IJCP July 2012 by sanjeev kumar

Online Submission

IJCP Group of Publications

Volume 23, Number 2, July 2012

Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

Dr KK Aggarwal CMD, Publisher, Group Editor-in-Chief

from the desk of group editor-in-chief 65 New Treatment for Acute Asthma in Children

Dr Veena Aggarwal MD, Group Executive Editor Anand Gopal Bhatnagar Editorial Anchor

IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma, Dr Kamala Selvaraj

KK Aggarwal

review article 67 Community-acquired Pneumonia

Rajiv Garg, KK Aggarwal

72 Selenium in Breast Cancer

Jyoti Yadav, Shubhrica

Cardiology Dr Praveen Chandra Dr M Paul Anand, Dr SK Parashar Paediatrics Dr Swati Y Bhave Dr Balraj Singh Yadav Dr Vishesh Kumar Diabetology Dr Vijay Viswanathan Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty

Original Study 79 Evaluation of Efficacy and Safety of Evecare

Syrup in Menstrual Irregularities: A Multicentric, Post Marketing Surveillance Study

Dentistry Dr KMK Masthan Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar Dermatology Dr Hasmukh J Shroff

clinical study 86 Efficacy and Tolerability of Trandolapril in

Mild-to-moderate Hypertension: A Double-blind Comparison with Enalapril

Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan Journal of Applied Medicine & Surgery Dr SM Rajendran Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

Mukta Umarji, Pralhad S Patki

Jyothi R, Pundarikaksha HP, Srinivasa Prabhu NC, Girish K, Vasundhara K

Original article 92 Assessment of Hypogonadism with Reference

to Clinical Features and Serum Testosterone Levels in Asian-Indian Male Type 2 Diabetics

Ibraheem Khan, Chandra Kant, Anil Samaria

Case Study

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

100 Autologous Bone Marrow Stem Cell Therapy

Shows Functional Improvement in Hemorrhagic Stroke

Alok Sharma, Hemangi Sane, Prerna Badhe, Pooja Kulkarni, Guneet Chopra, Mamta Lohia, Nandini Gokulchandran

case report

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.

106 Anton’s Syndrome and Cortical Blindness

Gadwalkar Srikant R, Deepa DV, P Rama Murthy, Ravi Dhar

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

photo quiz 109 Persistent Cough

Medilaw 112 Insight on Medicolegal Issues

Sudhir Gupta

around the globe 113 News and Views

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.

lighter reading 114 Lighter Side of Medicine

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from the desk of group editor-in-chief Dr KK Aggarwal

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

New Treatment for Acute Asthma in Children

ccording to a randomized controlled, double-blind study by Dorit Ater, MD, from Tel Aviv University in Israel, and colleagues published in May 21 in the journal Pediatrics, the use of hypertonic saline inhalations with albuterol (salbutamol) among preschool children with acute wheezing is associated with lower hospital admission rates and shorter hospital stays but is not linked with improved clinical scores. The use of hypertonic saline (HS) treatment with albuterol given to acutely wheezing children in the emergency department comprises 4 ml of HS 5% given with albuterol twice, every 20 minutes. This was the first study to examine HS treatment in preschool children (32 Âą 17 months of age) with a wheezing episode. Most wheezing episodes causing hospitalization or emergency department visits in preschool children are associated with viral respiratory tract infections. The most common viruses are rhinoviruses, detected in the lower airways and leading to lower airway inflammation. HS 5% may reverse some of the pathophysiologic abnormalities attributed to virus-induced acute wheezing episodes in small children because of promucus clearance and prohydration.

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

review article

Community-acquired Pneumonia Rajiv Garg*, KK Aggarwal**

Abstract Despite the availability of potent new antimicrobials and effective vaccines, community-acquired pneumonia (CAP) remains a common and potentially serious illness associated with considerable morbidity and mortality, particularly in elderly patients and those with significant comorbidities. The emergence of penicillin-resistant Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, the pathogens that account for approximately 85% of CAP cases, is a serious threat to public health. Of additional concern is that penicillin-resistant organisms are also frequently resistant to other agents, particularly first-generation cephalosporins, erythromycin, tetracycline and trimethoprim-sulfamethoxazole. Cefaclor, a broad-spectrum semi-synthetic second-generation oral cephalosporin with documented activity against many gram-positive and gram-negative pathogens, as well as some anaerobes, is a good therapeutic option.

Keywords: Community-acquired pneumonia, penicillin-resistant organisms, second-generation oral cephalosporin, cefaclor

ommunity-acquired pneumonia (CAP) is defined as pneumonia not acquired in a hospital or a long-term care facility. Despite the availability of potent new antimicrobials and effective vaccines, it remains a common and potentially serious illness associated with considerable morbidity and mortality, particularly in elderly patients and those with significant comorbidities.1 CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe. Less commonly, CAP results from secondary bacteremia from a distant source, such as Escherichia coli urinary tract infection and/or bacteremia. The overall annual incidence of CAP ranges from 5 to 11 per 1,000 persons, with more cases occurring in the winter months.2 In 2006, there were approximately 4.2 million ambulatory care visits for CAP in the United States, with Streptococcus pneumoniae as the most commonly identified pathogen.3 In 2007, >50,000 persons died from CAP.4 Mortality is highest for patients who require hospitalization, with a 30-day mortality rate of upto 23% in such patients.3 In recent years, there has been a change in both the epidemiology and treatment of pneumonia. CAP is

*Senior Medical Specialist and Head, Dept. of Medicine ESI Hospital, Noida, UP **Senior Physician and Cardiologist Moolchand Medcity, New Delhi

increasingly common among older patients and those with comorbidity like chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), renal failure, congestive heart failure, chronic lung disease (CLD) and other conditions. Two major variables that influence the spectrum of etiologic agent and initial approach to therapy are the severity of initial presentation and presence of either co-existing illness or advanced age. Patients with severe CAP have a distinct epidemiology and a somewhat different distribution of etiologic pathogens than patients with other forms of pneumonia. Similarly, the presence of comorbidity or advanced age can determine the likely pathogens involved.5 Causative organisms Typical bacterial pathogens that cause the condition include S. pneumoniae (penicillin-sensitive and -resistant strains), Haemophilus influenzae (ampicillin-sensitive and -resistant strains) and Moraxella catarrhalis (all strains penicillin-resistant). These three pathogens account for approximately 85% of CAP cases.6 The etiology of CAP varies by geographic region; however, S. pneumoniae is the most common cause of pneumonia worldwide. In-patients with an acute exacerbation of chronic bronchitis (AECB) who develop CAP that requires hospitalization, M. catarrhalis infection is the most common infecting pathogen. It is pertinent to note that Staphylococcus aureus, KlebsiellaÂ pneumoniae and Pseudomonas aeruginosa are

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

review article not typical causes of CAP in otherwise healthy hosts. S. aureus may cause CAP in individuals with influenza (e.g., human seasonal influenza and H1N1 [swine] influenza).7 K. pneumoniae CAP occurs primarily in individuals with chronic alcoholism. P. aeruginosa is a cause of CAP in patients with bronchiectasis or cystic fibrosis. In certain patients admitted to the ICU, the microbial etiology of the pneumonia may be complex. In a study by Cilloniz et al, polymicrobial infection was present in 11% of cases. The most frequently identified pathogens in polymicrobial infections were S. pneumoniae, respiratory viruses and P. aeruginosa. Chronic respiratory disease and acute respiratory distress syndrome criteria were independent predictors of a polymicrobic infection.8 The bacteriological profile of CAP is different in different countries and changing with time within the same country, probably due to frequent use of antibiotics, changes in environmental pollution, increased awareness of the disease and changes in life expectancy. For instance, S. pneumoniae remains the commonest organism leading to CAP in most parts of Europe, United States, UK, Iraq and Delhi. K. pneumoniae is the most common pathogen leading to admission to a medical intensive care unit in Singapore.5 Emergence of antimicrobial resistance An alarming increase in resistance of bacteria that cause CAP has been documented, especially in the staphylococci and pneumococci (S. pneumoniae), which are prevalent causes of disease and mortality.9 The emergence of antimicrobial resistance to S. pneumoniae is a serious threat to public health. Of additional concern is that penicillin-resistant organisms are also frequently resistant to other agents, particularly first-generation cephalosporins, erythromycin, tetracycline and trimethoprim-sulfamethoxazole.10 The two other typical bacterial pathogens associated with community-acquired respiratory infections, H. influenzae and M. catarrhalis, have also shown increasing rates of antimicrobial resistance. These organisms exhibit strong resistance to b-lactams, primarily via plasmid-mediated b-lactamase production, although H. influenzae can also produce altered penicillinbinding proteins. In a review, 33.5% of H. influenzae isolates were found to produce b-lactamase;11 the level of antibiotic resistance among H. influenzae is so high that use of penicillin, ampicillin, amoxicillin, erythromycin, tetracycline and first-generation cephalosporins for

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

the treatment of infections caused by H. influenzae is no longer recommended. Resistance to trimethoprimsulfamethoxazole also appears to be rising, with resistance rates in the United States and Canada of over 16% in 1997.11 b-lactamase-producing strains of M. catarrhalis have also been increasing over the past few decades. In the same review of isolates from the United States and Canada from 1997, over 92% of M. catarrhalis isolates were found to be b-lactamase producers.11 Management of the Patient with CAP Management of the patient with CAP is based on disease severity, local bacterial susceptibility and resistance patterns, and appropriate pharmacokinetic and pharmacodynamic targets for bacterial eradication. Diagnostic evaluation of CAP is important for appropriate assessment of severity of illness and for establishment of the causative agent in the disease. Microbiological tests are not completely reliable in identifying the etiology of pneumonia, and in 40-70% of pneumonia cases, the etiology is never determined. Until better rapid diagnostic methods are developed, most patients will be treated empirically. However, emerging resistance of these organisms to antimicrobial agents has affected empirical treatment of CAP.12 In this scenario, amoxicillin-clavulanate is no more preferred for empiric treatment for all communityacquired and healthcare-associated pneumonias. There is need for a broad-spectrum antibiotic which is effective against these multidrug-resistant pathogens. Cefaclor, a broad-spectrum semi-synthetic second-generation oral cephalosporin with documented activity against many gram-positive and gram-negative pathogens, as well as some anaerobes, is a good therapeutic option since resistance of S. pneumoniae (penicillin-sensitive and -resistant strains), H. influenzae (ampicillin-sensitive and -resistant strains), and M. catarrhalis to cefaclor is very low. Moreover, cefaclor treatment is significantly safer in regard to gastrointestinal side effects and relative risk of relapse in patients treated with amoxicillin/ clavulanate has been shown to be 2.6 greater compared to cefaclor.13

Cefaclor: A Dependable Second-generation Oral Cephalosporin Since, its introduction in 1979, cefaclor has maintained its record of efficacy in the management of lower respiratory infections like CAP. Factors that contribute to the efficacy and tolerability of cefaclor include its molecular stability, activity against the most prevalent gram-positive and gram-negative respiratory tract

review article

Clinical efficacy of cefaclor against pathogens associated with CAP A study was undertaken to determine the antimicrobial activity of cefaclor against the common respiratory tract pathogens isolated in patients. When a laboratory analysis was done on 466 isolates of respiratory tract pathogens, it was seen that of the 163 S. pneumoniae, 87 M. catarrhalis and 216 H. influenzae isolates >95% isolates were susceptible to cefaclor. The MIC 90 of cefaclor against these pathogens was <2 ug, which indicates that cefaclor would be effective in >90% of cases infected with these bacteria.14 These three pathogens account for approximately 85% of CAP cases. In a comparative study undertaken to evaluate the in vitro activity of cefaclor and other oral cephalosporins against a large number of freshly isolated clinical strains of gram-negative and gram-positive bacteria which are associated with CAP, it was demonstrated that cefaclor has a superior action against S. pneumoniae.15 Cefaclor was also the most active antibiotic against strains of H. influenzae, and was shown to be more active than cephalexin and cephradine against nonb-lactamase producing strains of Klebsiella species.15 In another study, Cefaclor demonstrated efficacy against b-lactamase-producing H. influenzae-resistant to ampicillin.16 E. coli, Klebsiella spp., Proteus mirabilis and H. influenzae have been shown to be more susceptible to clinically achievable concentrations of cefaclor than cephalexin. Cefaclor was also highly active against both β-lactamase-positive and -negative strains of H. influenzae at the recommended inoculum size and when compared to cephradine and cephalexin, cefaclor has been shown to be less resistant to staphylococcal penicillinase.17 It was demonstrated that at 2 μg/ml, cefaclor inhibited all b-lactamase-positive and -negative strains of H. influenzae at the generally recommended inoculum of 104 CFU/ml, in contrast to cephalexin and cephradine which required 32 ug/ml and 64 ug/ml, respectively for b-lactamase-positive organisms and

Cephradine 64 µg/ml

70 Antibiotic concentrations (µg/ml)

pathogens, rapid absorption, >90% bioavailability and good penetration into respiratory mucosa. Despite over three decades of widespread use, it remains clinically effective in patients with lower respiratory tract infections, especially in a scenario where antibiotic resistance among the common pathogen implicated in CAP is high. Additionally, since it lacks antitubercular activity, unlike fluoroquinolones, it is particularly useful when diagnosis is in doubt especially in a country like India, where tuberculosis is rampant.

60 50 40

Cephalexin 32 µg/ml

30 Cephradine

20 10 0

Cefaclor 2 µg/ml

Cephalexin 16 µg/ml Cefaclor 8 µg/ml 2 µg/ml

β-lactamase-producing strains Non β-lactamase-producing strains

Figure 1. Comparison of susceptibility of H. influenzae to cefaclor, cephalexin and cephradine.

8 ug/ml and 16 ug/ml, respectively for β-lactamasenegative organisms (Fig. 1). Clinical Efficacy of Cefaclor in CAP Six hundred ninety patients were enrolled in a multicenter, randomized, double-blind trial, to compare the efficacy and safety of cefaclor with those of cefdinir in the treatment of CAP.18 Patients received either 10 days of treatment with cefaclor (n = 343) at 500 mg thrice-daily or 10 days of treatment with cefdinir (n = 347) at 300 mg twice-daily. Microbiological assessments were performed on sputum specimens obtained at admission and at the two post-therapy visits, if available. Respiratory tract pathogens were isolated from 538 (78%) of 690 patient admission sputum specimens, with the predominant pathogens being H. parainfluenzae, H. influenzae, S. pneumoniae and S. aureus. The microbiological eradication rates at the test-of-cure visit were 93% (245 of 264 pathogens) and 92% (238 of 260 pathogens) for the evaluable patients treated with cefaclor and cefdinir, respectively. Diarrhea incidence during therapy was higher for patients treated with cefdinir (13.7%) than for patients treated with cefaclor (5.3%). These results indicate that cefaclor is as effective as cefdinir in the treatment of pneumonia but it has a better tolerability profile.

Efficacy of cefaclor as oral component of intravenous to oral switch therapy in CAP Treatment of CAP has come a long way from a full course of intravenous (IV) antibiotics to switch therapy and now, tentatively, to a full course of oral antibiotics. Treatment with oral antibiotics helps to minimize the use of IV catheters, reducing nursing time and

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

review article improving the patient’s comfort and mobility, and, thus, contributing to prevent complications of IV therapy, such as phlebitis, catheter-related infections, bedsores and thromboembolic events. Cefaclor has been shown to an effective oral antibiotic for switching over from a parenteral antibiotic in management of CAP.19 A study was conducted to compare the therapeutic outcome and analyze cost-benefit of a ‘conventional’ (7-day course of IV antibiotic therapy) versus an abbreviated (2-day IV antibiotic course followed by ‘switch’ to oral antibiotics) therapy for in-patients with CAP.19 The investigators used a multicenter prospective, randomized, parallel group with a 28-day follow-up, at the University-based teaching hospitals. Ninety-five patients were randomized to receive either a ‘conventional’ course of IV antibiotic therapy with cefamandole 1 g IV every 6-hour for seven days (n = 37), or an abbreviated course of IV therapy with cefamandole (1 g IV every 6-hour for 2 days) followed by oral therapy with cefaclor (500 mg every 8-hour for 5 days). No difference was found in the clinical courses, cure rates, survival or the resolution of the chest radiograph abnormalities among the two groups. The mean duration of therapy (6.88 days for the conventional group compared to 7-30 days for the early oral therapy group) and the frequencies of overall symptomatic improvement (97% vs 95%, respectively) were similar in both groups. Patients who received early oral therapy had shorter hospital stays (7.3 vs 9.71 days, p = 0.01), and a lower total cost of care ($2953 vs $5002, p < 0.05). The investigators came to the conclusion that early transition to an oral antibiotic like cefaclor after an abbreviated course of IV therapy in CAP is substantially less expensive and has comparable efficacy to conventional IV therapy.

semi-synthetic second-generation oral cephalosporin is a good therapeutic option. Also, cefaclor treatment is significantly safer in regard to gastrointestinal side effects and relative risk of relapse in patients treated with amoxicillin/clavulanate has been shown to be 2.6 greater compared to cefaclor. Moreover, twice-daily dosing of cefaclor ensures better patient compliance.

Conclusions Over the last several decades, the microbiology of CAP appears to have changed. S. pneumoniae (penicillinsensitive and -resistant strains), H. influenzae (ampicillinsensitive and -resistant strains), and M. catarrhalis (all strains penicillin-resistant) now account for approximately 85% of CAP cases. Of additional concern is that these penicillin-resistant organisms are also frequently resistant to other agents, particularly firstgeneration cephalosporins, erythromycin, tetracycline and trimethoprim-sulfamethoxazole. In this scenario, amoxicillin-clavulanate is no more preferred for empiric treatment for community-acquired and healthcareassociated pneumonias. Cefaclor, a broad-spectrum

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

References 1.

Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44 Suppl 2:S27-72.

Lim WS, Baudouin SV, George RC, et al.; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009;64 Suppl 3:1-55.

File TM Jr, Marrie TJ. Burden of community-acquired pneumonia in North American adults. Postgrad Med 2010;122(2):130-41.

Centers for Disease Control and Prevention. Fast Stats. Deaths and mortality. http://www.cdc.gov/nchs/fastats/ pneumonia.htm. Accessed September 20, 2010.

Shah BA, Singh G, Naik MA, Dhobi GN. Bacteriological and clinical profile of Community acquired pneumonia in hospitalized patients. Lung India 2010;27(2): 54-7.

Howard LS, Sillis M, Pasteur MC, Kamath AV, Harrison BD. Microbiological profile of community-acquired pneumonia in adults over the last 20 years. J Infect. 2005;50(2):107-13.

Cunha BA. Swine Influenza (H1N1) pneumonia: clinical considerations. Infect Dis Clin N Am 2010;24(2):203-28.

Cilloniz C, Ewig S, Ferrer M, Polverino E, Gabarües 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.

Tedesco KL, Rybak MJ. Daptomycin. Pharmacotherapy 2004;24(1):41-57.

10. Schriever CA, Fernandez C, Rodvold KA, Danziger LH. Daptomycin: a novel cyclic lipopeptide antimicrobial. Am J Health Syst Pharm 2005;62(11):1145-58. 11. Thornsberry C, Ogilvie P, Kahn J, Mauriz Y. Surveillance of antimicrobial resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in the United States in 1996-1997 respiratory season. The Laboratory Investigator Group. Diagn Microbiol Infect Dis 1997;29(4):249-57.

review article 12. File TM. Community-acquired pneumonia. Lancet 2003;362(9400):1991-2001.

16. Derry JE. Evaluation of cefaclor. Am J Hosp Pharm 1981;38(1):54-8.

13. Haczyński J, Bardadin J, Gryczyńska D, Gryczyński M, Gołabek W, Kawalski H, et al. A comparative study of cefaclor vs. amoxicillin/clavulanate in tonsillopharyngitis. Med Sci Monit 2001;7(5):1016-22.

17. Bill NJ, Washington JA 2nd. Comparison of in vitro activity of cephalexin, cephradine, and cefaclor. Antimicrob Agents Chemother 1977;11(3):470-4.

14. Ahmed A, Hafiz S, Rafiq M, Tariq N, Abdulla EM, Hussain S, et al. Determination of antimicrobial activity of Cefaclor on common respiratory tract pathogens in Pakistan. J Pak Med Assoc 2002;52(1):7-11. 15. Gillett AP, Andrews JM, Wise R. Comparative in vitro microbiological activity and stability of cefaclor. Postgrad Med J 1979;55 Suppl 4:9-11.

18. Drehobl M, Bianchi P, Keyserling CH, Tack KJ, Griffin TJ. Comparison of cefdinir and cefaclor in treatment of community-acquired pneumonia. Antimicrob Agents Chemother 1997;41(7):1579-83. 19. Omidvari K, de Boisblanc BP, Karam G, Nelson S, Haponik E, Summer W. Early transition to oral antibiotic therapy for community-acquired pneumonia: duration of therapy, clinical outcomes, and cost analysis. Respir Med 1998;92(8):1032-9.

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

review article

Selenium in Breast Cancer JYOTI YADAV*, SHUBHRICA

Abstract Breast cancer is the third most common cancer in human and the second leading cause of cancer death in woman. Selenium is an essential but an intriguing trace element. It has an important role in prevention of breast cancer via its antioxidant effect. An inverse relationship has been observed by many authors between serum selenium levels and development of cancer in humans as well as experimental animals. It has also been found to have preventive effect in doses of 100-200 µg/day. It also potentiates the effect of tamoxifen and doxirubicin.

Keywords: Selenium, trace element, prevention of breast cancer

elenium, an essential trace mineral, forms an important part of our immune defense function including prevention of breast cancer. Selenium occurs naturally in the soil and its level varies from place to place. Organic crops absorb and transfer it into a form that is bioavailable to humans. The effective form of selenium is L-selenomethionine, which is easily absorbed and stored in the body, hence is also used in clinical trials. Other forms, such as selenite, are not as easy for the body to assimilate. Sources of Selenium Commonly found in animal protein, selenium is also found in fish, vegetables, especially Brazil nuts. Animal meat and sea food are the richest sources of selenium available to human beings, though it is also present in fairly good amount in cereals, grains, fruit, dairy products1 and alcoholic drinks.2 Individuals who consume wine more than three times a week have higher serum selenium levels than individuals with lower consumption. Also, individuals who consume above seven units of spirit drinks a week have higher mean serum selenium concentration.2 Selenium Daily Requirement The recommended adequate daily intake of selenium for adults is around 50-200 µg, while for children it is

*Professor, Dept. of Physiology Pt. BD Sharma PGIMS, Rohtak, Haryana Address for correspondence Dr Jyoti Yadav 30/9J Medical Enclave, Rohtak, Haryana - 124 001 E-mail: drjyotiyadav2008@yahoo.com

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

20-120 µg.3 Daily doses of 100-200 µg of selenium inhibit genetic damage and cancer development in humans; however, about 400 µg of selenium/day is considered an upper limit.4 Even individuals with nutritionally adequate selenium intakes may benefit from selenium supplementation.5 Selenium Levels and Breast Cancer The mean serum selenium values in breast cancer patients is significantly lower than in noncancer patients. The use of oral contraceptive pills, being nulliparous and a low serum selenium level are associated with breast cancer.6 An inverse relationship exists between dietary selenium concentration and the incidence of human breast cancer. McConnell et al reported significantly lower mean serum selenium concentrations of breast cancer patients as compared to controls.7 Charalabopoulos et al found decreased serum selenium concentration in breast cancer patients but at the sametime also observed an increased concentration in the neoplastic breast tissue. These alterations may reflect part of the defense mechanisms against the carcinogenetic process.8 Lopez-Saez et al observed that alterations in serum concentrations of selenium in women with breast cancer appear to be consequence, rather than a cause of cancer. In accordance with the hypothesis, the findings suggested that very low selenium status could be due to the nature of cancer.9 The antioxidant functions of selenium have now been shown to reduce the risk of many cancers including breast cancer. Selenium also alters genes that cause cancer. Selenium is an intriguing essential trace element due to its potential role in influencing cancer incidence.

review article Several studies suggest that selenium may play a role in the prevention of cancer. In vivo prevention models of mammary cancer show that higher selenium intake is associated with lower incidence of tumor growth.10,11 In epidemiological studies, an inverse association between blood selenium levels and cancer risk has been reported.12-14 Several studies show that women with breast cancer have lower blood selenium levels than those of healthy controls,7,9,15-18 whereas other studies fail to confirm this observation.19,20 Selenium is regarded to be a breast cancer preventive factor involved in multiple protective pathways. It has been shown that low serum selenium may be merely a consequence of disease in general rather than a feature of cancer per se.21 Relation of Selenium, BRCA1 Gene and Breast Cancer Kowalska et al observed that women born with a BRCA1 mutation carry a lifetime risk of breast cancer of 80%. The BRCA1 gene product is involved in maintaining the integrity of the human genome and helps repair double-strand breaks. When blood lymphocytes from BRCA1 carriers are exposed to bleomycin, a known mutagen that induces double-strand breaks, an increased frequency of chromosome breaks per cell occurs, i.e., 0.58 in BRCA1 carriers versus 0.39 in noncarriers. In 32 female BRCA1 carriers supplemented with selenium (276 Âľg as Na2SeO3/day) for 1-3 months, the frequency of chromosome breaks was found to be reduced from 0.63/cell before supplementation with selenium to 0.40/cell after supplementation, bringing it to the level in noncarrier controls. Thus, selenium may have the potential to reduce breast cancer risk in these women.22 Supplementation of the culture media of human MCF-7 breast carcinoma cells with low levels of selenium (30 nM) provided as sodium selenite was shown to protect these cells from ultraviolet-induced gene mutations. Protection was dependent on functional BRCA1 activity, a protein implicated in breast cancer risk and DNA damage repair.23 Selenoproteins and Breast Cancer Selenium is an essential nutrient and exerts its effect largely through its presence in selenoproteins. Throughout evolution, the translation of selenoproteins has involved the incorporation of selenocysteine into the elongating peptide in response to a UGA codon, a triplet otherwise used to signal the termination of

protein synthesis.24 Recognition of the UGA triplet as selenocysteine requires an RNA signal sequence, referred to as the selenocysteine insertion sequence, located at 3â&#x20AC;&#x2122; and proximal to the UGA in prokaryotes,25 and in the 3â&#x20AC;&#x2122;untranslated region of eukaryotic selenoprotein mRNAs.26 Mammalian cells contain several dedicated molecules involved in synthesis and regulation of selenoprotein synthesis24 and data implicating selenoprotein levels as modifiers of cancer risk and therefore also as mediators of anticarcinogenic effects of selenium is now recognized. The cytosolic glutathione peroxidase (GPx)-1 is the first and best characterized mammalian selenoprotein, capable of using reducing equivalents from glutathione to detoxify hydrogen and lipid peroxides.27 Hu and Diamond found that the functional difference associated with codon identity at position 198 of GPx-1 was demonstrated by exclusively expressing each GPx-1 allele differing only at that position in breast cancer cells and showing that each responded differently to increasing levels of selenium. Their study implicated the Leu Allele in breast cancer risk as well as demonstrating fewer heterozygotes at the GPx-1 locus in tumor tissues compared to a DNA obtained from cancer free individuals. Using polyalanine repeat polymorphism located in GPx-1 coding sequence, genotype analysis revealed that the heterozygosity in breast tumors was significantly lower than that in cancer free population (39% vs 75%), indicating the likely frequent loss of this genetic locus. These results indicated a difference in allele frequency between DNAs obtained from cancers of this type versus controls, with fewer heterozygotes in breast cancer. Hu and Diamond also found that GPx-1 with Leu Allele has been shown to be less responsive to stimulation of its enzyme activity by selenium supplementation than GPx-1 with the pro-allele. They showed that selective loss of pro-198 allele of GPx-1 gene leading on to increased risk of tumor development. The Leu/Leu genotype has been found to be almost twice as common in DNA from breast cancer tissue as compared to cancer free individuals, while the Pro/Leu genotype was found to be low, indicating loss of heterozygosity at this locus in breast tumor development.28 In addition to the polymorphism at codon 198, there is an additional common polymorphism in which there are a variable number of tandem alanine codons, 4, 5 or 6 repeats, in GPx-1exon.28,29-33 Knight et al in casecontrol study observed an association of a particular variant with risk of cancer, i.e., 4 repeats were associated with breast cancer risk. In a study of 399

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

review article cases of invasive breast cancer and 372 controls, they found no association between breast cancer and GPx-1 pro-198 Leu. However, the allele of GPx-1 containing four GCG was found to be significantly associated with breast cancer risk in premenopausal women for carriers versus noncarriers.34 Plasma selenium and GPx activity fluctuate during the rat estrus cycle and is significantly greater in the periovulatory phase when estrogen levels are highest.35 Likewise, plasma selenium concentrations and plasma erythrocyte GPx activity fluctuate in synchrony with estradiol throughout the menstrual cycle in women.36 With respect to menopause, selenium status of in premenopausal women, both healthy and with breast cancer, is greater than that of postmenopausal women.9,37 While according to some authors, selenium seems not to be an important factor in the etiology of breast cancer20,38 neither in premenopausal nor in postmenopausal women.2 Thus, although there is suggestive evidence for a preventive role for selenium in breast cancer, rigorous retrospective and prospective studies are needed to confirm this hypothesis.20 Chen et al showed that selenium-enriched Spirulia platensis extract inhibited the growth of MCF-7 human breast cancer cells through induction of G1 cell cycle arrest and mitochondria-mediated apoptosis. This extract induced G1-phase arrest. Their results suggest the potential applications of selenium-enriched S. platensis extract in chemoprevention of human breast cancer.39 Chen et al found that selenocystine, a naturally occurring selenoamino acid, caused caspase-induced apoptosis in MCF-7 breast carcinoma cells and concluded that selenocysteine, is a promising anticancer selenocompound, induces MCF-7 cell apoptosis by activating reactive oxygen species (ROS)-mediated mitochondrial pathway and p53 phosphorylation.40 Breast carcinoma cells are highly sensitive to the organic selenium compounds, manifesting apoptosis at concentrations as low as 0.113 micron (0.0205 Âľg/ml) selenium.41 Selenium phycocyanin was identified as a potent antiproliferative agent against human breast adenocarcinoma MCF-7 cells.42 Breast cancer incidence in Nigerian women has significantly increased due to the associated widespread contamination of the soil and water by lead and other industrial metals. Lead belongs to the group of selenium antagonistic elements that interact with selenium, abolishing its anticarcinogenic effect. Higher levels of lead were found in blood and

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

head hair samples of newly diagnosed patients with infiltrating ductal carcinoma of breast. Lead and other metals also interact with iodine, another vitally important essential trace element believed to protect against breast cancer development.43 Breast cancer is the second leading cause of cancer death among women and the third most common cancer. Hamdy et al investigated the chemoprevention efficacy of each of soy genistin, selenium or a combination of them against breast cancer. Breast carcinoma was formed in 7,12-dimetylbenzanthracene (DMBA)-induced rats and abnormal changes were ameliorated in the rats treated with genistin/selenium due to antioxidant defense with high potential chemopreventive activity against DMBA-induced mammary tumors.44 Sep15 And Breast Cancer Sep15 was initially characterized in 1998 as a major 75Se-labeled protein detected in human T cells. It is expressed at relatively high levels in the prostate, liver, brain, kidney and testis, whereas it is low or not detectable in muscle, trachea and the mammary gland.45 A survey of frequency of Sep15 alleles in human DNA samples indicated a dramatically different allele distribution between Caucasians and African-Americans, with the T811/A1125 allele being represented four times more often among AfricanAmericans.46 In this population, there was a significant difference in allele frequency in DNA obtained from breast cancers compared with DNA obtained from cancer free individuals. In a detailed analysis of loss of heterozygosity at Sep15 in breast cancer, significantly fewer (28%) heterozygotes were observed at a genetic marker tightly linked to Sep15.47 An analysis of other microsatellite markers along human chromosome Ip did not detect a significant difference in the heterozygosity indices for these markers between breast tumor and control DNA. These data indicate that the loss of either Sep15, or perhaps another very tightly linked gene, is a common and important event in breast cancer development.47 Relation of Selenium, Chemotherapy and Breast cancer Selenium has a significant antineoplastic effect on breast tumor cells. Supplementation of selenium enhances chemotherapeutic effect of taxol and doxorubicin in these cells beyond that seen with the chemotherapeutic drugs used alone.48 Selenium induces inhibition of

review article angiogenesis in mammary cancer at chemopreventive levels of intake.49 Chemoprevention of mammary cancer with Se-allylselenocysteine and other selenoaminoacids in the rat has been experimentally verified.50,51 There was approximately 43% reduction in chemically-induced mammary tumors when rats were fed a diet with Se-enriched ramps.52 Li et al studied the therapeutic effect of methylselenocysteine combined with tamoxifen in MCF-7 breast cancer xenograft and the underlying mechanisms. They found synergistic growth inhibition of ER alpha-positive breast cancer xenografts by combination of tamoxifen with organic selenium compounds. Organic selenium may provide added benefit when combined with tamoxifen in adjuvant therapy or prevention.53 Ibanez evaluated the antitumoral activity of imidoselenocarbamate in vitro against breast adenocarcinoma (MCF-7) and found that it can be considered as the most promising candidates for the development of novel generations of antitumor agents.54 Linoleic acid and conjugated linoleic acids hydroxylated with selenium dioxide exhibited moderate in vitro cytotoxicity against a panel of human cancer cell lines including adenocarcinoma MCF-7 cells (IC(50)10-75 microM).55 Conclusion Selenium is an important trace element that helps in building our immune system including cancer prevention. Lower serum levels are associated with breast cancer as compared to controls. It also potentiates chemotherapy of breast cancer in experimental animals as well as human beings. REFERENCES 1.

Arthur JR, Nicol F, Hutchinson AR, Beckett GJ. The effects of selenium depletion and repletion on the metabolism of thyroid hormones in the rat. J Inorg Biochem 1990;39(2):101-8. Diaz Romero C, López Blanco F, Henríquez Sánchez P, Rodríguez E, Serra Majem L. Serum selenium concentration in a representative sample of the Canarian population. Sci Total Environ 2001;269(1-3):65-73. Committee on Dietary Allowances Food and Nutrition Board Recommended Allowances. 9th edition, National Dietary Academy of Sciences: Washington 1980:p162-3. El-Bayoumy K. The protective role of selenium on genetic damage and on cancer. Mutat Res 2001;475(1-2):123-39.

Combs GF Jr. Chemopreventive mechanisms of selenium. Med Klin (Munich) 1999;94 Suppl 3:18-24.

Rejali L, Jaafar MH, Ismail NH. Serum selenium level and other risk factors for breast cancer among patients in a Malaysian hospital. Environ Health Prev Med 2007;12(3):105-10.

McConnell KP, Jager RM, Bland KI, Blotcky AJ. The relationship of dietary selenium and breast cancer. J Surg Oncol 1980;15(1):67-70.

Charalabopoulos K, Kotsalos A, Batistatou A, Charalabopoulos A, Vezyraki P, Peschos D, et al. Selenium in serum and neoplastic tissue in breast cancer: correlation with CEA. Br J Cancer 2006;95(6):674-6.

Lopez-Saez JB, Senra-Varela A, Pousa-Estevez L. Selenium in breast cancer. Oncology 2003;64(3):227-31.

10. el-Bayoumy K, Chae YH, Upadhyaya P, Meschter C, Cohen LA, Reddy BS. Inhibition of 7,12-dimethylbenz(a) anthracene-induced tumors and DNA adduct formation in the mammary glands of female Sprague-Dawley rats by the synthetic organoselenium compound, 1,4-phenyl enebis(methylene)selenocyanate. Cancer Res 1992;52(9): 2402-7. 11. Ip C, Lisk DJ, Ganther HE. Chemoprevention with triphenylselenonium chloride in selenium-deficient rats. Anticancer Res 2000;20(6B):4179-82. 12. Comstock GW, Bush TL, Helzlsouer K. Serum retinol, beta-carotene, vitamin E, and selenium as related to subsequent cancer of specific sites. Am J Epidemiol 1992;135(2):115-21. 13. Willett WC, Polk BF, Morris JS, Stampfer MJ, Pressel S, Rosner B, et al. Prediagnostic serum selenium and risk of cancer. Lancet 1983;2(8342):130-4. 14. Salonen JT, Alfthan G, Huttunen JK, Puska P. Association between serum selenium and the risk of cancer. Am J Epidemiol 1984;120(3):342-9. 15. Kumar K, Thangaraju M, Sachdanandam P. Changes observed in antioxidant system in the blood of postmenopausal women with breast cancer. Biochem Int 1991;25(2):371-80. 16. Hardell L, Danell M, Angqvist CA, Marklund SL, Fredriksson M, Zakari AL, et al. Levels of selenium in plasma and glutathione peroxidase in erythrocytes and the risk of breast cancer. A case-control study. Biol Trace Elem Res 1993;36(2):99-108. 17. Huang YL, Sheu JY, Lin TH. Association between oxidative stress and changes of trace elements in patients with breast cancer. Clin Biochem 1999;32(2):131-6. 18. Chaitchik S, Shenberg C, Nir-El Y, Mantel M. The distribution of selenium in human blood samples of Israeli population - comparison between normal and breast cancer cases. Biol Trace Elem Res 1988;15:205-12. 19. Ghadirian P, Maisonneuve P, Perret C, Kennedy G, Boyle P, Krewski D, et al. A case-control study of toenail selenium and cancer of the breast, colon, and prostate. Cancer Detect Prev 2000;24(4):305-13.

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review article 20. Männistö S, Alfthan G, Virtanen M, Kataja V, Uusitupa M, Pietinen P. Toenail selenium and breast cancer-a case-control study in Finland. Eur J Clin Nutr 2000;54(2):98-103.

34. Knight JA, Onay UV, Wells S, Li H, Shi EJ, Andrulis IL, et al. Genetic variants of GPX1 and SOD2 and breast cancer risk at the Ontario site of the Breast Cancer Family Registry. Cancer Epidemiol Biomarkers Prev 2004;13(1):146-9.

21. Basu TK, Hill GB, Ng D, Abdi E, Temple N. Serum vitamins A and E, beta-carotene, and selenium in patients with breast cancer. J Am Coll Nutr 1989;8(6):524-9.

35. Smith AM, Cha C, Kimura RE. Plasma selenium and glutathione peroxidase activity fluctuate during the rat estrous cycle. Nutr Res 1995;15(1):267-77.

22. Kowalska E, Narod SA, Huzarski T, Zajaczek S, Huzarska J, Gorski B, et al. Increased rates of chromosome breakage in BRCA1 carriers are normalized by oral selenium supplementation. Cancer Epidemiol Biomarkers Prev 2005;14(5):1302-6.

36. Ha EJ, Smith AM. Plasma selenium and plasma and erythrocyte glutathione peroxidase activity increase with estrogen during the menstrual cycle. J Am Coll Nutr 2003;22(1):43-51.

23. Baliga MS, Wang H, Zhuo P, Schwartz JL, Diamond AM. Selenium and GPx-1 overexpression protect mammalian cells against UV-induced DNA damage. Biol Trace Elem Res 2007;115(3):227-42. 24. Hatfield DL, Gladyshev VN. How selenium has altered our understanding of the genetic code. Mol Cell Biol 2002;22(11):3565-76. 25. Zinoni F, Birkmann A, Leinfelder W, Böck A. Cotranslational insertion of selenocysteine into formate dehydrogenase from Escherichia coli directed by a UGA codon. Proc Natl Acad Sci U S A 1987;84(10):3156-60. 26. Berry MJ, Banu L, Harney JW, Larsen PR. Functional characterization of the eukaryotic SECIS elements which direct selenocysteine insertion at UGA codons. EMBO J 1993;12(8):3315-22. 27. Brigelius-Flohé R. Tissue-specific functions of individual glutathione peroxidases. Free Radic Biol Med 1999;27 (9-10):951-65. 28. Hu YJ, Diamond AM. Role of glutathione peroxidase 1 in breast cancer: loss of heterozygosity and allelic differences in the response to selenium. Cancer Res 2003;63(12): 3347-51. 29. Moscow JA, Schmidt L, Ingram DT, Gnarra J, Johnson B, Cowan KH. Loss of heterozygosity of the human cytosolic glutathione peroxidase I gene in lung cancer. Carcinogenesis 1994;15(12):2769-73. 30. Ratnasinghe D, Tangrea JA, Andersen MR, Barrett MJ, Virtamo J, Taylor PR, et al. Glutathione peroxidase codon 198 polymorphism variant increases lung cancer risk. Cancer Res 2000;60(22):6381-3. 31. Ichimura Y, Habuchi T, Tsuchiya N, Wang L, Oyama C, Sato K, et al. Increased risk of bladder cancer associated with a glutathione peroxidase 1 codon 198 variant. J Urol 2004;172(2):728-32. 32. Forsberg L, de Faire U, Marklund SL, Andersson PM, Stegmayr B, Morgenstern R. Phenotype determination of a common Pro-Leu polymorphism in human glutathione peroxidase 1. Blood Cells Mol Dis 2000;26(5):423-6. 33. Shen Q, Townes PL, Padden C, Newburger PE. An inframe trinucleotide repeat in the coding region of the human cellular glutathione peroxidase (GPX1) gene: in vivo polymorphism and in vitro instability. Genomics 1994;23(1):292-4.

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37. Smith AM, Chang MP, Medeiros LC. Generational differences in selenium status of women. Biol Trace Elem Res 2000;75(1-3):157-65. 38. Costello AJ. A randomized, controlled chemoprevention trial of selenium in familial prostate cancer: Rationale, recruitment, and design issues. Urology 2001;57(4 Suppl 1): 182-4. 39. Chen T, Wong YS, Zheng W. Induction of G1 cell cycle arrest and mitochondria-mediated apoptosis in MCF-7 human breast carcinoma cells by seleniumenriched Spirulina extract. Biomed Pharmacother 2009 Oct. 27. [Epub ahead of print] 40. Chen T, Wong YS. Selenocystine induces caspaseindependent apoptosis in MCF-7 human breast carcinoma cells with involvement of p53 phosphorylation and reactive oxygen species generation. Int J Biochem Cell Biol 2009;41(3):666-76. 41. Jariwalla RJ, Gangapurkar B, Nakamura D. Differential sensitivity of various human tumour-derived cell types to apoptosis by organic derivatives of selenium. Br J Nutr 2009;101(2):182-9. 42. Chen T, Wong YS. In vitro antioxidant and antiproliferative activities of selenium-containing phycocyanin from selenium-enriched Spirulina platensis. J Agric Food Chem 2008;56(12):4352-8. 43. Alatise OI, Schrauzer GN. Lead exposure: a contributing cause of the current breast cancer epidemic in Nigerian women. Biol Trace Elem Res 2010;136(2):127-39. 44. Hamdy SM, Latif AK, Drees EA, Soliman SM. Prevention of rat breast cancer by genistin and selenium. Toxicol Ind Health 2011 Nov 16. [Epub ahead of print] 45. Gladyshev VN, Jeang KT, Wootton JC, Hatfield DL. A new human selenium-containing protein. Purification, characterization, and cDNA sequence. J Biol Chem 1998;273(15):8910-5. 46. Hu YJ, Korotkov KV, Mehta R, Hatfield DL, Rotimi CN, Luke A, et al. Distribution and functional consequences of nucleotide polymorphisms in the 3’-untranslated region of the human Sep15 gene. Cancer Res 2001;61(5):2307-10. 47. Nasr MA, Hu YJ, Diamond AM. Allelic loss at the SEP 15 locus in breast cancer. Cancer Ther 2003;1:293-8. 48. Vadgama JV, Wu Y, Shen D, Hsia S, Block J. Effect of selenium in combination with Adriamycin or Taxol

review article on several different cancer cells. Anticancer Res 2000;20(3A):1391-414.

enriched ramps (Allium tricoccum). J Agric Food Chem 2000;48(11):5723-30.

49. Jiang C, Jiang W, Ip C, Ganther H, Lu J. Seleniuminduced inhibition of angiogenesis in mammary cancer at chemopreventive levels of intake. Mol Carcinog 1999;26(4):213-25.

53. Li Z, Carrier L, Belame A, Thiyagarajah A, Salvo VA, Burow ME, et al. Combination of methylselenocysteine with tamoxifen inhibits MCF-7 breast cancer xenografts in nude mice through elevated apoptosis and reduced angiogenesis. Breast Cancer Res Treat 2009;118(1):33-43.

50. Ip C, Zhu Z, Thompson HJ, Lisk D, Ganther HE. Chemoprevention of mammary cancer with Seallylselenocysteine and other selenoamino acids in the rat. Anticancer Res 1999;19(4B):2875-80. 51. Cann SA, van Netten JP, van Netten C. Hypothesis: iodine, selenium and the development of breast cancer. Cancer Causes Control 2000;11(2):121-7. 52. Whanger PD, Ip C, Polan CE, Uden PC, Welbaum G. Tumorigenesis, metabolism, speciation, bioavailability, and tissue deposition of selenium in selenium-

54. Ibáñez E, Plano D, Font M, Calvo A, Prior C, Palop JA, Sanmartín C. Synthesis and antiproliferative activity of novel symmetrical alkylthio- and alkylselenoimidocarbamates. Eur J Med Chem 2011;46(1):265-74. 55. Li Z, Tran VH, Duke RK, Ng MC, Yang D, Duke CC. Synthesis and biological activity of hydroxylated derivatives of linoleic acid and conjugated linoleic acids. Chem Phys Lipids 2009;158(1):39-45.

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Original Study

Evaluation of Efficacy and Safety of Evecare Syrup in Menstrual Irregularities: A Multicentric, Post Marketing Surveillance Study Mukta Umarji*, Pralhad S Patki*

Abstract A total of 1,000 female patients aged between 18-45 years with menstrual irregularities and those willing to give informed consent were included in this multicentric, post marketing surveillance study. At the initial visit, a detailed medical history, symptomatic evaluation and gynecological evaluation was carried out in all the patients. Out of the 1,000 patients, 372 had dysmenorrhea, 388 had menorrhagia and 240 patients had oligomenorrhea. Each patient was administered Evecare Syrup at a dose of 15 ml, twice-daily for a period of three months. Statistical analysis was carried out using GraphPad Prism, Version 4.03. In 372 patients suffering from dysmenorrhea, 14 had slight abdominal pain and 358 of them had total absence of symptoms at the end of treatment. In patients with menorrhagia, significant reduction was observed in the mean score of duration of menstruation, quantity of blood loss, blood flow loss and character of blood flow changed from clot to flow after treatment with Evecare Syrup. At the end of three months of treatment, 238 patients had normal menstruation, normal duration and flow in oligomenorrhea. No clinically significant adverse drug reactions were reported except for one patient, who had symptoms of nausea; one patient had symptoms of gaseous distension at third month of treatment and it did not require additional treatment or drug withdrawal. The results of the present study showing clinical benefit of Evecare Syrup appear promising in the management of menstrual irregularities.

Keywords: Evecare Syrup, multicenter clinical study, dysmenorrhea, menorrhagia, oligomenorrhea

enstruation occurs as a universal endometrial event following the withdrawal of estrogen and progesterone subsequent to a normal ovulatory cycle. Disruption of a regulated sequence of molecular, cellular and vascular events can lead to a range of menstrual disturbances.

estradiol and progesterone. Menstrual cycles are often irregular through adolescence, particularly the interval from the first to the second cycle. Early menstrual life is characterized by anovulatory cycles and the ovulation frequency is related to time since menarche as well as age at menarche.

Age of menarche varies globally, especially in the less developed countries. Menarche typically occurs within 2-3 years after thelarche (breast budding), at Tanner stage IV breast development, and is rare before Tanner stage III development.1 The median menstrual cycle length is 28 Âą 3 days and the average duration of menstrual flow is 5 Âą 2 days with a blood loss averaging 130 ml.2 This cyclical process is regulated in part by complex changes in the concentrations of five hormones: gonadotropin-releasing hormone (GnRH), folliclestimulating hormone (FSH), luteinizing hormone (LH),

Menstrual irregularities can be caused by disturbance of the central GnRH pulse generator as well as by significant weight loss, strenuous exercise, substantial changes in sleeping or eating habits and severe stressors. Chronic diseases, such as poorly-controlled diabetes mellitus, genetic and congenital conditions, such as Turner syndrome and other forms of gonadal dysgenesis can also be a cause.3

*Consulting Gynecologist Umarji Hospital, Shukrawarpet, Pune, Maharashtra **Head, Medical Services and Clinical Trials The Himalaya Drug Company, Research and Development, Makali, Bangalore Address for correspondence Dr Pralhad S Patki Head, Medical Services and Clinical Trials The Himalaya Drug Company, Research and Development, Makali, Bangalore - 560 058 E-mail: dr.patki@himalayahealthcare.com

Menorrhagia is menstrual bleeding longer than seven days or in an amount exceeding 80 ml from normal secretory endometrium after normal ovulation.4 It affects 10-30% of the menstruating women and may occur at some time during the perimenopause in upto 50% of the women. Metrorrhagia is uterine bleeding that occurs irregularly between menstrual periods. The bleeding is usually light, although it can range from staining to hemorrhage. Polymenorrhea is menstruation that occurs too frequently. Oligomenorrhea is an

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

Original Study abnormally infrequent menstrual bleeding characterized by 3-6 menstrual cycles per year. When menstrual bleeding does occur, it can be profuse and prolonged or decreased in amount. Primary amenorrhea should be considered for any adolescent who has not reached menarche by the age of 15 years or has not done so within three years of thelarche. There are three types of dysmenorrhea: Primary, secondary and membranous. Primary dysmenorrhea is characterized by the absence of an organic etiology, while secondary dysmenorrhea is associated with specific diseases or disorders, such as endometriosis, ovarian cysts, pelvic inflammatory disease, adenomyosis, cervical stenosis, fibroid polyps and possibly uterine displacement with fixation. Membranous dysmenorrhea (uterine cast) is rare and causes intense cramping pain due to the passage of the intact endometrial cast through an undilated cervix.5 In women with dysmenorrhea, the concentrations of prostaglandins (PG), both PGF2α and PGE2, in menstrual blood are significantly increased compared to those in women without dysmenorrhea as a result of endometrial synthesis and release of PGs.6,7 It is, therefore, logical that in the clinical management of both primary and secondary dysmenorrhea, nonsteroidal anti-inflammatory drugs (NSAIDs), which inhibit PG synthesis, offer a valid treatment. However, the treatment is less effective if the intake of the drug is delayed until the pain is more severe. Also side effects can occur, especially in women with asthma and allergic disorders and peptic ulcers.8 Oral contraceptives (OCs) are still used very often as treatment, especially in young women who also require contraception. They reduce uterine contractility, induce endometrial atrophy and reduce endometrial PG concentrations. But, side effects and potential of adverse drug reactions may limit their use in some women. Other treatments (e.g., danazol, GnRH agonists) have either too many side effects, are too invasive (e.g., surgical methods), or are ineffective for the treatment of an accompanying disorder, and cannot, therefore, be considered for routine treatment of dysmenorrhea. Evecare Syrup is a polyherbal formulation and various clinical studies have observed the beneficial effect in the management of uterine disorders. This study was planned to evaluate the efficacy and safety Evecare Syrup in menstrual irregularities. Aim To evaluate the clinical efficacy and safety of Evecare Syrup in the treatment of menstrual irregularities.

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

Material and Methods A multicentric, post marketing surveillance study was undertaken on 1,000 patients in the age group of 18-45 years presenting with history of irregular menstrual cycles. A written informed consent was obtained from all the study participants and they were informed of the voluntary nature of the trial. The study was conducted in accordance with regulatory standards of good clinical practice. Inclusion criteria: Female patients aged between 18-45 years with menstrual irregularities and those willing to give informed consent. Exclusion criteria: Patients who had systemic illness like hypertension, renal disease, tuberculosis, hepatic disease, diabetes, coagulation disorder, etc. and those who had any disorder of the reproductive tract, especially any benign or malignant growth, extensive cervical erosion, cervical polyps, endometriosis, tubercular endometritis and acute infective disorder, and patients with history of recent delivery or abortion, and those patients who refused to give informed consent. Women of childbearing age, who were not willing to follow the adequate contraceptive method and lactating women were also excluded from the trial.

Study Procedure At the initial visit, a detailed medical history, symptomatic evaluation and gynecological evaluation was carried out in all the patients. Out of the 1,000 patients, 372 had dysmenorrhea, 388 had menorrhagia and 240 patients had oligomenorrhea (Table 1). Most of the patients with oligomenorrhea had scanty and irregular menstruation. There were only a few patients with primary dysmenorrhea and they were of the younger age group. Patients with complaints of menorrhagia had no organic cause and were thoroughly assessed before they were put on Evecare therapy. The blood flow loss was graded using a predefined symptom score scale from 0 to 2 (0-normal, 1-moderate, 2-profuse). The character of blood flow was graded from 0 to 2, where 0 was normal flow, 1 was passage of 1-4 clots and Table 1. Distribution of Patients with Various Clinical Diagnoses of Menstrual Abnormalities (n = 1,000) Clinical diagnosis

No. of patients

Age (years)

Dysmenorrhea

372

25.70 ± 6.43

Menorrhagia

388

28.24 ± 7.15

Oligomenorrhea

240

27.00 ± 2.28

Original Study 2 was >4 clots. Each patient was administered Evecare Syrup at a dose of 15 ml, twice-daily for a period of three months. All patients were followed up every month till the end of treatment: Symptomatic evaluation and clinical examination was done; any adverse events (AEs) were recorded. Complete blood count and ultrasound scans were done for all patients before and after treatment. The protocol of the study was as per the International Conference on Harmonization-Good Clinical Practice (ICH-GCP) guidelines and the patients were free to withdraw from the study if they so desired. No other medication was allowed for these patients. 



Primary endpoint: Clinical recovery from the presenting symptoms of menstrual irregularities. Secondary endpoint: Assessment of clinical safety profile of Evecare Syrup.

Statistical Analysis Results were analyzed statistically by repeated measures of ANOVA and Friedman’s test followed by Dunnett’s multiple comparison test for evaluation of symptomatic scores. The minimum level of significance was fixed at 95% confidence limit and a 2-sided p value of <0.05 was considered significant. Statistical analysis was performed using GraphPad Prism Software, Version 4.03.

Adverse Events All AEs, either reported or observed by patients, were recorded with information about severity, date of onset, duration and action taken regarding the study drug. Relation of AEs to the study medication was predefined as ‘Unrelated’ (follows a reasonable temporal sequence from the administration of the drug), ‘Possible’ (follows a known response pattern to the suspected drug, but could have been produced by the patient’s clinical state or other modes of therapy administered to the patient), and ‘Probable’ (follows a known response pattern to the suspected drug that could not be reasonably explained by the known characteristics of the patient’s clinical state). Patients were allowed to voluntarily withdraw from the study, if they so desired without assigning reasons. Efforts were made to ascertain the reason for dropout in such patients. Noncompliance (defined as failure to take <80% of the medication) was not regarded as treatment failure, and reasons for noncompliance were noted. Results One thousand patients were enrolled into the trial and all the patients completed the study. The mean age of the patients in dysmenorrhea group was 25.70 ± 6.43;

it was 28.24 ± 7.15 in menorrhagia group and 27.00 ± 2.28 in the oligomenorrhea.

Effect of Evecare Syrup in Dysmenorrhea Three hundred seventy-two patients presented with clinical diagnosis of dysmenorrhea. The results of the study are shown in Table 2. A partial absence of symptoms was observed in 132 patients at second month and complete absence of symptoms in 14 patients. At the end of treatment, 14 had slight abdominal pain and 358 of them had total absence of symptoms (p < 0.001). No clinically significant adverse drug reactions were reported except for one patient who had nausea and it did not require additional treatment or withdrawal of drug.

Effect of Evecare Syrup in Menorrhagia The clinical diagnosis of menorrhagia was made in 388 patients. The results of the study are shown in Table 3. Treatment with Evecare therapy showed a significant (p < 0.001) reduction in the mean score of duration of menstruation, quantity of blood loss (number of pads changed per day) and blood flow loss (graded as profuse to normal) at the end of treatment. Reduction in the symptoms was evident from the second month of therapy itself. Duration of menstruation was 12.80 ± 0.37 at baseline and significantly reduced to 6.77 ± 0.48 (p < 0.05) and 5.12 ± 0.76 (p < 0.001) at the end of second and third months of treatment, respectively. There was a significant change in the mean score of character of blood flow from clot to flow at the end of 3-month treatment with Evecare (p < 0.05). No adverse drug reactions were reported except for one patient who had symptoms of gaseous distension at third month of treatment and it did not require additional treatment or drug withdrawal.

Effect of Evecare Syrup in Oligomenorrhea Two hundred forty patients had a clinical diagnosis of oligomenorrhea. The results of the study are shown in Table 2. Effect of Evecare on Symptomatic Relief in Patients with Dysmenorrhea (n = 372) Menstrual irregularity

Duration of treatment

No. of cases showing recovery Complete Partial Persistent

Dysmenorrhea

1st month

354

2nd month

132

226

3rd month

358*

*p < 0.001 as compared to at entry values.

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

Original Study Table 3. Effect of Evecare on Symptomatic Relief in Patients with Menorrhagia (n = 388) Parameter Duration of menstruation (No. of days)

Quantity of blood loss (No. of diapers changed/day) Blood flow loss (Profuse to normal)

Character of blood flow (Clot or Flow)

Duration of treatment

Score

Significance

Baseline

12.80 ± 0.37

1st month

9.80 ± 0.72

2nd month

6.77 ± 0.48

p < 0.05

3rd month

5.12 ± 0.76

p < 0.001

Baseline

6.76 ± 0.14

1st month

5.35 ± 0.20

2nd month

3.93 ± 0.12

p < 0.05

3rd month

3.06 ± 0.32

p < 0.001

Baseline

1.62 ± 0.09

1st month

1.14 ± 0.04

2nd month

0.86 ± 0.06

3rd month

0.72 ± 0.02

p < 0.001

Baseline

1.08 ± 0.12

1st month

0.88 ± 0.16

2nd month

0.64 ± 0.14

3rd month

0.58 ± 0.08

p < 0.05

Statistical analysis was carried out using repeated ANOVA test, and Friedman test followed by Dunnett’s multiple comparison test. NS: Not significant.

Table 4. Effect of Evecare on Symptomatic Relief in Patients with Oligomenorrhea (n = 240) Menstrual Duration of irregularity treatment Oligomenorrhea

No. of cases showing recovery Complete

Partial

Persistent

1st month

185

2nd month

156

3rd month

238*

*p < 0.001 as compared to at entry values.

Table 4. At the end of one month, a partial response was seen in 34 patients; they had moderate flow. In 21 patients there was total restoration of normal menstrual flow. At the end of two months, 156 patients had normal flow and 79 patients had moderate flow. At the end of three months, 238 patients had normal menstruation, normal duration and flow with significance of p < 0.001 as compared to at entry values. No adverse drug reactions were reported. Discussion An extensive review of literature on herbal formulations has provided a list of natural remedies for symptoms

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

related to hormonal and physiological imbalances. Several plants are known to be effective in treating hypogonadism, irregular menses, amenorrhea and other menstrual problems.9 Evecare Syrup is a polyherbal formulation that comprises extracts of Saraca indica, Boerhaavia diffusa, Symplocos racemosa, Tinospora cordifolia, Solanum nigrum, Asparagus racemosus, Aloe vera, Cocos nucifera, Santalum album, Cyperus rotundus, Acacia arabica, Hemidesmus indicus, Adhatoda vasica, Rubia cordifolia, Triphala, Dashamoola, Trikatu, Bombax malabaricum and Shilajeet. The beneficial results observed in this study could be due to synergistic actions of these herbs in Evecare Syrup. S. indica is rich in tannins, and glycosides, which make it useful in different uterine affections like menorrhagia, dysmenorrhea, postpartum hemorrhage and leukorrhea.10 Dashamoola is an aqueous extract of a combination of 10 plant roots known to be clinically beneficial in various disorders, which may be helpful in variety of conditions related to menstruation.11 Herbs included in Dashamoola like Clerodendrum phlomidis and Premna integrifolia have tonic and anti-inflammatory activities, which in turn improve the quality-of-life.12 Trials have shown that the bark extract of S. racemosa reduces the frequency and intensity of the contractions in both pregnant and nonpregnant uteri, suggesting its beneficial effect in menstrual irregularities.13 It is also used in different gynecological problems like menorrhagia, frequent abortions, reduced libido, leukorrhea and vaginal ulcerations.14 Trials have also suggested its role in renormalizing FSH, LH levels required for women well-being.15 T. cordifolia has antiinflammatory, analgesic and spasmolytic activities, which are helpful in managing various painful menstrual conditions; it regularizes the menstrual flow.16 S. nigrum has analgesic, anti-inflammatory, antispasmodic, central depressant and vasodilator activities, all of which are of help in premenstrual syndrome, and other painful menstrual conditions.17,18 B. diffusa is a potent antifibrinolytic and antiinflammatory; hence, it is used in menstrual disorders like menorrhagia,19,20 including dysmenorrhea.14 Use of A. racemosus has been reported in menorrhagia, and threatened abortion.14 The extract blocks the uterine contraction and spontaneous motility and may also block the pitocin sensitive receptors. This action suggests its use as uterine sedative and in different menstrual problems like dysmenorrhea.21 C. nucifera has estrogen-like activity and may be helpful in various menstrual irregularities.22 It also has antinociceptive and anti-inflammatory activities,

Original Study which confirm the popular use of this plant in several inflammatory disorders and thus is of help in dysmenorrhea.23 A. vera is used in spasmodic dysmenorrhoea due to its antispasmodic activity.24 Intragastric administration of A. vera powder at 60 mg/kg improved fertility rate in rabbits; it is used to improve fertility in women, which establishes the use of Evecare in assisted conception. Itâ&#x20AC;&#x2122;s additional anti-inflammatory activity is useful in various gynecological disorders.25 Extract of S. album has antioxidant activity and is also used as adaptogenic activity. It may be helpful in debilating conditions that may occur due to excessive menstrual bleeding.26 The extract of A. arabica has antioxidant activity and helps to renormalize the hormonal imbalances in the body leading to a regular menstrual cycle.27 The rhizomes of C. rotundus have been used in traditional medicine as an estrogenic and anti-inflammatory agent for the treatment of womenâ&#x20AC;&#x2122;s diseases. The extract of the rhizomes of C. rotundus L. have shown acetylcholinesterase inhibitory activity as well as inhibition of nitric oxide and superoxide production activity.28,29 A saponin from H. indicus is found to have anti-inflammatory and antinociceptive activities in both acute and subacute condition, which may ameliorate the menstrual discomforts.30,31 Triphala is a homogenous mixture of three fruits: Emblica officinalis, Terminalia chebula and T. bellerica. It is a rich source of vitamin C, ellagic acid, gallic acid, chebulinic acid, etc. Studies confirm its anti-inflammatory and antimicrobial activities, which may be helpful in various gynecological inflammatory disorders.32 The phenolic compounds present in Triphala extract are mostly responsible for their radical scavenging activity, and may be helpful in controlling various hormonal influences resulting in menstrual irregularities.33 The extract of A. vasica has anti-inflammatory activity is certainly of help in managing various inflammatory changes of the genitourinary system.34 Vasicine initiated rhythmic contractions of human myometrial strips from both pregnant and nonpregnant uteri. The effect is comparable to that of oxytocin and methergin. Various ethnopharmacology approaches show its styptic activities and use in various bleeding disorders.35 R. cordifolia has antioxidant and antimicrobial activities making it useful in various gynecological disorders.36 Trikatu is an Ayurvedic preparation containing black pepper, long pepper and ginger, which is prescribed routinely for a variety of diseases as part of a multidrug prescription may be due to its bioavailability enhancer activity.37,38 Mangiferin extracted from B. malabaricum shows antioxidant and analgesic activities and certainly

may be helpful in various gynecological disorders.39 Shilajeet has been demonstrated as a prospective modifier of analgesic tolerance. All these activities are beneficial in menstrual disorders.40 Conclusion The results of this multicentric, post marketing surveillance 3-month study show that the clinical benefits of Evecare Syrup appear promising in the management of menstrual irregularities. In menorrhagia, significant reduction was observed in the mean score of duration of menstruation, quantity of blood loss, blood flow loss and character of blood flow changed from clot to flow after treatment with Evecare Syrup. Similarly, patients with oligomenorrhea had normal menstruation, normal duration and flow. No clinically significant adverse drug reactions were reported except for nausea, and gaseous distension, which did not require additional treatment or the withdrawal of drug. The beneficial results observed in this study therefore could be due to synergistic actions of the herbs present in Evecare Syrup.

Acknowledgment Authors would like to thank all the investigators who took part in the study. Dr A Chewda, Mehsana, Gujarat; Dr A Chuyda, Mehsana, Gujarat; Dr Ami Mehta, Rajkot, Gujarat; Dr Amita Bhatt, Rajkot, Gujarat; Dr Ansari Shagufta NA, Bhiwandi, Mumbai; Dr Geeta Banerjee, Rewa, MP; Dr Asha Chirmal, Thane, Mumbai; Dr M Indrani, Salem, Tamil Nadu; Dr B Singh, Angul, Odisha; Dr Bella Palnitkar, Mumbai; Dr Devina Akhani, Morbi, Gujarat; Dr Deviyani Rajgor, Koparkhairane, Mumbai; Dr Diptirekha Dash, NALCO, Angul, Odisha; Dr Sanjib Nayak, Kolkata; Dr Fehmida C Shaikh, Kurla (W), Mumbai; Dr Geeta I Bhatia, Mumbai; Dr Hutokshi Zaroliwala, Colaba, Mumbai; Dr JJ Jadhav, Kurla (E), Mumbai; Dr Jayamala Patil, Ghansoli, Mumbai; Dr Jyotsana P Thakur, Thane, Mumbai; Dr Joshi, Mangrol, Junagadh, Gujarat; Dr Survesh Saxena, Rewa, MP; Dr Varalakshmi, Salem, Tamil Nadu; Dr Karabi Dutta, Kolkata; Dr Piyush Lata Maheshwari, Satna, MP; Dr Arul Mangal, Dharmapuri, Tamil Nadu; Dr Kusum Savaljia, Gujarat; Dr Lata More, Dombivli (W), Mumbai; Dr MM Kalwari, Prabhadevi, Mumbai; Dr Makarand Kulkarni, Badlapur (W), Mumbai; Dr Manik Kale, Dombivli (W), Mumbai; Dr Manish Trivedi, Bhavnagar, Gujarat; Dr Manisha Rudha, Kolkata; Dr Manjari, Mahim, Mumbai; Dr Maya Joshi, Bhavnagar, Gujarat; Dr Meena Yallur, Belgaum, Karnataka; Dr M Kumudha, Dharmapuri, Tamil Nadu; Dr Namita Kumar Sharan, Ulhasnagar, Mumbai; Dr Nishasben Dewani, Junagadh, Gujarat; Dr Nitel Thakker, Rajkot, Gujarat; Dr Nivedita Dalvi, Thane, Mumbai; Dr PS Yesaji, Mumbai; Dr Poonam Dinde, Airoli Naka, Mumbai; Dr Prasad J Kamath, Mumbai; Dr Pratina Das, Talcher, Angul, Odisha; Dr Priya Mahajan, Badlapur (E), Mumbai;

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

Original Study Dr Priya Payil, Lower Parel, Mumbai; Dr Puspanjali Nayak, Talcher, Angul, Odisha; Dr Rajashri Patil Deshmukh, Manpada, Mumbai; Dr Rashmi H Achrekar, Mumbai; Dr Rashmi Savla, Khar (E), Mumbai; Dr Ratikanta Khatva, Bhubaneswar; Dr Razia Khan, Bandra (E), Mumbai; Dr Rekha Patel, Canal Road, Rajkot, Gujarat; Dr SB Kappalguddi, Belgaum, Karnataka; Dr SJ Kamble, Mumbai; Dr SN Pamnani, Ulhasnagar, Mumbai; Dr S Nayak, Kolkata; Dr Rekha James, Jabalpur, MP; Dr Saroj Bandekar, Kurla (W), Mumbai; Dr Savita Dubli, Badlapur (E), Mumbai; Dr Seema Saeed, Bhiwandi, Mumbai; Dr Shahnaz S Momin, Thane, Mumbai; Dr Shalaka V Dharadhar, Mumbai; Dr Arvind Patel, Gujarat; Dr Shobha Nidamboor, Nerul, Mumbai; Dr Shobha Patil, Dombivli, Mumbai; Dr Shobha V Patil, Dombivli, Mumbai; Dr Sindhu Kamble, Mumbai; Dr Smita V Bhalerao, Mumbai; Dr Sudha Mehta, Bhavnagar, Gujarat; Dr Suparna Sen (Mrs.), Kolkata; Dr Surekha Shah, Koparkhairane, Mumbai; Dr Surya A Bhagwati, Marin Lines, Mumbai; Dr Sushma Shibe, Dombivli (W), Mumbai; Dr Swati V Singh, Dombivli, Mumbai; Dr Tabassum Momin, Bhiwandi, Mumbai; Dr UV Dharma, Thane, Mumbai; Dr Vasundhara Kulkarni, Mulund (E), Mumbai; Dr Veena Parikh, Bhavnagar, Gujarat; Dr Veena Zaveri, Ghatkopar, Mumbai; Dr YV Shah, Rajkot, Gujarat. References 1.

Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child 1969;44(235):291-303.

Berkow R (Ed.). The Merck Manual of Diagnosis and Therapy. Vol. 2, 15th edition, Rahway (NJ): Merck; 1987.

American Academy of Pediatrics Committee on Adolescence; American College of Obstetricians and Gynecologists Committee on Adolescent Health Care, Diaz A, Laufer MR, Breech LL. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics 2006;118(5):2245-50.

American College of Obstetrics and Gynecology. Dysfunctional uterine bleeding. Tech Bull 1982;66:5

Gerbie MD. Complications of menstruation: abnormal uterine bleeding. In: Current Obstetric & Gynecologic Diagnosis and Treatment. 6th edition, Pernoil ML, Benson RC (Eds.), Appleton & Lange: Norwalk (CN) 1987:p.612-7.

Lumsden MA, Kelly RW, Baird DT. Primary dysmenorrhea: the importance of both prostaglandins E2 and F2α. Br J Obstet Gynecol 1983;90(12):1135-40.

Strömberg P, Äkerlund M, Forsling ML, Kindahl H. Involvement of prostaglandins in vasopressin stimulation of the human uterus. Br J Obstet Gynecol 1983;90(4): 332-7.

Owen PR. Prostaglandin synthetase inhibitors in the treatment of primary dysmenorrhea. Am J Obstet Gynecol 1984;148(1):96-103.

Joglekar SN, Nabar SD, Hedge SS. In vivo and in vitro effect of an Ayurvedic formulation ‘M2 Tone’ on the uterus. Indian Practitioner 1984;37(9):847-54.

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10. Biswas TK, Debnath PK. Asoka (Saraca indica Linn): a cultural and scientific evaluation. Ind J Hist Sci 1972;7(2):99-114. 11. Anonymous. The Ayurvedic Formulary of India. Ministry of Health & FW. Govt. of India. New Delhi. 1st edition. Part-1 1978:p.46. 12. Gokani RH, Lahiri SK, Santani DD, Shah MB. Evaluation of immunomodulatory activity of Clerodendrum phlomidis and Premna integrifolia root. Int J Pharmacol 2007;3(4): 352-6. 13. Khare CP. Encyclopedia of Indian Medicinal Plants. Springer, Germany 2004:p.439-40. 14. Jadhav AN, Bhutani KK. Ayurveda and gynecological disorders. J Ethnopharmacol 2005;97:151-9. 15. Bhutani KK, Jadhav AN, Kalia V. Effect of Symplocos racemosa Roxb. on gonadotropin release in immature female rats and ovarian histology. J Ethnopharmacol 2004;94(1):197-200. 16. Khare CP. Encyclopedia of Indian Medicinal Plants. Springer, Germany 2004:p.454. 17. Zakaria ZA, Gopalan HK, Zainal H, Mohd Pojan NH, Morsid NA, Aris A, et al. Antinociceptive, antiinflammatory, and antipyretic effects of Solanum nigrum chloroform extract in animal models. Yakugaku Zasshi 2006;126(11):1171-8. 18. Perez RM, Perez JA, Garcia LM, Sossa H. Neuropharmacological activity of Solanum nigrum fruit. J Ethnopharmacol 1998;62(1):43-8. 19. Khare CP. Encyclopedia of Indian Medicinal Plants. Springer, Germany 2004:p.105. 20. Barthwal M, Srivastava K. Management of IUDassociated menorrhagia in female rhesus monkeys (Macaca mulatta). Adv Contracept 1991;7(1):67-6. 21. Goyal RK, Singh J, Lal H. Asparagus racemosus - An update. Ind J Med Sci 2003;57(9):408-14. 22. Radenahmad N, Saleh F, Sawangjaroen K, Rundorn W, Withyachumnarnkul B, Connor JR. Young coconut juice significantly reduces histopathological changes in the brain that are induced by hormonal imbalance: a possible implication to postmenopausal women. Histol Histopathol 2009;24(6):667-74. 23. Rinaldi S, Silva DO, Bello F, Alviano CS, Alviano DS, Matheus ME, et al. Characterization of the antinociceptive and anti-inflammatory activities from Cocos nucifera L. (Palmae). J Ethnopharmacol 2009;122(3):541-6. 24. Steven RS. Aloe vera: The healing plant. Health Foods Business 1994:p.23-4. 25. Khare CP. Encyclopedia of Indian Medicinal Plants. Springer 2004:p.44. 26. Scartezzini P, Speroni E. Review on some plants of Indian traditional medicine with antioxidant activity. J Ethnopharmacol 2000;71(1-2):23-43.

Original Study 27. Sundaram R, Mitra SK. Antioxidant activity of ethyl acetate soluble fraction of Acacia arabica bark in rats. Ind J Pharmacol 2007;39(1):33-8.

34. Chakraborty A, Brantner AH. Study of alkaloids from Adhatoda vasica Nees on their anti-inflammatory activity. Phytotherapy Res 2001;15(6):532-34.

28. Satyavati GV, et al. Medicinal plants of India. ICMR. Govt of India. New Delhi. Vol. 1. 1976:p.324.

35. Claeson UP, Malmfors T, Wikman G, Bruhn JG. Adhatoda vasica: a critical review of ethmopharmacological and toxicological data. J Ethnopharmacol 2000;72(1-2):1-20.

29. Xu Y, Zhang HW, Yu CY, Lu Y, Chang Y, Zou ZM. Norcyperone, a novel skeleton norsesquiterpene from Cyperus rotundus L. Molecules 2008;13(10):2474-81. 30. Satyavati GV, et al. Medicinal plants of India. ICMR. Govt of India. New Delhi. Vol. 2. 1976:p.17. 31. Verma PR, Joharapurkar AA, Chatpalliwar VA, Asnani AJ. Antinociceptive activity of alcoholic extract of Hemidesmus indicus R.Br. in mice. J Ethnopharmacol 2005;102(2):298301. 32. Sabina EP, Rasool M. Analgesic, antipyretic and ulcerogenic effects of Indian Ayurvedic herbal formulation Triphala. Res J Med Plant 2007;1(2):54-9. 33. Naik GH, Priyadarsini KI, Bhagirathi RG, Mishra B, Mishra KP, Banavalikar MM, et al. In vitro antioxidant studies and free radical reactions of triphala, an ayurvedic formulation and its constituents. Phytherap Res 2005;19(7):582-6.

36. Li X, Liu Z, Chen Y, Wang LJ, Zheng YN, Sun GZ, et al. Rubiacordone A: a new anthraquinone glycoside from the roots of Rubia cordifolia. Molecules 2009;14(1):566-72. 37. Johri RK, Zutshi U. An Ayurvedic formulation â&#x20AC;&#x2DC;Trikatuâ&#x20AC;&#x2122; and its constituents. J Ethnopharmacol 1992;37(2):85-91. 38. Atal CK, Zutshi U, Rao PG. Scientific evidence on the role of Ayurvedic herbals on bioavailability of drugs. J Ethnopharmacol 1981;4(2):229-32. 39. Dar A, Faizi S, Naqvi S, Roome T, Zikr-ur-Rehman S, Ali M, et al. Analgesic and antioxidant activity of mangiferin and its derivatives: the structure activity relationship. Biol Pharm Bull 2005;28(4):596-600. 40. Tiwari P, Ramarao P, Ghosal S. Effects of Shilajit on the development of tolerance to morphine in mice. Phytotherapy Res 2001;15(2):177-9.

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

clinical study

Efficacy and Tolerability of Trandolapril in Mildto-moderate Hypertension: A Double-blind Comparison with Enalapril Jyothi R*, Pundarikaksha HP**, Srinivasa Prabhu NC†, Girish K‡, Vasundhara K*

Abstract Objective: To compare the efficacy and tolerability between trandolapril and enalapril in mild-to-moderate hypertension. Material and Methods: This was a prospective, double-blind, parallel, comparative clinical trial involving 120 patients with mild-to-moderate hypertension. Patients were randomized to receive trandolapril 2-4 mg once-daily and enalapril 5-10 mg once-daily. The participants were followed for eight weeks. Results: Both the drugs achieved effective control of blood pressure (BP) at the end of eight weeks. The mean reduction in systolic BP (SBP) was 22.17 mmHg with trandolapril and 21.47 mmHg with enalapril group; the mean reduction of diastolic BP (DBP) was 9.57 mmHg with trandolapril and 11.13 mmHg with enalapril. Adverse events developed in 11 (18.3%) and 12 (20%) patients in trandolapril and enalapril group, respectively. Conclusion: The efficacy and tolerability of trandolapril was comparable to enalapril in mild-to-moderate hypertension with minor adverse events.

Keywords: Hypertension, ACEIs, trandolapril, enalapril

ypertension is one of the most prevalent vascular diseases in the world and posses a major public health problem. Angiotensinconverting enzyme inhibitors (ACEIs) are accepted as first-line therapy in the treatment of hypertension and heart failure.1 The principle antihypertensive effect is through renin-angiotensin-aldosterone (RAA) mechanism.2 They offer distinct advantages such as preventing or reversing cardiovascular remodeling,3 diabetic complications,4 improving endothelial function5 and also enhancing fibrinolysis.6 The American Heart Association and American College of Cardiology (AHA/ACC) recommend ACEIs as standard therapy in patients who are at high-risk for cardiovascular morbidity and mortality.7 In recent years, there has been a rapid growth in the number of

ACEIs entering the market. Most have claimed some sort of advantages based on differences in pharmacokinetics, metabolism or tissue ACE binding. Trandolapril is a new nonsulfhydryl lipophilic ACEI. The main pharmocodynamic effects of trandolapril are achieved by reduction in plasma angiotensin-II levels, which leads to a reduction in total peripheral vascular resistance, blood pressure (BP) and decreased sodium and water retention by the kidney.8 It has an effective long duration of action in the dose of 2-4 mg daily and is well-tolerated with minor adverse events.9 Few studies were done in Indian population to compare its efficacy and tolerability with other ACEIs. The present study was undertaken to compare the efficacy and tolerability of trandolapril with enalapril in mild-tomoderate essential hypertension. Material and Methods

*Assistant Professor **Professor and Head †Professor ‡Associate Professor Dept. of Pharmacology Kempegowda Institute of Medical Sciences, Bangalore Address for correspondence Dr Jyothi R Assistant Professor, Dept. of Pharmacology No-3, KIMS Staff Quarters, KIMS Campus BSK-II Stage, Bangalore - 70, Karnataka E-mail: sanjyoth03@yahoo.co.in

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

The present study was a randomized, double-blind, parallel, comparative clinical trial carried out in Kempegowda Institute of Medical Sciences Hospital and Research Centre, Bangalore, over a period of one year. The study protocol was approved by the Institutional Ethical Committee, and conducted in accordance with the Declaration of Helsinki. After obtaining written informed consent, 120 patients of either sex in the age group of 20-60 years with

clinical study mild-to-moderate hypertension (sitting diastolic BP [DBP] between 90-110 mmHg) were recruited for the study. Patients who were previously receiving antihypertensive medication were given two weeks’ washout prior to entry into the study. Patients with the following conditions were excluded from the study; pregnant and lactating women, patients with history of drug allergy or intolerance to ACEIs, patients unwilling to comply with the protocol requirement, patients with severe hypertension, patients already on antihypertensive drugs or other medications known to affect the outcome of the study, patients who had participated in other clinical trials in the past one month, patients with history or evidence of renal, hepatic or neurological disease, patients with uncontrolled diabetes and patients with suspected bilateral renal artery stenosis or single kidney. A detailed medical history, clinical examination, anthropometric measurements and baseline laboratory investigations were carried out. Patients fulfilling the study criteria were randomly assigned to two groups of 60 each to receive either trandolapril 2 mg or enalapril 5 mg. The BP was recorded at baseline, at 2, 4 and 8 weeks. BP was recorded 3 times at each visit after five minutes of rest in a sitting posture. Compliance was monitored by pill count method. Patients were monitored for adverse events throughout the study period. Laboratory investigations like Hb%, WBC count, blood urea, serum creatinine, lipid profile, serum electrolytes (sodium and potassium), FBS, urine analysis and ECG were done at baseline and at the end of eight weeks. Romhilt-Esters point score system10 was used to detect left ventricular hypertrophy (LVH) by using ECG. Data was expressed in percentages and mean ± SD. Student ‘t’ test was used to find the significance of systolic BP (SBP) and DBP between the two groups. ANOVA was used to find the significance of SBP and DBP during the study period within each group. Results Out of 120 patients, 64 were men and 56 women. The mean age in trandolapril and enalapril group was 51.21 ± 6.0 and 50.57 ± 6.16 years, respectively. Sixty-eight (56.66%) patients were from urban and 52 (43.33%) from rural area. The mean SBP at baseline in the trandolapril group was 151.57 ± 7.63 mmHg compared with 151.07 ± 7.14 mmHg in the enalapril group. The mean DBP at baseline in the trandolapril group was 98.40 ± 4.49 mmHg

Table 1. Demographic and Basic Characteristics Characteristics

Trandolapril

Enalapril

Age (years)

51.20 ± 6.01

51.57 ± 6.16

Sex: Male/Female (N)

33/27

31/29

Location: Urban/Rural (N)

28/32

40/20

Basal SBP (Mean ± SD) mmHg 151.57 ± 7.63

151.07 ± 7.14

Basal DBP (Mean ± SD) mmHg

100.53 ± 5.66

98.40 ± 4.49

N = 60 in each group. Values are mean ± standard deviation (SD).

Table 2. Comorbid Conditions in Study Groups Comorbid conditions

Trandolapril

Enalapril

11 (18.3)

9 (15)

Obesity

18 (30)

16 (26.7)

Diabesity

5 (8.3)

6 (10)

LVH

5 (8.3)

6 (10)

Type 2 diabetes mellitus

Numbers in parenthesis indicates percentage.

compared with 100.53 ± 5.66 mmHg in the enalapril group (Table 1). There were no significant differences between the two groups with respect to demographic and baseline characteristics. The most frequent comorbid conditions present in both groups included type 2 diabetes mellitus in 16.66% (n = 20), obesity (body mass index [BMI] ≥25 kg/m2) in 28.33% (n = 34), diabesity in 9.16% (n = 11) and LVH based on ECG changes in 9.16% (n = 11) of patients (Table 2). At the end of two and four weeks, 38% and 75% of the study subjects in trandolapril group and 27% and 58% in the enalapril group achieved reduction in DBP to <90 mmHg and reduction in DBP at four weeks was shown to be significant (p < 0.05). The dose of trandolapril was increased from 2-4 mg in 25% (n = 15) and enalapril from 5-10 mg in 41.7% (n = 25) of patients at the end four weeks in patients who did not show DBP reduction to <90 mmHg with the initial dose. The mean SBP/DBP in the trandolapril group was 151.57 ± 7.63/98.40 ± 4.49 at baseline, 144.30 ± 7.12/ 94.27 ± 4.58 after two weeks, 137.13 ± 6.16/91.45 ± 3.02 after four weeks and 129.40 ± 1.12/88.83 ± 1.34 after eight weeks. Mean fall in SBP and DBP was shown to be 22.17 and 9.57 mmHg (Table 3). The mean SBP/ DBP in the enalapril group was 151.07 ± 7.14/100.53 ± 5.66 at baseline, 143.73 ± 7.34/95.80 ± 4.75 after two weeks, 136.23 ± 6.19/ 91.87 ± 2.85 after four weeks and 129.60 ± 0.81/89.23 ± 1.17 after eight weeks. Mean fall in SBP and DBP was shown to be 22.17

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

clinical study Table 3. Changes in SBP and DBP in Trandolapril and Enalapril Groups during the Study Visits

Trandolapril

Enalapril

SBP

DBP

SBP

DBP

Basal

151.57 ± 7.63

98.40 ± 4.49

151.07 ± 7.14

100.53 ± 5.66

2 weeks

144.30 ± 7.12

94.27 ± 4.58

143.73 ± 7.34

95.80 ± 4.75

4 weeks

137.13 ± 6.16

91.45 ± 3.02

136.23 ± 6.19

91.87 ± 2.85

8 weeks

129.40 ± 1.12

88.83 ± 1.34

129.60 ± 0.81

89.23 ± 1.17

Values are mean ± standard deviation (SD). No statistical significance between two groups.

Table 4. Adverse Events in the Study Group Adverse events

Trandolapril

Enalapril

Cough

4 (6.66)

3 (5)

Giddiness

1 (1.66)

4 (6.66)

Headache

2 (3.33)

Fatigue

1 (1.66)

2 (3.33)

Myalgia

2 (3.33)

1 (1.66)

Abdominal discomfort

1 (1.66)

0 (0)

11 (18.33)

12 (20)

Total

Numbers in parenthesis indicates percentage.

and 9.57 mmHg (Table 3). Mean fall in SBP and DBP was shown to be 21.47 and 11.23 mmHg. There was no significant difference in mean fall in SBP and DBP in both groups. ECG was recorded in all patients at baseline and at the end of eight weeks. Eleven patients from both groups had pre-existing changes suggestive of LVH. Out of 11, one patient in trandolapril group showed partial reversal of LVH. All laboratory parameters both at baseline and at the end of eight weeks were within normal limits. Adverse events were encountered in 18.33% (n = 11) and 20% (n = 12) of patients in trandolapril and enalapril group, respectively. Cough (6.6%), headache (3.3%) and myalgia (3.3%) were experienced in the trandolapril group. Giddiness (6.6%), cough (5%), headache (3.3%) and fatigue (3.3%) were seen in the enalapril group (Table 4). The most common adverse event from both groups was cough in 5.8% (n = 7). All the adverse events were mild, transient and did not require any treatment, discontinuation of medication or withdrawal from the study. Discussion In the present study, reduction in DBP to <90 mmHg was achieved in 75% of patients who received

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

trandolapril 2 mg and in 58% of those who received enalapril 5 mg for four weeks. All patients achieved target DBP reduction by the end of eight weeks after doubling of dose in both groups. Similar findings were observed in studies carried out by Shankar et al,11 they had shown that 98.4% patients with trandolapril and 93% with enalapril achieved target DBP reduction at the end of eight weeks. In the present study, mean reduction in SBP and DBP was 22.17 and 9.57 mmHg in trandolapril group. In two noncomparative trials, where trandolapril was administered for a period of two weeks to 12 months in mild-to-moderate hypertension, mean reduction in SBP ranged from 7 to 31 mmHg and in DBP from 8 to 20 mmHg.12,13 Many controlled clinical trials have found that trandolapril produces clinically significant BP reduction and achieves target BP level in patients with hypertension.14,15 The observations reflect that trandolapril is equally efficacious and comparable to enalapril and that trandolapril offers a satisfactory approach for reduction of BP in mild-tomoderate hypertension. In this study, one patient from trandolapril group with LVH showed partial reversal. Schmieder16 observed in a meta-analysis that ACEIs brought about early and significant decrease in LVH mass and wall thickness in 13% of patients with a mean duration of 25 weeks. In this regard, there is a need to conduct further studies to confirm the observation. In the present study, cough was the common adverse event in both the groups, which accounted for 6.66% and 5% of patients, respectively. Many studies have proposed that bradykinin and substance P were responsible for the production of cough.17,18 In many studies, it was observed that the incidence of cough ranged from 2.3 to 39.1% and drug withdrawal was minimal.19-21 In the present study, we observed that cough was mild, transient and did not require discontinuation of medication or withdrawal from the study.

clinical study Conclusion The present study suggests that the efficacy and tolerability of trandolapril were comparable to enalapril in mild-to-moderate hypertension. Both drugs effectively controlled SBP and DBP at the end of eight weeks and were well-tolerated with few minor adverse events.

Acknowledgment Authors are thankful to M/s Hetero Drugs, Hyderabad for providing the clinical supplies.

References 1.

Hoffman BB. Therapy of Hypertension. In: Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 11th edition, Brunton LL, Lazo JS, Parker KL (Eds.) McGrawHill Co: New York 2006:p. 845-50.

World Health Organization. Hypertension Control. World Health Organization. Geneva. 1996. WHO Technical Reports Series. 862.

Reddy R, Chahoud G, Mehta JL. Modulation of cardiovascular remodeling with statins: fact or fiction? Curr Vasc Pharmacol 2005;3(1):69-79.

Ramos-Nino ME, Blumen SR. Benefits of ACE inhibitors in diabetes. Clin Med Therapeut 2009;1:1041-51.

Parmley WW. Evolution of angiotensin-converting enzyme inhibition in hypertension, heart failure, and vascular protection. Am J Med 1998;105(1A):27S-31S.

Dézsi L. Fibrinolytic actions of ACE inhibitors: a significant plus beyond antihypertensive therapeutic effects. Cardiovasc Res 2000;47(4):642-4.

Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS, et al; American College of Cardiology/ American Heart Association. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2001;38(7):2101-13.

Diaz A, Ducharme A. Update on the use of trandolapril in the management of cardiovascular disorders. Vasc Health Risk Manag 2008;4(6):1147-58.

Wiseman LR, McTavish D. Trandolapril. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in essential hypertension. Drugs 1994;48(1):71-90.

10. Hsieh BP, Pham MX, Froelicher VF. Prognostic value of electrocardiographic criteria for left ventricular hypertrophy. Am Heart J 2005;150(1):161-7.

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

11. Shankar PK, Vidyasagar S, Adiga S, Naidu MU, Usha Rani P, Rao D, et al. Efficacy and tolerability of trandolapril in mild to moderate hypertension - a double blind comparative clinical trial with enalapril in Indian population. Indian J Physiol Pharmacol 2006;50(4):421-6. 12. Backhouse CI, Orofiamma B, Pauly NC. Long-term therapy with trandolapril, a new nonsulfhydryl ACE inhibitor, in hypertension: a multicenter international trial. Investigator Study Group. J Cardiovasc Pharmacol 1994;23 Suppl 4:S86-90. 13. Poirier L, Bourgeois J, Lacourcière Y. Once-daily trandolapril compared with the twice-daily formulation in the treatment of mild to moderate essential hypertension: assessment by conventional and ambulatory blood pressures. J Clin Pharmacol 1993;33(9):832-6. 14. Pepine CJ, Handberg EM, Cooper-DeHoff RM, Marks RG, Kowey P, Messerli FH, et al; INVEST Investigators. A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International VerapamilTrandolapril Study (INVEST): a randomized controlled trial. JAMA 2003;290(21):2805-16. 15. Tytus RH, Burgess ED, Assouline L, Vanjaka A. A 26week, prospective, open-label, uncontrolled, multicenter study to evaluate the effect of an escalating-dose regimen of trandolapril on change in blood pressure in treatmentnaive and concurrently treated adult hypertensive subjects (TRAIL). Clin Ther 2007;29(2):305-15. 16. Schmieder RE, Martus P, Klingbeil A. Reversal of left ventricular hypertrophy in essential hypertension. A meta-analysis of randomized double-blind studies. JAMA 1996;275(19):1507-13. 17. Dendorfer A, Wolfrum S, Dominiak P. Pharmacology and cardiovascular implications of the kinin-kallikrein system. Jpn J Pharmacol 1999;79(4):403-26. 18. Ho CY, Gu Q, Hong JL, Lee LY. Prostaglandin E(2) enhances chemical and mechanical sensitivities of pulmonary C fibers in the rat. Am J Respir Crit Care Med 2000;162(2 Pt 1):528-33. 19. Adalet K, Buyukozturk K. Trandolapril in overweight patients with mild-to-moderate essential hypertension: the Turkish multicentre trandolapril study. Curr Ther Res 1996;57(12):980-9. 20. Braunwald E, Domanski MJ, Fowler SE, Geller NL, Gersh BJ, Hsia J, et al; PEACE Trial Investigators. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med 2004;351(20): 2058-68. 21. Gosse P, Vaur L, Dutrey-Dupagne C, Genes N, Destrée D, Elkik F. Evaluation of trandolapril alone or in combination with a calcium channel blocker in hypertensive patients over 60 years of age. Ann Cardiol Angeiol (Paris) 1995;44(9):517-24.

Original article

Assessment of Hypogonadism with Reference to Clinical Features and Serum Testosterone Levels in Asian-Indian Male Type 2 Diabetics Ibraheem Khan*, Chandra Kant**, Anil Samaria†

Abstract Objective: To assess the prevalence of hypogonadism in Asian-Indian males with type 2 diabetes (T2DM) with reference to clinical feature and total serum testosterone levels. Material and methods: In the cross-sectional study of 50 diabetics of 30-76 years age group preferably without chronic illness, total testosterone, body mass index (BMI) and waist circumference (WC) were measured. Overt hypogonadism was defined as the presence of clinical symptoms of hypogonadism and low testosterone level (total testosterone <8 nmol/l). Borderline hypogonadism was defined as the presence of symptoms and total testosterone of 8-12 nmol/l. Results: A low serum testosterone level was common in diabetic men and a significant proportion of these men had symptoms of hypogonadism. Overt hypogonadism was seen in 30% of men with total testosterone levels <8 nmol/l and borderline hypogonadism was found in 28% of men with total testosterone levels 8-12 nmol/l. Total serum testosterone levels significantly and negatively correlated with both BMI (r = –0.334, p < 0.05) and WC (r = –0.443, p < 0.001), with the association being stronger for WC. HbA1C also significantly and negatively correlated with serum testosterone levels (r = –0.503, p < 0.001). Conclusions: Testosterone levels are frequently low in men with T2DM and the majority of these men have symptoms of hypogonadism, even in the younger age group (early-onset hypogonadism). Obesity and BMI are also associated with low testosterone levels in Asian-Indian diabetic men.

Keywords: Type 2 diabetes, serum testosterone, overt hypogonadism, obesity

India has an estimated population of 44 million diabetic subjects, which is chiefly contributed by the urban population.2 Type 2 diabetes (T2DM) in Indians differs from that in Europeans in several aspects: The onset is

at a younger age,3 obesity is less common4 and genetic factors appear to be stronger.5 Insulin resistance (IR) is an common feature of T2DM.6 It is now increasingly being recognized that low testosterone level in men is associated with reduced insulin sensitivity and T2DM.7 An inverse relationship has been seen between testosterone levels and insulin concentrations in healthy men.8 Testosterone was inversely related to the degree of hyperglycemia.9 IR and risk of diabetes development was more in patient with low testosterone levels.10 Low testosterone was also associated with diabetic dyslipidemia.9 A recent study has demonstrated that free testosterone levels, which are independent of sex hormone-binding globulin (SHBG), are low in onethird of diabetics.11

*Postgraduate **Professor †Associate Professor Dept. of Medicine, Jawaharlal Nehru Medical College, Ajmer Address for correspondence Dr Ibraheem Khan Samraya, Weir, Bharatpur, Rajasthan - 321 408 E-mail: imedicine2008@gmail.com

Hypogonadism is defined as the presence of clinical symptoms and low testosterone levels (total testosterone <8 nmol/l). Although there is no uniform definition of classical hypogonadism, various guidelines for the diagnosis of hypogonadism are available, for example from Bhasin and colleagues.12 Recently published recommendations that patients with total testosterone <8 nmol/l should be treated with testosterone therapy,

iabetes mellitus (DM) comprises a group of common metabolic disorders that share the phenotype of hyperglycemia, factors may include reduced insulin secretion, decreased glucose utilization and increase glucose production depending upon the etiology of DM. Metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems. DM, with its attendant acute and long-term complications and the myriad of disorders associated with it, is a major health hazard.1

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

Original article those with testosterone 8-12 nmol/l and hypogonadal symptoms should be given a trial of testosterone therapy, and those with total testosterone >12 nmol/ l are not hypogonadal and should not be treated.13 Overt hypogonadism is the presence of clinical symptoms of hypogonadism and low testosterone levels (total testosterone <8 nmol/l). Borderline hypogonadism is the presence of symptoms along with total testosterone 8-12 nmol/l. The major symptoms of hypogonadism are reduced libido, reduced duration of erection, fatigue, reduced physical strength and mood changes. Questionnaires have been developed to assess hypogonadism. Androgen deficiency in the aging male (ADAM) questionnaire is one of them. It lacks specificity (66%) but it has reasonable sensitivity (88%) in the presence of low testosterone levels. This is a 10-item screening questionnaire used to evaluate ADAM.14 Normal testosterone production rates by the Leydig cells vary considerably between healthy young individuals and range from 3 to 10 mg/day.15 It is thought that most testosterone in the blood, about 65%, is strongly bound to SHBG; about 35% is relatively loosely to albumin and only 1-2% is free. Free and albumin-bound testosterone is called bioavailable testosterone because both fractions comprise the biologically active component that is readily available to the tissues, whereas SHBG-bound testosterone is tightly bound and thus considered inactive. Testosterone concentrations vary considerably between individuals. The normal range of total testosterone in young adult men being 12-35 nmol/l and bioavailable testosterone is 2.5-4.2 nmol/l.16 Testosterone concentrations also follow a diurnal rhythm with highest levels in morning and falling by as much as 35% in the afternoon and evening.17 A confounding factor is that SHBG rises with age, and thus free testosterone decreases more rapidly than total testosterone in older men. Thus, it is important to measure bioavailable or free testosterone in men with diabetes. Erectile dysfunction (ED) is best defined as persistent failure to generate sufficient penile body pressure to achieve vaginal penetration and/or the inability to maintain this degree of penile rigidity until ejaculation.18 Symptomatically, ED is common in diabetic men,19 although the etiology may be vascular disease, autonomic neuropathy, hypogonadism or a combination of these.20

Erection is a complex process mediated by combination of neurotransmission and vascular smooth muscle responses due to increase arterial inflow and signaling by endothelial cavernosal sinusoids and underlying smooth muscle cells. Cholinergic parasympathetic pathways, nonadrenergic, noncholinergic pathways and endothelial cells, all release nitric oxide (NO) that triggers a molecular cascade result in the relaxation of smooth muscle cell and occluding venous return through venous compression of the subtunical venules resulting in an erection. Parasympathetic outflow is impaired in diabetics and causes reduction in NO resulting in smooth cell apoptosis and decrease in sinusoidal compliance leading to ED.21 Loss of Libido Libido is defined as the biological need for sexual activity (the sex drive) and frequently is expressed as sex-seeking behavior. Evidence for a role of androgens in regulation of sexual behavior in the human male has been reviewed by Mooradian and colleagues.22 In a study, withdrawal of androgen therapy in hypogonadal males led to a decline of libido in 3-4 weeks, and untreated hypogonadal men have impairment in spontaneity of erection.23 According to Kapoor et al 63% diabetic men had loss of libido. Testosterone levels inversely correlate with waist circumference (WC) and body mass index (BMI). A plausible explanation for this is the hypogonadal - obesity cycle, which was first described by Cohen.24 Essentially, visceral adipocytes have a high activity of the enzyme aromatase, which converts testosterone to estrogen. Testosterone inhibits the enzyme lipoprotein lipase, which takes up free fatty acids into adipocytes.25 Lower testosterone levels result in increased triglyceride levels in adipocytes, which promote further adipocyte proliferation and hence higher aromatase activity. Testosterone levels are further lowered as a result of leptin resistance at the hypothalamic-pituitary and testicular levels, causing reduced luteinizing hormone (LH) release and testosterone secretion.26 It is known that a reduction in the degree of obesity results in an elevation of testosterone levels. Dhindsa and colleagues conducted some tests with gonadotropin-releasing hormone (GnRH) in T2DM patients with ED and demonstrated a normal LH, and follicle-stimulating hormone (FSH) rise, suggesting a hypothalamic rather than a pituitary defect.11 The existence of a hypothalamic defect resulting in hypogonadotropic hypogonadism in T2DM is of

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

Original article interest in view of its association with insulin resistance. Neuron-specific insulin receptor knockout (NIRKO) mice with a specific knockout of the insulin receptor in neurons exhibit hypogonadotropic hypogonadism.27 Plasma LH levels were decreased by 60-90% in NIRKO mice compared with controls. When these mice were injected with lupron, a GnRH receptor agonist, they displayed a normal to 2-fold increase in LH levels compared with control mice. These mice also had increased adipose tissue and IR. Metabolic syndrome, IR and visceral obesity have all been associated with low total testosterone levels in men.28 Data from literature in humans and NIRKO mice and from the study by Dhindsa and colleagues, seem to suggest that obesity/IR is associated with hypogonadism and that the hypogonadism appears to be hypogonadotropic in nature. Obesity is associated with increased plasma levels of proinflammatory cytokines such as tumor necrosis factor-a (TNF-a), interleukin (IL)-6, C-reactive protein and adhesion molecules.29,30 In this regard, it is interesting to note that TNF-a and IL-1b have been shown to reduce hypothalamic GnRH and LH secretion in animals and in vitro.31 So, it may be worthwhile to know the status of testosterone level in diabetic patients. Testosterone level is affected by factors like obesity, BMI and age of patient.19 Bioavailable testosterone appears to represent reliable index of biologically readily available testosterone, but is not well-suited for clinical routine, being too time-consuming and expensive. Hypogonadism was defined in many studies13,19 by total testosterone levels, so total testosterone levels can be used for the study. Very few studies have been done so far on this topic so an assessment of clinical hypogonadism in 50 patients of T2DM was done. AIM AND OBJECTIVES  

To estimate serum testosterone levels in T2DM. To correlate the serum testosterone levels with clinical hypogonadism in T2DM.

MATERIAL AND METHODS The study was conducted at Jawaharlal Nehru Medical College and Associated Group of Hospitals, Ajmer, Rajasthan to evaluate clinical and biochemical hypogonadism in men with T2DM (≥5 years duration) attending medical OPD and various medical wards.

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

Inclusion Criteria 



Male patients with T2DM in 30-76 years age group. Patients with T2DM ≥5 years.

Normal value was taken as control for that age group.

Exclusion Criteria 



Patients taking drugs which are known to interfere e.g., glucocorticoids, hormone replacement therapy, ketoconazole, opiods, alcohol, methadone, heroin and marijuana. Patients with features associated with congenital GnRH deficiency (midline facial defects, synkinesis or a family history of GnRH deficiency or anosmia). History of tumor, exposure to radiation, history of head trauma, spinal cord injuries, history of pelvic trauma and surgery. Any disease other than diabetes known to cause autonomic dysfunction. Any other chronic disease such as human immunodeficiency virus (HIV), end-stage renal disease, cirrhosis of liver and psychiatric disease.

Special Investigations 



Total testosterone was measured by electrochemilumiscence immunoassay by ECLIA kit. In patient with diabetes, blood sample was collected always between 8 a.m. and 10 a.m. Serum sample was obtained by centrifugation. Sample remained stable for one week at 2-8°C, for six month at –20°C, though it was not needed to freeze the serum sample for storage.

Examination of the Patients’ History Total 50 patients were taken. A detailed history of present illness was recorded including duration of the onset of symptoms (Table 1). Complete ADAM questionnaire, past history and family history for hypertension, and DM and history of medications was asked. Personal history like early morning erection, smoking, alcohol consumption, decrease in libido, lack of energy, decrease in strength and/or endurance, loss of height, decreased enjoyment of life, feeling of sadness and/or grumpy, decrease strength of erection, recent deterioration in ability to play sports and a recent deterioration in work performance were noted. Positive response was based on decreases in loss of libido, strength of erections or any three nonspecific

Original article questions that include fatigability, mood changes and loss of height.

Clinical Examination A detailed clinical examination was done. General examination including height, weight, WC (defined as the point midway between the iliac crest and the costal margin) and blood pressure (BP). Systemic examination included cardiovascular, respiratory, gastrointestinal and neurological examination (Table 1). Clinically ED (organic or psychogenic) was assessed by 

Stamp test



Testicular sensation test



Interruption of urination.

OBSERVATION and RESULTS

Statistical Analysis Values were expressed as a percentage of each group or as mean ± SE (standard error) unless otherwise stated. The impact of clinical variables on testosterone levels was determined by correlation. Comparisons between groups were made using X2 test. The unpaired ‘t’ test was used to compare testosterone levels in men with ED and without ED (Table 2). Student test was also used to compare testosterone in others variables like glycosylated hemoglobin (HbA1C), BMI, WC, smokers and nonsmokers, hypertension. Results were considered statistically significant at p < 0.05. Prevalence of low testosterone levels: Thirty percent (15 men) had testosterone level <8 nmol/l and 28% (14 men) had testosterone between 8 and 12 nmol/l. Prevalence of low testosterone levels was not uncommon in all age groups but it was maximum (80%) in old age >69 years and 43% in young adults (<40 years). Percentage of diabetic men with low testosterone per decade is shown in Figure 1. Prevalence of symptoms and low testosterone levels (hypogonadism): Prevalence of overt hypogonadism in diabetic patients with positive ADAM score was 30% (15 men) and borderline hypogonadism was 28% (14 men) based on symptoms as suggested by ADAM questionnaire and low serum testosterone levels. Incidence of positive symptoms in men with low testosterone by decade of age is shown in Figure 2. ED and loss of libido were the common symptoms, 46% and 52%, respectively, in these patients with low testosterone levels (<12 nmol/l), while the incidence of these symptoms were 60% and 64%, respectively in the diabetic study group. Only 16% patient had other symptoms.

Association of body composition and testosterone levels in diabetic Asian-Indian adults: Total serum testosterone levels significantly and negatively correlated with both BMI (r = –0.334, p < 0.05) and WC (r = –0.443, p < 0.001). Patients having BMI >23 kg/m2, 37% diabetic men had low testosterone <8 nmol/l and adding the value 8-12 nmol/l, it was increased to 78% (p < 0.01). In patients with WC, Table 1. The Baseline Characteristics of Subjects Parameter

Sample range

Age (years) Serum testosterone (nmol/l) Body mass index

35-76

54.3

±12.9

3.51-27.10

12.14

±6.04

5.6-12.4

8.27

±1.52

HbA1C (%) (kg/m2)

Average

18.75-33.89

23.54

±3.71

Waist circumference (cm)

75-105

87.2

±6.88

Systolic blood pressure (mmHg)

110-160

136.32

±14.51

Diastolic blood pressure (mmHg)

70-100

83.88

±6.70

5-17

7.48

±3.52

Duration (years) Smoking Others (occupation and residence) SD = Standard deviation

Table 2. Comparisons of Testosterone Levels in Men with and without Variables by Unpaired ‘t’ Test Variable

Mean

SD`

4.13

<0.001

4.42

<0.001

3.80

<0.001

2.38

<0.05

1.07

>0.05

0.122

>0.05

Serum testosterone levels With ED

9.48

4.24

Without ED

16.10

6.26

With HbA1C ≤9

13.75

6.24

With HbA1C >9

8.75

3.97

With WC <85 cm

15.02

6.47

With WC >85 cm

9.26

3.91

kg/m2

14.30

5.99

With BMI >23 kg/m2

10.30

5.54

In hypertensive

13.49

6.16

In nonhypertensive

11.51

5.97

In smokers

12.01

6.42

In nonsmokers

12.23

5.89

With BMI <23

ED = Erectile dysfunction; WC = Waist circumference; BMI = Body mass index.

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

Percentage of men with low testosterone

Original article Table 3. Association of Low Testosterone Level with Clinical Variable

90 80

Parameter (n)

70 60 50 Testosterone <8 nmol/l

40 30

Testosterone <12 nmol/l

20 10 0

<40 40-49 50-59 60-69 >69 Age in years

Percentage of men with low testosterone

Figure 1. Percentage of diabetic men with low testosterone and borderline testosterone levels as per decade.

90 80

BMI >23 kg/m2 (27)

<0.01

WC >85 cm (25)

<0.001

HbA1C >9% (16)

<0.01

Hypertension (16)

>0.05

Smoking (20)

>0.05

Erectile dysfunction (23)

<0.001

Loss of libido (26)

<0.001

Other symptoms (8)

<40 (7)

40-49 (10)

50-59 (14)

60-69 (14)

>69 (5)

Age

70 60

duration, smoking and history of hypertension could not be established (p > 0.05).

50 40

DISCUSSION

Hypogonadism, a clinical condition comprising both symptoms and biochemical evidence of testosterone deficiency is associated with T2DM.

20 10 0

<40

40-49 50-59 Age in years

60-69

>69

Figure 2. Incidence of positive symptoms in men with low testosterone by decade of age.

>85 the serum testosterone levels were â&#x2030;¤12 nmol/l in 80% cases (p < 0.001) (Table 3). Correlation between HbA1C and low testosterone: HbA1C significantly and negatively correlated with serum testosterone levels (r = â&#x20AC;&#x201C;0.503, p < 0.001). Eighty-six percent patients with HbA1C >9% had low testosterone levels, while 44% diabetics with HbA1C <9% had serum testosterone <12 nmol/l showing statistical significance (p < 0.001). Hypertension, smoking duration, socioeconomic factor and serum testosterone: Statistical correlation and significance between hypogonadism and diabetes

<8 nmol/l 8-12 nmol/l >12 nmol/l (15) (14) (21)

Indian Journal of Clinical Practice, Vol. 23, No. 2, July 2012

The purpose of this study was to determine the prevalence of clinical hypogonadism based on both symptoms and biochemical available measure of testosterone deficiency in men of T2DM in Indian perspectives. In present study, we observed that there is a high prevalence of symptomatic hypogonadism in men with T2DM. Previous studies11 have shown that about one-third of men with T2DM have low serum testosterone levels. In our study, we found that a high proportion of diabetic men had low levels of serum testosterone. There is no widely accepted consensus as to what constitutes the levels of testosterone below which treatment is to be considered. But on the basis of normal ranges and international recommendations overt hypogonadism <8 nmol/l and borderline hypogonadism 8-12 nmol/l serum testosterone level was considered. In the present study, 30% subjects with T2DM had symptoms and

Original article associated serum testosterone level <8 nmol/l, which was called as overt hypogonadism. Further 28% of diabetic men had symptoms of hypogonadism with testosterone level in the range of borderline hypogonadism i.e. 8-12 nmol/l. These findings support the study done by Kapoor and colleagues.19 Aging is associated with decline in testosterone levels even in healthy men according to Nieschlag, Behre and colleagues.32 In the Baltimore Longitudinal Study on aging, 8, 12, 19 and 28% of men aged >40, 50, 60 and 70 years, respectively had serum total testosterone levels below the normal range of <11.3 nmol/l in that study.33 Using the criteria in that study, we found a higher prevalence of hypogonadism across all age group 43% in <40, 60% in 40-49, 57% in 50-59, 57% in 60-69 and 80% in >69 years. Kapoor et al19 also found similar results in all diabetic age groups (42, 44, 39 and 56% in the age-groups 40-49, 50-59, 60-69 and 70-79 years, respectively). Although hypogonadism increases with age, it is also common in younger diabetic age groups. Dhindra and colleagues11 have shown low testosterone level in T2DM. Frequency of symptoms in all defined groups of their study was studied. It is important to note that the ADAM questionnaire lacks specificity and this questionnaire is useful only in the presence of a biochemical evidence of low level of serum testosterone. Asian-Indians are known to have a lower BMI than Europeans. For any given BMI, Asian-Indians have a greater waist-to-hip ratio than Europeans. To clarify the issue, Ramachandran and colleagues performed a case-control study in 82 subjects with T2DM and 82 sex- and age-matched nondiabetic controls from the Chennai Urban Rural Epidemiology Study.34 Visceral, subcutaneous and total abdominal fat were measured by computed tomography (CT), while dual-energy X-ray absorptiometry (DEXA) was used to measure central abdominal and total body fat.Diabetic subjects had significantly higher visceral and central abdominal fat compared to controls. Both measurements correlated well with each other as well as with the WC. Therefore, WC is a valid measure of visceral adiposity in this population. To clarify the anthropometric variables in Asian-Indian adults, 19,025 adults over 20 years of age were given an oral glucose tolerance test using World Health Organization (WHO) criteria.35 The calculations were done to stratify subjects with diabetes against subjects without diabetes using multiple logistic analyses. The upper limit of the stratum in which the risk became

clinically significant was considered the cut-off for normal values. The normal cut-off for BMI was 23 kg/m2 in both sexes. The cut-off for WC was 85 cm for men and 80 cm for women. The present study showed that there is strong negative correlation between WC and hypogonadism in cases of diabetes (r = â&#x20AC;&#x201C;0.443, p < 0.001) and between BMI and hypogonadism in these cases (r = â&#x20AC;&#x201C;0.334, p < 0.05). The study supports the results of previous study done by Kapoor and colleagues according to which there was strong correlation between body composition and total testosterone levels. We observed that serum testosterone decreased more in uncontrolled diabetic men showing correlation and statistical significance (r = â&#x20AC;&#x201C;0.503, p < 0.001). In this study, we did not find any association between the duration of diabetes, socioeconomic status and history of smoking with hypogonadism. The previous study did not show any clear cut relation with these findings. Further studies with a large number of subjects may determine the clear cut association. Testosterone therapy has important role in treatment of ED and also in management of IR. Men with ED who fail to respond to phosphodiesterase inhibitors have been shown to have low testosterone levels.36 Testosterone replacement therapy in two studies was found to convert sildenafil nonresponders to responders.37 Interventional studies have shown a beneficial effect of testosterone replacement therapy on IR. A study in healthy men with low total testosterone reported an improvement in insulin sensitivity with testosterone or dihydrotestosterone treatment.38 Testosterone treatment has also been shown to reduce IR in obese men, men with heart failure and T2DM subjects. Studies on T2DM men have shown an improvement in glycemic control with testosterone replacement therapy.39 Conclusion Testosterone levels are frequently low in men with T2DM and the majority of these men have symptoms of hypogonadism, even in the younger age group (early-onset hypogonadism). Obesity and BMI are also associated with low testosterone levels in Asian-Indian diabetic men. Control of diabetes and associated risk factor should be the goal of therapy. More studies are required to establish the benefit of testosterone replacement therapy on quality-of-life and the diabetic state in Indian men.

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Original article References 1.

Powers AC. Diabetes mellitus. Harrison’s Principles of Internal Medicine. 17th edition, Fauci AS, et al. (Eds.), McGraw Hill: New York 2008:2275-304.

Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al; Diabetes Epidemiology Study Group in India (DESI). High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001;44(9):1094-101.

Mohan V, Ramachandran A, Snehalatha C, Mohan R, Bharani G, Viswanathan M. High prevalence of maturityonset diabetes of the young (MODY) among Indians. Diabetes Care 1985;8(4):371-4.

Joshi SR. Metabolic syndrome - emerging clusters of the Indian phenotype. J Assoc Physicians India 2003;51: 445-6.

Viswanathan M, Mohan V, Snehalatha C, Ramachandran A. High prevalence of type 2 (non-insulin-dependent) diabetes among the offspring of conjugal type 2 diabetic parents in India. Diabetologia 1985;28(12):907-10.

Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 1988;37(12): 1595-607.

Kapoor D, Malkin CJ, Channer KS, Jones TH. Androgens, insulin resistance and vascular disease in men. Clin Endocrinol (Oxf) 2005;63(3):239-50.

Simon D, Preziosi P, Barrett-Connor E, Roger M, SaintPaul M, Nahoul K, et al. Interrelation between plasma testosterone and plasma insulin in healthy adult men: the Telecom Study. Diabetologia 1992;35(2):173-7.

Barrett-Connor E. Lower endogenous androgen levels and dyslipidemia in men with non-insulin-dependent diabetes mellitus. Ann Intern Med 1992;117(10):807-11.

10. Stellato RK, Feldman HA, Hamdy O, Horton ES, McKinlay JB. Testosterone, sex hormone-binding globulin, and the development of type 2 diabetes in middle-aged men: prospective results from the Massachusetts male aging study. Diabetes Care 2000;23(4):490-4. 11. Dhindsa S, Prabhakar S, Sethi M, Bandyopadhyay A, Chaudhuri A, Dandona P. Frequent occurrence of hypogonadotropic hypogonadism in type 2 diabetes. J Clin Endocrinol Metab 2004;89(11):5462-8. 12. Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2006;91(6):1995-2010.

for androgen deficiency in aging males. Metabolism 2000;49(9):1239-42. 15. Wu FCW. Disorder of male reproduction. In: Oxford Textbook of Medicine. Volume 11, Weatherall DJ, Ledingham JGG, WarrellDA (Eds.), Oxford University Press: Oxford 1996:p1679-87. 16. Tenover JS. Effects of testosterone supplementation in the aging male. J Clin Endocrinol Metab 1992;75(4): 1092-8. 17. Sternbach H. Age-associated testosterone decline in men: clinical issues for psychiatry. Am J Psychiatry 1998;155(10):1310-8. 18. Wagner G. Erection: physiology and endocrinology. In: Impotence: Physiological, Psychological Surgical Diagnosis and Treatment. Wagner G, Green R (Ed.), Plenum Press, New York: NY 1981:p25-36. 19. Kapoor D, Aldred H, Clark S, Channer KS, Jones TH. Clinical and biochemical assessment of hypogonadism in men with type 2 diabetes: correlations with bioavailable testosterone and visceral adiposity. Diabetes Care 2007;30(4):911-7. 20. McCulloch DK, Campbell IW, Wu FC, Prescott RJ, Clarke BF. The prevalence of diabetic impotence. Diabetologia 1980;18(4):279-83. 21. McVary KT. Clinical practice. Erectile dysfunction. N Engl J Med 2007;357(24):2472-81. 22. Mooradian AD, Morley JE, Korenman SG. Biological actions of androgens. Endocr Rev 1987;8(1):1-28. 23. Skakkebaek NE, Bancroft J, Davidson DW, Warner P. Androgen replacement with oral testosterone undecanoate in hypogonadal men: a double blind controlled study. Clin Endocrinol (Oxf) 1981;14(1):49-61. 24. Cohen PG. The hypogonadal-obesity cycle: role of aromatase in modulating the testosterone-estradiol shunt - a major factor in the genesis of morbid obesity. Med Hypotheses 1999;52(1):49-51. 25. Mårin P, Odén B, Björntorp P. Assimilation and mobilization of triglycerides in subcutaneous abdominal and femoral adipose tissue in vivo in men: effects of androgens. J Clin Endocrinol Metab 1995;80(1):239-43. 26. Isidori AM, Caprio M, Strollo F, Moretti C, Frajese G, Isidori A, et al. Leptin and androgens in male obesity: evidence for leptin contribution to reduced androgen levels. J Clin Endocrinol Metab 1999;84(10):3673-80. 27. Brüning JC, Gautam D, Burks DJ, Gillette J, Schubert M, Orban PC, et al. Role of brain insulin receptor in control of body weight and reproduction. Science 2000;289(5487):2122-5.

13. Nieschlag E, Swerdloff R, Behre HM, Gooren LJ, Kaufman JM, Legros JJ, et al. Investigation, treatment and monitoring of late-onset hypogonadism in males: ISA, ISSAM, and EAU recommendations. Int J Androl 2005;28(3):125-7.

28. Laaksonen DE, Niskanen L, Punnonen K, Nyyssönen K, Tuomainen TP, Salonen R, et al. Sex hormones, inflammation and the metabolic syndrome: a population-based study. Eur J Endocrinol 2003;149(6):601-8.

14. Morley JE, Charlton E, Patrick P, Kaiser FE, Cadeau P, McCready D, et al. Validation of a screening questionnaire

29. Dandona P, Weinstock R, Thusu K, Abdel-Rahman E, Aljada A, Wadden T. Tumor necrosis factor-alpha in sera

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Original article of obese patients: fall with weight loss. J Clin Endocrinol Metab 1998;83(8):2907-10. 30. Weisberg SP, McCann D, Desai M, Rosenbaum M, Leibel RL, Ferrante AW Jr. Obesity is associated with macrophage accumulation in adipose tissue. J Clin Invest 2003;112(12):1796-808. 31. Watanobe H, Hayakawa Y. Hypothalamic interleukin-1 beta and tumor necrosis factor-alpha, but not interleukin6, mediate the endotoxin-induced suppression of the reproductive axis in rats. Endocrinology 2003;144(11): 4868-75. 32. Nieschlag E, Behre HM, Bouchard P, Corrales JJ, Jones TH, Stalla GK, et al. Testosterone replacement therapy: current trends and future directions. Hum Reprod Update 2004;10(5):409-19. 33. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR; Baltimore Longitudinal Study of Aging. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab 2001;86(2): 724-31. 34. Ramachandran A, Snehalatha C, Yamuna A, Murugesan N, Narayan KM. Insulin resistance and clustering of cardiometabolic risk factors in urban teenagers in southern India. Diabetes Care 2007;30(7):1828-33.

35. Snehalatha C, Viswanathan V, Ramachandran A. Cutoff values for normal anthropometric variables in asian Indian adults. Diabetes Care 2003;26(5):1380-4. 36. Kalinchenko SY, Kozlov GI, Gontcharov NP, Katsiya GV. Oral testosterone undecanoate reverses erectile dysfunction associated with diabetes mellitus in patients failing on sildenafil citrate therapy alone. Aging Male 2003;6(2):94-9. 37. Shabsigh R, Kaufman JM, Steidle C, Padma-Nathan H. Randomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone. J Urol 2004;172(2):658-63. 38. Simon D, Charles MA, Lahlou N, Nahoul K, Oppert JM, Gouault-Heilmann M, et al. Androgen therapy improves insulin sensitivity and decreases leptin level in healthy adult men with low plasma total testosterone: a 3-month randomized placebo-controlled trial. Diabetes Care 2001;24(12):2149-51. 39. Kapoor D, Goodwin E, Channer KS, Jones TH. Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with type 2 diabetes. Eur J Endocrinol 2006;154(6): 899-906.

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Case Study

Autologous Bone Marrow Stem Cell Therapy Shows Functional Improvement in Hemorrhagic Stroke

Alok Sharma*, Hemangi Sane*, Prerna Badhe**, Pooja Kulkarni**, Guneet Chopra*, Mamta Lohiaâ&#x20AC; , Nandini Gokulchandran*

Abstract In hemorrhagic stroke, damage to the brain tissue is inevitable and no effective treatment for functional improvement is currently available except neurorehabilitation. Stem cell therapy is a rapidly growing field and has recently opened new avenues for brain repair strategies. We present a case study of a 69-year-old female treated with stem cell therapy for right-sided hemiplegia caused due to left thalamic hemorrhagic stroke. Inspite of regular physiotherapy, the patient had constant residual neurodeficit, one year after the stroke, which was severely incapacitating. In view of the same, the patient was given intrathecal autologous bone marrow derived stem cell therapy as part of the neuroregeneration and rehabilitation therapy (NRRT) along with rehabilitation. After the therapy, patient showed functional as well as neurological improvements (cognition and motor strength) without any side effects. There is accumulating experimental data showing the benefits of cell transplantation on functional recovery after hemorrhagic stroke. This case study supports the concept of neuroregeneration with bone marrow stem cells as a novel strategy having great therapeutic potential. However, large clinical studies are needed to further investigate autologous bone marrow stem cell therapy in addition to neurorehabilitation for treating the disability in hemorrhagic stroke.

Keywords: Hemorrhagic stroke, bone marrow stem cells, autologous transplantation, neuroregeneration, rehabilitation

troke is the leading cause of mortality and significant morbidity in India (prevalence of approximately 0.5%) and worldwide.13 It is ranked as the sixth leading cause of DALY (disabilityadjusted life years) in 1990 and projected to rank fourth by 2020. Hemorrhagic stroke, of all strokes, is a major cause of serious long-term disability and the survivors of ischemic insults have no effective treatment available other than neurorehabilitation. To repair the human brain after hemorrhagic stroke may seem unrealistic because of the loss of many different neuronal cells. One of the most encouraging approaches has been restorative therapy using stem cell replacement in the ischemic areas.2 Apart from their individual impact, research shows that exercise enhances the effect of stem cells by helping the mobilization of local stem cells and encouraging angiogenesis. Hence, the concept of neuro-

*Dept. of Research and Development **Dept. of Neurorehablitation â&#x20AC; Dept. of Medical Services and Clinical Research NeuroGen Brain and Spine Institute, Surana Sethia Hospital and Research Centre Chembur, Mumbai Address for correspondence Ms Pooja Kulkarni NeuroGen Brain and Spine Institute, Surana Sethia Hospital and Research Centre Suman Nagar, Sion - Trombay Road, Chembur, Mumbai - 400 071 E-mail: publications@neurogen.in, poojakul28@gmail.com

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regenerative rehabilitation therapy (NRRT) endeavors to combine the impact of neuroregeneration and rehabilitation for a better therapy outcome. Although, evidence of the beneficial effects of stem cells in animal stroke models is growing, there is lack of enough clinical data.3 Our case study is an effort towards this direction. Case Study We present a 69-year-old female patient with history of hemorrhagic infarct, a year ago, leading to rightsided hemiplegia with impaired cognition, speech as well as bladder and bowel function. Magnetic resonance imaging (MRI) revealed left thalamic bleed with intraventricular extension. Patient received standard treatment for the same and had a ventriculoperitoneal (VP) shunt in place. She also underwent neurorehabilitation for one year. Then, on our pre-stem cell treatment evaluation, patient was hypertonic with spasticity of Grade 1 (According to Modified Ashworth Scale). She was hyperreflexic with reduced sensations over right-half of the body and had muscle power of Grade 2/5 in right upper and lower limb and Grade 5/5 strength on the left-half of her body. She was impaired cognitively with affection of orientation in time, place and person, along with

case study hemineglect of right side of her body and emotionally labile. Functionally, she was dependent on the caregiver for all her activities of daily living (ADLs). Stroke Rehabilitation Assessment of Movement (STREAM) score was 19. Functional Independence Measure (FIM) score was 39 with severe affection in areas of selfcare, sphincter control, mobility and social cognition. She was given autologous bone marrow stem cells (BMSCs) intrathecally, since she had exhausted all other treatment options. Methods The NRRT has been designed and the patients are selected for the therapy-based on the inclusion criterion as per the World Medical Associations Helsinki declaration.4 The NRRT is approved by the Institutional Committee for Stem Cell Research and Therapy (IC-SCRT). Granulocyte colony-stimulating factor (G-CSF) (300 mg) injections were administrated subcutaneously, 48 hours and 24 hours prior to the bone marrow aspiration. The G-CSF administered before the transplantation helped in stimulation of CD34+ cells and also in survival and multiplication of the stem cells. Bone marrow (100 ml) was aspirated from the iliac bone and mononucleocytes (MNC) were obtained after density gradient separation. Viable count of the isolated MNCs was taken and checked for CD34+ by fluorescence-activated cell sorting (FACS) analysis. A total of 50 x 106 MNC were then injected intrathecally in L4-L5 using a lumbar puncture needle and catheter.14 Stem cell therapy was followed by neurorehabilitation including regular physiotherapy, occupational therapy and counseling to reduce her impairment and improve functionality. The patient showed progressive improvements after the therapy as mentioned below. Results

Cognition Prior to stem cell therapy, there was total neglect of right-half of body and immediately after the stem cell therapy, awareness of the right side of the body was present and the patient tried to use it for functional activities. Emotionally, she was less labile and crying spells had reduced significantly. She had increased attention span, with ability to participate in conversations and read the clock and tell time accurately. She could identify colors, weeks and months of the year and was well-oriented in time and place along with improvements in her comprehension and memory skills.

Motor System She could move her right upper extremity voluntarily. Improvement in gross as well as fine motor activity was observed. Tightness/spasticity/clawing of right hand had reduced and could open and close her fist. Strength in her upper extremity had grossly improved from Grade 2 to 3++. Strength in her right lower limbs had improved from Grade 2 to 3++. Also, spasticity in her muscles had reduced significantly with near normal voluntary control.

Activities of Daily Living Independently she can now tie a knot, cut vegetables, peel peas and pick up coins and marbles with her right hand, transfer from bed to wheelchair and vice versa, stand up from chair and remain standing for about 10 minutes with an assistive device. On the bed, she could shift and roll independently. On reassessment her FIM6 had increased from 39 to 84 with major improvements seen in sections of self-care activities, transfer skills, social cognition and communication. STREAM7 score improved from 19 to 53, with an overall improvement in voluntary movements/activities using the right side of the body. Discussion In hemorrhagic stroke, the ultimate aim of any therapeutic strategy is to achieve maximum possible restoration of normal function. Stem cell therapy is a cellular approach that has the potential to induce all of the neurorestorative processes essential for facilitating recovery of neurological function.5 Stem cells are undifferentiated cells that retain the capacity to proliferate and produce generations of progenitor cells, which can differentiate into virtually all cell types of the body in response to the proper stimuli.8 The main rationale to employ stem cell therapies in stroke patients is to replace infarcted brain tissue in a way that lost neurons are replaced and there is reestablishment of a functional neuronal circuitry with proper nerve conduction. It has been observed that the transplanted stem cells can act as biological mini pumps releasing a missing transmitter or secrete growth factors which can stimulate plastic responses, improve the survival and function of host neurons and restore synaptic connection by providing a local reinnervation and neuronal replacement. The stem cells can become integrated into existing neural and synaptic networks, and re-establish functional afferent and efferent connections.10,13

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case study The nonregenerative trait of the injured adult brain has been challenged in recent years and neural plasticity has been observed experimentally in both global and focal brain ischemia in animal models. There are several sources of stem cells that may be useful in hemorrhagic stroke, embryonic stem cells derived from the inner cell mass of preimplantation embryos, neural stem cells found in specific regions of brain, bone marrow, umbilical cord blood and adipose tissue.1 In our case study, BMSC were chosen as they are easily accessible through the aspiration of the bone marrow, can be isolated from patients themselves thereby bypassing the ethical problems and can easily be administered to the patients for autotransplantation. The MNCs obtained from bone marrow, comprises of a variety of cells like hematopoietic stem cells, tissue specific progenitor cells, mesenchymal stromal cells and specialized blood cells in different stages of development. They produce trophic factors in host tissue after transplantation, which is beneficial for tissue protection and restoration, along with a potential to differentiate into local cells in response to environmental signals and cues. They are also known to home onto the site of injury and promote angiogenesis. In a study by Lee et al, cells of human neural stem cells (NSC) line, transplanted into the brain of mice after intracerebral hemorrhage (ICH), gave rise to both neurons and astrocytes and induced behavioral recovery in the rotarod and limb placing tests.8 In another study, human BMSCs transplanted in rats after ICH, showed formation of new neuronal connections and significantly improved neurological function was found one week after transplantation.12 Behavioral recovery in the beam-walking test was observed in the groups of rats that received intraarterial and intraventricular delivery of BMSC in a study by Zhang and coauthors,15 who used cells of rat origin. Autologous mesenchymal stem cells have been widely used in the clinical trials in brain injury diseases such as multiple sclerosis, glioma and recently with stroke.11,10 In our case study, autologous bone marrow stem cell transplantation was given intrathecally to a hemorrhagic stroke patient as part of the NRRT. After the therapy the patient showed improvement functionally due to better cognition, voluntary control and motor strength, as stated above and evident from improvements in FIMS as well as STREAM scores. The patient was not recovering with neurorehabilitation alone for one year and that the patient

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showed functional improvement, only after addition of stem cell therapy suggests that BMSC played a significant role by various mechanisms as stated above. Conclusion Autologous intrathecal transplantation of BMSCs fully circumvents the problem of immune rejection and bears no ethical concerns. Intrathecal transplantation is a noninvasive and most importantly a safe method for bone marrow stem cell transplantation without any major side effects. In view of experimental data, the patient was treated with autologous bone marrow stem cells as a last resort to improve functionality thereby decreasing her disability. Post stem cell therapy, along with continued neurorehabilitation, the patient showed functional and neurological improvements which were progressive in nature. This case study represents one of the earliest clinical data on intrathecal delivery of autologous bone marrow derived stem cells showing functional improvement in hemorrhagic stroke, supporting laboratory experimental data. Further large clinical studies are needed to investigate functional improvement by autologous bone marrow stem cell therapy in addition to neurorehabilitation for treating the disability in hemorrhagic stroke. Suggested reading 1.

Andres RH, Guzman R, Ducray AD, Mordasini P, Gera A, Barth A, et al. Cell replacement therapy for intracerebral hemorrhage. Neurosurg Focus 2008;24(3-4):E16.

Bliss T, Guzman R, Daadi M, Steinberg GK. Cell transplantation therapy for stroke. Stroke 2007;38 (2 Suppl):817-26.

Chen J, Li Y, Wang L, Zhang Z, Lu D, Lu M, et al. Therapeutic benefit of intravenous administration of bone marrow stromal cells after cerebral ischemia in rats. Stroke 2001;32(4):1005-11.

Carlson RV, Boyd KM, Webb DJ. The revision of the Declaration of Helsinki: past, present and future. Br J Clin Pharmacol 2004;57(6):695-713.

Dharmasaroja P. Bone marrow-derived mesenchymal stem cells for the treatment of ischemic stroke. J Clin Neurosci 2009;16(1):12-20.

Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level functional independence measure (FIM). Scand J Rehabil Med 1994;26(3): 115-9.

Daley K, Mayo N, Wood-DauphinĂŠe S. Reliability of scores on the Stroke Rehabilitation Assessment of Movement (STREAM) measure. Phys Ther 1999;79(1):8-19; quiz 20-3.

case study 8.

Lee HJ, Kim KS, Kim EJ, Choi HB, Lee KH, Park IH, et al. Brain transplantation of immortalized human neural stem cells promotes functional recovery in mouse intracerebral hemorrhage stroke model. Stem Cells 2007;25(5):1204-12.

Lipska K, Sylaja PN, Sarma PS, Thankappan KR, Kutty VR, Vasan RS, et al. Risk factors for acute ischaemic stroke in young adults in South India. J Neurol Neurosurg Psychiatry 2007;78(9):959-63.

10. Mohyeddin-Bonab M, Mohamad-Hassani MR, Alimoghaddam K, Sanatkar M, Gasemi M, Mirkhani H, et al. Autologous in vitro expanded mesenchymal stem cell therapy for human old myocardial infarction. Arch Iran Med 2007;10(4):467-73. 11. Tandon PN. Transplantation and stem cell research in neurosciences: where does India stand? Neurol India 2009;57(6):706-14.

12. Seyfried D, Ding J, Han Y, Li Y, Chen J, Chopp M. Effects of intravenous administration of human bone marrow stromal cells after intracerebral hemorrhage in rats. J Neurosurg 2006;104(2):313-8. 13. Wiltrout C, Lang B, Yan Y, Dempsey RJ, Vemuganti R. Repairing brain after stroke: a review on post-ischemic neurogenesis. Neurochem Int 2007;50(7-8):1028-41. 14. Yoon SH, Shim YS, Park YH, Chung JK, Nam JH, Kim MO, et al. Complete spinal cord injury treatment using autologous bone marrow cell transplantation and bone marrow stimulation with granulocyte macrophagecolony stimulating factor: Phase I/II clinical trial. Stem Cells 2007;25(8):2066-73. 15. Zhang H, Huang Z, Xu Y, Zhang S. Differentiation and neurological benefit of the mesenchymal stem cells transplanted into the rat brain following intracerebral hemorrhage. Neurol Res 2006;28(1):104-12.

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case report

Anton’s Syndrome and Cortical Blindness Gadwalkar Srikant R*, Deepa DV**, P Rama Murthy†, Ravi Dhar**

Abstract Introduction: Anton’s syndrome is a condition where the patient is unaware of being blind and denies the problem even when it is pointed out to him. On the contrary, in cortical blindness patient is aware of his blindness and does not deny it. In both, bilateral lesions of the occipital lobes are seen. Case presentation: We present two cases of cortical blindness, Case 1 being consistent with diagnosis of Anton’s syndrome where patient denied of her blindness. Both cases revealed bilateral occipital lobe infarcts. Conclusions: Cerebrovascular disease is the most common cause of cortical blindness. These occur as a result of successive infarctions as seen in Case 1 or from a single embolic or thrombotic occlusion as seen in Case 2. First case is Anton’s syndrome with patient denying blindness, whereas second case is cortical blindness. It is due to involvement of other cortical centers in Anton’s syndrome that patient denies blindness.

Keywords: Anton’s syndrome, cortical blindness, bilateral occipital lobe infarcts Case Presentation

Case 1 A 52-year-old married, right-handed woman presented with history of headache and sudden, painless loss of vision since five days. Patient was apparently normal five days back when she developed acute onset headache. After around five hours she started colliding into objects suggesting she was blind. Patient denied being blind and had no ocular symptoms like floaters, watering of eyes or ocular pain. She had no history of fever, seizures, trauma or any drug intake. There was no history suggestive of any other cranial nerve involvement, motor deficits or sensory loss. There was no history of any bladder or bowel involvement. There was no history of previous medical illnesses or any visual abnormalities. Following this, she was taken to a general physician where she was found to have high blood pressure and was prescribed antihypertensive medication and referred to the present hospital. On arrival to the hospital, patient had a Glasgow Coma Scale score of 15 out of 15, but was agitated. Her blood pressure recording was 130/80 mmHg. On examination, *Professor and Head **Postgraduate Student †Associate Professor Dept. of General Medicine, Vijayanagar Institute of Medical Sciences Bellary, Karnataka Address for correspondence Dr Gadwalkar Srikant R Professor and Head, Dept. of Medicine, Vijayanagar Institute of Medical Sciences Bellary - 534 101, Karnataka E-mail: srikantbly@gmail.com

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patient had severe visual impairment with no perception of light. She walked into objects but denied of being blind. On asking her to describe the object in front of her, her reply was incorrect. Patient was oriented to time, place and person; speech, intelligence was normal but irritable in her behavior. There was no abnormality of any other cranial nerves. Pupillary reflexes were intact with normal fundus. Patient had normal power in all four limbs and no sensory loss. Cerebellar functions were normal. Skull and spine examination was normal. Rest of the examination was normal. The laboratory investigations revealed normal hemogram and biochemistry. Electrocardiogram, echocardiography, carotid and vertebral Doppler were normal. Computed tomography (CT) revealed ill-defined hypodensity in the right occipital region with surrounding edema and hypodensity in left temporoparietooccipital regions (Fig. 1). Magnetic resonance imaging (MRI) revealed altered signals in the left temporoparietooccipital and right occipital lobes suggestive of a large subacute infarct in the left temporoparietooccipital lobe with a gliotic lesion (chronic infarct) in the right occipital lobe (Figs. 2-4). Patient was subjected to anticerebral edema measures which reduced her agitated behavior. Antiplatelet agents and statins were started. There was no significant improvement in her vision. Patient was discharged after seven days with focus on secondary prevention and rehabilitation.

Case 2 A 60-year-old married, right-handed man presented with history of sudden, painless loss of vision since one

case report

Figure 4. Radiological findings: Coronal sections of MRI showing altered signals in the left temporoparietooccipital lobe and right occipital lobes suggestive of a large subacute infarct in the left temporoparietooccipital lobe involving P2 segment of PCA and a gliotic lesion (chronic infarct) in the right occipital lobe.

Figure 1. Radiological findings: Axial CT brain plain showing ill-defined hypodensities in the right occipital and left temporoparietooccipital regions suggesting infarcts.

trauma or any drug intake. There was no history suggestive of any other cranial nerve involvement, motor deficits or sensory loss. There was no history of any bladder or bowel involvement. He was a known hypertensive on antihypertensive medication since past eight years. He is married, having two children. He was a smoker and alcoholic since 20 years. On arrival to the hospital, patient had a Glasgow Coma Scale score of 15 out of 15. His blood pressure recording was 160/92 mmHg. On examination, patient had severe visual impairment with no perception of light. His higher mental functions were normal. There was no abnormality of any other cranial nerves. Pupillary reflexes were intact with normal fundus. Patient had normal power in all four limbs and no sensory loss. Skull and spine examination was normal. Cerebellar functions were normal. Rest of the examination was normal.

Figure 2 and 3. Radiological findings: Axial sections of MRI showing altered signal in the left temporoparietooccipital lobes and right occipital lobe suggestive of a large subacute infarct in the left temporoparietooccipital lobe involving P2 segment of PCA and a gliotic lesion (chronic infarct) in the right occipital lobe.

day. Patient was apparently normal on the previous day, when he developed sudden, painless loss of vision and had no ocular symptoms like floaters, watering of eyes or ocular pain. He had no history of fever, seizures,

The laboratory investigations revealed normal hemogram and biochemistry. Electrocardiogram, echocardiography, carotid and vertebral Doppler were normal. CT revealed ill-defined hypodensities in the right occipitotemporal and left occipital regions with surrounding edema. Patient was managed for anticerebral edema and antiplatelet agents and statins were started. There was no significant improvement is his vision. Patient was discharged after four days with focus on secondary prevention and rehabilitation. With further follow-up, both patients had a slight improvement in vision though recovery in visual acuity remained low.

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case report Discussion The ability to recognize visually presented objects and words depends on the integrity not only of the visual pathways and primary visual area of the cerebral cortex (area 17 of Brodmann) but also of those cortical areas that lie just anterior to area 17 that is areas 18 and 19 of the occipital lobe and area 39 - the angular gyrus of the dominant hemisphere (visual association areas).1 Bilateral infarction in the distal PCAs produces cortical blindness (blindness with preserved pupillary light reaction). The patient is often unaware of the blindness or may even deny it (Anton’s syndrome). Tiny islands of vision may persist, and the patient may report that vision fluctuates as images are captured in the preserved portions. Rarely, only peripheral vision is lost and central vision is spared, resulting in ‘gunbarrel’ vision.2 Although cerebrovascular disease is the most common cause, surgery, particularly cardiac surgery and cerebral angiography are also major causes.3 We have presented two cases of cortical blindness due to infarcts in the PCA territory. The first case consistent with diagnosis of Anton’s syndrome had chronic infarct on the right side and acute infarct on the left side. She did not complain of any symptoms of visual loss related to the old infarct probably not noticed by the patient. This highlights the detailed examination of visual fields

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in all cases of suspected stroke as patient may have visual anasognosia and deny blindness. Less-complete bilateral lesions leave the patient with varying degrees of visual perception. There may also be visual hallucinations of either elementary or complex types. The mode of recovery from cortical blindness has been studied carefully by Gloning and colleagues, who describe a regular progression from cortical blindness through visual agnosia and partially impaired perceptual function to recovery. Even with recovery, the patient may complain of visual fatigue (asthenopia) and difficulties in fixation and fusion.4 In our cases, there has been no remarkable improvement in visual acuity. References 1.

Ropper AH, Brown RH. Adams & Victor’s Principles of Neurology. 8th edition, The McGraw-Hill Companies: USA 2005; 34:676.

Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo S. Harrison’s Principles of Internal Medicine. 18th edition, Vol. 2. The McGraw-Hill Companies: USA 2012; 370:p.3287.

Aldrich MS, Alessi AG, Beck RW, Gilman S. Cortical blindness: aetiology, diagnosis, and prognosis. Ann Neurol 1987; 21(2):149-58.

Ropper AH, Brown RH. Adams & Victor’s Principles of Neurology. 8th edition, The McGraw-Hill Companies: USA 2005; 22:404-5.

photo quiz

Persistent Cough

31-year-old black man presented with a cough that began about four months before, when he was a smoker. Although he had quit smoking, his cough worsened. The cough was productive with scant yellow sputum and did not improve with a course of azithromycin. The patient did not have fever, weight loss, shortness of breath, or fatigue. He had not been exposed to occupational dust or chemicals; however, he was a firefighter. He had a history of allergic rhinitis for which he was taking fexofenadine/pseudoephedrine (Allegra-D). He had a family history of lung cancer and asthma. On physical examination the patient appeared well and was afebrile. His nasal mucosa was swollen, and he had an injected pharynx. Findings on lung examination were normal. His lungs were clear to auscultation with normal inspiratory effort. There was no wheezing, rhonchi, or rales. Chest radiography was performed (see accompanying figure).

A. Bronchogenic carcinoma.

Question

B. Histoplasmosis.

Based on the patientâ&#x20AC;&#x2122;s history, physical examination, and radiologic findings, which one of the following is the most likely diagnosis?

C. Pneumocystis jiroveci pneumonia. D. Sarcoidosis. E. Tuberculosis. SEE THE NEXT PAGE FOR DISCUSSION...

Source: Adapted From Am Fam Physician. 2012;85(1):63-65.

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photo quiz Discussion The answer is D: sarcoidosis. Sarcoidosis is a chronic multisystem granulomatous disease of unknown etiology. It typically affects young and middle-aged adults and is three to four times more common in blacks than in whites.1 Common presenting symptoms include cough, dyspnea, and chest pain. Chest radiography classically reveals bilateral hilar adenopathy with or without parenchymal opacities.2 In more advanced cases, hilar nodes may be smaller, and there may be evidence of pulmonary fibrosis and volume loss. Pleural involvement is rare. The diagnosis of sarcoidosis requires suggestive clinical and radiologic findings, a histologic demonstration of noncaseating granulomas in involved organs, and the exclusion of alternative explanations.3 The first-line treatment of sarcoidosis is oral corticosteroids.3 Alternative agents include methotrexate, cyclophosphamide, azathioprine, chloroquine, and tumor necrosis factor antagonists. Patients may have spontaneous remission, or the clinical course may be chronic with progressive loss of lung function. The age-adjusted mortality rate is 4.32 per 1 million persons.4 Bronchogenic carcinoma is an unlikely cause of chronic cough; however, it should be considered in current and former smokers with a new cough or hemoptysis.5 Radiologic findings may vary from pleural thickening to nodules, lobar collapse, consolidation, unilateral hilar enlargement, or pleural effusion. Histoplasmosis is endemic in fertile river valleys, such as those of the Mississippi, Missouri, Ohio, Saint Lawrence, and Rio Grande rivers.6 Infections in patients who are immunocompetent are generally asymptomatic but may cause fever, chills, dry or productive cough, arthralgias, and rash. The diagnosis relies on high or rising serum antibody complement fixation titers.7 Radiographs may show ill-defined opacities, areas of consolidation, hilar adenopathy, pulmonary nodules, parenchymal infiltrates, cavitation, and mediastinal fibrosis. Granulomas are typically caseating. Pneumocystis jiroveci (formerly Pneumocystis carinii) is an opportunistic pathogen that commonly infects immunocompromised patients, such as those with AIDS. Characteristic symptoms are fever, nonproductive cough, disproportionate breathlessness, and failure to respond to standard antibiotics. Common radiologic findings are bilateral, diffuse interstitial infiltrates without hilar adenopathy. Pneumatoceles or pneumothorax may be

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Summary Table Condition

Radiographic findings

Bronchogenic carcinoma

Findings vary and may include unilateral hilar enlargement; peripheral pulmonary opacity; lung, lobar, or segmental collapse; nodules; consolidation; pleural thickening; pleural effusion; broadening of mediastinum; enlarged cardiac shadow; elevation of hemidiaphragm; rib destruction

Histoplasmosis

Ill-defined opacities; areas of consolidation; parenchymal infiltrates; pulmonary nodules; hilar adenopathy; cavitation; mediastinal fibrosis

Pneumocystis jiroveci pneumonia

Bilateral, diffuse interstitial infiltrates without hilar adenopathy; pneumatoceles or pneumothorax may be present; pleural effusions are absent; chest radiographs may appear normal

Sarcoidosis

Stage I: Bilateral hilar enlargement, usually symmetric; paratracheal nodes often enlarged; spontaneous resolution within one year in most cases Stage II: Combination of hilar glandular enlargement and pulmonary opacities that are often diffuse Stage III: Diffuse pulmonary shadows without evidence of hilar adenopathy Stage IV: Pulmonary fibrosis; volume loss; pleural involvement rare

Tuberculosis

Small homogenous infiltrates; hilar and paratracheal lymph node enlargement; atelectasis from airway compression; cavitation; pleural effusion

present, but pleural effusions are absent. Findings on chest radiography are normal in about 5-10 percent of patients with P. jiroveci infection.8 The diagnosis is confirmed if the organism is identified in sputum using specific stains.8 Adequate specimens can be obtained through induced sputum or bronchoalveolar lavage. Patients with tuberculosis typically present with the slowly progressive constitutional symptoms of malaise, fever, night sweats, weight loss, and chronic cough. Radiographic abnormalities include hilar and paratracheal lymph node enlargement, infiltrates, atelectasis, pleural effusion, and cavitation.7 A tuberculin skin test identifies Mycobacterium tuberculosis infection, but does not distinguish between latent and active disease. The diagnosis can be confirmed if M. tuberculosis is identified with cultures or with DNA or RNA amplification techniques.7

photo quiz REFERENCES 1.

Statement on sarcoidosis. Joint statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med. 1999;160(2):736-755. King TE Jr. Clinical manifestations and diagnosis of sarcoidosis. UpToDate. http://www.uptodate.com/ contents/clinical-manifestations-and-diagnosis-ofsarcoidosis (subscription required). Accessed May 2010. Brown KK. Chronic cough due to chronic interstitial pulmonary diseases. ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 suppl):180S-185S. Swigris JJ, Olson AL, Huie TJ, et al. Sarcoidosis-related mortality in the United States from 1988 to 2007. Am J Respir Crit Care Med. 2011;183(11):1524-1530.

Silvestri RC, Weinberger SE. Evaluation of subacute and chronic cough in adults. UpToDate. http://www.uptodate. com/contents/evaluation-of-subacute-and-chroniccough-in-adults (subscription required). Accessed May 2010.

Theodore PR, Jablons D. Thoracic wall, pleura, mediastinum, and lung. In: Doherty GM, ed. Current Diagnosis & Treatment: Surgery. 13th ed. New York, NY: McGraw-Hill; 2010.

Chesnutt MS, Gifford AH, Prendergast TJ. Pulmonary disorders. In: McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment 2010. 49th ed. New York, NY: McGraw-Hill; 2010.

Shelburne SA, Hamill RJ. Mycotic infections. In: McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment 2010. 49th ed. New York, NY: McGraw-Hill; 2010.

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Medilaw

Insight on Medicolegal Issues Sudhir Gupta

Inevitable Medical Accident in Healthcare Delivery An inevitable medical accident or ‘unavoidable medical occurrence’ in healthcare delivery is that which could not be possibly prevented by the exercise of ordinary medical/surgical/paramedics and nursing care, caution and skill. In medical profession, it means any medical/surgical accident that results in damage/injury/disability or death that was not avoidable by any such precautions as a reasonable qualified medical professional or hospital doing such an act then, ‘could be expected to take.’ A general/reasonable medical professional is not credited by the law with exact perfection of judgment. As observed by Greene MR, an accident is “one out of the ordinary course of things, something so unusual as not to be looked for by a person of ordinary prudence. During the course of treatment, an accident occurs which could not be avoided by any ordinary skill or care on the part of the doctor administering the treatment, the accident is said to be inevitable accident. The term ‘inevitable accident’ has been defined as an accident not avoidable by any such precautions as a reasonable man can be expected to take’. In the case of (Gerber V. Pines 21) the plaintiff claimed damages against the defendant alleging that during the administration of a hypodermic injection the defendant left part of a broken needle in her buttock. The defendant denied liability and said that the breakage of the needle was due to a sudden muscular spasm and that no skill or care on his part could have prevented the fracture of the needle or the retention of the broken part in the plaintiff‘s body. The judge found that there had been no negligence on the part of the defendant in so far as the fracture of the needle was concerned, he found however, that had been a breach of duty on the part of defendant in not informing the plaintiff or her husband that the needle had fractured and that a piece of it was still in her body. For this the judge awarded the plaintiff a small sum by way of damages. Additional Professor Forensic Medicine and Toxicology, AIIMS, New Delhi

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In cases of inevitable medical accident, a very positive/ sympathetic/grief sharing approach should be taken by the doctor towards his/her patient and all logistic medical/surgical services must be extended/provided to the patient without cost by the doctor/hospital to restore/enhance faith and trust of this profession since the service which medical professionals render to the people/society and nation is the noblest one. The patient must also be told that inevitable medical accident was due to the elementary forces of nature unconnected with the hospital/doctor and they are there to share with the patient’s suffering. Triage in medical care and emergency treatment – Can a doctor ignore a routine appointment if a serious patient arrives? The term ‘triage’ is a French word used in military medical services, which refers to the process of sorting injured/sick patient on the basis of urgency/priority of treatment. Triage in trauma care/emergency department is a very quick/necessary decision to first evacuate those with best chance of survival and to leave for later evacuation those who had little or no chance of survival. The doctors’ right to decide the issue of priority of attending the patients has been upheld by the Consumer Disputes Redressal Agencies (CDRAs). The right of medical doctor is an important aspect of medical practice as often the patient’s perception of emergency differs from that of Doctors. In BS Hegde vs Dr Sudhanshu Bhattacharya, the National Commission held that a doctor has the absolute right to decide which patient he would examine first and even out of turn depending on the condition of the patient. There is nothing improper or unreasonable if the doctor gives precedence to patients with active/acute cardiac problem/other medical/surgical condition where urgent medical attention of doctor is called for in preference to the routine consultation. In addition, it cannot be held that the patients must be examined at the appointed time irrespective of the time he may have to spend in examining the previous patients. (George, James E, Law and emergency care, The CV Mosby Co, St. Louise,1980 pp 66-67).

around the globe

News and Views Vitamin B12 Deficiency with Metformin Linked to Neuropathy In patients with type 2 diabetes taking metformin, vitamin B12 deficiency is associated with higher levels of peripheral neuropathy, according to a study presented here at the American Diabetes Association 72nd Scientific Sessions. Chronic metformin use has been previously shown to be associated with vitamin B12 deficiency. Peripheral neuropathy is typically diagnosed as diabetic neuropathy, but this can also be a symptom of vitamin B12 deficiency. (Source: Medscape) Calcium scores help chest pain triage A new risk prediction model that includes coronary artery calcium scores for low-risk chest pain patients may be better than current models at estimating the probability of coronary artery disease (CAD), researchers suggested. Three predictive models were tested: 



A basic model including age, sex, symptoms and setting A clinical model including the basic model factors plus diabetes, hypertension, dyslipidemia, body mass index and smoking An extended model including the clinical model factors and use of the CT-based coronary calcium score. (Source: Medpage Today)

Culturally adapted CBT reaches depressed HIV–positive Hispanics A cognitive behavioral therapy program designed to treat depression and nonadherence in people with HIV infection has been adapted to the Latino culture, and shows promise in the treatment of Hispanic people living on the American-Mexican border. (Source: Medscape) Certolizumab pegol shows efficacy in psoriatic arthritis Certolizumab pegol (Cimzia, UCB Pharma), a tumor necrosis factor (TNF) inhibitor approved by the US Food and Drug Administration for the treatment of

rheumatoid arthritis (RA) and Crohn’s disease, has been shown to be effective in both skin and joint symptoms of psoriatic arthritis, compared with placebo. This finding comes from the interim results of the RAPID-PsA phase 3 trial presented here at the European League Against Rheumatism Congress 2012. (Source: Medscape) NAFLD: No clear role for heritability Nonalcoholic fatty liver disease (NAFLD), as defined by sonographic criteria, does not appear to be inherited. It does however, appear to coexist with vascular parameters linked to increased cardiovascular risk. Dam D. Tarnoki, MD, from Semmelweiss University in Budapest, Hungary, and colleagues published the results of a twin study online May 31 in Liver International. Although scientists have examined families to address the question of heritability in NAFLD, this is the first twin study to investigate the relative contribution of genetic and environmental factors in the disease. (Source: Medscape) Zoster vaccine shows no benefit after a shingles episode Administration of the varicella vaccine in older people with a recent history of shingles does not confer additional immunity, a population-based study suggests. The findings, published online June 4 in the Journal of Infectious Diseases, indicate that immediate vaccination may be unwarranted. (Source: Medscape) Gut flora might trigger or worsen RA The bridge between genetic susceptibility for rheumatoid arthritis (RA) and environmental triggers might be the bacteria in the digestive tract. Research led by Mayo Clinic immunologist Veena Taneja, PhD, and published in the April 2012 issue of PloS ONE provides the first demonstration that HLA genes and the gut environment interact to affect arthritis susceptibility. The researchers suggest that the gut microbiome might be a useful biomarker in RA studies. (Source: Medscape)

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lighter reading

He asked her what was wrong and she replied, “I wanted to buy a red rose for my mother. But I only have seventy-five cents, and a rose costs two dollars.” The man smiled and said, “Come on in with me. I’ll buy you a rose.” He bought the little girl her rose and ordered his own mother’s flowers. As they were leaving he offered the girl a ride home. She said, “Yes, please! You can take me to my mother.” She directed him to a cemetery, where she placed the rose on a freshly dug grave. The man returned to the flower shop, cancelled the wire order, picked up a bouquet and drove the two hundred miles to his mother’s house.”

laugh a while

—Ms Ritu Sinha

A young blonde was on vacation in the depths of Louisiana. She wanted a pair of genuine alligator shoes in the worst way, but was very reluctant to pay the high prices the local vendors were asking. After becoming very frustrated with the “no haggle” attitude of one of the shopkeepers, the blonde shouted, “Maybe I’ll just go out and catch my own alligator so I can get a pair of shoes at a reasonable price!” The shopkeeper said, “By all means, be my guest. Maybe you’ll luck out and catch yourself a big one!” Determined, the blonde turned and headed for the swamps, set on catching herself an alligator. Later in the day, the shopkeeper is driving home, when he spots the young woman standing waist deep in the water, shotgun in hand. Just then, he sees a huge 9 foot alligator swimming quickly toward her. She takes aim, kills the creature and with a great deal of effort hauls it on to the swamp bank. Lying nearby were several more of the dead creatures. The shopkeeper watches in amazement. Just then the blonde flips the alligator on it’s back, and frustrated, shouts out, “Damn it, this one isn’t wearing any shoes either!” —GM Singh

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“Life’s battles don’t always go to the stronger or faster man, but sooner or latter the man who wins, is the man who thinks he can.” —Vince Lombardi

“A successful man is one who can lay a firm foundation with the bricks others have thrown at him.” —David Brinkley

TB Skin Test Also known as: Purified Protein Derivative; PPD; Mantoux; Latent tuberculosis infection test To help determine whether or not you may have been exposed to and become infected with the Mycobacterium tuberculosis bacteria.!!

Allergy Testing Allergies are hypersensitivities, overreactions of the immune system to substances that do not cause reactions in most people. Allergen specific IgE testing - Immunoassay and line blot tests are blood tests that are used to screen for type 1 allergen-specific IgE antibodies. —Navin Dang, Dr Arpan Gandhi

Dr. Good and Dr. Bad Situation: A patient came with recurrent headache.

It is a sinus headache

This could be migraine

©IJCP Academy

A man stopped at a flower shop to order some flowers to be wired to his mother who lived two hundred miles away. As he got out of his car he noticed a young girl sitting on the curb sobbing.

QUOTE

A Bouquet for Mother

lab update

An Inspirational Story

Lighter Side of Medicine

Lesson: Sinus headache is commonly diagnosed by

clinicians and self-diagnosed by patients, but acute or chronic sinusitis appears to be an uncommon cause of recurrent headaches, and many patients presenting with sinus headache turn out to have migraine or, less often, tension type headache. Dr 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 –

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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.

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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.

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.

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Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the

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Confidence intervals for the measurements should be provided wherever appropriate.

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

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Discussion –

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

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

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.

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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

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.

2. Total number of pages ________________________

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. –

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summary, etc.)_______________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________

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