-term opioid treatment, for which alternative treatment options are inadequate. A study published in the August issue of Anesthesia and Analgesia has pointed that epidural anesthesia during childbirth may reduce the risk for postpartum depression. Study authors noted that at 6 weeks postpartum, 14% of the women who had opted for epidural anesthesia during delivery had depressive symptoms compared with 34.6% of the women who did not choose epidural anesthesia. A report published online in Clinical Infectious Diseases has revealed that among patients on longterm voriconazole therapy, high plasma fluoride levels and skeletal pain are highly suggestive of periostitis. A regimen of negative shoulder movements and stretching may present a long-term treatment for chronic subacromial shoulder pain and reduce the need for surgery, suggests a new study published online in the British Journal of Sports Medicine.
ÂÂ
ÂÂ
ÂÂ
ÂÂ
ÂÂ
ÂÂ
ÂÂ
ÂÂ
Certolizumab, a monoclonal antibody against TNF-alpha, seems effective in patients with rheumatoid arthritis (RA) that no longer responds to other anti-TNF therapies, suggested a recent small trial published online in the Annals of the Rheumatic Diseases. Regular use of fish oil supplements is associated with a significant reduction in cognitive decline and brain atrophy in older adults, suggests a new study published online in the journal Alzheimer’s and Dementia. A new study published in Stroke has reported that women who were sexually abused in childhood may be more likely to have higher thickening of the inner lining of the arteries in middle age, an early indication of atherosclerosis. A new meta-analysis has suggested that medical therapy plus revascularization with PCI using newer-generation drug-eluting stents (DES) improves survival better than an initial strategy of optimal medical therapy (OMT) only. No such advantage was seen for PCI using either baremetal stents or early-generation DES. The report has been published in BMJ. A study published online July 16 in JAMA has pointed that patients who had an ischemic stroke within 3 months before undergoing elective noncardiac surgery were at relatively high risk for cardiovascular events and mortality but the risks stabilized after 9 months. Thus, patients who have sustained a stroke should wait for 9 months before having elective surgery. A reconstruction technique involving regional nerve transfers and nerve grafts has been suggested by researchers at the Hospital for Sick Children and the University of Toronto that can restore sensation in children with corneal anesthesia. The report is published online in JAMA Ophthalmology. A new research has shown that using a computerized decision aid to help automate developmental surveillance and screening (DSS) at well-child visits helps more children being screened and leads to earlier diagnoses for those with developmental delay. The findings are published in JAMA Pediatrics. A UK report has revealed that more experienced clinicians are better at diagnosing pelvic inflammatory disease (PID). Researchers from Leeds Teaching Hospitals NHS Trust noted that experienced clinicians diagnosed PID in 89.7% of women they assessed compared with 70.0% for inexperienced clinicians, thereby suggesting that
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
289
Around the Globe inexperienced clinicians may be missing 20% of cases of PID. The report was published online in Sexually Transmitted Infections. ÂÂ
According to a study published online July 28 in Diabetes, a diet low in both carbohydrates and saturated fat appears ideal for treating type 2 diabetes.
ÂÂ
The overall lipid profile in patients with type 2 diabetes appears to be better with metformin treatment as compared to glipizide treatment, suggests a new study published online in Diabetes Care.
ÂÂ
Motoric cognitive risk syndrome, a newly developed diagnosis that includes cognitive symptoms and slow gait in patients without dementia or mobilityrelated disability, is common in older adults and seems to be an early risk factor for cognitive decline, suggests a new study published online in Neurology.
ÂÂ
A new study published online in Stroke has noted an association between baseline P-wave morphology and subsequent ischemic stroke risk, even after accounting for atrial fibrillation (AF). The significant association between P-wave terminal force in lead V1 (PTFV1) and subsequent ischemic stroke persisted in participants without AF, suggesting that atrial disease could cause stroke even in the absence of AF.
ÂÂ
Alirocumab, a monoclonal antibody that inhibits proprotein convertase subtilisin/kexin type 9 (PCSK9), has been found to effectively reduce LDLcholesterol levels among patients who received the investigational drug in a number of clinical trials.
ÂÂ
ÂÂ
Hormone therapy (HT) in newly menopausal women reduces vasomotor symptoms, including hot flashes and improves some markers of cardiovascular disease (CVD); however, it has no effect on the progression of atherosclerosis, reports an article published online July 28 in the Annals of Internal Medicine. A new PhD study involving 3,000 adolescents has shown that their knee pain often termed as “growing pains” tends to carry on. Researchers noted that one in three adolescents between the ages of 12 and 19 experience pain in their knees. About 7% of the adolescents experience daily knee pain in the front of the knee. The findings were published in BMC Pediatrics.
ÂÂ
A new study published in Psychological Science has stated that peers can have a significant impact on a child’s language abilities, for better or worse. It was noted that while peers with strong language skills can help improve their classmates’ abilities, being in the company of peers with weak skills may hinder kids’ language development.
ÂÂ
A cross-sectional survey published online in Menopause has stated that caffeine intake is associated with worse hot flashes and night sweats, but fewer problems with mood, memory and concentration, in menopausal women.
ÂÂ
Individuals who are physically active and do not spend a lot of time sitting down are less likely to be obese as compared to those who spend a lot of time sitting and are involved in low levels of physical activity, suggests a new study published July 28 in Diabetologia.
ÂÂ
A once-daily oral regimen known as PaMZ has shown promise in both drug-sensitive and multidrug-resistant tuberculosis (TB), suggested a new research presented at the 20th International AIDS Conference. Researchers noted that after 8 weeks of treatment, 71% patients treated with PaMZ compared to 38% of those treated with the standard TB protocol were culture-negative. The PaMZ regimen consisted of moxifloxacin 400 mg and pyrazinamide 1,500 mg, plus PA-824 100 mg or PA-824 200 mg.
ÂÂ
A study published online July 30 in the American Journal of Infection Control has noted that resorting to fist bumps, where two people briefly press the top of their closed fists together and ditching handshakes, could reduce the spread of bacteria and illnesses. Fist bumps were actually noted to transfer about 90% fewer bacteria than handshakes.
ÂÂ
Omalizumab seems effective in controlling chronic hives for up to 24 weeks, suggested a clinical trial published online in the Journal of Investigative Dermatology.
ÂÂ
The European Commission approved apixaban, an oral factor Xa inhibitor, for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and for the recurrence of DVT and PE. The approval was granted following a positive opinion from the European Medicines Agency Committee for Medicinal Products for Human Use (CHMP).
■■■■
290
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Expert View
Do β-blockers Cause Sexual Dysfunction? KK Aggarwal
E
rectile dysfunction (ED), the persistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity,1 is a highly prevalent medical problem affecting a significant proportion of men. ED has important impact on quality-of-life and, is believed to be related to drug therapy, leads to noncompliance to therapy. Cardioactive drugs are commonly associated with adverse side effects amongst which ED is a common one. Issue of cause and effect are confused because cardiovascular disease ‘per se’ may cause ED, as there appears to be a higher rate of sexual dysfunction in untreated men with cardiovascular disease compared with men of similar age.
It has been reported that b-blockers such as propranolol may induce ED through central and peripheral (genital) effects as it increases the latency to ex copula ejaculation, the latency to initial erection and reduces the number of erectile reflexes.2 Similar findings have been reported with other b-blockers although their effect on sexual behavior is more evident with the lipophilic b-blockers than with the hydrophilic. Early human studies have suggested a high incidence of ED in treated hypertensives and helped to re-enforce the idea that b-blockers may induce ED. However, despite the common belief of the induction of ED with b-blocker use, clinical studies failed to confirm a relationship between use of such drugs and ED.3 ED in patients with cardiovascular disease may be related to psychological factors involving the fear of the disease and of the effect of the drugs prescribed. The role of psychologic component and of anxiety in sexual dysfunction is well-demonstrated and placebo may be very effective in the treatment of ED due to psychological problems. Early reports from the Medical Research Council working party on mild-to-moderate hypertension showed that ED occurred more frequently in patients taking either bendrofluazide or propranolol than in those taking placebo.4 Subsequently, Rosen et al that investigated the sexual sequelae of several classes of antihypertensive drugs (b-blockers, a-agonists, diuretics) in normal and hypertensive males in a Senior Physician and Cardiologist, Moolchand Medcity, New Delhi
comparative study with placebo, found a lack of consistent drug effects on measures of sexual response. In accordance with the study of Rosen et al, a study conducted by Silvestri et al5 to investigate the role of psychologic component and of anxiety in sexual dysfunction, found that the incidence of ED in patients blinded on study drug was low. In the study, the incidence of ED was as high as 31.2% in the patients knowing the possible side effects of the drug, while in the group of patients that did not know the drug they were taking the incidence was 10 times less frequent. These findings demonstrate on one hand the importance of psychological mechanism inducing ED, and on the other hand the fact that the most of b-blockers affect on ED is caused by psychological concerns. The mostly psychological nature of b-blocker-induced ED is further suggested by the fact that in the majority of cases ED was completely reversed by placebo. The study data were in agreement with recent prospective randomized double-blinded studies that found that sex life and ED are not affected by b-blockers.6 Several studies suggest that anxiety is common among people with sexual dysfunctions, with different levels and natures of anxiety and that anxiety reduction procedures improve some, also if probably not all, aspects of sexual dysfunctions.7 The result of the study suggest that knowledge about side effects can produce anxiety that may affect erectile function. In another study, the role of the pharmacologic effect of metoprolol (METO), a b-blocker, per se on the occurrence of ED was evaluated.8 The investigators selected 114 men (age 57 ± 4.7 years) without ED but with newly diagnosed arterial hypertension, who could be treated with METO. The hypertensive men were randomized into three groups. In Group 1 patients were fully informed (they knew that the drug was METO and that it might induce ED). In Group 2 patients were partially informed (they knew that the drug was METO, but were not informed that it might induce ED). In Group 3 patients were not informed either about the drug used or about the possible occurrence of ED. The first phase of the study lasted 60 days. After 60 days the incidence of ED was 32% in Group 1, 13% in Group 2, and 8% in Group 3 (p <
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
291
Expert View 0.01). All patients with ED entered the second, crossover, double-blind phase of the study. METO was continued at unchanged dosage and tadalafil (20 mg) and a placebo were given to treat ED. Both treatments were equally effective. The investigators came to the conclusion that prejudice about the possible occurrence, i.e. the Hawthorne effect, of ED with METO facilitates the occurrence of this side effect in hypertensive men. Since, the etiology of this ED was largely psychological, it was not surprising that placebo was as effective as tadalafil in reversing this side effect. In conclusion, it can be said that the occurrence of ED in patients on b-blockers is low, much lower than commonly thought. It is suggested that both patient’s and doctor’s expectations on the risk of experiencing ED may influence the occurrence of this bothersome side effect. References 1. NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993;270(1):83-90. 2. Srilatha B, Adaikan PG, Arulkumaran S, et al. Sexual dysfunction related to antihypertensive agents: results from the animal model. Int J Impot Res 1999;11(2):107-13.
3. Rosen RC, Kostis JB, Jekelis A, et al. Sexual sequelae of antihypertensive drugs: treatment effects on self-report and physiological measures in middle-aged male hypertensives. Arch Sex Behav 1994;23(2):135-52. 4. Adverse reactions to bendrofluazide and propranololfor the treatment of mild hypertension. Report of Medical Research Council Working Party on Mild to Moderate Hypertension. Lancet 1981;2(8246):539-43. 5. Silvestri A, Galetta P, Cerquetani E, et al. Report of erectile dysfunction after therapy with beta-blockers is related to patient knowledge of side effects and is reversed by placebo. Eur Heart J 2003;24(21): 1928-32. 6. Franzen D, Me tha A, Seifert N, et al. Effects of beta-blockers on sexual performance in men with coronary heart disease. A prospective, randomized and double blinded study. Int J Impot Res 2001;13(6):348-51. 7. Norton GR, Jehu D. The role of anxiety in sexual dysfunction: a review. Arch Sex Behav 1984;13(2):165-83. 8. Cocco G. Erectile dysfunction after therapy with metoprolol: the Hawthorne effect. Cardiology 2009;112(3):174-7.
■■■■
292
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
mediLAW
How Applicable are Consent Laws in India? Dr. K K Aggarwal
observations of the hon’ble SUPREME court (adapted from excerpts from Prabha Manchanda case in SCI) In India, majority of citizens requiring medical care and treatment fall below the poverty line. Most of them are illiterate or semi-literate. They cannot comprehend medical terms, concepts and treatment procedures. They cannot understand the functions of various organs or the effect of removal of such organs. They do not have access to effective but costly diagnostic procedures. Poor patients lying in the corridors of hospitals after admission for want of beds or patients waiting for days on the roadside for an admission or a mere examination, is a common sight. For patients, any treatment with reference to rough and ready diagnosis based on their outward symptoms and doctor’s experience or intuition is acceptable and welcome so long as it is free or cheap; and whatever the doctor decides as being in their interest, is usually unquestioningly accepted. Patients are passive, ignorant and uninvolved in treatment procedures. The poor and needy face a hostile medical environment - inadequacy in the number of hospitals and beds, nonavailability of adequate treatment facilities, utter lack of qualitative treatment, corruption, callousness and apathy. Many poor patients with serious ailments (eg., heart patients and cancer patients) have to wait for months for their turn even for diagnosis and due to limited treatment facilities, many die even before their turn comes for treatment. What choice do these poor patients have? Any treatment of whatever degree, is a boon or a favour, for them. The stark reality is that for a vast majority in the country, the concepts of informed consent or any form of consent and choice in treatment, have no meaning or relevance. The position of doctors in government and charitable hospitals, who treat them, is also unenviable. They are overworked, understaffed, with little or no diagnostic or surgical facilities and limited choice of medicines and treatment Senior Physician and Cardiologist, Moolchand Medcity, New Delhi Member, Ethics Committee, Medical Council of India
procedures. They have to improvise with virtual nonexistent facilities and limited dubious medicines. They are required to be committed, service oriented and noncommercial in outlook. What choice of treatment can these doctors give to the poor patients? What informed consent they can take from them? On the other hand, we have the doctors, hospitals, nursing homes and clinics in the private commercial sector. There is a general perception among the middle class public that these private hospitals and doctors prescribe avoidable costly diagnostic procedures and medicines and subject them to unwanted surgical procedures, for financial gain. The public feel that many doctors who have spent a crore or more for becoming a specialist, or nursing homes which have invested several crores on diagnostic and infrastructure facilities, would necessarily operate with a purely commercial and not service motive; that such doctors and hospitals would advise extensive costly treatment procedures and surgeries, where conservative or simple treatment may meet the need; and that what used to be a noble service oriented profession is slowly but steadily converting into a purely business. But unfortunately not all doctors in government hospitals are paragons of service, nor fortunately, all private hospitals/doctors are commercial minded. There are many a doctor in government hospitals who do not care about patients and unscrupulously insist upon ‘unofficial’ payment for free treatment or insist upon private consultations. On the other hand, many private hospitals and doctors give the best of treatment without exploitation, at a reasonable cost, charging a fee, which is reasonable recompense for the service rendered. Of course, some doctors, both in private practice or in government service, look at patients not as persons who should be relieved from pain and suffering by prompt and proper treatment at an affordable cost, but as potential income-providers/customers who can be exploited by prolonged or radical diagnostic and treatment procedures. It is this minority who bring a bad name to the entire profession. Health care (like education) can thrive in the hands of charitable institutions. It also requires more serious
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
293
mediLAW attention from the State. In a developing country like ours where teeming millions of poor, downtrodden and illiterate cry out for health-care, there is a desperate need for making health-care easily accessible and affordable. Remarkable developments in the field of medicine might have revolutionalized health care. But they cannot be afforded by the common man. The woes of nonaffording patients have in no way decreased. Gone are the days when any patient could go to a neighbourhood general practitioner or a family doctor and get affordable treatment at a very reasonable cost, with affection, care and concern. Their noble tribe is dwindling. Every doctor wants to be a specialist. The proliferation of specialists and super specialists, have exhausted many a patient both financially and physically, by having to move from doctor to doctor, in search of the appropriate specialist who can identify the problem and provide treatment. What used to be competent treatment by one general practitioner has now become multi-pronged treatment by several specialists. Law stepping in to provide remedy for negligence or deficiency in service by medical practitioners, has its own twin adverse effects. More and more private doctors and hospitals have, of necessity, started playing it safe, by subjecting or requiring the patients to undergo various costly diagnostic procedures and tests to avoid any allegations of negligence, even though they might have already identified the ailment with reference to the symptoms and medical history with 90% certainly, by their knowledge and experience. Secondly more and more doctors particularly surgeons in private practice are forced to cover themselves by taking out insurance, the cost of which is also ultimately passed on to the patient, by way of a higher fee. As a consequence, it is now common that a comparatively simple ailment, which earlier used to be treated at the cost of a few rupees by consulting a single doctor, requires an expense of several hundred or thousands on account of four factors: (i) Commercialization of medical treatment; (ii) increase in specialists as contrasted from general practitioners and the need for consulting more than one doctor; (iii) varied diagnostic and treatment procedures at high cost; and (iv) need for doctors to have insurance cover. The obvious, may be naive, answer to unwarranted diagnostic procedures and treatment and prohibitive cost of treatment, is an increase in the participation
294
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
of health care by the state and charitable institutions. An enlightened and committed medical profession can also provide a better alternative. Doctors in private practice and hospitals and nursing homes run commercially. The relationship of doctors and patients are contractual in origin, the service is in consideration of a fee paid by the patient, where the contract implies that the professional men possessing a minimum degree of competence would exercise reasonable care in the discharge of their duties while giving advice or treatment. There is a need to keep the cost of treatment within affordable limits. Bringing in the American concepts and standards of treatment procedures and disclosure of risks, consequences and choices will inevitably bring in higher cost-structure of American medical care. Patients in India cannot afford them. People in India still have great regard and respect for doctors. The members of medical profession have also, by and large, shown care and concern for the patients. There is an atmosphere of trust and implicit faith in the advice given by the doctor. The India psyche rarely questions or challenges the medical advice. At the same time is may also be noted that public awareness of medical negligence in India is growing. Hospital managements are increasingly facing complaints regarding the facilities, standards of professional competence and the appropriateness of their therapeutic and diagnostic methods. Having regard to the conditions obtaining in India, as also the settled and recognized practices of medical fraternity in India, the supreme court is of the view that to nurture the doctor-patient relationship on the basis of trust, the extent and nature of information required to be given by doctors should continue to be governed by the Bolam test rather than the ‘reasonably prudential patient’ test evolved in Canterbury. It is for the doctor to decide, with reference to the condition of the patient, nature of illness, and the prevailing established practices, how much information regarding risks and consequences should be given to the patients, and how they should be couched, having the best interests of the patient. A doctor cannot be held negligent either in regard to diagnosis or treatment or in disclosing the risks involved in a particular surgical procedure or treatment, if the doctor has acted with normal care, in accordance with a recognised practices accepted as proper by a responsible body of medical men skilled in that particular field, even though there may be a body of opinion that takes a contrary view. Where there are more than one recognized school of established medical practice, it is not negligence for a doctor to follow any one of those practices, in preference to the others.
lighter reading
Connie told her 4-year-old grandson, Dean, not to jump on the beds. After several warnings she punished him, explaining that should he fall, he would hurt himself badly. Several minutes passed and he was back to jumping on the beds. Connie said, “Dean, you weren’t jumping on the beds again, were you?” He stood with his little head dropped low and said, “I’m trying, but it’s so hard to quit.” Getting Rid of the Problem A farmhand is driving around the farm, checking the fences. After a few minutes he radios his boss and says, “Boss, I’ve got a problem. I hit a pig on the road and he’s stuck in the bull-bars of my truck. He’s still wriggling. What should I do?” “In the back of your truck there’s a shotgun. Shoot the pig in the head and when it stops wriggling you can pull it out and throw it in a bush.” The farm worker says okay and signs off. About 10 minutes later he radios back. “Boss I did what you said, I shot the pig and dragged it out and threw it in a bush.”
Quote
Jumping on Beds
HUMOR
LAUGH-A-WHILE
Lighter Side of Medicine “Nature loves you ten times more than a mother loves her newborn”. —Sri Sri Ravi Shankar
Repairs When a guy’s printing on his printer began to grow faint, he called a local repair shop where a friendly man informed him that the printer probably needed only to be cleaned. Because the store charged $50 for such cleanings, he told him he might be better off reading the printer’s manual and trying the job himself. Pleasantly surprised by his candor, he asked, “Does your boss know that you discourage business?” “Actually, it’s my boss’s idea,” the employee replied sheepishly. “We usually make more money on repairs if we let people try to fix things themselves first.”
Dr. Good and Dr. Bad Situation: A patient with ulcerative colitis was on 5-ASAs.
Continue it
Get renal functions dome every six months
“So what’s the problem now?” his Boss snapped. ©IJCP Academy
“The blue light on his motorcycle is still flashing!” Get me a Battleship After lunching at the Algonquin Hotel, Robert Benchley walked through the lobby, out the front door and said to the uniformed man on the sidewalk, “My good man, would you please get me a taxi?” The man immediately took offense and replied indignantly, “I’m not a doorman! I happen to be a rear admiral in the United States Navy.” Robert Benchley instantly quipped: “All right then, get me a battleship.”
296
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Lesson: In a June 4 online paper in Frontline Gastroenterology, Dr Andrew F Muller and colleagues at The Kent and Canterbury Hospital note that 5-ASAs have become a cornerstone in management of inflammatory bowel disease (IBD). However, although their safety profile is generally favorable, in some cases the agents have been associated with a significant decline in renal function and interstitial nephritis. Because of this, the Medicines and Healthcare Products Regulatory Agency and the British Society of Gastroenterology recommend monitoring anywhere from every 3 to every 12 months.
KK Aggarwal
Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Indian Journal of Clinical Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter –
– –
The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.
Manuscript – Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures). –
The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.
–
All pages should be numbered consecutively beginning with the title page.
Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors. Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed,
name of the corresponding authors, acknowledgment of financial support and abbreviations used. – The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary. – A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included. – The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page. – A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text. Summary – The summary of not more than 200 words. It must convey the essential features of the paper. – It should not contain abbreviations, footnotes or references. Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives. Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others. – Ethical guidelines followed by the investigations should be described. Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected. – Method of selecting the sample (cases, subjects, etc. from the statistical universe). – Method of allocating the subjects into different groups. – Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques. –
Confidence intervals for the measurements should be provided wherever appropriate.
Results – These should be concise and include only the tables and figures necessary to enhance the understanding of the text.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
297
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. –
298
The legend must include enough information to permit interpretation of the figure without reference to the text.
Indian Journal of Clinical Practice, Vol. 25, No. 3, August 2014
Indian 1.____________Foreign 1._ _______________
7. All authors’ signatures________________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________
Online Submission Also e-Issue @ www.ijcpgroup.com For Editorial Correspondence
Dr KK Aggarwal
Group Editor-in-Chief Indian Journal of Clinical Practice E-219, Greater Kailash, Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com
R.N.I. No. 50798/90 Date of Publication 13th of Same Month Date of Posting 13-14 Same Month
POSTAL REGISTRATION NO. DL (S)-01/3200/2012-2014 Posted in N.D. PSO New Delhi