International Journal of - Rohilkhand Medical College...

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International Journal of

Advanced & Integrated Medical Sciences

October-December 2016 Volume 1 Number 4 eISSN 2456-2726

Editor-in-Chief Chander Mohan

An Official Publication of the Society for Advanced & Integrated Medical Sciences (Registered under

Societies Registraton Act No. 21,1860)

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October-December 2016 Vol. 1 No. 4

International Journal ofAdvanced & Integrated Medical Sciences

IJAIMS

iv

From the Editor-in-Chief’s Desk

“Life is like riding a bicycle. To keep your balance you must keep moving”Albert Einstein

Heartiest Congratulations to all the readers from our editorial team. With all your support and best wishes, the journal is now indexed with Index Copernicus, and we are targeting to get our journal indexed in other databases also, for which we need to continue to maintain the quality of articles. In the present time, there is a need for a strong foundation in basic sciences which is a paramount for the optimal performance of clinicians to strengthen the accuracy of investigation and management. Itisourdutytokeeplearningandtokeepabreastofthelatestdevelopmentsineachfieldsothatthereaderswillbemorebenefited. I would like to request you all our readers to continue to give us support in the form of quality articles to keep us moving in a balanced way in the spread of knowledge and experiences.

Chander MohanEditor-in-Chief

International Journal of Advanced & Integrated Medical SciencesProfessor and Head

Department of ENT, Rohilkhand Medical College and HospitalBareilly, Uttar Pradesh, India

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ORIGINAL ARTICLES

• Comparative Study of 0.1% Olopatadine vs 0.05% Cyclosporine in Patients of Recalcitrant Vernal Keratoconjunctivitis ............................................................................. 139-142

Etti Goyal, Jaya Devendra, Pranav Gupta

• A Clinicopathological Study of various Conjunctival Lesions in Children ......................................143-147 Juhi Goel, Swapnila Prasad, Ashutosh Dokania

• An Epidemiological Study on Perception of the Cataract Patients regarding Cataract Surgery in Tertiary Care Hospital, Bareilly, Uttar Pradesh ................................................. 148-150

Pankaj Kumar, Hari S Joshi, Rashmi Katyal, Pratyush Ranjan

• Impact of Health Education in Perception of Patients regarding Storage of Health Records among Patients attending Tertiary Care Hospital, Bareilly .....................................151-157

VK Tiwari, Abhishek Kumar, Ashok Agarwal, HS Joshi, Deepak Upadhyay, Pooja Bansal

• Prehospital Trauma Care ............................................................................................................................. 158-163 SM Sharma

• TheStudyofSociodemographicProfileofPediatricTuberculosis Patients in Bareilly District, Uttar Pradesh: A Cross-sectional Study ............................................... 164-166

Piyush Gupta, Arun Singh, Hari S Joshi, Pankaj Kumar, Himalaya Singh

• AStudyofPrecondylarTubercleinNorthIndianCrania ....................................................................167-168 SHH Zaidi

Original Research

• Assessment of Knowledge and Practice of Mothers of Children under fiveregardingZincTherapyinChildhoodDiarrhea ............................................................................ 169-172

Dipak Kumar Dhar, Nilratan Majumder, Debasish Paul

• Radiological Evaluation of Thyroid Diseases using Gray Scale and Color Doppler Sonography ......................................................................................................................... 173-182

Sagar Tyagi, Pramod Kumar, Atul Mehrotra, Pradeep Parakh, Lalit Kumar, Parveen Hans

Review Article

• VestibularImplant:AreWeReadyforIt? ................................................................................................ 183-185 Chander Mohan, Abhinav Srivastava

Case Studies

• Brugada Syndrome: Killer Genetic Heart Disorder ............................................................................... 186-187 Payodh Chaudhary, Nitin Agarwal, Malini Kulshrestha, RR Chaudhary


October-December 2016 Volume 1 Number 4

Contents


vi

• AModifiedCutler-BeardTechniquetoManageExtensiveSebaceousGland Carcinoma of Upper Eyelid ......................................................................................................................... 188-190

Pranav Gupta, Y Rizvi, Etti Goyal

• RareCaseofIntrahepaticPancreaticPseudocystmisdiagnosedasHepaticAbscess .....................191-193 Parveen Hans, Sagar Tyagi, Prashant Sinha, Lalit Kumar, Deepanshu Gupta, Robin Singh

• SublingualEpidermoidCyst:ARarePresentation ............................................................................... 194-195 Ashish K Maurya, Shalini Jadia, Leena Jain, Sadat Qureshi

Images in Surgery

• Spontaneous Cholecystocutaneous Fistula ............................................................................................. 196-198 Rajesh Abbey

Great Scientist in Medicine

• LaennecContributionstotheFieldofMedicine .................................................................................... 199-201 VK Tiwari

International Journal of Advanced & Integrated Medical Sciences

Comparative Study of 0.1% Olopatadine vs 0.05% Cyclosporine in Patients of Recalcitrant Vernal Keratoconjunctivitis

International Journal of Advanced & Integrated Medical Sciences, October-December 2016;1(4):139-142 139

IJAIMSIJAIMS

Comparative Study of 0.1% Olopatadine vs 0.05% Cyclosporine in Patients of Recalcitrant Vernal Keratoconjunctivitis1Etti Goyal, 2Jaya Devendra, 3Pranav Gupta

ABSTRACT

Introduction: Vernal keratoconjunctivitis (VKC) is a chronic, recurrent, bilateral inflammatory disease showing exacerba-tions during the spring and summer seasons, affecting young children. Present study was conducted with the aim of compar-ing the efficacy of cyclosporine 0.05% with olopatadine 0.1% in recalcitrant patients of VKC.

Materials and methods: A prospective randomized controlled trial was performed on 40 eyes (20 patients of recalcitrant VKC) during the period of May 2015 to September 2015. A short course of mild steroid was given for 5 days to all patients as they presented with acute exacerbation of recalcitrant VKC.

Left eye of each patient received topical cyclosporine 0.05%, which is a nonsteroidal immunomodulator, twice daily, and right eye of the same patient received olopatadine 0.1%, which has a dual action, i.e., mast cell stabilizer action as well as antihistaminic activity, twice daily for a period of 3 months. Grading of signs and symptoms was done at the time of pre-sentation and at 2 weeks, 1 month, and 3 months interval.

Results: When compared with baseline, scores for signs and symptoms at 2 weeks reduced significantly for both cyclospo-rine and olopatadine. However, at 3 months, scores as regards signs and symptoms were found to be lower in cyclosporine as compared with olopatadine eyes.

Conclusion: Cyclosporine 0.05% was found to be equally effective in treating signs and symptoms as olopatadine in the early phase of the treatment. But, a significant improvement was noted in cyclosporine eyes as compared with olopatadine eyes in the late period.

Keywords: Immunomodulator, Mean symptom score, Nonsteroidal, Recalcitrant.

How to cite this article: Goyal E, Devendra J, Gupta P. Comparative Study of 0.1% Olopatadine vs 0.05% Cyclosporine in Patients of Recalcitrant Vernal Keratoconjunctivitis. Int J Adv Integ Med Sci 2016;1(4):139-142.

OrIgInAl ArtIcle

1,3Postgraduate Student (3rd Year), 2Professor and Head1,3Department of Ophthalmology, Rohilkhand Medical College and Hospital, Mahatma Jyotiba Phule Rohilkhand University Bareilly, Uttar Pradesh, India2Department of Ophthalmology, Teerthanker Mahaveer Medical College and Research Centre, Teerthanker Mahaveer University Moradabad, Uttar Pradesh, India

Corresponding Author: Etti Goyal, Postgraduate Student (3rd Year), Department of Ophthalmology, Rohilkhand Medical College and Hospital, Mahatma Jyotiba Phule Rohilkhand University, Bareilly, Uttar Pradesh, India, Phone: +919536117926 e-mail: [email protected]

10.5005/jp-journals-10050-10048

Source of support: Nil

Conflict of interest: None

INTRODUCTION

Vernal keratoconjunctivitis (VKC) is a chronic, recurrent, bilateral inflammatory disease of cornea and conjunctiva affecting young children, mostly in their first decade of life.1 Signs and symptoms of VKC show exacerbations during spring and summer seasons, but a small percent-age of patients have the perennial form.2

Diagnosis of this allergic condition is done by the presence of characteristic clinical features which consist of itching, tearing, mucous discharge, conjunctival hyperemia, cobblestone papillae seen over upper tarsal conjunctiva, Tranta’s spots over the limbus, and superfi-cial keratitis. Severe corneal involvements in the form of shield ulceration and conjunctival cicatrization are sight threatening.

The pathogenesis of VKC is considered to be mul-tifocal with the involvement of immune, nervous, and endocrine systems.3-5

Steroids are being used as the mainstay of treatment for VKC, but a standard treatment protocol is not yet established. Steroids are very effective in controlling the acute exacerbation, but they may cause intraocular pressure elevation in steroid-responders, risk of corneal infection, and cataract. Therefore, they are used for a short period of time.6 Topical mast cell stabilizers and antihis-taminics are also used to reduce the signs and symptoms of the disease. Olopatadine 0.1% acts as a mast cell stabi-lizer as well as an antihistaminic in treating patients of VKC. Studies have shown that it is more effective than sodium cromoglycate, ketorolac, and levocabastine.7-9 Cyclosporine 0.05% is a nonsteroidal immunomodula-tor, used as an effective alternative for the control of ocular inflammation. It inhibits eosinophilic infiltration into the conjunctiva without affecting systemic immune responses.10

In the present prospective study, we compared the effects of topical olopatadine 0.1% vs topical cyclosporine 0.05% on the signs and symptoms of patients of recal-citrant VKC, with an aim to earmark the superiority of either of the drugs in the management of VKC.

Etti Goyal et al

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MATERIALS AND METHODS

This was a randomized prospective controlled trial per-formed on 40 eyes of 20 patients of recalcitrant VKC, who came to the outpatient department (OPD) at Rohilkhand Medical College and Hospital, Bareilly, India, during the period of May 2015 to September 2015.

Inclusion Criteria

• Age>5years• PatientsofrecalcitrantVKC• Bilateralsymmetricalpresentation

Exclusion Criteria

• Patientswhodidnotgiveconsent• Patientswithotheractiveocularinflammatorydis-

orders apart from VKCAllpatientspresentingintheOPDbetweenMay1,

2015 and September 30, 2015, and fulfilling the inclusion criteriawereincludedinthestudy.Atotalof20patients(40eyes)wereenrolledinthestudy.Aninformedconsentwas taken from them after which each patient was sub-jected to a detailed slit lamp examination.

Symptoms like itching, tearing, foreign body sensa-tion, and discharge were graded on a scale of 0 to 3 on the basis of grading system adopted from Ozcan et al11 (Table 1).

Signs like limbal hypertrophy, bulbar conjunctival hyperemia, and tarsal conjunctival hypertrophy were noted and graded on a scale of 0 to 3. Grading system is shown in Table 2.

Aftergradingofsignsandsymptoms,treatmentwasinitiated.Allpatientsreceivedashortcourseoftopicalfluorometholone thrice daily, in both eyes for a period of 5days.Alongwiththis,righteyeofeachpatientreceivedtopical olopatadine 0.1%, twice a day and left eye of same patient received topical cyclosporine 0.05% (Imudrops), twice daily. Patients were followed up for a period of

3 months, and scoring of signs and symptoms was done at 2 weeks, 1 month, and 3 months intervals.

Statistical Analysis

Statistical analysis of data was done using Statistical Package for the Social Sciences software version 22.0 andunpairedt-testwasapplied.Ap-valueof<0.05wasconsidered statistically significant.

RESULTS

The present study was done on 40 eyes of 20 patients of VKC in whom majority were male (70%) as compared with females (30%).

Mean age of the patients was 9.4 years, with minimum and maximum age being 7 and 14 years respectively.

Mean scores for signs and symptoms of both olopatadine-treated eyes and cyclosporine-treated eyes are given in Table 3. At 2 weeks posttreatment,olopatadine-treated eyes showed a significant reduction in mean symptom score (p <0.01). Similarly, in cyclo-sporine-treated eyes, a highly significant reduction was seen (p <0.001).Bothdrugswereindividuallyeffectivein lowering the mean symptom and sign score posttreat-ment at 1 and 3 months intervals when compared with mean baseline symptom and sign scores.

On comparative analysis of mean symptom and sign score between olopatadine- and cyclosporine-treated eyes, the response noted was not statistically significant at 2 weeks (p >0.05).At1and3months,ahighlysignificantdifference was noted (p <0.001)(Table4).

DISCUSSION

Vernal keratoconjunctivitis is a chronic allergic inflam-mation, which is characterized by recurrent, mostly symmetrical involvement of both eyes.12 Disease shows seasonal exacerbations, but occasional perennial forms are also encountered.

Table 1: Grading of symptoms

GradeSymptoms 0 1 2 3Itching No Occasional Frequent ConstantTearing Normal Sensation of fullness in sac Infrequent spilling of tears over

lid marginConstant spilling of tears over lid margins

Foreign body sensation Absent Mild Moderate SevereDischarge No Small amount of mucoid

dischargeModerate amount of mucoid discharge

Eyelids matted together on awakening

Table 2: Grading of signs

GradeSigns 0 1 2 3Limbal hypertrophy No One quadrant Two quadrant >2 quadrantsBulbar conjunctival hyperemia No Mild Moderate SevereTarsal conjunctival papillary hypertrophy No Mild Moderate Severe

Comparative Study of 0.1% Olopatadine vs 0.05% Cyclosporine in Patients of Recalcitrant Vernal Keratoconjunctivitis


IJAIMS

Male pediatric population is typically more affected than female,1,5,13 and similar observation was noted in the present study, with male:female ratio of 2.3:1.

Rarely seen in adults, VKC affects young children in the first decade of life.14,15 Leonardi et al16 conducted a study on 406 VKC patients and reported that 83% of the patients were less than 10 years of age at the time of presentation and same age distribution was seen in this study.

Vernal keratoconjunctivitis is a multifactorial disease with immune-mediated processes. T-helper 2 (Th2) lym-phocytes, eosinophils, immunoglobulin E (IgE), mast cells, interleukins, and other cell mediators are known to play a major role.11 Few authors have reported that neural factors and sex hormones also contribute to the pathogenesis of VKC.3,12,14

Asforotherallergicconditions,themainaimoftreat-ment in VKC is blockage of release of allergic mediators and control of allergic inflammatory cascade and, in turn, protection of ocular structures. Various treatment modalities of VKC are topical mast cell stabilizers, anti-histaminics, corticosteroids, and immunomodulators.

Cyclosporine is an immunomodulator, which acts as an anti-inflammatory agent by blocking histamine release from mast cells through inhibition of calcineu-rin essential for IgE receptor mediated exocytosis of preformed mediators from mast cells. It also acts by inhibiting Th2 lymphocyte proliferation and interleukin (IL)-2 and IL-5 production and, thus, prevents eosinophil infiltration.17

Various studies have reported the benefit of cyclo-sporine in reducing the ocular signs and symptoms in patients of VKC with different grades of severity.18-21 In the present study, a comparison of efficacy of both cyclosporine and olopatadine with regard to objective symptoms like itching, tearing, foreign body sensation, discharge, and signs like limbal hypertrophy, hyperemia of bulbar conjunctiva, and papillary hypertrophy over the palpebral conjunctiva was done.

Asignificant improvement insymptomsandsignswas noted at 2 weeks in eyes treated with cyclospo-rine as well as those treated with olopatadine, but the results were highly significant in the eyes treated with cyclosporine.

At2weeks,whenwecomparedboth,nostatisticallysignificant results were seen. Then after a period of 1 month, improvement in the cyclosporine eyes was statistically significant with a p <0.01forsymptomsandp <0.01forsigns.After3-monthinterval,highlysignifi-cant difference was noted in the cyclosporine-treated eyes for both symptoms and signs (p <0.001).

Limitations of the study were a small sample size and a short follow-up period. Further studies are required to establish the efficacy of cyclosporine as a prophylactic measure for the acute exacerbations in patients of recal-citrant VKC.

CONCLUSION

In early phase of the treatment, both cyclosporine 0.05% and olopatadine 0.1% were found to be equally effective

Table 3: Mean symptom and sign score of patients

Treatment periodOlopatadine Cyclosporine

Mean SD t p-value Mean SD t p-valueAt presentation Symptom 6.9 1.34 – – 6.9 1.34 – –

Sign 4.5 1.15 – – 4.5 1.15 – –2 weeks Symptom 5.5 0.83 2.74 0.006 5.1 0.73 3.66 < 0.001

Sign 3.4 0.84 2.4 0.013 2.9 1.10 3.13 0.0031 month Symptom 3.5 1.08 6.16 < 0.001 2.2 0.63 9.84 < 0.001

Sign 2.4 0.70 4.85 < 0.001 1.7 0.48 6.95 < 0.0013 months Symptom 1.8 0.42 11.24 < 0.001 0.7 0.48 13.49 < 0.001

Sign 1.3 0.45 7.95 < 0.001 0.3 0.48 10.42 < 0.001SD: Standard deviation

Table 4: Comparative analysis between olopatadine and cyclosporine

Treatment periodOlopatadine Cyclosporine

t p-valueMean SD Mean SD2 weeks Symptom 5.5 0.83 5.1 0.73 1.12 0.13

Sign 3.4 0.84 2.9 1.10 1.14 0.131 month Symptom 3.5 1.08 2.2 0.63 3.28 0.002

Sign 2.4 0.70 1.7 0.48 2.60 0.0083 months Symptom 1.8 0.42 0.7 0.48 5.42 < 0.001

Sign 1.3 0.45 0.3 0.48 4.63 < 0.001SD: Standard deviation

Etti Goyal et al

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in alleviating signs and symptoms of VKC. But, in the late period, a clinical and statistical significant improvement was noted in cyclosporine-treated eyes as compared with olopatadine-treated eyes.

REFERENCES

1. KeklikciU,DursunB,CinguAK.Topicalcyclosporinea0.05%eyedrops in the treatment of vernal keratoconjunctivitis – randomizedplacebo-controlledtrial.AdvClinExpMed2014May-Jun;23(3):455-461.

2. AkpekEK,HasiripiH,ChristenWG,KalayciD.Arandomizedtrial of low dose mitomycin C in treatment of severe vernal keratoconjunctivitis. Ophthalmology 2000 Feb;107:263-269.

3. Spadavecchia L, Fanelli P, Tesse R, Brunetti L, Cardinale F, BellizziM,RizzoG,ProcoliU,BellizziG,ArmenioL.Efficacyof 1.25% and 1% topical cyclosporine in the treatment of severe vernal keratoconjunctivitis in childhood. Pediatr AllergyImmunol2006Nov;17(7):527-532.

4. BozkurtB,ArtacH,ArslanN,GokturkB,BozkurtMK,ReisliI, Irkec M. Systemic atopy and immunoglobulin deficiency in Turkish patients with vernal keratoconjunctivitis. Ocul Immunol Inflamm 2013;21(1):28-33.

5. LabcharoenwongsP,JirapongsananurukO,VisitsunthornN,KosrirukvongsP,SaenginP,VichyanondP.Adouble-maskedcomparison of 0.1% tacrolimus ointment and 2% cyclosporine eye drops in the treatment of vernal keratoconjunctivitis in children.AsianPacJAllergyImmunol2012Sep;30(3):177-184.

6. Carnahan MC, Goldstein DA. Ocular complications oftopical peri-ocular, and systemic corticosteroids. Curr Opin Ophthalmol 2000 Dec;11(6):478-483.

7. Ketelaris CH, Ciprandi G, Missotten L, Turner FD, Bertin D, Berdeaux G, International Olopatadine Study Group. Acomparison of efficacy and tolerability of olopatadine hydro-chloride 0.1% ophthalmic solution and cromolyn sodium 2% ophthalmic solution in seasonal allergic conjunctivitis. Clin Ther 2002 Oct;24(10):1561-1575.

8. AbelsonMB,GreinerJV.Comparativeefficacyofolopatadine0.1% ophthalmic solution versus levocarbastine 0.05% oph-thalmic suspension using the conjunctival allergen challenge model. Curr Med Opin 2004 Dec;20(12):1953-1958.

9. Deschenes J, Discepola M, Abelson MB. Comparativeevaluation of olopatadine ophthalmic solution (0.1%) versus ketorolac ophthalmic suspension (0.5%) using the pro-vocativeantigenchallengemodel.ActaOphthalmolScand1999;(228):47-52.

10. Fukushima A, Yamaguchi T, Ishida W, Fukata K, Liu FT, UenoH.CyclosporinAinhibitseosinophilicinfiltrationintothe conjunctiva mediated by type IV allergic reactions. Clin Exp Ophthalmol 2006 May-Jun;34(4):347-353.

11. OzcanAA,ErsozTR,DulgerE.Managementofseverealler-gic conjunctivitis with topical cyclosporin a 0.05% eyedrops. Cornea 2007 Oct;26(9):1035-1038.

12. Abelson MB, Gomes PJ. Olopatadine 0.2% ophthalmicsolution: the first ophthalmic antiallergy agent with once-dailydosing.ExpOpinDrugMetabToxicol2008Apr;4(4): 453-461.

13. Bonini S, Bonini S, Lambiase A, Marchi S, Pasqualetti P,Zuccaro O, Rama P, Magrini L, Juhas T, Bucci MG. Vernal keratoconjunctivitis revisited: a case series of 195 patients with long-term followup. Ophthalmology 2000 Jun;107(6): 1157-1163.

14. Bonini S, Bonini S, Vernal Keratoconjunctivitis. Ocul Immunol Inflamm 1993;1(1-2):13-17.

15. GuptaV,SahuPK.TopicalcyclosporinAinthemanagementof vernal keratoconjunctivitis. Eye (Lond) 2001 Feb;15(Pt 1): 39-41.

16. LeonardiA,BuscaF,MotterleL,CavarzeranF,FregonaIA,PlebaniM,SecchiAG.Caseseriesof406vernalkeratocon-junctivitis patients: a demographic and epidemiological study.ActaOphthalmolScand2006Jun;84(3):406-410.

17. Daniell M, Constantinou M, Vu HT, Taylor HR. Randomised controlledtrialoftopicalcyclosporinAinsteroiddependentallergic conjunctivitis. Br J Ophthalmol 2006 Apr;90(4): 461-464.

18. PucciN,NovembreE,CianferoniA,LombardiE,BernardiniR, CaputoR,CampaL,VierucciA.Efficacyandsafetyofcyclo-sporineeyedropsinvernalkeratoconjunctivitis.AnnAllergyAsthmaImmunol2002Sep;89(3):298-303.

19. Bleik JH, Tabbara KF. Topical cyclosporine in vernal kerato-conjunctivitis.Ophthalmology1991Nov;98(11):1679-1684.

20. TakamuraE,UchioE,EbiharaN,OkamotoS,KumagaiN,ShojiJ,NakagawaY,NambaK,FukushimaA,FujishimaH,et al. A prospective, observational, all-prescribed-patientsstudy of cyclosporine 0.1% ophthalmic solution in the treat-mentofvernalkeratoconjunctivitis.NihonGankaGakkaiZasshi 2011 Jun;115(6):508-515.

21. Tesse R, Spadavecchia L, Fanelli P, Rizzo G, Procoli U, BrunettiL,CardinaleF,MinielloVL,BellizziM,ArmenioL. Treatment of severe vernal keratoconjunctivitis with 1% topical cyclosporine in an Italian cohort of 197 children. PediatrAllergyImmunol2010Mar;21(2Pt1):330-335.

A Clinicopathological Study of various Conjunctival Lesions in Children


IJAIMSIJAIMS

A Clinicopathological Study of various Conjunctival Lesions in Children1Juhi Goel, 2Swapnila Prasad, 3Ashutosh Dokania

ABSTRACT

Conjunctival cysts are of a common occurrence in clinical parlance. These tend to be mostly asymptomatic. However, the underlying cause may be vision threatening. Thus, we conducted a clinicohistopathological study of conjunctival cysts in pediatric age group who presented to our outpatient depart-ment in Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. The aim was to analyze the risk factors, clinical presentation, treatment modalities, and a certain type of cysts in order of their frequency. Significant history, detailed ocular examination, and relevant investigations that were carried out in 10 cases of conjunctival lesions were noted. The manage-ment was done and the histopathological examination (HPE) reports were charted. Despite a similar clinical presentation, HPE revealed varied diagnosis. These comprised choristo-matous cysts (4), subconjunctival cysticercosis (2), inclusion cysts (2), inflammatory cyst (1), and capillary hemangioma (1). Conjunctival cysts are not just a cosmetic blemish. A detailed ocular examination, early diagnosis, and treatment can help prevent various vision-threatening complications.

Keywords: Conjunctival cysts, Cysticercosis, Lipodermoid.

How to cite this article: Goel J, Prasad S, Dokania A. A Clinicopathological Study of various Conjunctival Lesions in Children. Int J Adv Integ Med Sci 2016;1(4):143-147.



INTRODUCTION

While conjunctivitis is the commonest disorder, con-junctival swellings also form a sizable portion of affec-tion in children. These swellings may be congenital or acquired, and each, in turn, may be a cystic or a solid swelling. Conjunctival lesions are usually asymptomatic but may cause foreign body sensation, dry eye, reduced ocular mobility, astigmatism, and cosmetic blemish. Malignancies in children are extremely rare, accounting for 3% of conjunctival tumors1 and a definitive diagnosis is based on histopathological examination (HPE). The mainstay of treatment is excision. A search of medical

OrIgInAl ArtIcle

1Postgraduate Student, 2Senior Resident, 3Professor and Head

1-3Department of Ophthalmology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Corresponding Author: Juhi Goel, Postgraduate Student Department of Ophthalmology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, e-mail: [email protected]

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literature did not reveal any previous reports on the incidence of conjunctival lesions among children from India. This report presents a series of 10 cases of various conjunctival lesions seen in pediatric age group detected over a period of 1 year at Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India.


A retrospective chart-based review was conducted on cases of conjunctival lesions over a period of 1 year. Medical records were retrieved using the international classification of diseases 10 code H 11.4. Ten charts were obtained and details of history, clinical examination, including visual acuity evaluation using the Snellen chart, anterior segment assessment by slit lamp biomicroscopy, and detailed pos-terior segment examination which was performed via a dilated direct and indirect ophthalmoscopy were noted. Relevant investigations which were carried out, including hematological examination, X-ray chest, orbit and paranasal sinuses, B-scan, computed tomography (CT) scan, and mag-netic resonance imaging to assess the nature and extent of the lesions were also evaluated. In most of the cases, cysts were excised and surgically excised tissues were sent for HPE. The findings obtained on histopathological study were also charted.

RESULTS

In this study, 10 cases of conjunctival lesions were ana-lyzed in children. Males (60%) were more frequently affected as compared with females (40%). Most of the swellings were cystic (70%) and rest were solid (30%) in nature. It was seen that left eye was affected in 7 cases and right eye in 3 cases. The most common site of origin was found to be bulbar conjunctival (90%). Majority of cases were found to be common in the age group of 7 to 12 years of age (60%), followed by 13 to 18 years of age (30%) and then those before 6 years of age (Graph 1).

It was seen that mostly the affected children presented within a period of 0 to 6 months of onset of symptoms, of which the appearance or progressive increase in size of swelling was of utmost importance (Graph 2). Of the symptoms which were noted, foreign body sensation was found in 60% cases, followed by progression of swelling (50%) and watering (40%) (Table 1).

On clinicohistopathological evaluation, it was seen that the 40% of cases were of choristomas that included one case

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of limbal dermoid cyst, one case of epidermal cyst, and two cases of lipodermoid cysts. Twenty percent cases were those of parasitic cysts, with two cases of subconjunctival ocular cysticercosis. Others were inclusive of capillary hemangioma (10%), inclusion cyst (10%), inflammatory cyst (10%), and multiple serous cysts (10%) (Graph 3).

DISCUSSION

Conjunctival lesion can be acquired or congenital. In this study, majority of cases were found to be common in the age group of 7 to 12 years of age (60%). These can be cystic lesions, such as epithelial implantation cyst, epithelial cyst (epithelial down growth or pigmented cyst), parasitic cyst, degenerative cyst (pterygium), postinflammatory cyst (Vernal kerato - conjunctivitis), or they can be solid tumors that may originate from any of the several dif-ferent types of tissues contained in the conjunctiva, such as tissues of choristomatous, epithelial, melanocytic, vascular, fibrous, xanthomatous, and lymphoid origin. In this study, majority of cases were found to be cystic (70%

cases) and the rest 30% were solid lesions. Some of the important risk factors associated with conjunctival lesions include solar radiation, heavy outdoors work, dust, wind, unhygienic living conditions, ocular surface injury, and chemical exposure, such as trifluridine, arsenic, beryllium, and petroleum products.

In this study, it was noted that the occurrence of such lesions was more with males (six cases), although gender does not pose to be a risk factor. Also, it was seen that due to some unknown cause, the left eye was more commonly involved (seven cases). The most common site of origin was found to be bulbar conjunctival (90%) out of which majority of cases were seen affecting the temporal side (seven cases), and the medial side of bulbar conjunctiva was affected in two cases.

The clinical presentation of conjunctival lesions may range from mild ocular discomfort in the form of foreign body sensation, dry eye to serious complications, such as painless progressive proptosis, optic nerve compres-sion, globe displacement, motility deficits, astigmatism, or diplopia as seen with dermoids. Ocular cysticercosis may lead to blindness in 3 to 5 years if left untreated. In this study, the presenting symptoms in order of their frequency were as follows: Foreign body sensation (60% cases), increase in size of the swelling (50% cases), water-ing (40% cases), difficulty in closure of eyelid (30% cases), mild ocular pain (30% cases), mild ptosis (10% cases), and astigmatism (10% cases).

Graph 1: Age-wise distribution of cases Graph 2: Frequency of cases on the basis of duration

Graph 3: Percentage wise distribution of various conjunctival lesions

Table 1: Frequency distribution of symptoms

Symptoms Number of casesPain 3Visual defects 1 (Astigmatism)Foreign body sensation 6Watering 4Difficulty in lid closure 3Mechanical ptosis 1Swelling progression 5



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About 80% of the entire cystic lesions of conjunctiva are inclusion cysts. They can be primary or secondary.2 Secondary inclusion cysts are more common. In this case series, it was seen that the commonest conjunctival cystic lesion in pediatric age group was secondary inclusion cysts, which included two cases of parasitic cysts, two cases of serous inclusion cyst, and a single case of chronic nonspecific inflammatory cyst.

Both cases of parasitic cyst were of subconjunctival cysticercosis. It is caused by Cysticercus cellulosae, the larval form of Taenia solium, which is endemic in tropical areas with an incidence of 10 to 30%. It occurs world-wide, mainly in rural regions with insufficient sanitary conditions. The ocular cysticercosis can involve any part of the eye. Most commonly affected ocular tissue is subretinal space (35%), vitreous (22%), subconjunc-tival tissue (22%), anterior segment (5%), eyelid, and orbit (1%).3-5 Literatures also state the medial side to be more commonly involved than lateral on account of the anatomic course of the ophthalmic artery. This coincides with both cases in our series. Intraocular involvement has been reported to be common in the Western coun-tries and in North India, while extraocular involvement is reported in South India. This might be due to differ-ences in the types of platyhelminths in different regions, or perhaps due to climatic or environmental factors.6,7 However, this was not collateral with that seen in our study (Figs 1A and B).

In one of the cases, a 13-year-old female presented with a conjunctival swelling for past 2 months. It was soft, mildly tender, and nonreducible. Ocular mobil-ity was full and free in all directions. There was mild eosinophilia. Computed tomography scan showed mildly edematous and bulky medial rectus muscle. Intracranial cavity showed findings within the normal limits. Urine and stool examinations were normal. Also, the other case was a 14-year-old female, a nonvegetarian,

who presented with an oval mass, 6 × 4 mm on bulbar conjunctiva. It was soft, mobile, and nontender. B-scan showed a cystic cavity with parasitic infestation. She showed mild leukocytosis with eosinophilia and raised erythrocyte sedimentation rate. On stool examination, cysticercosis was found. She was given oral albendazole for 4 weeks. In both cases, cyst was excised and sent for HPE. Moreover, the patients were managed by complete surgical excision followed by albendazole therapy in a dose of 15 mg/kg/day in two divided doses, which was tapered over 4 weeks.

Multiple serous cysts were managed conservatively with topical nonsteroidal inflammatory drugs and anti-biotics. They regressed over a period of 4 to 6 weeks. Inclusion cysts were meticulously excised surgically. B-scan was helpful in most cases as it revealed a cystic lesion in these cases.

The most common conjunctival tumors in children include nevus (64%), dermolipoma (5%), lymphangioma (3%), and capillary hemangioma (3%).1,8 In this study, among the conjunctival tumors, we had four cases of dermoids and a single case of capillary hemangioma. Deeper dermoids may present in adolescence or adult-hood, while anterior dermoids typically present in first decade. Even in this series, all four cases were anterior dermoids and belonged to first decade of life. The most common location for the anterior lipodermoid cyst is at the superolateral aspect of the orbit (Figs 2A and B), which may be attached to the orbital rim at the fron-tozygomatic suture. Syndromic associations, such as Goldenhar syndrome should be ruled out.

In our study, various radiological investigations were done to see the nature and extent of lesions. In three cases, noncontrast CT orbit revealed a lipomatous lesion. Moreover, in the fourth case, a 5-year-old female child presented with a mass in left eye since childhood. It was an oval 8 × 9 mm mass found at limbus around 5 o’clock.

Figs 1A and B: (A) Subconjunctival cysticercosis; and (B) HPE: A cystic cavity with cysticercus larva having invaginated scolex and hooklets with an outer integument

A B

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Hair follicles were seen protruding out of the mass. It was firm, fixed, and yellowish brown in color. B scan and MRI showed findings suggestive of a limbal dermoid cyst. This cyst is not associated with other abnormalities, such as preauricular appendages, hemifacial microsomia, microtia, and vertebral anomalies for which an additional workup was done. Blood counts were normal. Cyst exci-sion with sectoral superficial keratectomy was done. Histopathology revealed choristomatous tissue, includ-ing epidermal appendages, hair follicles, adipose tissue, suggestive of limbal dermoid cyst.

Subconjunctival hemangiomas are a clinical rarity, with an incidence of 1 to 2% only. They generally exhibit two phases of growth, a proliferative phase and an invo-lutional phase. One half of all lesions will involute at an age of 5 years, and 75% will involute by 7 years of age. In this study, a single case of capillary hemangioma was considered (Fig. 3). Care needs to be taken while dissect-ing a conjunctival hemangioma as it may bleed profusely. But, this is not the case in our study, as it was reported to be in its involution stage.

CONCLUSION

Conjunctival lesions are not just a cosmetic blemish but can cause severe ocular discomfort and can even be vision threatening. Despite similar appearances, the serology and histopathological reports may reveal varied diag-nosis. Therefore, a detailed history, clinical ocular and systemic assessment, investigations including serology and imaging along with histopathology of the excised tissue are essential in all cases. The mainstay of treatment in majority of cases is surgical excision, and diagnosis should be confirmed by histopathological analyses. Early diagnosis and treatment can prevent vision-threatening complications.

REFERENCES

1. Shields CL, Shields JA. Conjunctival tumors in children. Curr Opin Ophthalmol 2007 Sep;18(5):351-360.

2. Shreya T, Jagriti J, Mallika K, Sapan P, Jatin W, Avijit V. Clinical study of histologically proven conjunctival cysts. Saudi J Ophthalmol 2015 Apr-Jun;29(2):109-115.

Fig. 3: Capillary hemangioma

Figs 2A and B: (A) Lipodermoid cyst; and (B) HPE: Variably stratified squamous epidermal lining. Dermis shows proliferating blood vessels with fibroconnective and adipose tissue (deeper)

A B



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3. Duke-Elder S. System of ophthalmology. Vol. VIII (Part I). London: Henry Kimpton; 1965. p. 423.

4. Bartholomew RS. Subretinal cysticercosis. Am J Ophthalmol 1975 Apr;79(4):670.

5. Cano MR. Ocular cysticercosis. In: Ryan SJ, Glaser BM, Michels RG, editors. Retina. 2nd ed. St. Louis (MO): CV Mosby; 1994. p. 1553-1558.

6. Kruger-Leite E, Jalkh AE, Quiroz H, Schepens CL. Intraocular cysticercosis. Am J Ophthalmol 1985 Mar 15;99(3):252-257.

7. Sen DK, Mathur RN, Thomas A. Ocular cysticercosis in India. Br J Ophthalmol 1967 Sep;51(9):630-632.

8. Sherman RP, Rootman J, Lapointe JS. Orbital dermoids: clinical presentation and management. Br J Ophthalmol 1984 Sep;68(9):642-652.

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An Epidemiological Study on Perception of the Cataract Patients regarding Cataract Surgery in Tertiary Care Hospital, Bareilly, Uttar Pradesh1Pankaj Kumar, 2Hari S Joshi, 3Rashmi Katyal, 4Pratyush Ranjan

ABSTRACT

Blindness is one of the significant social problems in India with 7 million of the total 45 million blind people in the world residing in our country. Major barriers to cataract surgery are poverty, no transportation, need not felt, and sex related. The low lit-eracy rate among females and poor accessibility of the surgical sites were identified as important barriers in rural areas. There was also association found between socioeconomic status and cataract among cataract patients. In this study, a total of 208 participants who attended the ophthalmology outpatient department were studied for the observation on perception of cataract patient regarding cataract surgery. Data were analyzed and results were compared with other global studies.

Keywords: Cataract, Perception, Tertiary care.

How to cite this article: Kumar P, Joshi HS, Katyal R, Ranjan P. An Epidemiological Study on Perception of the Cataract Patients regarding Cataract Surgery in Tertiary Care Hospital, Bareilly, Uttar Pradesh. Int J Adv Integ Med Sci 2016;1(4):148-150.



INTRODUCTION

Blindness is one of the significant social problems in India with 7 million of the total 45 million blind people in the world residing in our country.1 Prevalence of blindness was found to be 1.49%, with cataract contributing to 77% of it. With the increasing life expectancy and expanding population, the number of cases is expected to increase in the near future.2

The term cataract is derived from the Greek word “cataractos,” which means waterfall. Cataract is opacity or clouding of the crystalline lens that prevents light rays

OrIgInAl ArtIcle

1Postgraduate Student (3rd Year), 2Professor and Head 3Associate Professor, 4Consultant1-3Department of Community Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India4Department of Ophthalmology, National Society for the Prevention of Blindness, Shaheed Bhagat Singh Eye Hospital Bareilly, Uttar Pradesh, India

Corresponding Author: Hari S Joshi, Professor and Head Department of Community Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, Phone: +919415833751, e-mail: [email protected]

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from reaching the retina. Cataract is the main cause of low vision and blindness in the world. Majority of cataract (85%) is regarded as senile or age related with uncertain etiology. However, it is a preventable cause for blindness rectified by the use of appropriate surgical services. The absence of effective utilization of such services leaves many of those affected by it with severely impaired vision. Significantly, a majority of those living with blind-ness due to cataract and poor access to services are in the developing world.3-5 Earlier studies identified the major barriers to cataract surgery as poverty, no transportation, need not felt, and sex related. The low literacy rate among females and poor accessibility of the surgical sites were identified as important barriers in rural areas.

Blindness continues to be one of the major public health problems in developing countries. Cataract and corneal diseases are major causes of blindness in coun-tries with less-developed economies.6 According to the World Health Organization, corneal diseases are among the major causes of vision loss and blindness in the world today, after cataract and glaucoma.7

Considering the complicated epidemiology of visual impaired and wide variety of factors involved, region-specific intervention strategies are required for every community. Therefore, proving appropriate data is the first step in these communities. Various studies estimat-ing the burden of visual impairment and blindness in the elderly have been conducted in various parts of the country in the past. However, there has been lack of appropriate community-based data on prevalence of ocular morbidities on adults. Thus, in view of the impor-tance of the problem and lack of the appropriate com-munity-based data, the present study was undertaken.

AIMS AND OBJECTIVES

To find out the perception regarding the cataract surgery among cataract patients attending in Tertiary Care Hospital, Bareilly, Uttar Pradesh, India.


After taking clearance from the Ethical Committee, the indexed study was carried out at the Tertiary Health Care Hospital, Bareilly, Uttar Pradesh, India. A

An Epidemiological Study on Perception of the Cataract Patients regarding Cataract Surgery in Tertiary Care Hospital


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semi-structured schedule was prepared, modified, and finalized as needed, which included both open- and closed-ended questions. The study was pretested by carrying out pilot study on a sample of 40 cataract study participants to check feasibility and development of the schedule. These 40 study participants were not included in the study. After taking informed written consent, study participants were explained the purpose, benefits, risks, anonymity, and confidentiality of the study than face-to-face interviews with cataract study participants was done and then data collection was started. All the cataract study participants to take part in the study were interviewed till the period of study of 1 year. Data were entered and analyzed using Statistical Package for the Social Sciences version 22.0.

RESULTS

Table 1 shows that maximum number of study par-ticipants were worried about the cost of the operation (88.9%), followed by being afraid to undergo operation, fear of losing eyesight, clearly see with other eye, and fear of leading to death, which were 76.4, 59.1, 42.8, and 30.2% respectively.

Graph 1 shows that maximum number of cataract patients were from low socioeconomic class IV (47%), followed by classes V, III, II, and I, which were 33, 12, 6, and 2% respectively.

DISCUSSION

The indexed study is carried out in Bareilly, Uttar Pradesh, India, with the objective to identify the percep-tion related to cataract surgery. In the present study, the major barrier that comes out is the cost of operation, which is about 88.9% followed by afraid of undergoing an operation (76.4%) and the least is feared to death (30.2%), and also Rabiu8 and Bowman et al9 observed the same results in their respective studies, whereas some of the studies like Brian and Taylor,10 Fletcher et al,11 Melese et al,12 and Turner et al13 found that their results were not consistent with the observations as in our study.

In our study, the relationship between socioeconomic status and cataract patients was also observed and the results observed that low socioeconomic status had positive association with cataract, and Knight and Lindfield14 and Wesolosky and Rudnisky15 also observed the same results.

CONCLUSION

In this study, the maximum percentage of perception of barriers is the cost of the operation, whereas some of the studies observed the same result, and there was also association found with the socioeconomic status. That is, cataract is associated with low socioeconomic status.

RECOMMENDATIONS

This study concluded that the major barrier relating to the uptake of cataract surgery was the cost of the opera-tion, which was very high in about 88.9% of the study participants. Therefore, there is a need for government sharing, finding out the new and cheaper techniques, and, most importantly, the health education and health information among the population.

ACKNOWLEDGMENT

The authors are thankful to the faculties and staff of the Department of Ophthalmology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India for their timely support and cooperation during the research work.

REFERENCES

1. Government of India. National Health Policy 2002. New Delhi: Ministry of Health and Family Welfare.

2. Government of India. Health Information of India 1995-1996. New Delhi: DGHS, Ministry of Health and Family Welfare.

3. World Health Organization. Strategies for the prevention of blindness in national programme: a primary health care approach. 2nd ed. Geneva, Switzerland: WHO; 1997. p. 67-73.

4. World Health Organization. Approaches to prevent visual impairment in Vision 2020 the right to sight. Global initiative for elimination of avoidable blindness action plan 2006-2011. Geneva, Switzerland: WHO, IAPB; 2008.

Table 1: Perception of the cataract patients regarding cataract surgery

Perception regarding cataract surgery No (%) (208)Afraid of undergoing an operation 159 (76.4%)Worried about the cost of operation 185 (88.9%)Fear of losing the eyesight 123 (59.1%)Fear of leading to death 63 (30.2%)Can see clearly with the other eye 89 (42.8%)

Graph 1: Perception of the cataract patients regarding cataract surgery

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5. Limburg H, World Health Organization. Manual for rapid assessment of cataract surgical services prevention of blind-ness and deafness. Geneva, Switzerland: WHO; 2001. p. 1-604.

6. Garg P, Krishna PV, Stratis AK, Gopinathan U. The value of corneal transplantation in reducing blindness. Eye (Lond) 2005 Oct;19(10):1106-1114.

7. Causes of blindness and visual impairment. Last accessed 2011 Oct 30. Available from: http://www.who.int/blindness/causes/en/

8. Rabiu MM. Cataract blindness and barriers to uptake of cataract surgery in a rural community of northern Nigeria. Br J Ophthalmol 2001 Jul;85(7):776-780.

9. Bowman RJ, Jatta B, Faal H, Bailey R, Foster A, Johnson GS. Long-term follow up of lid surgery for trichiasis in Gambia: surgical success and patients perceptions. Eye (Lond) 2000 Dec;14(Pt 6):864-868.

10. Brian G, Taylor H. Cataract blindness – challenges for the 21st century. Bull World Health Organ 2001;79(3):249-256.

11. Fletcher AE, Donoghue M, Devavaram J, Thulasiraj RD, Scott S, Abdalla M, Shanmugham AK, Murugan PB. Low uptake of eye services in rural India: a challenge for programs of blind-ness prevention. Arch Ophthalmol 1999 Oct;117(10):1393-1399.

12. Melese M, Alemayehu W, Friedlander E, Courtright P. Indirect costs associated with accessing eye care services as a barrier to service use in Ethiopia. Trop Med Int Health 2004 Mar;9(3):426-431.

13. Turner VM, West SK, Munoz B, Katala SJ, Taylor HR, Halsey N, Mmbaga BB. Risk factors for trichiasis in women in Kongwa, Tanzania: a case-control study. Int J Epidemiol 1993 Apr;22(2):341-347.

14. Knight A, Lindfield R. The relationship between socio-economic status and access to eye health services in the UK: a systematic review. Public Health 2015 Feb;129(2):94-102.

15. Wesolosky JD, Rudnisky CJ. Relationship between cataract severity and socioeconomic status. Can J Ophthalmol 2013 Dec;48(6):471-477.

Impact of Health Education in Perception of Patients regarding Storage of Health Records among Patients


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Impact of Health Education in Perception of Patients regarding Storage of Health Records among Patients attending Tertiary Care Hospital, Bareilly1VK Tiwari, 2Abhishek Kumar, 3Ashok Agarwal, 4HS Joshi, 5Deepak Upadhyay, 6Pooja Bansal

ABSTRACT

Objective: To know the patients’ attitude regarding preserving records: pre- and postcounseling.

Materials and methods: A questionnaire was administered to all the subjects, and data were assessed by applying statistical test. The health education awareness is regularly carried out in outpatient department (OPD) and inpatient department (IPD) by various audiovisual aids.

Setting: A cross-sectional study was conducted among the patients from OPD and IPD of the Department of Pulmonary Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India.

Results: Out of 998 patients studied, 421 (42.2%) of them were preserving record and 577 (57.8%) did not. After counsel-ing both groups who were preserving and not preserving the records, a remarkable change was observed, i.e., 800 (80.2%) patients from OPD and IPD started preserving their records in a positive way and were bringing at the time of consultation.

Conclusion: With the sustained and regular health educa-tion/motivation, the patients realized the importance of record keeping.

Keywords: Counseling, Health awareness, Health education, Health motivation, Health records.

How to cite this article: Tiwari VK, Kumar A, Agarwal A, Joshi HS, Upadhyay D, Bansal P. Impact of Health Education in Perception of Patients regarding Storage of Health Records among Patients attending Tertiary Care Hospital, Bareilly. Int J Adv Integ Med Sci 2016;1(4):151-157.



ORIGINAL ARtIcLe

1,3,Professor, 2,6Resident, 4Professor and Head 5Assistant Professor

1,2Department of Pulmonary Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

3Department of Pediatrics, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

4,5Department of Community Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

6Department of Forensic Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Corresponding Author: VK Tiwari, Professor, Department of Pulmonary Medicine, Rohilkhand Medical College and Hospital Bareilly, Uttar Pradesh, India

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INTRODUCTION

The health record is a vital and relevant document made by a health care practitioner at the time of or subsequent to a consultation and/or examination or the application of health management. A health record/reports like X-ray, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, angiography, pulmonary function test, bronchoscopy, echocardiography, microbiological culture/susceptibility reports and other records, such as admission/discharge notes, medical certificate records, referral letters, prescriptions, etc., contain information about the health of an individual.

The importance of record keeping by the patients has been observed to be the vital throughout the life of the patient. The records should be preserved well as far as possible so that these can be utilized when the need arises, especially for the evaluation and compara-tive assessment of the patient’s health condition. Many people, especially those who are illiterate, ignorant, and unaware of the importance of keeping health records, find it irrelevant with regard to the diagnosis, treatment, and prognosis. The follow-up assessment and outcome is not possible or difficult in these patients.

Most of the patients reporting at outpatient depart-ment (OPD) and inpatient department (IPD) do not pre-serve their records. It creates difficulty for consultants to make proper diagnosis and assessment for their progno-sis and outcome. That is why, many times the patients do not find relief and sometimes it results in serious outcome. This is mostly observed in the cases of tuberculosis and other lung diseases, like pneumonia, chronic obstructive lung diseases, interstitial lung disease, malignancy, etc.

Hence, the present study has been planned to assess the perception of patients regarding record keeping and provide them health education regarding importance of storage of treatment-related documents. The studies related with personal keeping of the records by the patients have not been conducted till date, but few studies do have related data regarding storage of documents by hospital.1-4 With this study, we want to highlight that proper storage of documents is the most basic and crucial step in order to provide a better diagnostic treatment and prognostic aid in tuberculosis and other pulmonary diseases.

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A prospective longitudinal study was conducted among the patients attending OPD/IPD in Pulmonary Medicine Department, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, from July 1, 2014 to January 31, 2016. All the patients coming to OPD during the first year of study and gave consent were included in the study. Both new and old patients participated. One indi-vidual was enrolled only once in the study during his/her first visit to OPD regardless of their further course, i.e., hospital or home-based treatment.

Inclusion Criteria

• Patientsaged18yearsorabove• Onlyclinicallystablepatients,and• Patientssufferingfromchronicdiseaseslikechronic

obstructive lung disease, interstitial lung disease, malignancy, tuberculosis, etc.

Exclusion Criteria

• Patientsnotgivingconsentforstudyand• Patientswhodiedduringthestudyperiod.

A questionnaire was administered to all the patients to assess demographic details, their perception about medical record keeping on first visit as well as follow-up regarding details of maintenance of medical records. Primary data regarding the perception and practices of the patients in storing health records and demographic details were taken while enrolling patients first time in the study and health education was imparted regarding the importance of medical record keeping. Sources of health education were: Individual/group motivation, videos/skit programs, pamphlets, leaflets, folders, instructed files, brochures, display boards, posters, and banners.

First follow-up was done after 1 month of enrollment in the study and practices of storage of health records were assessed. During the first follow-up, the patients were reeducated again regardless of their practices of record keeping. Second follow-up was done after 3 months of enrollment; the impact of health education and counselling was viewed by assessing their practices regarding record keeping. While assessing the prac-tices, important medical documents like radiological investigations (X-rays, ultrasonography, CT scan, and MRI), pathological investigations, other investigations like echocardiogram, electrocardiogram, and previous prescriptions were included in medical records.

OBSERVATIONS AND RESULTS

The present study was carried out as a prospective study to assess the patient’s knowledge about carrying

the documents at the time of hospital visits, to assess the methods of keeping important documents, their perception regarding importance of document, and to assess impact of health education in proper storage of health records.

During the study period for first inclusion of patients, a total of 1,028 patients were enrolled in the study.However,only998patientscameforcompletefollow-up,i.e., two follow-up visits and were included in the final analysis of results. These patients were also evaluated based on the demographic profile.

Of998patients,631(63.2%)patientsweremales,664(66.5%)belongedtoagegroupof36to65years,and766(76.8%)werefromruralbackground.Majoritypatientswereilliterate–658(65%),married–852(85.4%),laborbyoccupation–458(45.9%),andfromnuclearfamily–598(59.9%).Inaddition,502(50.3%)patientsweregivenIPD-basedmedicalcareandrest,496(49.7%)patients,weregiven home-based treatment and OPD-based follow-up (Table 1).

Outofa totalof998patients,only42.2%hadtheirprevious records preserved and good practices of main-taining health record. After providing proper counseling and health education to both groups, who were preserv-ing and not preserving the records, in the first month of follow-up, there was an increase in record keeping bypatientsfrom42.2to78.2%andonsecondfollow-up(onthirdmonth)itreached80.2%.Whiletestfordiffer-ence is done in proportions, change in practices among patients for keeping the records and carrying at the time of consultation was found to be significant (p < 0.001). Therefore, there was significant increase in practice of record keeping after health education.

There was significant increase in record keeping prac-tices in both sex, both rural and urban residents, in both IPDandOPDpatients,andbothnuclearandjointfamilybackground. But, only significant increase in record keeping was seen in married persons in comparison to unmarried persons (Table 1). It shows that proper health education increases record keeping practice in all persons regardless of their gender, age, education, occupation, family type and treatment pattern type. Therefore, health education targeting the general population will help in improving the good habit of record keeping regardless of basic demographic characteristics.

Table 2 shows questions and response of patients who did not store records. Among all, the most common reason for not storing records was that 221 (38.3%)thought that storage was not necessary as the disease was cured, course completed, or became asymptomatic, 161 (27.9%) were ignorant about record keeping, 125(21.7%)didnotcareorthoughtthatitwasnotnecessary,and70(12.1%)hadlostordestroyedrecordsbysomeone



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Table 1: Demographic profile of the patients enrolled in the study

Demographic characteristics

Number of patients (n = 998)

Patients with previous practices of maintenance of health record (n = 421)

Patients who preserve records after follow-up1 month (n = 780) 3 months (n = 800) p-value (Extended

Mantel–Haenszel chi-square for trend)No. of patients No. of patients

GenderMale 631 (63.2%) 294 (69.8%) 511 (65.5%) 521 (65.1%) <0.001Female 367 (36.8%) 127 (30.2%) 269 (34.5%) 279 (34.9%) <0.001Age (years)14–25 114 (11.4%) 84 (20%) 82 (10.5%) 88 (11%) <0.00126–35 132 (13.2%) 80 (19.0%) 108 (13.8%) 108 (13.5%) <0.00136–45 210 (21%) 100 (23.8%) 172 (22.1%) 172 (21.5%) <0.00146–55 251 (25.2%) 73 (17.3%) 189 (24.2%) 199 (24.9%) <0.00156–65 203 (20.3%) 50 (11.9%) 159 (20.4%) 163 (21.2%) <0.00166–75 50 (5%) 10 (2.4%) 36 (4.6%) 36 (4.5%) <0.001>75 38 (3.8%) 24 (5.7%) 34 (4.4%) 34 (4.3%) <0.001ResidenceRural 766 (76.8%) 281 (66.7%) 578 (74.1%) 598 (74.8%) <0.001Urban 232 (23.2%) 140 (33.3%) 202 (25.9%) 202 (25.3%) <0.001EducationIlliterate 658 (65%) 245 (58.2%) 508 (65.1%) 528 (66%) <0.001≤5th standard 124 (12.4%) 28 (6.7%) 104 (13.3%) 104 (13%) <0.0016th to 10th standard 140 (14%) 96 (22.8%) 104 (13.3%) 104 (13%) <0.001Graduate and above 76 (7.6%) 52 (12.4%) 64 (8.2%) 64 (8%) <0.001Marital statusMarried 852 (85.4%) 311 (73.9%) 668 (85.6%) 668 (83.5%) <0.001Unmarried 146 (14.6%) 110 (26.1%) 112 (14.4%) 112 (14%) 0.914IPD/OPDIPD 502 (50.3%) 235 (55.8%) 424 (54.4%) 428 (53.5%) <0.001OPD 496 (49.7%) 186 (44.2%) 356 (45.6%) 372 (46.5%) <0.001OccupationUnskilled labor 188 (18.8%) 66 (15.7%) 148 (19%) 162 (20.3%) <0.001Skilled labor 270 (27.1%) 122 (29%) 208 (26.7%) 208 (26%) <0.001Businessman 109 (10.9%) 34 (8.1%) 93 (11.9%) 93 (11.6%) <0.001Employee/job 76 (7.6%) 30 (7.1%) 64 (8.2%) 64 (8%) <0.001Medical/paramedical Staff 12 (1.2%) 6 (1.4%) 12 (1.5%) 12 (1.5%) <0.001Student 44 (4.4%) 28 (6.7%) 32 (4.1%) 32 (4%) <0.001Unemployed 46 (4.6%) 6 (1.4%) 36 (4.6%) 36 (4.5%) <0.001Household work 243 (24.3%) 123 (29.2%) 181 (23.2%) 187 (23.4%) <0.001Others 10 (1.0%) 6 (1.4%) 6 (0.8%) 6 (0.8%) 0.825Family typeJoint 400 (40.1%) 157 (37.3%) 314 (40.3%) 322 (40.3%) <0.001Nuclear 598 (59.9%) 264 (62.7%) 466 (59.7%) 478 (59.8%) <0.001Total 998 (100%) 421 (100%) 780 (100%) 800 (100%) <0.001

else.Moreover,255(44.2%)puttheirrecordsindustbin,destroyed, or threw them, 192 (33.3%) used them inhouseholdpurposes,95(16.5%)gaverecordstochildrenfor playing, and 40 (6.9%) used in making decorativeitems like flower pot, window sheets, etc. Maximum 339 (58.8%)ofpatientsdisposedtheirrecordsafterthediseasecuredandrest238(41.2%)hadsomeotherreasons.

Table 3 shows questions administered to patients and their response regarding their way of storing documents. Itwasfoundthat214(50.8%)ofthemkepttheminthickcarrybag,198 (47%) inprescriptionfile,while9 (2.1%)

patientskeptthemwithoutfileorbag;388(92.2%)patientskeptthemflat,7.4%oftheminfoldedmanner,and0.5%didnotcare;114(27.1%)keptrecordsonflatsurfacewithcoverand35(8.3%)withoutcover;154(36.6%)keptrecordsincupboard/drawer/box/suitcaseandsomeofthem86(20.4%)hungonwall;32(7.6%)onwindowordoor.In71(16.9%)patientsrecordswerewithinreachtothechildren;39(9.3%)patientskeptrecordsindifferentplaces,whereas382(90.7%)keptinoneplace;260(61.8%)patientsbroughtrecords in unarranged manner when reporting to the doctor,while161(38.2%)broughttheminarrangedmanner.

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DISCUSSION

Theprimaryobjectiveofpatient-relateddocumentsistoenable the treating health care practitioners to provide quality health care to the patients. It is thus a living docu-ment that tells the past and present story and forecasts the happenings in the future, if the records are adequately preserved and maintained and it also facilitates the health care professionals at each visit. In other words, the patient’s health record is a powerful tool that facilitates the treating physicians to view the patient’s medical history and identify their problems or pattern of sickness that may help to determine the course of health care.

Thisappearstobethefirststudyonthissubjecteverconducted in the field of medicine. Various studies have been carried out pertaining to the storage of records by hospitals in developed countries,5,6 but in developing coun-tries like India, where these facilities are not available in all hospitals, the patients have no alternative except to store their records in a proper manner. For this, the patients are given health education in various health education aware-ness programs in the Department of Pulmonary Medicine and Community Medicine of RMCH.

Health awareness programs are regularly carried out in OPD and IPD through audiovisual aids, such as (1) liquid crystal display projection, (2) motivation(group and individual). Regular group health education activities are being carried out twice a week in wards for

patients, their relatives and friends by: (3) Distribution of booklets, leaflets, and through health education boards, (4) various camps, such as World TB Day, World Asthma Day, World No Tobacco Day, World chronic obstructive pulmonary disease Day, and World Health Day camps, (5) thick envelope, thick files with clips, and hard poly bags are provided to patients to store their documents safely in proper manner. The health education activi-ties and health day camps are carried jointly by theDepartment of Pulmonary Medicine and Community Medicine(Figs1to7).

Table 2: Questions and response of patients who do not store records

Response

Number of patients (n = 577) Percentage

Why?Do not care/not necessary 125 21.7Do not know that they have to store records

161 27.9

Storage not necessary as disease cured/course completed

221 38.3

Lost or destroyed by someone else 70 12.1Do you?Give records to children for playing 95 16.5Use for household purposes (in place of window, dusting or cleaning purposes, etc.)

192 33.3

Put them in dustbin/damage or throw

255 44.2

For making decorative item 40 6.9At what time you dispose (or throw)?After death of patient 28 4.9After disease cured 344 59.6After present course of treatment 66 11.4During course of treatment 44 7.6After the next X-ray is done 40 6.9Got old and damaged by its own 60 10.4

Table 3: Questions and response of patients who store records

Response

Number of patients (n = 421) Percentage

How do you keep them?Prescription file 198 47.0Carry bag made of polythene, paper, or cotton

214 50.8

Without file or bag 9 2.1Do you keep them?Flat 388 92.2Folded 31 7.4Do not care 2 0.5Where do you keep records?Hanging on wall 86 20.4Hanging on window or door 32 7.6On flat surface with cover 114 27.1On flat surface without cover 35 8.3In cupboard, drawer, box, or suitcase 154 36.6Do children reach to records?Yes 71 16.9No 350 83.1Where do you keep them?One place 382 90.7Different places 39 9.3How do you bring them to doctor?Properly arranged (with respect to date, in one place or file and complete records)

161 38.2

Unarranged (not in sequence, not in one place or file and incomplete records)

260 61.8

Fig. 1: Liquid crystal display TV projection in OPD



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Fig. 2: Group motivation in ward Fig. 3: Health education in ward

Fig. 4: Individual motivation in OPD

Thus, good record keeping by the patients has been observed to promote the better understanding of the health problem by the treating physicians in better way and within the short possible interaction session. The properly preserved records of the patients embrace trans-parencies and in fact these records speak themselves in

Fig. 5: Health education boards

a clear way and these may further promote better com-munication, understanding, and a sound health care provider and beneficiary relationship.

In our study, 577 (57.8%) patients did not preserve theirhealthrecordsandamongthem161(27.9%)patientswere ignorant about the benefit of health record keeping as they had not been told by anyone to store their health records;221(38.3%)thoughtintheirmindthatitsstoragewas not necessary as the disease got cured or course had been completed and the next time doctor would not consider their old records and would advice new inves-tigations. In these patients health education has shown remarkable change during two counseling done in first and 3 month of follow-ups, as the percentage reduced to 21.8%andfurther19.8%(Table2).Thiscreatedahopethat merely on health educating on different occasion, we can change or correct the perception of an individual.

Not only educating individuals to store their health records, our aim also included to make them aware to the proper method of health records storage, so that they do not get damaged and persist with patient for longer duration. The health records should be kept in thick carry

Composition

Sticky Note

Please check artwork

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bag or file, unfolded (especially X-rays, CT, MRI, etc.) in proper safe place away from the reach of small children and properly arranged in one place, which reduces inconvenience to the doctor and allow him to understand the disease early. The awareness was spread among the patients who were not aware of the proper method of health records storage.

CONCLUSION

With the sustained and regular health education/ motivation, the patients realized the importance of record keeping. It also improved the proper diagnosis, manage-ment, and prognosis of the case. On postcounseling, there was marked improvement in data storage.

Fig. 6: Health education through booklet/leaflet

Figs 7A and B: (A) Thick OPD files; and (B) hard envelopes

This study has shown that the documentation of the patients suffering from respiratory diseases can be improved by the health education activities on this aspect. These findings can also be utilized in other medical specialties, such as orthopedics, pediatrics, medicine, surgery, etc.

REFERENCES

1. Tang PC, Ash JS, Bates DW, Overhage JM, Sands DZ. Personal health records: definitions, benefits and strategies for over-coming barriers to adoption. J Am Med Inform Assoc 2006 Mar-Apr;13(2):121-126.

2. Tang PC, Lansky D. The missing link: bridging the patient-provider health information gap. Health Aff (Millwood) 2005 Sep-Oct;24(5):1290-1295.

A B



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3. Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability. Health Aff (Millwood). Health Affairs Web Exclusive, January 19, 2005.

4. Bates DW. Physicians and ambulatory electronic health records.HealthAff(Millwood)2005Sep-Oct;24(5):1180-1189.

5. Health Professions Council of South Africa: Guidelines on keeping of patient records. Booklet 14. Pretoria, May 2008.

6. Pellegrino ED. Medical professionalism: can it, should it survive. J Am Board Fam Pract 2000 Mar-Apr;13(2): 147-149.

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Prehospital Trauma CareSM Sharma

ABSTRACT

The global human population is spread all over the world, but cities, towns, and large villages have dense concentrations of human inhabitation. The inhabitants of cities and towns do have easy and satisfactory access for the management of traumatized patients. However, trauma victims in remote and distant regions, generally, do not have ambulance services or treatment centers nearby to deal effectively with injuries. Even on highways, at accident sites, the injured may succumb to the injuries due to delay in rescue and nonavailability of vital basic life support compounded by delay in transportation of the patient to appropriate hospital or dedicated trauma center. Other factors which add to mortality are nonavailability of trained and experienced personnel at the accident site, inad-equate and improper resuscitation during transportation, and referral to a hospital ill-equipped to treat traumatized patients. Trauma is the leading cause of death for patients in their first four decades of life. Prehospital trauma care to save life has not received the necessary attention in developing world due to diverse reasons, including lack of trained staff, inadequate funding, lack of awareness, ignorance, lack of will, and unpre-dictability of occurrence of accidents. Trauma management remains neglected in third world countries; however, the devel-oped countries have made continuous efforts to save lives of traumatized patients by systematized prehospital care at the site of accident, rescue, and extrication of victims, rendering life-saving resuscitation on the spot and quick and safe evacuation of the patients to trauma centers by surface and air ambulances depending upon the terrain and distance of the site of occur-rence from hospital with continuous monitoring of the patient onboard. Prehospital trauma care needs focused attention to evolve a system and institutions which would impart care to the wounded inclusive of rescue, resuscitation, stabilization of vital parameters, and safe transportation to a dedicated hospital to save life and prevent morbidity.

Keywords: Basic life support in trauma, Emergency surgical care, Prehospital trauma care, Trauma.

How to cite this article: Sharma SM. Prehospital Trauma Care. Int J Adv Integ Med Sci 2016;1(4):158-163.



INTRODUCTION

Trauma is the leading cause of death for patients in their first four decades of life.1 With rapid industrialization,

orIgInAl ArtIcle

Professor and Head

Department of Surgery, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Corresponding Author: SM Sharma, Professor and Head Department of Surgery, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, Phone: +917895387710 e-mail: [email protected]

10.5005/jp-journals-10050-10052

urbanization, and increased volume of traffic on roads, about six million people lose their lives annually due to injuries and 90% of these injured belong to underdevel-oped world. In addition, an overwhelming proportion of these deaths occurs before patients even reach the hospital.2 Due to nonavailability of basic care, 30% of deaths occur at the site of accident and 80% of remaining patients die in the first hour after the injury, the golden hour, the timeframe during which patients could have been saved had they reached the trauma center safely. The traumatized may die on the spot due to injury to heart, major vessels, vital organs, including brain, and crush injuries. These deaths occur due to airway obstruc-tion, failure of breathing, massive hemorrhage, and polytrauma. Prehospital basic life support after rescue of the injured and quick and safe evacuation to a trauma center by trained paramedics within 1 hour after the occurrence of injury may save the patient in first golden hour. The “golden hour” as summarized by the 3R rule of Dr Donald Trunkey, an academic trauma surgeon, is: “Getting the right patient to the right place at the right time.”3 Evacuation of patients to hospital safely at the earliest definitely improves survival and outcome.

The concept of prehospital trauma care has emerged after the experiences of injuries sustained by soldiers in wars. Napoleon’s Army had in service the flying ambu-lances which carried surgeons and medical supplies to the battle field and transported wounded soldiers to rear. These horse-driven carriages were put to use by Napoleon’s surgeon Dominique-Jean Larrey in 1792. The battles and wars have consistently strengthened the importance of prehospital trauma care. Each and every war inclusive of Gulf War, Korean Peninsular Conflict, and Vietnam War has highlighted the importance of on-the-spot rescue, resuscitation, basic life support, and evacuation of severely wounded back to appropriate hos-pital by quickest possible means by helicopters and fixed wing aircrafts with trained and experienced emergency medical personnel traveling with casualties as attendants. This concept of evacuation of the casualties made stable by life-support measures and fit to travel from battle field to rear has definitely helped to save lives. No patient in an unstable condition or inadequately supported to sustain and undertake long journey be transported till declared fit to undertake journey.

Indian Armed Forces, especially the Indian Army, has evolved an exceedingly successful system of prehospital

Prehospital Trauma Care


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trauma care for the traumatized patients due to gunshot wounds, shell blast injuries, accidental falls into crevices in glacier, avalanche injuries sustained in remote regions of India in high altitude battleground of Siachen glacier, and other heights of Ladakh since 1984, which includes basic life support at the front line by a trained medical officer and his team, quick stabilization, and evacuation by small or large helicopters depending on the condition of the patient and necessity of sick attendants. Patients with mild to moderate injuries travel in sitting position without an attendant, whereas severely wounded lying patients who require trained attendants travel by larger helicopters to base camps where they are resuscitated and comforted. The patients can also be evacuated to General Hospital (GH) or the Medical Aid Complex, i.e., located within an hour’s reach by helicopter flight through and above tall snow-covered mountains in rarified air. Aerial evacuation can only be carried out during daylight and in good weather conditions. It is not uncommon for pilots to spot the injured in glacier after the last light and evacuate the patients from Karakoram ranges in adverse weather conditions to hospitals beyond Ladakh ranges. The sur-vival rate of the injured evacuated by air reaches 100% because of highly satisfactory initial life support, quick air evacuation, and early corrective intervention. The GH has comforts of controlled temperature and facilities of specialized intervention. From GH, the patients can be shifted to tertiary care hospitals in plains by fixed-wing aircrafts. The system of chain of rescue, basic life support, evacuation, resuscitation, intervention, and onward trans-fer for highly specialized management is institutional-ized with no scarcity of human and material resources. The aerial evacuation is easy, simplified, and available on demand from not so distant multiple helipads.

AIMS AND OBJECTIVES

The injured may be left unattended and unnoticed at the site of accident and patient may be damaged further by ignorant and untrained bystanders who by improper but good- intentioned handling of the victim may cause more harm, a situation far worse than getting delayed due to want of resuscitation and transfer to hospital. Aim of prehospital care is to save the life of acutely trauma-tized patient by prompt rescue and extrication of injured, provide basic life support by experienced personnel, resuscitation, and early evacuation to appropriate hospital.

Trauma occurs due to diverse reasons like road traffic accidents, falls, interpersonal violence, industrial acci-dents, wars, battles, fires, physical agents, cold injuries like frost bite and sports injuries. There is direct relationship between occurrence of trauma deaths and illiteracy, lack of awareness about safety precautions, poor governance, and mismanagement, lack of respect for norms, undisciplined

conduct, and irresponsible behavior. Trauma deaths have trimodal distribution. Nearly 50% of victims lose their lives immediately or a few minutes after injury called the first peak. Second peak results in 30% deaths within the first 4 hours after injury and third peak with 20% deaths occurs days and weeks after resuscitation and treatment in hospital due to complications.

During major accidents involving large number of casualties, role of prehospital trauma management and hospital services are stretched to maximum. In such situ-ations, those patients who need immediate resuscitation, evacuation to trauma centers for surgery must be sorted out or prioritized from less traumatized to focus on the most needy patients both for resuscitation, transfer, and surgery. Trauma accounts for occupation of 10% of hospital beds, and is the fourth most common cause of death and results in loss of many years of productive life.

Objectives of prehospital trauma care involve prompt communication and activation of the system, proper actions at the scene of the crash by first responders, and the prompt response of the system or simply offer fastest possible basic life support that includes airway, breathing, control of bleeding, and transportation of the right patient to the right place at right time.4 The main objectives and steps involved in prevention of deaths and morbidity due to trauma should involve detection of accidents and injury, the site of accident, duration and time of accident, mode of injury, the number of casualties affected, established mechanism to report the accident at the earliest to nearby hospitals, administrative authorities, nearest ambulance services, calling for help of trained paramedics and emergency medical technicians. The next step should be to resuscitate the injured by basic life-support measures like arrest of hemorrhage, mainte-nance of airway, protection of cervical spine, restoration of breathing, infusion of intravenous or intraosseous fluids, endotracheal intubation, splintage of fractured bones, and early evacuation to a trauma center or a hospital equipped to treat traumatized patients. Level of care, offered at the site, varies according to the facilities available in a given situation.5

PREHOSPITAL TRAUMA CARE IN INDIA

India remains one of the countries having large number of deaths due to trauma, which is preventable and also manageable provided an effective prehospital trauma care system is in practice. Level of care, offered at the site, varies according to the facilities available in a given situation.5

Currently, there is no uniform policy or a system to direct the management of traumatized before they reach the appropriate and designated hospital for trauma man-agement. In India, half a million patients sustain injuries

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due to road traffic accidents alone annually and about 150,000 lose their lives in such accidents. Despite such a grave loss of precious lives and immense loss of produc-tive years and working hands, no prehospital trauma care exists in India except in the Armed Forces which has been able to successfully utilize resources to provide an excellent world class or even the best prehospital care to wounded even in remotest regions like snow bound high mountains of Ladakh inclusive of location of casualties in desolate places, picking them up safely by small and large helicopters, bring them to resuscitation centers, and transferring them onward to designated hospitals by helicopters and even by fixed-wing aircrafts to ter-tiary care hospitals in North Indian plains. However, no such policy or a health service exists for traumatized on easily accessible highways. There is no system of mobile clinics replete with life-saving equipment and trained man power to locate and pick up the injured.

CREATING AWARENESS AMONG MASSES

India is a developing state with a large expanding popula-tion, migration, industrialization, and increasing network of surface transport resulting in more and more accidents. The trauma services have not been developed to keep pace with the needs for ever-increasing traumatized patients. There is urgent need to educate and enlighten the masses about the necessity to prevent accidents and injury, enforce law and discipline to check the offend-ers on workplace, roads, and industrial units. All-out attempts must be put in to educate people to provide first aid to injured people. Simple steps for stopping bleeding from external wounds, application of tourniquet, jaw thrust can be provided by bystanders before the arrival of trained paramedics or technicians. Media too can play a role in disseminating such useful techniques. All citi-zens can be advised and trained or even guided as how to pick up wounded with spinal injury. Interested citi-zens, police personnel, fire fighters, unemployed youth, students, shopkeepers, and petrol pump personnel can be trained to help patients by the skills they would learn from educators.

PREHOSPITAL CARE TRAUMA SERVICES AND NATIONAL CADRE

A national prehospital trauma care cadre should be developed particularly to cater for the injured on high-ways and roads. Mobile ambulance services must be organized which should be operationalized by trained paramedics and emergency medical technicians and the mobile ambulances should be self-sufficient in life-saving equipment like endotracheal tubes, ambu bags, drugs, infusion fluids, and defibrillators besides having

tourniquet, dressing material, and devices for rescue. The reporting of occurrence of trauma should be entrusted to passersby, local self-government leaders, and local officials. In high-volume road traffic injuries, doctors and nurses too should form the dedicated team for prehospital trauma care. All large hospitals must have quick reaction teams of highly trained staff including doctors trained as intensivists who should be ready to move to accident site and manage the severally injured and escort them to hospitals for definitive management. Therefore, a state and national-level institutionalized prehospital trauma care service be evolved under a single autonomous authority both at national and state level adequately funded, resourceful, and manned by experienced trained human power. The rural and remote regions too should be similarly covered under prehospital trauma care health service. Nongovernmental organizations, vol-unteers, and traditionally devoted bodies too can be involved in such humane tasks. The prehospital trauma care services can be selectively outsourced to private parties to lessen the burden on state services.

Air Ambulances

Western countries started developing prehospital trauma care for civilians decades back inclusive of mobile ambu-lances, paramedics, and emergency medical technicians and moving further to undertake air evacuation of injured by helicopters and even by fixed-wing aircrafts. Such services have been made functional by state in a few countries, and in some countries air ambulances are being financed by charity organizations and private parties (Fig. 1).

India too must have air ambulances financed by state and private parties to evacuate the patients to defini-tive centers to treat trauma. Evacuation by air not only reduces the time interval between occurrence of injury

Fig. 1: Injured patient can be airlifted by air ambulance from remote regions during first golden hour in a sitting position by small helicopters



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and definitive treatment at designated trauma center or a hospital but is also cost-effective comparable to on-road ambulance services. Only those patients should be air-lifted who are fit to undertake journey, and the trauma-tized patients must be stabilized before airlift to hospitals. The paramedics or the first responders must not waste valuable time in resuscitating the traumatized at accident sites like trying to do central venous catheterization or conducting difficult intubation which may turn out to be beyond their capabilities. Air evacuation of traumatized means saving valuable time to preserve the patient within first golden hour and reducing mortality.

Trauma Centers

Trauma centers came into existence in the United States five decades back and we too need these. These centers are dedicated to traumatized patients and are open 24 hours and has a trauma team to manage such patients. The exclusive care for injured is directed only to trauma and, therefore, is focused on resuscitation and injured parts by a dedicated team of anesthesiologists, surgeons, orthopedic surgeon, maxillofacial surgeon, and others. Trauma centers reduce mortality and save lives five to eightfold. India must have trauma centers at high-volume injured turnout cities and towns. Personnel living near the highways too must be trained in basic life support and first aid to augment subsequent management by trauma centers (Fig. 2).

Basic Life Support and First Responders

First responders are the persons who reach the scene of accident first and assess the situation, call for help, try to extricate the injured without causing further damage. These bystanders help trained paramedics who are trained to give life support in maintaining the airway,

protecting the cervical spine, maintain breathing, con-trolling bleeding by external compression, give oxygen therapy, assist in ventilation and improving circulation, and helping in early and safe evacuation to hospital.

Advance Life Support

Advance life support to injured is provided by highly trained and skilled paramedics, who can intubate the patient, infuse fluids by intravenous fluids, perform cri-cothyroidotomy, stabilize the spine, and prevent further injury. However, the question of attempted “Stay and play” vs “scoop and run” approach in the management of trauma has no clear-cut answer.6

Stay and Play

Stay and play means that patient may be delayed at the accident site for evacuation to a hospital and is being revived and resuscitated. Undue delay in sending the patient to a definitive hospital may result in loss of valu-able time compromising the patient safety. Therefore, too much time should not be spent in undertaking pro-cedures which may go wrong. The patient can be given life-support help and transferred to hospital if fit to undertake journey safely. Air evacuation may be called to save time and life by quick transfer.

Scoop and Run

Scoop and run involves immediate to early evacuation of the patient to hospital. A seriously wounded patient must be given life-saving help and resuscitation before premature transfer of the patient to hospital. The deci-sion to hold back or immediately transfer the case to hospital must be taken by an experienced doctor. Scoop and run is a good practice for a patient unlikely to benefit by retention at the accident site or who does not require life-saving measures. Such patients may have a bony trauma, or a patient with brain injury who may need early decompression. The scoop and run decision reduces the time for definitive surgery which may save the life; however, stay and play may be required in a patient who is in urgent need of basic life support like airway restoration, breathing, and arrest of hemorrhage. In such a situation, valuable time should not be wasted in unnecessary manipulations which may be without reward and fruitless. A strong medical commander of experience must in either of the procedure take a decision in favor of scoop and run or stay and play. It is, therefore, vital that rescue team and the initial basic life support and advanced life-support system should have provision of inclusion of highly experienced doctors, nurses, and technicians.

Fig. 2: Patients with gunshot wounds must be evacuated at the earliest to hospitals after basic life support to save their lives

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Airway Management

Airway management had been advocated in patients with traumatic brain injury, cervical spine, or thoracic trauma before evacuation unless the same can be performed easily en route.7 Despite the claimed advantages, prehos-pital endotracheal intubation (ETI) and rapid-sequence induction performed by less-experienced paramedical staff lead to higher mortality and poorer neurologic outcomes.7 Patients with brain injury do benefit by pre-hospital ETI but it may turn out to be inappropriate in a patient with hemorrhage. Endotracheal intubation needs skill and experience and may be of much harm in the hands of inexperienced paramedic. Laryngeal airway mask is valuable for its simplicity and safety.

Intravenous Fluid Management

Prehospital fluid resuscitation for major trauma is contro-versial.8 Traumatized patients with blood loss may need intravenous fluids in shocked state. At scene, intravenous infusion with crystalloids in optimum volume will be of immense value when the patient may be anticipated to reach the trauma center after the first golden hour. Too much infusion of fluids may provoke bleeding from open wounds resulting in loss of clotting factors. Prime impor-tance must be placed first in arresting bleeding from open wounds. Closed cavity hemorrhage cannot be managed at accident site. At scene, intravenous cannulation may not be possible due to collapsed veins and, therefore, central venous catheterization or simpler intraosseous infusion may have to be resorted to. Infusion of drugs like tranexamic acid is useful. Central venous catheterization should be done by an experienced and confident person preferably an anesthesiologist. Too much time should not be compromised at scene for a procedure which may utilize precious time. After injury and during transpor-tation patient must be guarded against hypothermia, acidosis, and coagulopathy.

Control of Bleeding and Pain Management

Bleeding should be controlled by direct and indirect pressure, elevation, wound packing, tourniquet, and hemostatic agents. Quick clot granules will arrest the hemorrhage by absorbing water when it comes in contact with blood and concentrates the clotting factors and platelets, thereby it stops bleeding. The patient must be kept free from pain by analgesia and sedatives. The pain can be reduced by stabilization of spine and splintage of fractured bones.

CONCLUSION

Trauma is preventable and should not occur if all pre-cautions are taken to avoid it. High speed, indiscipline,

lack of regulatory control, lax laws, drunk driving, bad roads, old vehicles, overloaded vehicles, inexpe-rienced driving, teen driving, lack of proper training for driving, ignorance of traffic rules, lack of persever-ance and haste in pushing the vehicles ahead, lack of prehospital trauma care, and virtual absence of trauma centers are principal causes of mortality due to injuries on roads.9

Prehospital trauma care needs an institutionalized nationwide dedicated service under single authority at national and state levels. A mechanism has to be evolved for immediate reporting of occurrence of injury at any geographical location in India by local officials and people. Mass education of entire eligible population must be done as first aid providers, which should include train-ing in rescue and extrication of victims, arrest of hemor-rhage by pressure or packing, and airway restoration. Help of voluntary organizations and mass media should be taken in reaching out to masses for awareness. The first responders should have a dedicated team of trained paramedics and highly experienced technicians. Ideally, there should be a quick reaction team which should have on its panel dedicated doctors and nurses for initial care at scene who should provide advance life support to injured patients. All hospitals again should have Quick Reaction Medical Team manned by critical care intensivists who should reach the scene to provide necessary care before the transportation of patients to hospital.

Nation should usher in a network of mobile and air ambulances for quick on-board resuscitation and trans-portation of patients to hospitals. Large cities and towns should have exclusive trauma centers to render focused care to injured traumatized patients.

REFERENCES

1. American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors. Chicago: American College of Surgeons; 1997. p. 10.

2. Krug EG, Sharma GK, Lozano R. The global burden of inju-ries. Am J Public Health 2000 Apr;90(4):523-526.

3. Lerner EB, Moscati RM. The golden hour: scientific fact or medical “urban legend”? Acad Emerg Med 2001 Jul;8(7):758-760.

4. Cotton BA, Jerome R, Collier BR, Khetarpal S, Holevar M, Tucker B, Kurek S, Mowery NT, Shah K, Bromberg W, et al. Guidelines for prehospital fluid resuscitation in the injured patient. J Trauma 2009 Aug;67(2):389-402.

5. Sasser S, Varghese M, Kellermann A, Lormand JD, editors. Pre-hospital trauma care systems. World Health Organization Geneva; 2005. Available from: http://www.who.int/violence_injury_prevention/ publications/services/39162_oms_new.pdf.

6. Gold CR. Prehospital advanced life support vs “scoop and run” in trauma management. Ann Emerg Med 1987 Jul;16(7):797-801.



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7. Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, et al. Prehospital rapid sequence intubation improves func-tional outcomes for patients with severe traumatic brain injury: a randomized controlled trail. Ann Surg 2010 Dec;252(6):959-965.

8. Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G, European Resuscitation Council. European Resuscitation Council guidelines for resuscitation 2005. Section 4 Adult advanced life support. Resuscitation 2005 Dec;67 (Suppl 1):S39-S86.

9. Sharma SM. Road traffic accidents in India. Int J Adv Integ Med Sci 2016;1(2):57-64.

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The Study of Sociodemographic Profile of Pediatric Tuberculosis Patients in Bareilly District, Uttar Pradesh: A Cross-sectional Study1Piyush Gupta, 2Arun Singh, 3Hari S Joshi, 4Pankaj Kumar, 5Himalaya Singh

ABSTRACTIntroduction: Tuberculosis in children is mainly due to failure of tuberculosis control in adults. In India, over 100,000 children die from tuberculosis every year. The risk of developing disease after infection is determined by various factors, including age at exposure, sex, family, and socioeconomic status. There are no such studies carried out in Bareilly district till date; therefore, with this view, this study is being conducted.

Aims and objectives: To know the sociodemographic profile of pediatric tuberculosis patients in Bareilly district.

Materials and methods: A cross-sectional study was carried out on 120 children aged 0 to 14 years registered at various tuberculosis units (TUs) in Bareilly district. The selection of TUs was done by simple random sampling.

Result and conclusion: Out of total 120 cases in the study, majority of them were females (65%), followed by 35% male pediatric tuberculosis cases; 61.7% study participants belonged to 10 to 14 years of age, and 51.7% belonged to lower socio-economic status.

Keywords: Pediatric, Socioeconomic status, Tuberculosis.

How to cite this article: Gupta P, Singh A, Joshi HS, Kumar P, Singh H. The Study of Sociodemographic Profile of Pediatric Tuberculosis Patients in Bareilly District, Uttar Pradesh: A Cross-sectional Study. Int J Adv Integ Med Sci 2016;1(4):164-166.



INTRODUCTION

Tuberculosis (TB) remains a worldwide public health problem caused by Mycobacterium tuberculosis. The actual burden of pediatric TB is not known due to diagnostic difficulties. It is assumed that about 10% of total TB load is found in children. Globally, about 1 million cases of pedi-atric TB are estimated to occur every year, with more than

orIgInAl ArtIcle

1,4Junior Resident (3rd Year), 2Professor, 3Professor and Head 5Junior Resident (2nd Year)

1-5Department of Community Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Corresponding Author: Piyush Gupta, Junior Resident (3rd year), Department of Community Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, Phone: +918475975207, e-mail: [email protected]

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100,000 deaths.1 Among the new TB cases, 5% of patients were in pediatric age group (0–14 years).2 Children rarely have sputum smear positive TB and it is unlikely that they are a powerful source of transmission of TB. Tuberculosis in children is mainly due to failure of TB control in adults. The risk of infection to a child depends on extent of expo-sure to infectious droplet nuclei. An infant whose mother has sputum smear positive pulmonary tuberculosis has a high chance of becoming infected.3 The risk of developing disease after infection is determined by various factors, including age at exposure, nutritional and immune status, genetic factors, virulence of the organism, and magnitude of initial infection.4

AIMS AND OBJECTIVES

The aim of this article is to know the sociodemographic profile of pediatric TB patients in Bareilly district.


A facility-based cross-sectional study was carried out at various tuberculosis units (TUs) of Bareilly district, Uttar Pradesh, India, from December 2014 to November 2015 on all pediatric patients in the age group of 0 to 14 years diagnosed as TB and registered under Revised National Tuberculosis Control Program (RNTCP).

Prevalence of pediatric TB in India (as stated by the World Health Organization) is 7%. Taking 5% allowable error, 10% of nonresponse rate and using the formula sample size (n) = 4 pq/d2, the calculated sample size is 110.

Bareilly has a total of 20 TUs, 45 designated micro-scopic centers (DMCs), and 711 directly observed treat-ment, short-course (DOTS) centers. Tuberculosis units were selected by simple random sampling, from the above-selected TUs. Designated microscopic centers will be selected by simple random sampling method. All pediatric cases registered at selected DMC and fulfilling our inclusion criteria, i.e., all pediatric cases in the age group of 0 to 14 years diagnosed as TB, and registered under RNTCP put on DOTS regimen and willing to participate in the study, are selected for the study. After obtaining clearance from Institutional Ethical Committee of the college, and informed consent taken from the patients/guardians/parents of pediatric TB cases, data

The Study of Sociodemographic Profile of Pediatric Tuberculosis Patients in Bareilly District, Uttar Pradesh


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regarding sociodemographic profile were collected using predesigned and pretested schedule for the pediatric TB patients registered under RNTCP during their visit to hospital/health center. The results were displayed with the help of graph and tables according to the aim and objectives of the study. Valid inferences were drawn and discussed with the other related studies reported from various parts of the world.

RESULTS

A facility-based cross-sectional study was conducted on pediatric TB patients in Bareilly district, Uttar Pradesh, and the observed results are described by tables and graphs.

Graph 1 shows that majority of the study participants were females, i.e., 65.1% as compared with males, i.e., 34.9% out of 120 study participants, and most of them belonged to age group 10 to 14 years, which is followed by 5 to 9 years and <5 years, which is 61.7, 25.8, and 12.5% respectively.

Table 1 shows that majority of study participants were Hindus and belonged to lower socioeconomic status.

DISCUSSION

Majority of the study participants belong to 10 to 14 years of age, which were 74 (61.7%) followed by 5 to 9 years and <5 years, which were 31 (25.8%) and 15 (12.5%). Similar results were found in Kamble et al5 where majority of study subjects, 276 (59.7%), were in the age group of 11 to 14 years, followed by the age group of 6 to 10 years. Out of 120 study participants, majority of them were females, 78 (65%), followed by males 42 (35%). Similar cross-sectional study by Satyanarayana et al6 on char-acteristics and program-defined treatment outcomes among childhood in Delhi also reported more females,

651 (61.0%), in their study. In the present study, out of 120 children, 62 (51.7%) were Hindus as compared with Muslims children, which were 58 (48.3%). Similarly, Kamble et al5 observed that the present study revealed that 347 (75.1%) study subjects were Hindus, 78 (16.9%) were Muslims, 23 (5%) were Sikhs, and 14 (3%) were Christians.

Majority of the children 62 (51.7%) belonged to lower socioeconomic status out of 120 children, followed by lower middle socioeconomic status, which were 23 (19.1%). Contrary to this observation, it was found that Bai and Devi7 in Kottayam district of Kerala observed that slightly more than half (51.8%) belonged to low, 46.2% to middle, and 2% to high socioeconomic groups.

CONCLUSION

With the help of above findings, it can be concluded that majority of pediatric TB cases were female, 10 to 14 years of age, Hindus, and belonged to lower socioeconomic status. So government and local bodies need to focus on these areas and necessity of more studies to see the effect of these socioeconomic factors on treatment-seeking behavior and treatment outcomes of DOTS in the pedi-atric TB cases.

REFERENCES

1. Government of India. TB India 2014, RXITCP Annual status report, DGHS. New Delhi: Ministry of Health and Family Welfare; 2014.

2. Ministry of Health. Tuberculosis and lung disease. 2nd ed. Ministry of Health, Division of Leprosy; 2013. p. 3.

3. Park, K. Park’s text book of preventive and social medicine. 23rd ed. Jabalpur: M/s Banarsidas Bhanot; 2015. p. 193-195.

4. Marais BJ, Gie RP, Schaaf HS, Hesseling AC, Obihara CC, Starke JJ, Enarson DA, Donald PR, Beyers N. The natural

Table 1: Distribution of pediatric TB patients according to sociodemographic variables

Character Number Percentage ReligionHindu 62 51.7Muslim 58 48.3Type of familyNuclear 60 50Joint 60 50Socioeconomic status (BG Prasad socioeconomic classification)Lower 62 51.7Lower middle 23 19.1Upper lower 20 16.7Upper middle 14 11.7Upper 1 0.8Total 120 100

Graph 1: Distribution of pediatric TB patients (%) according to age and sex in study

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history of childhood intra-thoracic tuberculosis: a critical review of literature from the pre-chemotherapy era. Int J Tuberc Lung Dis 2004 Apr;8(4):392-402.

5. Kamble B, Panesar S, Singh S, Kishore J. Tuberculosis status among cured or treatment completed pediatric tuberculo-sis patients under revised National Tuberculosis Control Programme in Delhi. Sch J App Med Sci 2016 May;4(5C): 1617-1623.

6. Satyanarayana S, Shivashankar R, Vashist RP, Chauhan LS, Chadha SS, Dewan PK, Wares F, Sahu S, Singh V, Wilson NC, et al. Characteristics and programme-defined treatment outcomes among childhood tuberculosis (TB) patients under the National TB Programme in Delhi. PLoS One 2010 Oct;5(10):e13338.

7. Bai SS, Devi RL. Clinical spectrum of tuberculosis in BCG vaccinated children. Indian Pediatr 2002 May;39(5):458-462.

A Study of Precondylar Tubercle in North Indian Crania


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A Study of Precondylar Tubercle in North Indian CraniaSHH Zaidi

ABSTRACT

Studies of nonmetric cranial variants have been a field of major interest to all the research workers, especially, because of their racial and regional importance. Twenty eight North Indian skulls of patients from Uttar Pradesh were studied for the precondylar tubercle, a cranial variant in the present study. The findings are documented, discussed, and compared with other studies from different parts of the world and are found to be of considerable regional and racial significance.

Keywords: Anthropologicalcharacters, Cranial variant, Precondylar tubercle, Races.

How to cite this article: Zaidi SHH. A Study of Precondylar Tubercle in North Indian Crania. Int J Adv Integ Med Sci 2016;1(3):167-168.



INTRODUCTION

Occasionally, a bony tubercle lies immediately ante-rior and medial to occipital condyles, the precondylar tubercle. A centrally placed tubercle is regarded as two fused tubercles.

Nonmetric cranial variants have been a subject of study by many esteemed.1 Many such variants have been observed on a racial basis also and are of considerable ethnic interest but lesser of forensic significance.2 Berry3 made a special study of nonmetrical human cranial variants.

The present study is undertaken to know the inci-dence of variant of precondylar tubercle and to draw significant conclusion, if any, from this study.


Twenty eight North Indian human crania were studied, which were obtained from Anatomy Museum of Rohilkhand Medical College, Bareilly.

Incidence of precondylar tubercle was noted in these crania (Fig. 1).

orIgInAl ArtIcle

Professor and Head

Department of Anatomy, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Corresponding Author: SHH Zaidi, Professor and Head Department of Anatomy, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, Phone: +919411867520 e-mail: [email protected]

10.5005/jp-journals-10050-10054

RESULTS

Out of 28 skulls studied, precondylar tubercle was not seen in two skulls. Thus 7.1% was the incidence of this cranial variant.

DISCUSSION

Cranial variants have aroused the curiosity of anato-mists for many decades.4 It was Wood-Jones,5 who first proposed that the differing incidences of these minor variants which occurred in different races might be useful in anthropological studies. Laughlin and Jorgensen6 put this idea in practice and Berry and Berry2 suggested that a wide range of these variants could be used to calculate a distance statistic between population samples.

This paper is concerned with description and racial and regional incidence of precondylar tubercle as one of the important cranial variant.

Cranial variants like all other variants have been studied by many workers; most of them are recognized only in anatomical text books, being described in terms, such as rare or occasionally found; nevertheless, a few of them have been utilized as anthropological.7,8 Some variants are consequences of disease or other extrinsic influences9-11; however, most of these variants result from normal developmental processes and are genetically determined.2

In a given race, the frequency of any particular variant is more or less constant race and is somewhat similar in related races. Chambellan12 seems to have been first to

Fig. 1: Precondylar tubercle in crania

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suggest the possibility of using such traits as anthropo-logical characters.

Russel in 1900 gathered together data on a number of skull variants in American group and gave the first indication of their use in the comparison of populations. Woodjones5,13 used data on skull variants in a more sys-temic comparison number of far eastern group.

Berry3 made a special study of nonmetrical human cranial variations, and his findings are given in Table 1.

In our study, it was observed that precondylar tubercle was present in two crania. Hence, the current study pro-vides valuable data from Uttar Pradesh, the largest state of India, and compares the same with data from different parts of the world.

The findings are of considerable racial and regional global significance.

REFERENCES

1. Todd TW, Tracy B. Racial features in American Negro cranium. Am J Phys Anthropol 1930 Oct;15(1):53-110.

2. Berry AC, Berry RJ. Epigenetic variation in the human cranium. J Anat 1967 Apr;101(Pt 2):361-380.

3. Berry AC. Factors affecting the incidence of non-metrical skeletal variants. J Anat 1975 Dec;120(Pt 3):519-535.

Table 1: Variations in nonmetrical human cranium3

Egypt (summed)

Nigeria (Ashanti)

Palestine (Lachish)

Palestine (Modern) India (Punjab) Burma

North America (British Columbia)

South America (Peru)

Our study (U.P.) North India

34/496 skulls

2/112 skulls

6/106 skulls 0/32 skulls

6/106 skulls 10/102 skulls

0/98 skulls 0/106 skulls 2/28 skulls

6.9% 1.8% 5.6% 0% 5.6% 9.8% 0% 0% 7.1%

4. Le Double AF. Variations des Os du Crane. Paris: Vigot; 1903. pp. 400.

5. Wood-Jones F. The non-metrical morphological characters of the skull as criteria for racial diagnosis: Parts I-III. J Anat 1930-1931 Jan;65(Pt 2):179-195;368-378;438-445.

6. Laughlin WS, Jorgensen JB. Isolate variation in Greenlandic Eskimo crania. Acta Genet Stat Med 1956;6(1 Part 2):3-12.

7. Brothwell DR. Digging up bones. The excavation, treat-ment and study of human skeletal remains. London: British Museum (Natural History); 1963. p. 192.

8. Brothwell DR. Of mice and men. Epigenetic polymorphism in the skeleton. In: Caso A, et al., editors. Homenaie a juan Comas en su 65 Aniversaria. Vol. 2. Mexico; 1965. p. 9-21.

9. Dorsey GA. Wormian bones in artificially deformed Kwakiutl crania. Am Anthropol 1897 Jun;10(6):169-173.

10. Moller C, Sandison AT. Usura orbitae (enbra orbitalia) in the collection of crania in the Anatomy department of university of Glasgow. Path Microbiol 1963;26:175-183.

11. Roche AF. Aural exotoses in Australian aboriginal skulls. Ann Otol Rhinol Laryngol 1964 Mar;73:1-10.

12. Chambellan M. Etude Anatomique et Anthropologique sur les Os Wormiens. Thesis, Paris; 1883. Cited by Dorsey, 1897.

13. Wood-Jones F. The non-metrical morphological characters of the skull as criteria for racial diagnosis: Part IV. J Anat 1933-1934 Oct;68(Pt 1):96-108.

Assessment of Knowledge and Practice of Mothers of Children under five regarding Zinc Therapy in Childhood Diarrhea


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Assessment of Knowledge and Practice of Mothers of Children under five regarding Zinc Therapy in Childhood Diarrhea1Dipak Kumar Dhar, 2Nilratan Majumder, 3Debasish Paul

ABSTRACTAim: Zinc is now considered as an important treatment inter-vention along with low-osmolarity oral rehydration salts in diar-rhea. But awareness about the use of zinc remains low. The present study was conducted with an objective of assessing knowledge and practice of mothers of under-5 children about zinc supplementation in diarrhea.

Materials and methods: A hospital-based cross-sectional study was carried out in the Paediatric Outpatient Department Agartala Government Medical College and GB Pant Hospital, Agartala, Tripura, India, with a sample size of 700 mothers of under-5 children over 2 months. Convenience sampling technique was employed and the data were collected in a structured, interview schedule. Descriptive statistics and tests like chi-square test were used for analysis.

Results: Only 1.9% of all the respondents (13 out of 700) had heard about zinc therapy in diarrhea. Out of them, 11 mothers had actually used zinc in practice and 7 could tell the duration of therapy. None of them were aware of what benefit is conferred by zinc in an episode of diarrhea. An association between knowledge levels and educational status and occupation of mothers was found to be statistically significant.Conclusion: The study reaffirmed the abysmally low level of awareness about zinc supplementation among mothers. Therefore, health education can be used as a tool to promote knowledge and practice of zinc supplementation in diarrhea to reduce mortality and morbidity.

Keywords: Diarrhea, Knowledge, Mothers, Zinc.

How to cite this article: Dhar DK, Majumder N, Paul D. Assessment of Knowledge and Practice of Mothers of Children under five regarding Zinc Therapy in Childhood Diarrhea. Int J Adv Integ Med Sci 2016;1(4):169-172.



INTRODUCTION

Diarrhea is a major cause of morbidity and mortality among young children, contributing to 16% of the total

OrIgInAl reSeArch

1,3Postgraduate Student (2nd Year), 2Associate Professor1,3Department of Physiology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India2Department of Paediatrics, Agartala Government Medical College and GB Pant Hospital, Agartala, Tripura, India

Corresponding Author: Dipak Kumar Dhar, Postgraduate Student (2nd Year), Department of Physiology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India e-mail:[email protected]

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deaths among under-5 children globally. Among them, a staggering 47% of deaths occur in the Southeast Asian countries alone. It is estimated that there are 2.5 billion cases of diarrhea worldwide among children less than 5 years of age. Though with the advent of oral rehydra-tion salts (ORS) and improvement in the standards of sanitation and hygiene, the global deaths from diarrhea have come down from 5 million deaths annually to 1.5 million deaths in 2004,1 but the incidence of diarrhea has remained relatively stable over the past few decades. This showcases that the prevention aspect still needs to be emphasized.

Since the 1970s, oral rehydration therapy has been the mainstay of diarrhea treatment programs. In recent years, zinc has also emerged as a necessary adjunct to ORS. Zinc is a micronutrient that can be found in all tissues of the body and is essential for cell growth, cell differentiation, and DNA synthesis.2 It is also essen-tial for the maintenance of a healthy immune system.3 Zinc is believed to improve absorption of water and electrolytes by the intestine, faster regeneration of gut epithelium, increased levels of enterocyte brush border enzymes, and an enhanced immune response, leading to increased clearance of the pathogen from the gut in an episode of diarrhea.4 It has been reported in several studies that children receiving zinc appeared to recover quickly than others.1 Zinc has been associated with a 25% reduction in the duration of acute diarrhea, 30% reduction in the volume of stools, and a 40% reduction in treatment failure and death in persistent diarrhea.1,4 It also lowers the incidence of diarrhea in the following 2 to 3 months. The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) now rec-ommend the use of low-osmolarity ORS for the correction and prevention of dehydration and 10 to 20 mg of zinc for 10 to 14 days as treatment for all episodes of diarrhea (10 mg per day for infants under 6 months). It has been said that with the use of this combination, up to 88% of the deaths due to diarrhea can be prevented.5 In view of all these benefits, zinc therapy was incorporated in the Integrated Management of Childhood Illness guidelines and the WHO list of essential drugs for use in diarrhea in 2005.4 Prompted by the joint statement made by the WHO and UNICEF and the recommendations of the

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Indian Academy of Pediatrics, the Government of India in 2007 issued guidelines for zinc supplementation along with ORS in all cases of diarrhea.6

As mother is usually the prime caregiver of a sick child, it is her behavior, attitude, and practices that largely determine the outcome of an episode of diarrhea. Use of the available resources for treatment and prevention depends on the mother’s level of knowledge, which are indirectly determined by factors, such as her educational status, occupation, prior experience of managing the disease, etc. Lack of awareness is attributed as the main cause of poor use of available interventions.7 The present study is, therefore, intended to assess the knowledge and practices about zinc therapy in childhood diarrhea.


A hospital-based cross-sectional study was carried out in the Department of Paediatrics, Agartala Government Medical College, Agartala, Tripura, India, over a period of 2 months (July–August 2013). The study population comprised mothers of under-5 children visiting the Paediatric Outpatient Department (OPD) of the college. Mothers of children who were above 5 years of age and those who were not willing to participate in the study were excluded from the study.

A total of 700 mothers fulfilling the selection criteria were interviewed with a predesigned and structured interview schedule. Convenience sampling technique was used while recording the data. As the targeted sample was 700 and it had to be covered over a 2-month (8 weeks) period, to maintain uniformity of sampling, in a single week, 88 mothers needed to be interviewed. Considering the fact that OPD remains closed on Sundays, over the remaining 6 days of the week, first 15 registered mothers who met the selection criteria were interviewed in a one-by-one, face-to-face manner.

Approval was obtained from the Institutional Ethical Committee prior to the study. Informed consent was taken from every respondent before starting the inter-view, and the information thus obtained was dealt with confidentiality. The data thus obtained were entered in computer using Statistical Package for the Social Sciences 13 version. Descriptive statistics and suitable statistical tests like chi-square test were applied. A p-value <0.05 was considered significant.

RESULTS

Majority of the total participants (81%) were housewives. Nursing staff comprised 1% of the respondents. With regard to education, majority were primary educated (45.4%) and only 8.7% were either graduates or higher educated. Only 1.9% of all the respondents (13) reported that they had heard about zinc therapy in diarrhea. Only 11 of them had actually used zinc in practice. The dif-ferent sources from where they came to know about it are depicted in Graph 1. The knowledge of the mothers (among those who had heard) regarding the duration of zinc therapy is shown in Graph 2. Only one mother among them reported to have observed visible quicker recovery with the use of zinc as compared with a previous episode. None of them could tell what benefit zinc confers in the event of diarrhea. The knowledge and awareness of zinc therapy in childhood diarrhea was found to be significantly associated with the educational level and occupation of the mother (Table 1).

DISCUSSION

The study confirmed the low levels of awareness regard-ing zinc therapy in diarrhea. Only 13 mothers (1.9%) had heard of zinc therapy, which was almost similar to a study conducted by UNICEF across 10 cities in India. UNICEF reported that the knowledge about zinc among mothers

Graph 1: Sources from where mothers knew about zinc therapy among those who had heard

Graph 2: Knowledge about duration of zinc therapy among those who had heard

Assessment of Knowledge and Practice of Mothers of Children under five regarding Zinc Therapy in Childhood Diarrhea


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Table 1: Association between knowledge of mothers regarding the use of zinc with educational level and occupation of mother

Determinants

Whether heard of use of zinc therapy in diarrhea

TotalYes No

Number % Number %Distribution of the respondents according to educational levela

Illiterate 0 0 114 16.59 114Primary educated 0 0 318 46.29 318Secondary educated 4 30.77 223 32.46 227Graduate and above 9 69.23 32 4.65 41Total 13 100.00 687 100.00 700Distribution of the respondents according to occupationb

Housewife 5 38.46 562 81.81 567Officegoer 3 23.08 42 6.11 45Teacher 0 0 5 0.73 5Nursing staff 5 38.46 2 0.29 7Unskilled labor 0 0 53 7.72 53Shopkeeper 0 0 23 3.35 23Total 13 100.00 687 100.00 700

ap-value = 0.000, bp-value = 0.000 by chi-square test

was almost nil.8 Similar low awareness levels were also reported by Rokkappanavar et al,9 where only 3.8% of mothers administered zinc. Among them, majority did so after medical consultation. Our study also pointed out that the source of knowledge about zinc was mostly from previous experience of using it in an episode of diarrhea (38.46%) and from doctors (30.76%). However, the present findings differed from studies done in Bangladesh and Kenya where about 35 and 32% of mothers respectively, were aware of zinc and administered it.10,11

The present study also showed that only 1% of the participants (7 out of 13 mothers who had heard about zinc therapy) knew the correct duration for which it has to be given. This underlines the fact that even if zinc is prescribed by a doctor, lack of knowledge can in most cases lead to noncompliance for the entire duration. Patterns of noncompliance to full duration has been reported in various studies where 82% of caregivers stopped zinc supplementation by the 7th day.12 However, a study from Nepal reported comparatively better levels where 29% of mothers knew about zinc and 18% used them.13 A study from rural Kenya carried out to assess knowledge and acceptability of zinc after a session of counseling by community workers reported still better findings where 67% of the caretakers used zinc, among which 88% reported satisfaction with the treatment. Also, 25% of them used zinc at home and 48% after medical consultation. As compared with those who had not used zinc, they could answer more questions regarding the correct use of zinc.14 In contrast, in our study, only one respondent could appreciate the satisfactory effect of zinc, and none of them could tell what benefit occurs with zinc supplementation.

Our study also revealed that education levels and occupation of the mother were significantly associated with the knowledge about zinc supplementation. Similar findings were reported by various other studies.9,12

Therefore, the present study has displayed the low awareness about zinc supplementation in diarrhea. It stresses the need and highlights the scope of health education in familiarizing zinc therapy among mothers, because a mother is the center of family care in a home.

Community-based, multicentric studies can give a better picture of the true patterns and different varia-tions in them (like urban and rural) than a hospital-based study, which is the limitation of the study. Also, a follow-up study can showcase the actual rate of compliance to zinc therapy as compared with a cross-sectional design. It will also enable researchers to find out reasons of noncompliance and assess acceptability of prescribed zinc.

CONCLUSION

Zinc has been recognized as a critical treatment interven-tion in diarrhea in addition to low-osmolarity ORS for quite some time now. Despite the fact that India being one of the 46 countries of the world to have explicit national policy on zinc therapy in diarrhea,1 the knowledge and use of zinc by the mothers, who are the first caregivers of a child, remain appallingly low, which has also been revealed in our study. Therefore, there is enough room to scale up health education measures and disseminate the benefits and appropriate usage of zinc in the community. This in turn will reduce the burden of diarrheal diseases in the society and also in the country.

ACKNOWLEDGMENT

The study was conducted as a part of the short-term studentship program of the Indian Council of Medical Research (ICMR), New Delhi in 2013 and the report accepted. The support offered by ICMR is gratefully acknowledged by the authors.

REFERENCES

1. The United Nations Children’s Fund/World Health Organization. Diarrhoea: why children are still dying and what can be done. 2009. p. 5-6.

2. Sandstead HH. Zinc deficiency. A public health problem? Am J Dis Child 1991 Aug;145(8):853-859.

3. World Health Organization. Trace elements in human nutrition and health: Zinc. 1996.

4. Chiabi A, Monebenimp F, Bogne JB, Takou V, Ndikontar R, Nankap M, Youmba JC, Tchokoteu PF, Obama MT, Tetanye E. Current approach in the management of diarrhea in children: from theory and research to practice and pragmatism. Clin Mother Child Health 2010;7(1):1243-1251.

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5. Clinical management of acute diarrhoea: WHO/UNICEF joint statement. Geneva: World Health Organization; 2004.

6. Bhatnagar S, Lodha R, Choudhury P, Sachdev HP, Shah N, Narayan S, Wadhwa N, Makhija P, Kunnekel K, Ugra D, et al. IAP Guidelines 2006 on management of acute diarrhea. Indian Paediatr 2007 May;44(5):380-389.

7. Bhatnagar S, Alam S, Gupta P. Management of acute diarrhea: from evidence to policy. Indian Pediatr 2010 Mar;47(3):215-217.

8. Management Practices for Childhood Diarrhoea in India 2009. UNICEF; 2009. p. 4-7.

9. Rokkappanavar KK, Nigudgi SR, Ghooli S. A study on knowl-edge and practice of mothers of under-five children regard-ing management of diarrhoea in urban field practice area of MRMC, Kalaburagi, Karnataka, India. Int J Community Med Public Health 2016;3(3):705-710.

10. Akhtaruzzaman M, Hossain MA, Khan RH, Karim MR, Choudhury AM, Islam MS, Ahamed F, Khan N, Ahammed SU, Dhar SK, et al. Knowledge and practices of mothers on childhood diarrhoea and its management attended at a

tertiary hospital in Bangladesh. Mymensingh Med J 2015 Apr;24(2):269-275.

11. Ogunrinde OG, Raji T, Owolabi OA, Anigo KM. Knowledge, attitude and practice of home management of childhood diarrhoea among caregivers of under 5 children with diar-rhoeal disease in Northwestern Nigeria. J Trop Pediatr 2012 Apr;58(2):143-146.

12. Valekar SS, Fernandez K, Chawla PS, Pandve HT. Compliance of zinc supplementation by care givers of children suffer-ing from diarrhea. Indian J Community Health 2014;26, (Suppl S2):137-141.

13. Ghimire S, Ghimire S, Sikharam HK, Baral BK. Maternal knowledge and management practice towards child-hood diarrhoea in Bhaktapur, Nepal. Int J Recent Sci Res 2015;6(5):4347-4351.

14. Otieno GA, Bigogo GM, Nyawanda BO, Aboud F, Breiman RF, Larson CP, Feikin DR. Caretakers’ perception towards using zinc to treat childhood diarrhoea in rural Western Kenya. J Health Popul Nutr 2013 Sep;31(3):321-329.

Radiological Evaluation of Thyroid Diseases using Gray Scale and Color Doppler Sonography


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Radiological Evaluation of Thyroid Diseases using Gray Scale and Color Doppler Sonography1Sagar Tyagi, 2Pramod Kumar, 3Atul Mehrotra, 4Pradeep Parakh, 5Lalit Kumar, 6Parveen Hans

ABSTRACT

Introduction: The thyroid gland is the largest of all endo-crine glands and is the only one which is amenable to direct physical examination and high resolution real-time grayscale sonography because of its superficial location. High Resolution Ultrasonography (USG) with Color Doppler is used to assess the nature of the lesion according to its vascularity and also the hemodynamic characteristics of the gland. Thus, the combination of Gray scale Sonography and Color Flow Doppler provide huge benefits and help in increasing the sensitivity, specificity and accuracy in distinguishing benign and malignant thyroid nodules. Nearly 50% of patients with a clinically palpable solitary thyroid nodule have avoided surgery because of thyroid ultrasound.Aims and objectives: The present study is aimed to determine the role of high resolution USG in the evaluation of lesions of the thyroid with Fine-needle aspiration cytology (FNAC) cor-relation and compare it with other studies.Materials and methods: This is a prospective study carried out on 50 patients (44 female and 6 male) who attended ENT or Surgery outpatient department/inpatient department (OPD/IPD) and were referred to the Department of Radio-Diagnosis for high resolution USG of neck at Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. This study was conducted for a period of one year from March 2015 to February 2016. The ultrasound machine used was GE LOGIQ V5.Result and Conclusion: Our present study consisted of 50 cases which were clinically suspected suffering from thyroid dysfunction. Thyroid ultrasound was very efficient in picking up lesions in all 50 cases in our study. In comparison, to other studies our study gave a similar picture in terms of benign lesions being much more common than malignant lesions. The most common benign lesion determined in our study was colloid goiter which was the most common benign lesion in many other studies. In comparison to other studies, we were able to detect malignant nodules with a better specificity. Chronic thyroiditis was also very efficiently detected using ultrasound in our study.Keywords: Fine-needle aspiration cytology, Thyroid, Ultrasound.How to cite this article: Tyagi S, Kumar P, Mehrotra A, Parakh P, Kumar L, Hans P. Radiological Evaluation of Thyroid Diseases using Gray Scale and Color Doppler Sonography. Int J Adv Integ Med Sci 2016;1(4):173-182.Source of support: XXXX

Conflict of interest: XXXX

orIgInAl reSeArch

1,6Resident Doctor, 2,3Associate Professor, 4Professor and Head, 5Professor1-6Department of Radiodiagnosis, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, IndiaCorresponding Author: Sagar Tyagi, Resident Doctor Department of Radiodiagnosis, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, Phone: 9958486762 e-mail: [email protected], [email protected]

10.5005/jp-journals-10050-10056

INTRODUCTION

The thyroid gland is the largest of all endocrine glands and is the only one which is amenable to direct physical examination and high-resolution real-time grayscale sonography because of its superficial location.

Thyroid sonography was first introduced in 1966 to 1967.1 Thyroid ultrasound is now the best prevalence indicator for the assessment of thyroid disorders. It is used to differentiate cystic thyroid lesions from solid ones and solitary nodules from multinodular goiter. Also it is used to detect any extrathyroidal lesions, such as enlarged cervical lymph nodes if any. Nearly 50% of patients with a clinically palpable solitary thyroid nodule have avoided surgery because of thyroid ultrasound.2

The newly developed high-resolution ultrasono graphy (USG) with color Doppler is used to assess the nature of the lesion according to its vascularity and also the hemody-namic characteristics of the gland. Thus, the combination of grayscale sonography and color flow Doppler provides huge benefits and helps in increasing the sensitivity, speci-ficity, and accuracy in distinguishing benign and malig-nant thyroid nodules.3 Although individual USG features may help, accurate prediction of thyroid malignancy can be made when multiple signs appear in USG.

Fine-needle aspiration cytology (FNAC) is now a well-established, first-line, simple, and quick screening test as well as the diagnostic tool for surgical and non-surgical goiters. Limitation of FNAC is mainly because of inadequate sampling, inexperience of the pathologist, and overlapping of cytological features.4

The present study was aimed to determine the role of high-resolution USG in the evaluation of lesions of the thyroid with FNAC correlation and compare it with other studies.

Fig. 1: Color Doppler machine – GE LOGIQ V5

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Fig. 2: Transverse scan of thyroid gland with normal thyroid parenchyma

Fig. 4: Ultrasound scan of strap muscles and sternocleidomas-toid muscle and common carotid artery in relation to right lobe of thyroid gland

Fig. 3: Ultrasound evaluation of right lobe of thyroid gland to estimate thyroid volume

Fig. 5: Ultrasound of normal vascularity of right lobe using power Doppler


This was a prospective study carried out on 50 patients (44 females and 6 males) who attended the ear, nose, and throat or surgery outpatient department/inpatient department (OPD/IPD) and were referred to the Department of Radio-diagnosis for high-resolution USG of neck at Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. This study was conducted for a period of 1 year from March 2015 to February 2016. The ultrasound machine used was GE LOGIQ V5 (Fig. 1).

Patients presenting with swelling in the thyroid region and those with clinical suspicion of thyroid dysfunction were included in the study. Patients with swelling in the neck other than thyroid or patients already diagnosed and treated for thyroid lesion were excluded.

Examination Method

The thyroid gland was examined with the use of high- resolution linear array transducer ranging from 7 to 12 MHz. The patient was examined in the supine posi-tion with the neck hyperextended to identify the inferior

margin of the gland, which may extend up to the clavicle in some patients. A small pillow was placed under the shoulders so as to delineate structures well, particularly in patient with a short, stocky habitus.

The gland was evaluated with the help of criteria of solid, mixed, and cystic pattern. Solid nodules were divided into homogeneous and heterogeneous echo pattern. Homogeneous nodules were further subdivided into hyper-echoic, isoechoic, and hypoechoic echotexture. The mixed group was divided into predominantly solid, predomi-nantly cystic, and a complex group where no component was predominant. Various other sonographic features were also assessed. Cervical lymph nodes with any abnormal features in terms of size or echotexture were also subjected to FNAC. Color Doppler was used to study the vascularity of the thyroid gland. The inferior thyroid artery was identi-fied and spectral waveforms were obtained (Figs 2 to 5).

After the history, physical examination, ultrasound examination, thyroidal hormonal assay, and FNAC, a diagnosis was made and statistical analysis was done by using proportion. The sensitivity, specificity, and positive



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predictive value (PPV) were determined for all cases using the following formula:Sensitivity: a/(a + b)Specificity: d/(c + d)Positive predictive value: a/(a + c)Negative predictive value: d/(b + d)True positive: aFalse negative: bFalse positive: cTrue negative: d

RESULTS

In the present study, out of 50 cases, 44 (88%) patients were females and 6 (12%) were males. The male to female ratio was 1:7.3. Most of the patients, 19 (38%), were in 21 to 30 years of age group, the youngest being 8 years old and the eldest being 65 years old. The mean age was 36 years (Graphs 1 and 2).

All 50 (100%) patients presented with swelling in the neck either diffuse or nodular, out of which, 5 (10%)

Graph 1: Sex distribution of study subjects Graph 2: Age and sex distribution of study subjects

Graph 3: Symptoms

Fig. 6: Transverse scan of well-defined cystic lesion in right lobe

patients complained of associated pain; 4 (8%) patients had hoarseness of voice; 4 (8%) had difficulty in breath-ing; and 3 (6%) complained of palpitation (Graph 3).

With respect to consistency, out of 50 cases, 28 (56%) had solid consistency, 13 (26%) had cystic, and 9 (18%) turned out to be mixed lesions (Figs 6 to 8) (Graph 4).

Graph 4: Internal consistency of study subjects

Composition

Sticky Note

Please check artwork correction.

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Fig. 7: Transverse scan of well-defined solid lesion in isthmus

Fig. 8: Ultrasonography image of ill-defined mixed lesion in right lobe

Fig. 9: Transverse scan of well-defined anechoic lesion in left lobe

Fig. 11: Transverse scan of isoechoic lesion in right lobe

Fig. 10: Transverse scan of well-defined anechoic lesion in left lobe

With respect to echogenicity, out of 50 patients, 19 (38%) lesions were hyperechoic, 15 (30%) were hypoechoic, 13 (26%) were anechoic, and 3 (6%) were isoechoic as compared with normal thyroid parenchyma (Figs 9 to 12) (Graph 5).

With respect to margin, 47 (94%) out of 50 cases had well-defined margins, whereas 3 (6%) had ill-defined margins (Figs 13 and 14) (Graph 6).

With respect to vascularity, 10 (20%) cases showed inter-nal vascularity along with peripheral vascularity, 26 (52%) showed peripheral pattern, and 12 (24%) cases showed no significant vascularity (Figs 15 and 16) (Graph 7).

With respect to halo, 11 (22%) out of 50 cases had thin peripheral complete halo whereas thick incomplete halo was seen in only one (2%) case (Fig. 17) (Graph 8).

Graph 5: Echogenecity relative to adjacent parenchyma



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Fig. 13: Transverse scan of well-defined lesion in right lobe

Fig. 12: Transverse scan of well-defined hypoechoic lesion in left lobe

Fig. 14: Transverse scan of ill-defined lesion in right lobe

Fig. 15: Transverse scan of a lesion with peripheral vascularity

In this study, microcalcification was seen in 1 (2%) case, egg shell calcification in 2 (4%), and coarse calci-fication in 3 (6%) out of 50 cases (Figs 18 to 20) (Graph 9).

Number of cases identified as benign in USG was 36, out of which 35 were benign and 1 turned out to

be malignant in FNAC. Number of cases identified as malignant in USG was 4, and all proved out to be malig-nant in FNAC. The overall sensitivity, specificity, and PPV of USG in identifying a benign lesion were 97.14, 86.66, and 94.44% respectively. The overall sensitivity, specificity,

Graph 6: Margins Graph 7: Doppler of study subjects

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Fig. 16: Transverse scan of peak systolic velocity of inferior thyroid artery

Fig. 17: Ultrasonography image of a lesion with thin halo

Fig. 18: Transverse scan of a lesion with microcalcification

Fig. 19: Longitudinal scan of a lesion with egg shell calcification and shadowing

and PPV of USG in identifying a malignant lesion were 80, 100 and 100% respectively (Graph 10).

On FNAC, 5 (10%) were malignant, 35 (70%) were benign, and 10 (20%) were proved to be thyroiditis. The most common benign pathology in the present study was colloid goiter seen in 23 (46%) cases. Papillary carcinoma

was seen in 4 (80%) out of 5 cases whereas anaplastic car-cinoma was diagnosed in 1 (2%) (Figs 21 to 23). No case of medullary carcinoma was found in our study (Table 1) (Graph 11).

All the 4 malignant cases on USG were correctly diag-nosed as malignant on cytology and 1 case which was

Graph 8: Halo

Graph 9: Calcifications



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Fig. 20: Ultrasonography image of a lesion with coarse calcification

Graph 10: Comparison between USG and FNAC diagnosis

Table 1: Comparison between USG and FNAC diagnosis

Diagnosis USG detected Cytopathologically detectedBenign lesions 36 35Thyroiditis 10 10Malignant lesions 4 5

Graph 11: Fine-needle aspiration cytology diagnosis of the present cases

Fig. 21: Ultrasonography image of hyperechoic nodules suggestive of multinodular goiter

Fig. 23: Transverse scan of both peripheral and internal vascularity in chronic thyroiditis

Fig. 22: Longitudinal scan of diffusely hypoechoic gland with multiple thin echogenic septations suggestive of chronic thyroiditis

misdiagnosed as multinodular goiter on USG because of multiple well-defined nodules with high echogenicity also turned out to be a case of papillary carcinoma. Out of 36 benign cases, 1 turned out to be papillary carcinoma and 1 turned out to be Hashimoto’s thyroiditis on cytology.

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Both cases on USG had multiple well-defined echogenic nodules and were diagnosed as multinodular goiter on USG (Fig. 24). Out of 10 cases of thyroiditis, 1 (2%) case proved out to be primary follicular hyperplasia on cytology (Fig. 25).

Comparison of sonographically positive and negative benign cases with FNAC revealed:

Sonographically benign

Fine-needle aspiration cytology

TotalYes NoYes 34 2 36No 1 13 14Total 35 15 50

Statistical values:Sensitivity: 34/35 × 100 = 97.14%Specificity: 13/15 × 100 = 86.66%Positive predictive value: 34/36 × 100 = 94.44%

Comparison of sonographically positive and negative malignant cases with FNAC revealed:

Sonographically malignant



Statistical values:Sensitivity: 4/5 × 100 = 80%Specificity: 45/45 × 100 = 100%Positive predictive value: 4/4 × 100 = 100%

Comparison of sonographically positive and negative chronic thyroiditis cases with FNAC revealed:

Sonographically chronic thyroiditis



Statistical values:Sensitivity: 9/10 × 100 = 90%Specificity: 39/40 × 100 = 97.5%Positive predictive value: 9/10 × 100 = 90%

DISCUSSION

All five malignant lesions were seen in females. Percentage of malignancy in females in our study turned out to be 11.3%. In a similar study conducted by Nam Goong et al,5 the age range was 26 to 75 years with mean age of 51 years, which was very high as compared with our study. All the cases of malignancy were above the mean age, and the mean age of malignant cases turned out to be 52.

In a study by Simeone et al6, 87.2% cases were benign and 12.7% cases were malignant which can be related to our study. Out of 17 malignant cases, 9 (52.9%) had papillary carcinoma, 2 (11.7%) had medullary carcinoma, 2 (11.7%) had follicular carcinoma, 2 (11.7%) had anaplas-tic carcinoma, and 2 (11.7%) had metastases.

Fine-needle aspiration cytology diagnosis No. of patients PercentageColloid goiter 23 46Hashimoto’s thyroiditis 9 18Follicular neoplasm 6 12Colloidal nodule 5 10Papillary carcinoma 4 8Autoimmune thyroiditis 1 2Primary follicular hyperplasia 1 2Anaplastic carcinoma 1 2Total 50 100

In our study, we found colloid goiter to be the com-monest lesion with 23 out of 50 cases (46%). Almost 10 of these lesions were predominantly cystic, 9 were pre-dominantly hyperechoic, 2 were isoechoic, and 2 cases were hypoechoic in nature. Scheible et al7 found that

Fig. 25: Cytopathology image of follicular neoplasmFig. 24: Cytopathology image of colloid in a case of goiter



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13 (52%) out of the 25 cases were colloid goiters in their study.

Workers Percentage of colloid goiters

Scheible et al7 52

Present study 46

James and Charboneau8 stated that the most specific sign of a benign thyroid nodule is eggshell or periph-eral calcification. Our study revealed only 2 (4%) cases showing such peripheral or egg shell calcification. Both turned out to be benign.

Calcification No. of patients %

Coarse calcification 3 6

Eggshell calcification 2 4

Microcalcification 1 2

Erdogan et al9 had found 24 cases of Hashimoto’s thyroiditis while evaluating 55 patients with hyperthyroidism. Micronodulation was seen in all cases. Small micronodules were seen in all the cases in our study.

Workers Percentage of hashimoto’s thyroiditis

Erdogan et al9 43.6

Present study 18

Lin et al10 had found 11 cases of chronic thyroid-itis. Ultrasound patterns of 11 cases were diffusely enlarged gland with diffuse hypoechogenicity. In our study, we found 10 cases of chronic thyroiditis out of which 9 showed diffuse enlarged gland with diffuse hypoechogenicity.

Papillary carcinoma accounts for 75 to 90% of primary thyroid cancers. Ultrasound appearance of benign and malignant nodules overlaps; however, certain features are helpful in differentiating between the two. These features include microcalcifications, local invasion, lymph node metastases, and a nodule, i.e., taller than wide with markedly reduced echogenicity, all of which goes in favor of malignancy. Other features, such as absence of halo, ill-defined irregular margins, solid composition, and vas-cularity are less specific but may be useful ancillary signs.

In our study as we found papillary carcinoma in 80% of all malignant cases.

In a study by Hoang et al,11 they stated that microcalci-fications are one of the most specific ultrasound findings of a thyroid malignancy. Microcalcifications were found in 29 to 59% of all primary thyroid carcinomas. In our study, we detected only one case of malignancy showing microcalcification. One case of malignancy showed coarse calcification.

WorkersPercentage of malignancy showing microcalcification

Hoang et al11 59Present study 20

Most of the authors have agreed that specific USG fea-tures of thyroid carcinoma do not exist12; however, some have stated that carcinomas are usually hypoechoic, but Solbiati et al13 found out that only 68% of the malignant lesions were hypoechoic. In our study we found five cases of malignancy out of which only three (60%) were hypoechoic. Therefore, hypoechoic echotexture should not be considered an independent factor in determining malignancy.

WorkersPercentage of malignancy showing hypoechogenicity

Solbiati et al13 68

Present study 60

Echogenicity relative to the adjacent thyroid parenchyma No. of patients %

Hyperechoic 19 38

Hypoechoic 15 30

Anechoic 13 26

Isoechoic 3 6

All three cases in our study with ill-defined margins proved out to be carcinoma of which two were papillary carcinoma. Thus it proved out to be a significant factor in determining malignancy of thyroid nodules.

Margin No. of patients %

Well-defined 47 94

Ill-defined 3 6

Internal vascularity occurs in 69 to 74% of thyroid malignancies according to a study by Hoang et al.11 All five proven cases of malignancy showed internal vascularity. Therefore, this factor was highly sensitive for malignancy. Hence, USG is good at ruling out a malignancy lesion, thus playing a role in management.

Doppler %

Peripheral flow pattern 26 52

No significant vascularity 12 24

Both together (peripheral and internal flow) 10 20

Thyroid inferno (peak systolic velocity >70 cm/second) 2 4

Workers

Specificity in detection of malignancy using absent halo sign, microcalcification, and intranodal flow pattern

Rago et al14 97.2

Present study 100

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In the study conducted by Dhanadia et al15 for detection of malignancy by ultrasound had sensitivity of 83.3%, specificity 72.7%, PPV 29.4%, and NPV 96.9%. In our study, detection of malignancy by ultrasound had a sensitivity of 80% and specificity of 100%. Positive predictive value came out to be 100%.

Our study also had limitations in the form of a small sample size. Therefore, it is recommended to conduct a similar study with a larger sample size in order to identify the malignancy markers more accurately.

CONCLUSION

Color Doppler sonography is a noninvasive procedure for investigating thyroid gland which is safe, fast, inex-pensive, popular, and cost-effective and can be repeated many a times. As it is located superficially and has a good vascularity, high-resolution grayscale and color Doppler sonography is helpful in demonstrating normal thyroid anatomy and pathological conditions with remarkable clarity.

Our experience demonstrates significantly improved sensitivity for high-resolution ultrasound over other investigations for the anatomic characterization of thyroid lesions. Ultrasound is valuable in identifying malignant or potentially malignant thyroid nodules. Ultrasound appearance of benign and malignant nodules overlap, however, certain features are helpful in differ-entiating between the two. The newly developed high-resolution USG along with color Doppler flow studies can reveal fine details of the thyroid gland and the hemody-namic features of thyroid neoplasms.

Color flow Doppler sonography is gaining importance for the functional evaluation of the thyroid disorders. Color flow Doppler sonography could differentiate an untreated Grave’s disease from Hashimoto’s thyroiditis, which have almost similar grayscale findings. Thyroid ultrasound differentiates solid from cystic lesions, solitary nodules from multinodular and diffuse enlarge-ment, and is also helpful in characterizing extra thyroidal lesions.

Thyroid ultrasound can also be used in calculation of thyroid volume. Finally in selected cases, direction of fine-needle aspiration biopsy can be best accomplished with sonography, eliminating the need of multiple needle punctures. Our present study consisted of 50 cases, which were clinically suspected suffering from thyroid dysfunc-tion. Thyroid ultrasound was very efficient in picking up lesions in all 50 cases in our study. In comparison to other studies, our study gave a similar picture in terms of

benign lesions being much more common than malignant lesions. The most common benign lesion determined in our study was colloid goiter, which was the most common benign lesion in many other studies. In comparison to other studies, we were able to detect malignant nodules with a better specificity. Chronic thyroiditis was also very efficiently detected using ultrasound in our study.

REFERENCES

1. Fujimoto F, Oka A, Omoto R, Hirsoe M. Ultrasound scan-ning of the thyroid gland as a new diagnostic approach. Ultrasonics 1967 Jul;5:177-180.

2. Walker J, Findlay D, Amar SS, Small PG, Wastie ML, Pegg CA. A prospective study of thyroid ultrasound scans in the clini-cally solitary thyroid nodule. Br J Radiol 1985;58(691):617-619.

3. Marquesee E, Benson CB, Frates MC, Doubilet PM, Larsen PR, Cibas ES, Mandel SJ. Ultrasonography in the management of thyroid nodules. Ann Intern Med 2000 Nov 7;133(9):696-700.

4. Khafagi F, Wright G, Castles H, Perry-Keene D, Mortimer R. Screening for thyroid malignancy: the role of fine needle aspi-ration biopsy. Med J Aust 1988 Sep 19;149(6):302-303, 306-307.

5. Nam Goong IS, Kim HY, Gong G, Lee HK, Hong SJ, Kim WB, Shong YK. Ultrasonography guided FNA of thyroid incidentaloma: correlation with pathological findings. Clin Endocrinol 2004 Jan;60(1):21-28.

6. Simeone JF, Daniels GH, Mueller PR, Maloof F, van Sonnenberg E, Hall DA, O’Connell RS, Ferrucci JT Jr, Wittenberg J. High resolution real time sonography of the thyroid. Radiology 1982 Nov;145(2):431-435.

7. Scheible W, Leopold GR, Woo VL, Gosink BB. High-resolution real-time ultrasonography of thyroid nodules. Radiographics 1979 Nov;133(2):413-417.

8. James EM, Charboneau JW. High-frequency (10 MHz) thyroid ultrasonography. Semin Ultrasound 1985;6:294-298.

9. Erdogan MF, Anil C, Cesur M, Baskal N, Erdogan G. Color flow Doppler sonography for the etiologic diagnosis of hyperthyroidism. Thyroid 2007 Mar;17(3):223-228.

10. Lin JD, Huang BY, Huang HS, Juang JH, Jeng LB. Ultrasonography and fine needle aspiration cytology of acute suppurative thyroiditis. Changgeng Yi Xue Za Zhi 1993 Jun;16(2):93-98.

11. Hoang JK, Lee WK, Lee M, Johnson D, Farrell S. US features of thyroid malignancy: pearls and pitfalls. Radiographics 2007 May-Jun;27(3):847-860; discussion 861-865.

12. Watters DA, Ahuja AT, Evans RM, Chick W, King WW, Metreweli C, Li AK. Role of ultrasound in the management of thyroid nodules. Am J Surg 1992 Dec;164(6):654-657.

13. Solbiati L, Arsizio B, Ballarati E. Microcalcifications: a clue in the diagnosis of thyroid malignancies. Radiology 1990;117:140.

14. Rago T, Vitti P. Role of thyroid ultrasound in the diagnostic evaluation of thyroid nodules. Best Pract Res Clin Endocrinol Metab 2008;22(6):913-928.

15. Dhanadia A, Shah H, Dave A. Ultrasonographic and FNAC correction of thyroid lesions. Gujarat Med J 2014 Mar;69(1): 75-81.

Vestibular Implant: Are We Ready for It?


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Vestibular Implant: Are We Ready for It?1Chander Mohan, 2Abhinav Srivastava

ABSTRACT

The present article aims to provide an overview of the research and development in the field of vestibular implants for patients suffering from bilateral vestibulopathy. There is a strong justification for surgical intervention in such patients because of a negative impact and disability of disease on the life of the patients. A few animal and human studies have been undertaken, and the available data from both animal and human studies are encouraging. It is evident that there is a technical feasibility for the use of vestibular implants. Although normal vestibular function is not expected, significant, physical improvement is expected in these patients.

Keywords: Oscillopsia, Vestibular implants, Vestibulopathy.

How to cite this article: Mohan C, Srivastava A. Vestibular Implant: Are We Ready for It? Int J Adv Integ Med Sci 2016; 1(4):183-185.



INTRODUCTION

The primary goal of cochlear implant, which was intro-duced about three decades ago, was to afford serviceable hearing to profoundly deaf patients. It was contemplated that they would perceive basic speech and environmental sounds, but the scenario has changed over a period of time. People with implants are doing reasonably well and they are very near normally hearing people.

Another device in its early phase of development is in the offing, viz. a vestibular implant for patients with fluctuating vestibular function. Abnormal hyperfunction can be suppressed, but those with fluctuating vestibular function cannot be helped. Oscillopsia, though uncom-mon, is highly debilitating. Vestibular implant is being developed to help such disabled patients.

Patients with bilateral vestibulopathies have varying degrees of disability. Treatment option for these patients is to teach them to adapt and cope with their disability. A vestibular implant that uses electrical stimulation of

revIew ArtIcle

1Professor and Head, 2Assistant Professor1,2Department of ENT, Rohilkhand Medical College and Hospital Bareilly, Uttar Pradesh, India

Corresponding Author: Abhinav Srivastava, Assistant Professor, Department of ENT, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, Phone: +919794956306 e-mail: [email protected]

10.5005/jp-journals-10050-10057

vestibular neurons is in the developmental stage as one treatment option for these patients. The implant is sup-posed to replace absent or severely reduced semicircular canal function.

REVIEW OF LITERATURE

Short-term electrical stimulation of the vestibular periph-ery has a long history. In the early 19th century, Purkynje (1820, quoted by Merfeld and Lewis1) used low-frequency electrical stimulation between the left and right ears to induce vertigo. Later studies by Mach2 reported nystag-mus, illusory motion of visual object and illusions of self-tilt by electrical stimulation of the vestibular periphery.

Suzuki, Cohen, et al3,4 implanted electrodes for short duration electrical stimulation of the vestibular periph-ery. They used voltage pulses to limit current spread and observed that individual ampullary nerve branches could be stimulated, and that the eye responses to such stimuli were like natural responses.

Study of long-term stimulation of vestibular periph-ery was undertaken as nothing was known about the behavior of nervous system to chronic stimulation of the vestibular periphery. Vestibular periphery of animals was chronically stimulated for 24 hours/day for 7 days a week for many months.5-7 Initially, a brisk nystagmus was induced when pulsatile current pulses were turned on.

It was seen that animals acclimated to this baseline stimulation, and the time required for acclimation became less and less with repeated exposures to stimulation.

Recently, the first human study by Wall et al8 has been published that utilized electrical stimulation provided by electrodes inserted into the vestibular periphery for focal vestibular stimulation using short-term current pulses intraoperatively.8 The study demonstrated an electrically evoked response in humans as was seen previously in animal models.

Guyot et al9 chronically implanted electrodes near the left posterior ampullary nerve of a deaf patient as part of a cochlear implant surgery. Electrical stimulation was provided intermittently for varying periods of time. When the baseline pulsatile current pulses were turned on, a nystagmus was evoked. This nystagmus dissipated over a period of about 30 minutes. When the stimulus was turned off after 27 minutes of constant stimulation, a nystagmus in the opposite direction was initiated, which indicates adaptation. When the stimulus was alternately turned on and off, the duration of the nystagmus response

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decreased. This is the first study of human plasticity to electrical stimulation provided by electrodes chronically implanted near vestibular neurons.10

A study by Guinand et al11 assessed the quality of life for patients diagnosed with bilateral vestibulopathy. It was observed that bilateral vestibulopathy affects the quality of life by negatively affecting physical and social function and that there is a clear need for a therapeutic solution for patients of bilateral vestibulopathy, such as a vestibular implant.

Surgery for Vestibular Implant

Vestibular implant surgery is in the initial stage of devel-opment. Two surgical approaches have been described for inserting electrodes for vestibular stimulation: Extralabyrinthine and intralabyrinthine and also its combined approach.

A comparison of the two surgical approaches used to insert electrodes to stimulate canal ampullary nerve branches has been reviewed. The intralabyrinthine approach utilizing the osseous canal lumen to guide the electrode to the ampullae was originally pioneered by Suzuki and Cohen.3 The other approach is extralabyrin-thine and has been utilized for human studies performed by the Geneva group.9,10 The extralabyrinthine approach has two components using transmeatal approach. The posterior ampullary nerve is reached via a transmeatal approach after drilling the floor of the round window niche. The other two ampullary nerve branches are reached transmeatally after the removal of the head of the malleus and incus.

Drawbacks to the extralabyrinthine approach are that the ampullary nerves may sometimes be difficult to reach. There is risk of both sensorineural and conductive hearing loss following reconstruction of the ossicular chain. These can be facial nerve damage. The main advantage is that the electrodes can be located near the desired neurons and stimulation might be possible even if the peripheral dendrites have been destroyed up to Scarpa’s ganglion following peripheral damage.

Complications associated with the intralabyrinthine approach include perilymph leaks following canal fenes-tration, possible sensorineural hearing loss, and difficulty in stimulating neurons if they have died back to Scarp’s ganglion, but the facial nerve is less likely to be damaged and the middle ear is preserved in this procedure.

Combination of both approaches has been success-fully used for stimulating ampullary neurones selectively. Both approaches are surgically compatible. Individual ampullary nerves can be stimulated by any of the approaches in the same patient.

Two recent vestibular implant studies by Dai et al12 and Bierer et al13 have evaluated the effects of a vestibular

implant on hearing in rhesus monkeys. The studies suggest that electrode implantation in all three canals is not likely to result in considerable hearing loss. Once there is development and refinement in the vestibular implant technology, the risk to hearing will roughly be similar to the risk of a cochlear implant.

The vestibular implants have been developed to replace the function of vestibular system. The first vestibular implants were installed in three patients in Europe. These implants restore the function of the semi-circular canals. Semicircular canals are thought to be the most important, and it is technically easier to restore their functions by putting electrodes into the ampullae of the canals.13

CONCLUSION

The deficits associated with severe bilateral vestibulopa-thy suggest that this treatment option would benefit the quality of life of patients. Vestibular implants will restore partial vestibular function in patients with severe bilateral peripheral deficit. Numerous challenges and queries remain unanswered, the most important being the ethical issues related to vestibular implants, the decision in making about the surgical approach for implants, and finally the effects of implants on hearing. With the progress in the field of vestibular implants and ongoing research, all these queries will be answered over a period of time. Justifying ongoing research efforts, all available data suggest that vestibular implants would benefit patients suffering from severe bilateral vestibular loss.

REFERENCES

1. Merfeld DM, Lewis RF. Replacing semicircular canal func-tion with a vestibular Implant. Curr Opin Otolaryngol Head Neck Surg 2012 Oct;20(5):386-392.

2. Mach, E. Fundamentals of the theory of movement percep-tion. New York: Kluwer Academic/Plenum Publisher; 1875.

3. Suzuki JI, Cohen B. Head, eye, body and limb move-ments from semicircular canal nerves. Exp Neurol 1964 Nov;10:393-405.

4. Cohen B, Suzuki JI, Bender MB. Nystagmus induced by elec-trical stimulation of the ampullary nerves. Acta Otolaryngol 1965 Jan;60(1-6):422-436.

5. Lewis RF, Gong W, Ramsey M, Minor L, Boyle R, Merfeld DM. Vestibular adaptation studied with a prosthetic semicircular canal. J Vestib Res 2002-2003;12(2-3):87-94.

6. Merfeld DM, Gong W, Morrissey J, Saginaw M, Haburcakova C, Lewis RF. Acclimation to chronic constant-rate peripheral stimulation provided by a vestibular prosthesis. IEEE Trans Biomed Eng 2006 Nov;53(11):2362-2372.

7. Lewis RF, Haburcakova C, Gong W, Makary C, Merfeld DM. Vestibuloocular reflex adaptation investigated with chronic motion-modulated electrical stimulation of semicircular canal afferents. J Neurophysiol 2010 Feb;103(2):1066-1079.

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8. Wall C 3rd, Kos MI, Guyot JP. Eye movements in response to electric stimulation of the human posterior ampullary nerve. Ann Otol Rhinol Laryngol 2007 May;116(5):369-374.

9. Guyot JP, Sigrist A, Pelizzone M, Kos MI. Adaptation to steady-state electrical stimulation of the vestibular system in humans. Ann Otol Rhinol Laryngol 2011 Mar;120(3):143-149.

10. Guyot JP, Sigrist A, Pelizzone M, Feigl GC, Kos MI. Eye move-ments in response to electrical stimulation of the lateral and superior ampullary nerves. Ann Otol Rhinol Laryngol 2011 Feb;120(2):81-87.

11. Guinand N, Boselie F, Guyot JP, Kingma H. Quality of life of patients with bilateral vestibulopathy. Ann Otol Rhinol Laryngol 2012 Jul;121(7):471-477.

12. Dai C, Fridman GY, Della Santina CC. Effects of vestibular prosthesis electrode implantation and stimulation on hearing in rhesus monkeys. Hear Res 2011 Jul;277(1-2):204-210.

13. Bierer SM, Ling L, Nie K, Fuchs AF, Kaneko CR, Oxford T, Nowack AL, Shepherd SJ, Rubinstein JT, Phillips JO. Auditory outcomes following implantation and electrical stimulation of the semicircular canals. Hear Res 2012 May;287(1-2):51-56.

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Brugada Syndrome: Killer Genetic Heart Disorder1Payodh Chaudhary, 2Nitin Agarwal, 3Malini Kulshrestha, 4RR Chaudhary

ABSTRACT

Brugada syndrome is a rare inherited arrhythmic disorder, which predisposes to ventricular arrhythmia that is responsible for sudden and unexpected nocturnal death syndrome.

Keywords: Brugada syndrome, Sudden and unexpected nocturnal death syndrome, Ventricular arrhythmia.

How to cite this ar ticle: Chaudhary P, Agarwal N, Kulshrestha M, Chaudhary RR. Brugada Syndrome: Killer Genetic Heart Disorder. Int J Adv Integ Med Sci 2016; 1(4):186-187.



INTRODUCTION

Brugada syndrome is a hereditary arrhythmic disorder (autosomal dominant inheritance), caused by muta-tion in the SCN5A gene. It is a cardiac sodium channel abnormality that predisposes to ventricular arrhythmia and responsible for sudden cardiac death. Prevalence is approximately 0.15% in adults and 0.005% in children in Asia and less than 0.02% in the West. Its incidence in Japan is high, i.e., 14.2 per 100,000 person per year. It is identified in both genders and all races, but is most common in young male patients (75%). It remains life-long asymptomatic in individuals, but sudden cardiac death may occur as early as the first year of life. Fever is the most common precipitating factor for arrhythmic cardiac events. In patient with structurally and function-ally normal heart, electrocardiogram (ECG) appears like right bundle branch block with ST segment elevation in V1–V3.

CASE REPORT

A young 40-year-old male presented in emergency with history of palpitation and chest heaviness for 2 to 3 hours

CASE STUDIES

1Junior Resident, 2Assistant Professor, 3,4Professor

1-4Department of General Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Corresponding Author: Malini Kulshrestha, Professor Department of General Medicine, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India, e-mail: [email protected]

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with fainting attack and mild fever without chills and shivering for 1 day. No history of perspiration, breathless-ness, and cough was present.

He gave a history of several on–off fainting attacks in the past 12 years, and there was no definite interval for these symptoms. He had been treated as a case of myocardial infarction/unstable angina on clinical basis without relief of symptoms in past. No previ-ous ECG was available. He also gave a history of his younger brother’s death in the night due to unexplained cause at the age of 30 years. However, his father is asymptomatic.

The patient was conscious, oriented with pulse 78 beats/minute, regular, normovolumic, normal in character, synchronous, arterial wall not palpable, and with no radiofemoral delay. Blood pressure was 124/84 mm Hg in the right arm supine position. Tempera-ture was 100°F at the time of admission. Respiratory rate was 20/minute, regular, and abdominothoracic. The peripheral capillary oxygen saturation (SpO2) was 98%. All systemic examinations were clinically within limits. Hemogram, electrolytes, and chest X-ray were normal. The ECG showed saddleback ST segment elevation in V1–V2 (Fig. 1). Cardiac biomarkers were negative 6 hours postadmission. No functional or structural abnormal-ity was detected in two-dimensional echocardiogra-phy. Therefore, ECG changes gave us clues to make a diagnosis of Brugada syndrome and was thought to be responsible for sudden and unexpected nocturnal death syndrome of patient on the same night of admission.

DISCUSSION

Brugada syndrome constitutes a deadly threat that often remains latent for many years, only to manifest itself in a lethal arrhythmia in persons considered to be otherwise healthy. Main reason for delayed diagnosis of Brugada syndrome is the periodic normalization of electrocar-diographic features of the syndrome,1 which is related to incomplete penetration of the gene responsible for the syndrome. Moreover, changes in ECG may be subject to influences of factors, such as body temperature2 or autonomic system tone.3,4 It has an autosomal dominant pattern of inheritance with incomplete penetrance. Yearly screening of ECG and genetic testing is recommended for family members. Implantable cardiac defibrillator is

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the choice of treatment and should be advised for those having ECG changes.

CONCLUSION

All ST elevations are not due to myocardial infarction and may have different etiology with risk of sudden cardiac death.

REFERENCES

1. Naccarelli GV, Antzelevitch C. The Brugada syndrome: clini-cal, genetic, cellular and m molecular abnormalities. Am J Med 2001 May;110(7):573-581.

2. Dumaine R, Towbin JA, Brugada P, Vatta M, Nesterenko DV, Nesterenko VV, Brugada J, Brugada R, Antzelevitch C. Ionic mechanisms responsible for the electrocardiographic pheno-type of the Brugada syndrome are temperature dependent. Circ Res 1999 Oct 29;85(9):803-809.

3. Miyazaki T, Mitamura H, Miyoshi S, Soejima K, Aizawa Y, Ogawa S. Autonomic and antiarrhythmic drug modulation of ST segment elevation in patients with syndrome. J Am Coll Cardiol 1996 Apr;27(5):1061-1070.

4. Wichter T, Matheja P, Eckardt L, Kies P, Schäfers K, Schulze-Bahr E, Haverkamp W, Borggrefe M, Schober O, Breithardt G, et al. Cardiac autonomic dysfunction in Brugada dsyndrome. Circulation 2002 Feb 12;105(6):702-706.

Fig. 1: Electrocardiogram with saddleback ST segment elevation in V1–V2

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A Modified Cutler-Beard Technique to Manage Extensive Sebaceous Gland Carcinoma of Upper Eyelid1Pranav Gupta, 2Y Rizvi, 3Etti Goyal

ABSTRACTIntroduction: Sebaceous gland carcinoma (SGC) is a rare tumor affecting the elderly, with a predisposition for females arising from the meibomian glands and occurring more com-monly on the upper eyelid. Diagnosis is difficult because the tumor mimics chalazion or blepharitis. Sebaceous gland car-cinoma has a mortality rate of about 5 to 10%.

Aim: To present a modified Cutler-Beard technique of lid reconstruction to manage a case of extensive SGC of upper lid.

Materials and methods: A 65-year-old male presented with a rapidly growing extensive mass of right upper eyelid (size 4.2 × 4 × 2.1 cm) causing mechanical ptosis. Histopathology confirmed the diagnosis as SGC. Wide excision of the lesion was performed sacrificing the whole upper eyelid. Lid recon-struction was done employing lower eyelid as per the bridged flap technique with the use of 4 mm silicon band to enhance lid stability. Patient achieved a satisfactory functional and cosmetic result following the second stage of the procedure.

Conclusion: Total loss of upper eyelid is often dealt with clas-sical lid sharing technique of reconstruction first described by Cutler-Beard. For lid stability, use of tarsus from contralateral eye, ear cartilage has their attendant problems. A 4.0 silicon band was used to replace the sacrificed tarsus, achieving good results.

Keywords: Bridged flap, Meimobian gland, Pleomorphic, Silicon band, Vacuolated.

How to cite this article: Gupta P, Rizvi Y, Goyal E. A Modified Cutler-Beard Technique to Manage Extensive Sebaceous Gland Carcinoma of Upper Eyelid. Int J Adv Integ Med Sci 2016;1(4):188-190.



INTRODUCTION

Sebaceous gland carcinoma (SGC) is the third most common malignancy arising from meibomian glands, glands of Zeis, sebaceous glands of the caruncle, and

CASE STUDIES

1,3Postgraduate Student (3rd Year), 2Associate Professor

1-3Department of Ophthalmology, Rohilkhand Medical College and Hospital, Mahatma Jyotiba Phule Rohilkhand University Bareilly, Uttar Pradesh, India

Corresponding Author: Pranav Gupta, Postgraduate Student (3rd Year), Department of Ophthalmology, Rohilkhand Medical College and Hospital, Mahatma Jyotiba Phule Rohilkhand University, Bareilly, Uttar Pradesh, India, Phone: +917830003283, e-mail: [email protected]

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eyebrow.1 Worldwide incidence of SGC is 1 to 1.5%.2 In Indian population, it constitutes about 31.2% of eyelid malignancies.3 Treatment of choice is wide surgical exci-sion with microscopic monitoring of the margins pref-erably with frozen section technique.4 Surgical excision of the tumor leaves a large lid defect that requires adequate lid reconstruction. Goal of lid reconstruction is normal anatomical and functional restoration.5 Choice of reconstructive procedure depends upon extent and tissue loss.

CASE REPORT

A 65-year-old male farmer presented with an indurated, erythematous painless mass involving entire right upper eyelid of about 1 year duration. There was no history of trauma or previous ocular surgery. Swelling started as a small lid marginal nodule mimicking a chalazion and gradually progressed to involve entire upper lid. Mucopurulent discharge persisted and enhanced with time, forming marginal crusting. On local examination, 4.2 × 4 × 2.1 cm sized, firm, multilobulated, indurated, erythematous swelling involving the entire upper lid causing mechanical ptosis and conjunctival congestion was pronounced at the lower fornix (Figs 1A and B). Cornea and other structures of anterior segment were normal. Fundus examination was also normal. Visual acuity was: Oculus dexter (OD) – 6/12 to 6/9, Oculus sinister (OS) – 6/9. Intraocular pressure measurements were: OD – 14.6 mm Hg, OS – 14.6 mm Hg. Ocular motil-ity was unrestricted.

On general and systemic examination, no significant abnormality was detected. Routine blood investigations were carried out and erythrocyte sedimentation rate was raised (43 mm after first hour). Fine-needle aspiration cytology of the nodule showed characteristic malignant cells and cytoplasmic vacuolation, which was suggestive of SGC.

After 3 weeks, patient reported with continuous mild pain over lids and periocular area with complete shut-down of eyelid. Swelling had increased in size to about 5.1 × 4.6 × 2.8 cm in its greatest dimensions with hard to firm consistency. Conservative option being ruled out, wide radical excision of the tumor sacrificing the complete upper lid was subsequently planned. As surgery involved sacrificing whole upper eyelid, a Cutler-Beard operation

A Modified Cutler-Beard Technique to Manage Extensive Sebaceous Gland Carcinoma of Upper Eyelid


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was contemplated. Total lid excision under general anes-thesia was undertaken along with lid reconstruction with lower lid sharing technique of Cutler-Beard procedure. Tarsus reconstruction was employed using a 4 mm silicon band (Figs 2A and B) sutured with conjunctiva and the levator aponeurosis using 5-0 vicryl. Orbicularis and skin were sutured separately, followed by pressure bandage for 48 hours. Excised mass (Fig. 3A) was sent for histopathological examination that revealed vacuolated cytoplasm and hyperchromatic pleomorphic nuclei and mitotic figures (Fig. 3B).

After a hospital stay of 1 week with conservative treatment, the patient was discharged. During fortnightly follow-up, uneventful recovery was noted with no infec-tion or discharge or wound dehiscence.

Second-stage surgery was undertaken after 8 weeks following initial surgery, incising upper lid 1 mm above the bucket handle sling margin. Care was undertaken to form a uniform lid edge with everted conjunctiva. Conjunctiva and skin at the newly formed lid margin were sutured with 5-0 vicryl and knots were buried (Figs 4A and B).

Postoperative recovery was good; functional and cos-metic status of newly formed upper lid was satisfactory.

DISCUSSION

Lid reconstruction, even though falling in the arena of oculoplastic surgeon, often invokes a general

Figs 1A and B: (A) Extent of lesion; and (B) undersurface of the lesion

A B

Figs 2A and B: (A) Excised mass; and (B) histopathological section

Figs 3A and B: (A) 4.0 mm silicon band; (B) silicon band being sutured

A B

A B

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ophthalmologist in view of emergent requirements. It is required in various clinical conditions like lid tumors and malignancies, traumatic lid defects, colobomas, burns, postirradiation, and severe variant of herpes zoster ophthalmicus.6

The following key factors had to be noted while evalu-ating lid defects: Eyelid involvement – upper or lower; depth of defect – superficial or full thickness; involvement of lid margin in defect; size of defect – 25, 40, 50, 75, or 100%; shape of defect – vertical, horizontal, irregular, or pentagonal; elasticity of lids (age factor); involvement of canthal tendon; and involvement of levator muscle or lacrimal apparatus. Smaller lid defects up to 25% in young and 40% in old may be repaired by primary lid closure. A large defect above 60% has little option like cheek rotation flap (Mustrade’s) or tarsoconjunctival advancement flap (Hughe’s).7

Bridged advancement flap (Cutler-Beard procedure) has been sited to give excellent results where complete upper lid sacrifice is a compulsion. Cutler-Beard tech-nique was proposed in year 1955 as a viable surgical option for upper lid reconstruction.8 It is based on the concept of lower lid sharing. Its major disadvantage was insufficient transfer of tarsus to upper lid causing a floppy lid formation. Tarsus reconstruction was sought using various grafts like donor sclera, ear cartilage, buccal cartilage, nasal septum, or even tarsus from contralateral eye.9 Added morbidity of the modifications in already physically challenged patient was a cause for concern.

Present work had tried a routine 4 mm silicon band used by the vitreoretinal surgeon to replace these homo-grafts. Key advantages were easy availability, saving of surgical time, and a taut lid margin contour was achieved. Complications of the surgery were not different from routine Cutler-Beard procedures like lagophthalmos, ectropion/entropion of lids, absence of cilia, lid notch-ing, and lid retraction. The present case noted a mild lagophthalmos insufficient to produce corneal exposure and central lid notching that required a subsequent cor-rection by Z-plasty.

CONCLUSION

Sebaceous gland carcinoma is a matter of concern in Indian subcontinent due to its relative high incidence and late diagnosis and it may fox as recurrent chalazion initially. Cutler-Beard surgery should be regarded as the procedure of choice where complete resection of upper lid becomes necessary. Morbidity and surgical time can be reduced by use of 4 mm silicon band for upper lid reconstruction.

REFERENCES

1. Shields JA, Demirci H, Marr BP, Eagle RC Jr, Shields CL. Sebaceous carcinoma of the ocular region: a review. Surv Ophthalmol 2005 Mar-Apr;50(2):103-122.

2. Gardetto A, Rainer C, Ensinger C, Baldisserra I, Piza-Katzer H. Sebaceous carcinoma of eyelid: a rarely worth considering. Br J Ophthalmol 2002 Feb;86(2):243-244.

3. Vemuganti GK, Rai NN. Symposium on ophthalmic cytology: neoplastic lesions of eyelid, eyeball and orbit. J Cytol 2007 Jan-Mar;24(1):30-36.

4. Jakobiac FA, To K. Sebaceous tumors of the ocular adnexa. In: Albert DM, Jakobiac FA, editors. Principles and practice of ophthalmology. 2nd ed. Vol. 4. Philadelphia (PA): WB Saunders; 2000. p. 3382-3405.

5. McCord CD Jr, Nunery WR. Reconstruction of the lower eyelid and outer canthus. In: McCord CD Jr, Tanenbaum M, editors. Oculoplastic surgery. 2nd ed. New York (NY): Raven Press; 1987.

6. Jelks GW, Smith BJ. Reconstruction of the eyelid and asso-ciated structure, In: McCarty JG, editor. Plastic surgery. Philadelphia (PA): WB Saunders; 1990. p. 1671-1784.

7. Mustarde JC. Repair and reconstruction in the orbital region. New York (NY): Churchill Livingstone; 1980.

8. Fischer T, Noever G, Langer M, Kammer E. Experience in upper eyelid reconstruction with the Cutler-Beard technique. Ann Plast Surg, 2001 Sep;47(3):338-342.

9. Codner MA. Reconstruction of the eyelids and orbit. In: Plastic surgery. London (UK): Mosby; 2000. p. 1425-1464.

Figs 4A and B: (A) After stage 1 surgery; (B) after stage 2 surgery

A B

Rare Case of Intrahepatic Pancreatic Pseudocyst misdiagnosed as Hepatic Abscess


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Rare Case of Intrahepatic Pancreatic Pseudocyst misdiagnosed as Hepatic Abscess1Parveen Hans, 1Sagar Tyagi, 2Prashant Sinha, 3Lalit Kumar, 1Deepanshu Gupta, 1Robin Singh

ABSTRACT

Introduction: Pseudocyst formation is a well known compli-cation of pancreatitis. Intrahepatic pancreatic pseudocyst is very rare event and only about 30 cases have been reported in literature. We report here a case of 32-year-old male who was previously diagnosed as a case of hepatic abscess. He was referred to our department for ultrasonography (USG) and contrast enhanced computed tomography (CECT) abdomen with complaint of recurrent pain in upper abdomen. On the basis of findings of CECT Abdomen, diagnosis of large intrahepatic pancreatic pseudocyst in left lobe of liver is made.

Conclusion: Intrahepatic pseudocyst should be considered a differential diagnosis of cystic hepatic lesions in the patients with chronic or recent episode of acute pancreatitis. Computed tomography and high level of amylase in the collection plays an important role for diagnosing this complication.

Keywords: Computed tomography, Intrahepatic pseudocyst, Pancreatic pseudocyst, Pancreatitis.

How to cite this article: Hans P, Tyagi S, Sinha P, Kumar L, Gupta D, Singh R. Rare Case of Intrahepatic Pancreatic Pseudocyst misdiagnosed as Hepatic Abscess. Int J Adv Integ Med Sci 2016;1(4):191-193.



INTRODUCTION

Pseudocyst formation is a well-known complication of pancreatitis. It can occur anywhere in abdomen and even in mediastinum, depending upon where activated pancreatic enzymes are released and what path they follow.

Common sites of occurrence are body, tail, head of pancreas, lesser sac, perisplenic area, retroperitoneum, and pararenal areas.1 Intrahepatic pancreatic pseudocyst is a very rare event and only about 30 cases have been reported in the literature.

CASE STUDIES

1Junior Resident, 2Senior Resident, 3Professor

1-3Department of Radiodiagnosis, Rohilkhand Medical College & Hospital, Bareilly, Uttar Pradesh, India

Corresponding Author: Parveen Hans, Junior Resident Department of Radiodiagnosis, Rohilkhand Medical College & Hospital, Bareilly, Uttar Pradesh, India, e-mail: [email protected]

10.5005/jp-journals-10050-10060

We report here the case of a 32-year-old male who was previously diagnosed as a case of hepatic abscess and underwent pigtail drainage. He was referred to our department for ultrasonography (USG) and contrast enhanced computed tomography (CECT) abdomen with complaint of pain in upper abdomen. Based on the find-ings of CECT abdomen, diagnosis of large intrahepatic pancreatic pseudocyst in left lobe of liver was made.

CASE REPORT

A 32-year-old male presented with pain in upper abdomen associated with vomiting and fever for past 2 months. He was admitted in some other hospital and diagnosed as a case of liver abscess and pigtail was inserted. Patient got some relief and the catheter was removed after 15 days. Patient developed wound with discharge at the site of tube insertion.

He came to our hospital with complaint of recurrent upper abdomen pain and discharging sinus in epigastric region. Patient was nonalcoholic and there was no history of diabetes mellitus, tuberculosis, and hypertension. On examination, patient was icteric, otherwise well-oriented, afebrile with satisfactory general condition. On local examination, abdomen was distended and tender, hepatomegaly was present, wound in epigastrium with discharge (0.5 × 0.5 cm).

Blood investigations show raised serum amylase (126 IU/L) and lipase (563 IU/L). Liver function test was deranged with raised serum alkaline phosphatase (514 IU/L). He was referred to our department for USG whole abdomen and CECT abdomen.

Ultrasonography

Liver was enlarged in size (17.0 cm Cranio-caudal) with a large cystic lesion and with fine echoes in left lobe mea-suring 16 × 9.5 × 9 cm (Fig. 1). The lesion shows no color flow or solid areas. Fistulous connection was seen between the cystic lesion and skin in epigastric region. Pancreatic head was bulky with heterogeneous echo texture (Fig. 2). Pancreatic body and tail obscured by bowel gases.

Contrast-enhanced Computed Tomography

The CECT reveals a large, nonenhancing, cystic lesion (HU-9) with imperceptible wall involving left lobe of liver

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and showing communication with peripancreatic collec-tion. Fistulous communication with skin over epigastric region was also noted. Pancreas shows heterogeneous enhancement and a cystic area in region of tail. Multiple areas of peripancreatic collection were seen in lesser sac and retroperitoneum (Figs 3A, B and 4).

Ultrasonography-guided aspiration was done and fluid showed high level of amylase.

DISCUSSION

Pseudocyst formation is a well-known complication of both acute and chronic pancreatitis. Pancreatic

Figs 3A and B: The CECT abdomen, axial section: (A) Large, nonenhancing, cystic lesion involving left lobe of liver; and (B) pancreas shows heterogeneous enhancement, peripancreatic collection, and fat stranding

Fig. 4: The CECT coronal image; large, nonenhancing, cystic lesion in left lobe of liver communicating (red arrows) with lesser sac collection

Fig. 1: Ultrasound showing large intrahepatic pseudocyst in left lobe of liver

Fig. 2: On USG, pancreatic head was found bulky with heterogeneous echo texture

A B

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pseudocyst is defined as collection of pancreatic fluid and inflammatory exudate encapsulated by fibrous tissue.1

It can occur anywhere in abdomen and even in mediastinum, depending upon where activated pancre-atic enzymes are released and what path they follow. Common sites of occurrence are body, tail, head of pan-creas, lesser sac, perisplenic area, retroperitoneum, and pararenal areas.1

Intrahepatic pancreatic pseudocyst is a very rare event and only about 30 cases have been reported in the litera-ture. Intrahepatic pseudocysts are usually single and most commonly involve the left lobe, but multiple intrahepatic pseudocysts have also been described.2-4

The pathophysiology of intrahepatic pancreatic pseu-docyst formation can be explained by two mechanisms.3,5 The first mechanism consists of the accumulation of the pancreatic juice in the peripancreatic or prerenal space and thereafter eroding through the posterior layer of the parietal peritoneum and into the lesser sac. The lesser sac collection then tracks along the lesser omentum or gastrohepatic ligament toward the liver leading to the formation of left lobe subcapsular collections as seen in our case.

The second mechanism consists of spreading of pancreatic fluid from the head of the pancreas into the hepatoduodenal ligament and porta hepatis along the portal vein and its branches. This results in formation of intraparenchymal collections.3,5,6 Subcapsular pseudo-cysts are located just beneath the liver capsule and are biconvex in shape, while intraparenchymal pseudocysts are located away from the liver capsule and near the porta hepatis branches.7

Diagnosing an intrahepatic pseudocyst is difficult as it is usually not considered in the differential diagnosis of cystic hepatic lesions. Moreover, when an intrahepatic pseudocyst develops long after an episode of pancreatitis, or when the pancreas appears normal on imaging studies, it is rarely diagnosed.

The aspiration of amylase-rich fluid and the documen-tation of a communication with the peripancreatic collec-tion on CECT or disrupted pancreatic duct on endoscopic

retrograde cholangiopancreaticography will confirm the diagnosis of an intrahepatic pseudocyst.

There are no definite guidelines on the management of intrahepatic pseudocysts. Surgical drainage, radio-logically guided percutaneous drainage/aspiration, and transpapillary stent have been successfully used in the treatment of intrahepatic pseudocysts of pancreas.8

CONCLUSION

Intrahepatic pseudocyst should be considered as a differ-ential diagnosis of cystic hepatic lesions in patients with chronic or recent episode of acute pancreatitis. The CT image and high level of amylase in the collection plays an important role for diagnosing this complication.

REFERENCES

1. Federle MP, Anne VS. Pancreatic pseudocyst. In: Federle MP, editor. Diagnostic imaging. 1st ed. Utah: Amirsys; 2004. 3:24-27.

2. Mofredj A, Cadranel JF, Dautreaux M, Kazerouni F, Hadj-Nacer K, Deplaix P, Francois G, Danon O, Lukumbo S, Collot G, et al. Pancreatic pseudocyst located in the liver: a case report and literature review. J Clin Gastroenterol 2000 Jan;30(1):81-83.

3. Okuda K, Sugita S, Tsukada E, Sakuma Y, Ohkubo K. Pancreatic pseudocyst in the left hepatic lobe: a report of two cases. Hepatology 1991 Feb;13(2):359-363.

4. Epstein BM, Conidaris C. Pseudocysts involving the left lobe of the liver: CT demonstration. Br J Radiol 1982 Dec;55(660):928-930.

5. Scappaticci F, Markowitz SK. Intrahepatic pseudocyst complicating acute pancreatitis: imaging findings. AJR Am J Roentgenol 1995 Oct;165(4):873-874.

6. Casado D, Sabater L. Multiple intrahepatic pseudocysts in acute pancreatitis. World J Gastroenterol 2007 Sep 14;13(34):4655-4657.

7. Mehler CI, Soyer P, Kardache M, Pelage JP, Boudiaf M, Panis Y, Abitbol M, Hamzi L, Rymer R. Computed tomog-raphy of intrahepatic pancreatic pseudocysts. J Radiol 1998 Aug;79(8):751-755.

8. Bhasin DK, Rana SS, Chandail VS, Nanda M, Nadkarni N, Sinha SK, Nagi B. An intra-hepatic pancreatic pseudocyst successfully treated by endoscopic transpapillary drainage alone. J Pancreas 2005 Nov 10;6(6):593-597.

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Sublingual Epidermoid Cyst: A Rare Presentation1Ashish K Maurya, 2Shalini Jadia, 3Leena Jain, 4Sadat Qureshi

ABSTRACT

Infection of pilo-sebacious gland or traumatic migration of epidermis to the deeper layers of the skin can lead to epider-moid cyst. Any site of the body which is lined by squamous epithelium can be the site of epidermoid cyst. We present a case of sublingual epidermoid cyst in a 14-year-old female, who pre-sented with a slow-growing, soft, midline swelling in submental region. Cyst was excised under local anesthesia with sedation. Histopathological examination revealed a cystic wall lined by keratinizing squamous epithelium with lamellated keratin and fibrocollagenous tissue with congested blood vessels, along with subcutaneous fat and muscle bundles, which is suggestive of epidermoid cyst.

Keywords: Epidermoid cyst, Keratinized squamous epithelium, Submental swelling.

How to cite this article: Maurya AK, Jadia S, Jain L, Qureshi S. Sublingual Epidermoid Cyst: A Rare Presentation. Int J Adv Integ Med Sci 2016;1(4):194-195



INTRODUCTION

Epidermoid cysts are rare lesions in the head and neck and are most often located in the submental region.1 They can be present all over the body where squamous epithelial lining is present. The cyst can be defined as epidermoid when the lining present only epithelium, dermoid cyst when skin adnexa are found, and teratoid cysts when other tissues as muscle, bone, and cartilage are present.2 Diagnosis can be confirmed by histopatho-logical examination. Surgical excision of the cyst is often required and entire cyst wall should be removed to prevent recurrence.3

CASE REPORT

A 14-year-old female patient presented to the Otorhino-laryngology Department of our Medical College, with

CASE STUDIES

1,3Associate Professor, 2Professor and Head, 4Assistant Professor

1Department of ENT, Rohilkhand Medical College and Hospital Bareilly, Uttar Pradesh, India

2-4Department of ENT, People’s College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India

Corresponding Author: Ashish K Maurya, Associate Professor Department of ENT, Rohilkhand Medical College and Hospital Bareilly, Uttar Pradesh, India, Phone: +919617948246, e-mail: [email protected]

10.5005/jp-journals-10050-10061

the complaint of a midline swelling in submental region with little difficulty in tongue movements. The swelling (Fig. 1) was 3 × 3 cm in size, round in shape, firm, cystic, nontender, mobile, and no movement seen on tongue protrusion or swallowing. Temperature of overlying skin was normal. No punctum or pus point can be appreciated. An old healed scar mark was present. Ultrasonography of the swelling was suggestive of a midline cystic swelling (dermoid/epidermoid cyst). Diagnosis was confirmed by fine needle aspiration cytology. Surgery was planned for excision of the cyst under local anesthesia with sedation. A midline horizontal incision was given over submental swelling; cyst was excised out from the surrounding tissue and removed in total (Figs 2 and 3). The excised swelling measured 4.5 × 2.5 cm (Fig. 4). Wound was closed

Fig. 1: Swelling in submental area

Fig. 2: Swelling in situ (front)

Sublingual Epidermoid Cyst: A Rare Presentation


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in layers and specimen sent for histopathological exami-nation. Histopathological examination revealed cystic wall lined by keratinized squamous epithelium with lamellated keratin and fibrocartilaginous tissue. Patient did well postoperatively. No recurrence was seen during the follow-up at 6 months.

DISCUSSION

Epidermoid cyst can be seen anywhere in the body where squamous epithelial lining is present. Only 7% are seen in head and neck, mostly present with a midline, pain-less, suprahyoid slow-growing swellings, and only 0.1% of them are seen in the oral cavity.4 These cysts can be congenital or acquired. Congenital cysts of ectodermal origin are extremely rare. Acquired cysts are more common and are usually derived from traumatic or iatrogenic inclusion of epithelial cells or from occlusion of a sebaceous gland duct. Among all the theories of epi-dermoid cyst formation, the epithelial implant theory is the most commonly accepted theory. The small size cyst remains asymptomatic but larger sublingual cyst can cause discomfort in chewing, tongue movements, and swallowing. Large submental cysts can give a “double chin appearance”.5 Epidermoid cysts are also described as “pearly tumors” because of shiny, smooth, and waxy character of their dry keratin.6

Epidermoid cyst of the floor of the mouth derived from entrapped epithelial rests during midline closure of bilateral first and second branchial arches in third and fourth week of gestation.7,8

Ultrasonography is the best investigation for these types of cysts. It is economical, reliable, and without radiation exposure.9 Fine needle aspiration cytology can differentiate most of the types. Dermoid/epidermoid cysts above the mylohyoid muscle within sublingual

space can be approached by an intraoral approach, and the cyst below the mylohyoid muscle is seen as an obvious submental swelling. An external submandibular approach is preferred.1 The complete excision without rupturing the cyst is very important as the contents can cause inflammation and recurrence.

REFERENCES

1. Lohaus M, Hansmann J, Witzel A, Flechtenmacher C, Mende U, Reisser C. Uncommon sonographic findings of an epidermoid cyst in the head and neck. HNO 1999 Aug;47(8): 737-740.

2. Calderon S, Kaplan I. Concomitant sublingual and submental epidermoid cysts: a case report. J Oral Maxillofac Surg 1993 Jul;51(7):790-792.

3. Mavorah B, Bovet R. Treatment of retro auricular keratinous cysts. J Dermatol Surg Oncol 1984 Jan;10(1):40-44.

4. Turetschek K, Hospodka H, Steiner E. Case report: epidermoid cyst of floor of the mouth: diagnostic imaging by sonography, computed tomography and magnetic resonance imaging. Br J Radiol 1995 Feb;68(806):205-207.

5. Longo F, Maremonti P, Mangone GM, De Maria G, Calipheno L. Midline (dermoid) cysts of the floor of the mouth: report of 16 cases and review of surgical techniques. Plast Reconstr Surg 2003 Nov;112(6):1560-1565.

6. Darrouzet V, Vidal VF, Hilton M, Nguyen DQ, Fougere SL, Guerin J, Bebear JP. Surgery of cerebropontine angle epi-dermoid cysts: role of widened retrolabyrinthine approach combined with endoscopy. Otorhinolaryngol Head Neck Surg 2004 Jul;131(1):120-125.

7. Pancholi A, Raniga S, Vohara PA, Vaidya V. Midline submen-tal epidermoid cyst: a rare case. Internet J Otorhinolaryngol 2006;4(2):74-77.

8. Ulku CH, Uyar Y, Kocaogullar Y, Avunduk MC. Iatrogenic epidermal inclusion cyst of the parapharyngeal space: unusual complication of ear surgery. Skull Base 2004 Feb;14(1):47-51

9. Walstad WR, Solomon JM, Schow SR, Ochs MW. Midline cystic lesion of the floor of the mouth. J Oral Maxillofac Surg 1998 Jan;56(1):70-74.

Fig. 3: Swelling in situ (lateral) Fig. 4: Excised swelling

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Spontaneous Cholecystocutaneous FistulaRajesh Abbey

ABSTRACT

Spontaneous biliary fistulae are encountered, not very rarely, in one’s surgical practice. These fistulae are of three types: Internal, external, and combined. Internal spontaneous biliary fistulae are the commonest. External fistulae could be spontaneous or because of therapeutic, iatrogenic, or traumatic reasons are extremely rare. Spontaneous cholecystocutaneous fistula (SCCF), secondary to calculous cholecystitis, is an extremely rare presentation in the present-day scenario. It used to be quite common before the year 1900, but is very rare now because of better management of cholecystitis and cholelithiasis. Usually, SCCF is a complication of neglected chronic cholelithiasis. This is seldom seen today because of the early diagnosis and better management made feasible by ultrasound as first-line investigation, broad spectrum antibiotics, and effective surgical management of biliary tract diseases. It is a very rare case of 35-year-old female patient presenting in the outpatient depart-ment, with the multiple stones carefully preserved, which she had been extruding through the fistulous opening in the umbilicus, for the last 1 year. She was investigated and was operated for the same condition. Though the entity is very rare, clinicians should keep this condition in mind while examining any case of chronic discharging sinus or fistula on the abdominal wall, particularly the wound extruding stones in which case the diagnosis is self-revealing. In the absence of positive history of expelling stones, the diagnosis can be confirmed by computerized tomogram fis-tulography. Though the early diagnosis and improvement in the management of gallbladder disease has improved tremendously, the possibility of this condition arising mostly from the neglected gallbladder disease should always be kept in mind as such cases are again being reported from all over the world.

Keywords: Cholecystocutaneous fistula, Cholecystoumbilical fistula, Chronic calculous cholecystitis, Computerized tomogram fistulogram, Laparoscopic cholecystectomy.

How to ci te this ar t icle: Abbey R. Spontaneous Cholecystocutaneous Fistula. Int J Adv Integ Med Sci 2016; 1(4):196-198.



INTRODUCTION

Most of these internal fistulae communicate with duodenum (77%), colon (15%), and stomach (6%).1 Rarely, it can communicate with the urinary system or bronchial

IMAgeS In Surgery

Professor

Department of Surgery, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Corresponding Author: Rajesh Abbey, Professor, Department of Surgery, Rohilkhand Medical College and Hospital, Bareilly Uttar Pradesh, India, e-mail: [email protected]

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tree.2 Spontaneous external biliary fistulae are very rare and were first described in 1670 by Thilesus.3 In the world literature, only 65 cases had been described, since the year 1900.2,4 Less than 20 cases prior to year 2006 have been reported in the last 50 years. Now, most biliary fistulae are postoperative complications of liver and biliary tract surgery or trauma. External biliary fistulae can be further subdivided into spontaneous, therapeutic, traumatic, and iatrogenic fistulae. External spontaneous cholecystocutaneous fistula (SCCF) is a very rare surgical complication of neglected calculous biliary disease that has become even increasingly rarer because of easy and early diagnosis and expedient sur-gical intervention for gallstone disease. External biliary fistulae sometimes occur spontaneously as a result of intrahepatic abscess (pyogenic or parasitic), necrosis or perforation of the gallbladder, or other inflammatory processes involving the biliary tree. Though the entity had almost vanished, recently, a few cases are being reported from all over the world. In spite of early diag-nosis and better management of gallbladder disease, it is feared that this may not be a revisit by this, once not so uncommon entity, and a clinician should arouse a suspicion of SCCF in the patient having chronic discharg-ing sinus or fistula on the abdominal wall whether the history of the gallbladder disease is forthcoming or not. A 35-year-old female patient presented to the outpatient department with a history of passing multiple stones, repeatedly, from her umbilicus for the last 1 year (Fig. 1). There was no history of episodes of fever, chills, rigors,

Fig. 1: Spontaneous external cholecystoumbilical fistula, extruding gallstones from umbilicus

Spontaneous Cholecystocutaneous Fistula


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and anorexia. On examination, thinly built, asthenic patient had an umbilical fistula, having serous discharge from the umbilicus. The patient presented the carefully preserved stones which she used to frequently expel from her umbilicus. The fistula was chronic and painless. Clear history of passing large, faceted, multiple stones repeatedly through the umbilicus was the mainstay of the clinical diagnosis, which was confirmed by the computerized tomogram fistulogram, as it delineated the tract and demonstrated the multiple stones present in the fistulous tract leading to the umbilicus. There was no history of abdominal trauma or previous surgery in this patient. Cholecystectomy of the chronically inflamed and shrunken gallbladder was done along with exci-sion of the fistulous tract. The fistulous tract containing multiple stones, extending from gallbladder to umbilicus and traversing anterior abdominal wall was dissected and excised from anterior abdominal wall. The tract was identified emerging from the gallbladder, which was shrunken and fibrosed. There were no stones in the gallbladder. Postoperative period remained uneventful. Spontaneous external biliary fistula discharging into the skin surface, as in the present case, is rare. It is defined as a rupture of the gallbladder through all layers of the abdominal wall, with the creation of a fistulous tract to the skin, not preceded by any biliary surgery or trauma. The process of fistula formation is precipitated by obstruction of the cystic duct, which raises the pressure in the gallbladder, impairing the vascular supply and resulting in focal necrosis. This inflammatory process is typically insidious and recurrent. The fistula usually forms through the fundus of the gallbladder, since this part of the gallbladder is farthest from the cystic artery and thus most likely to be affected by ischemia. Chronic inflammation of the gallbladder can cause the gallbladder fundus to adhere to the abdominal parities triggering the

formation of fistulous tract. Underlying pathophysiology is the perforation of gallbladder which may be acute, sub acute, or chronic; it is the chronicity of the diseased gallbladder which is responsible for SCCF. Retained gallstones following laparoscopic cholecystectomy may cause biliary fistula or abdominal wall sinuses.5 This occurs because gallstones can harbor bacteria, which may form localized abscess with localized sinus, in an attempt to discharge the foreign body. Salmonella typhi, which has a predilection for the gallbladder, can cause chronic cholecystitis and may predispose to spontaneous SCCF.6 Communication to the umbilicus may be through the falciform ligament.

Sometimes the only manifestation may be the passing of the stones and discharge from the fistula, which is the case in the present patient also. The fistula itself may be painless as in the present case. Passing of the stones through the fistula with the discharge confirms the diagnosis clinically as in the present case. Various condi-tions which can be considered for differential diagnosis are metastatic carcinoma, tubercular sinus, pyogenic granuloma, chronic osteomyelitis of ribs with seques-trum, and infected epidermal inclusion cyst. Possibility of the SCCF should always be considered in any patient who has a chronic discharging sinus in abdominal wall or umbilicus. Moreover, the typical history of the patient is self-revealing and diagnostic.

Computerized tomogram fistulogram can dem-onstrate the fistulous tract and its contents, making a definitive diagnosis as was done in the present case (Figs 2, 3). The contrast will demonstrate the tract and gallbladder. Fistulography also may demonstrate the common bile duct, permitting evaluation of the biliary anatomy. It may also demonstrate multiple fistulous tracts or communications in some rare cases. Clinical presentation and radiological imaging provide valuable

Fig. 2: Computerized tomogram fistulogram demonstrating cholecystoumbilical fistulous tract containing multiple gallstones Fig. 3: Computerized tomogram fistulogram demonstrating

cholecystogastric fistulous tract containing multiple gallstones

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information in making the diagnosis of this rarely seen condition. Surgery is required most of the time and includes cholecystectomy with the excision of the tract, as both the gallbladder and the fistulous tract need to be excised to achieve a cure; in the present case open cholecystectomy with the excision of the tract was done and a subhepatic drain was placed which was removed on the third day.

The gallbladder was shrunken and fibrosed, whereas the fistulous tract contained multiple gall stones and the tract was adherent with the anterior abdominal wall as well with the surrounding tissue. The tract was opening into the umbilicus externally. The diagnosis of this rare entity often proves challenging if the clear history of passing the calculi per fistula is not there as a significant proportion of these patients present with nonspecific symptoms. Ideally, the treatment should include broad spectrum antibiotics, drainage of the abscess, and elective cholecystectomy with excision of the fistula.7

The possibility of external SCCF though very rare in present-day scenario should be kept in mind, in a patient having discharging sinus over abdomen or lower chest wall. In the patient passing stones through these fistulae, the diagnosis is obvious. Though with the advent of newer and efficient investigative and operative

modalities, the diagnosis and management of gallbladder disease has been made easier, yet the entity may be the result of neglected gallbladder disease as quite a few of these cases have been recently observed, as the modern-day advances in the treatment of gallstone disease are still not available in some pockets of the poorer population who prefer to bear or ignore the disease for the socioeco-nomic reasons, or is it a revisit by this entity?

REFERENCES

1. Glenn F, Reed C, Grafe WR. Biliary enteric fistula. Surgerynecolobstet 1981;153:527-531.

2. Henry CL, Orr TG. Spontaneous external biliary fistula.Surgery 1949;26(4):641-646.

3. Horhammer Cl. Ueberestraperitonealeperforatio der gal-lenblase. Munchener Medizinische Wochenschrift 1916;10: 1451-1452.

4. Fitchett CW. Spontaneous external biliary fistula. Vamed Mon (1918) 1970;97(9):538-543.

5. Cherry Ee Peck Koh, http://emedicine.medscape.com/ article/197206 FRACS, MBBS, MS; Chief editor: John Geibel, MD, DSc, MA.

6. Birch BR, Cox S. Spontaneous external biliary fistula uncom-plicated by gallstones. Postgrad Med J 1991;67(786):391-392.

7. Leela S, Sangal S, Finch G. Spontaneous Cholecystocuta- neous Fistula: A Rare Presentation of Gallstones. Journal of surgical case reports 2010:5:1-5.

Laennec Contributions to the Field of Medicine


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INTRODUCTION

Rene Theophile Hyacinthe Laennec was a master of clinical diagnosis. Using his invention, the stethoscope, he perfected the art of physical examination of the chest, methods to examine, and also introduced many terms that are still used today. He wrote two books that were masterful descriptions of the diseases of chest and heart. He wrote the first descriptions of bronchiectasis and cirrhosis, and classified pulmonary conditions. He described murmurs and thrills, bronchial and vesicular breathing, pectoriloquy (as a sign of tubercular cavities), egophony, bronchophony, a variety of rales, and normal and abnormal breath sounds. Laennec’s distinguished career and invention of the stethoscope contributed great advances to the study and diagnosis of chest diseases.

Rene Laennec was a French physician who invented the stethoscope. He is also known as the father of clinical auscultation. Rene Theophile Hyacinthe Laennec is considered to be one of the greatest doctors of all times. Born as the son of a lawyer, he was actually discouraged from practicing medicine, but as fate would have it, under his uncle’s able guidance, the young Rene too developed an interest in medicine and began his medical studies. He soon enrolled as a medical student in Paris’ finest hospital, the Charite, and studied under prominent physicians like Dupuytren and Jean-Nicolas Corvisart-Desmarets. A brilliant physician, he became a member of the Societed’ Instruction Medicale.

The present-day ornamental garland of the doctor hung around his neck had its modest beginning at the start of the 19th century. The introduction of auscultation – a new method to diagnose diseases – was his great-est contribution to medical science. This method involves listening to and identifying various sounds made by different organs. Before the invention of this method, Laennec’s diagnostic method involved placing his ear on the chest of the patient. This method made him quite uncomfortable while examining the young women and fatty patients, and hence, this led to innovation of a new device called stethoscope, which he initially termed as “chest examiner.” Though criticized initially, his works were way ahead of his time and had a great impact on medical science.1-3

Laennec was an illustrious, instructive, and popular speaker in all branches of medicine.

MAJOR RESEARCH/SCIENTIFIC STUDIES AND WORK

Father of Clinical Auscultation

Laennec introduced mediate auscultation using stethoscope for sounds of lungs and heart and revolutionized medi-cine. Laennec listened to the sounds of air entering and leaving the lungs, which were named breath sounds. He is considered as the father of clinical auscultation and wrote the first description of bronchiectasis and cirrhosis. He also classified the pulmonary conditions, such as pneumonia, bronchiectasis, pleurisy, emphysema, pneumotho-rax, phthisis, and other lung diseases. He learned to recognize these conditions from the sounds he heard with his stethoscope. His classification of pulmonary conditions is still used today.4,5

Throughout Laennec’s medical work and research, his diagnoses were supported with observations and findings from autopsies.1 Rene Laennec started publishing important scientific papers on various topics in 1802. One of his major papers was on peritonitis (inflammation of the abdominal cavity’s lining).2

During the Napoleonic wars in 1812–1813, he was in charge of the wards in the Salpêtrière Hospital in Paris reserved for wounded soldiers. A staunch Roman Catholic, his religious affiliation helped him to secure an appoint-ment as personal physician to Joseph Caedinal Fesch, half-brother of Napoleon and French ambassador to the Vatican in Rome.1,2

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Invention of Stethoscope

Lung Sounds

In 1816, Rene Laennec was appointed as physician at the Necker Hospital in Paris. During that period, the doctors used to place their ear on the chest of the patient to listen to the chest sounds. When a young overweight woman came to him complaining of chest problems, he found the traditional method of listening to heartbeats ineffective. So, he rolled a paper into a cylinder and placed one side on the woman’s chest and the other to his ear. He could now hear the sounds more clearly. He improvised the new device he had just designed and called it a stethoscope, from stethos (chest) and skopos (examination). The initial model, he developed consisted of a wooden tube and was monoaural. The other advancements include the developments of binaural stethoscope. The new device helped him in classifying the terms rales, rhonchi, crepitance, pectoriloqy, bronchophony, and egophony (sound resembling bleating of goat) pertaining to the sounds captured by the stethoscope. He published “De l’auscultation mediate” (“On Mediate Auscultation”) in 1819. It was the first discourse on a variety of heart and lung sounds heard through the stethoscope.1,4-6

In 1819, Laennec published his book on auscultation, i.e., listening to the sounds made by heart and lungs, by contracting muscles, by rush of blood in aneurysms, intestinal sounds, crepitus over a fractured site of bone, by fetus in utero, or to any sound produced in the skeleton or any internal part in the body in antenatal care and during delivery; fetal heart sounds are heard through fetoscope, a type of stethoscope.1

Melanoma

While still a student, Laennec was the first to lecture on melanoma. He coined the term melanoma (Greek meaning mela, Milan or black), referring to the type of cancer that typically occurs in the skin but may rarely occur in the mouth, intestine, or eye. He was the first to recognize that melanotic lesions in the lungs were the result of metastatic melanoma. His report was published as a bulletin in 1806.7,8

Tuberculosis

When Laennec was physician at the Necker Hospital in Paris, he focused on tuberculosis and chest diseases. He became deeply absorbed in the mysteries of chest, studying many chests and comparing his observations with post-mortem findings. During autopsies, he observed that the chests of tubercular patients were filled with fluid with pus and cavities. Tuberculosis was common in Laennec’s time accounting for many deaths. He himself suffered from tuberculosis and many of his family members died from the disease, including his mother, brother, and uncle. His mentors, Bichat and Bayle, also succumbed to the disease.1,2

Laennec’s Cirrhosis

His researches helped him in understanding the liver disease, cirrhosis. He coined the term cirrhosis, using the Greek word (kirrhos: tawny) that referred to the tawny, yellow nodules, separated by a fine fibrous tissue as characteristic of the disease. Laennec’s cirrhosis used to describe micronodular cirrhosis (growth of small masses of tissues in the liver that cause degeneration of liver function). Laennec’s cirrhosis, a disease associated with inflammatory polyarthritis, is named after him.1,2,9

Laennec Thrombus

It is an antenatal thrombus in the heart.

Laennec’s Pearls

Refers to sputum produced by asthmatics.2

Heart Sounds

Laennec familiarized himself with normal sounds of heart and described the abnormal sounds secondary to diseases of heart valves, which were later verified by postmortem examination. In both of his books, the sections of heart were not nearly as significant as that of chest because the physiology of the heart was understood very little at that time. However, Laennec distinguished two heart sounds, attributing the first heart sound to ventricular systole and the second sound to atrial systole.



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Hamman’s Murmur

Also known as Laennec–Hamman symptom, Laennec–Muller–von-Bergmann–Hamman symptom or Hamman’s crunch is a crunching sound heard over the precordium due to spontaneous mediastinal emphysema. Laennec also announced classification of anatomical lesion into encaphaloid and cirrhosis type.

ACHIEVEMENTS/AWARDS

• WithinayearofenteringEcolePratique,LaennecobtainedfirstprizesinbothMedicineandSurgeryatmedicalschool. The following year, in June 1802, he published his first paper and while still a student, published a number of papers on such noble topics as peritonitis, amenorrhea, prostate gland, liver diseases, and tubercular lesion.

• In1804,hisdoctoralthesisonrelationshipoftheancientGreekHippocraticdoctrinetopracticalmedicinewasacceptedandhewaselectedtotheSocietedeI’EcoledeMedicine,formerlytheRoyalSocietyofMedicine.

• Hebecameaneditorandcontributortotheesteemed“JournalofMedicine,Surgery,andPharmacy.”• Withtheinventionofstethoscopein1819,hebecamealecturerofinternationalrepute.• In1822,LaennecwasappointedchairandprofessorofmedicineattheCollegedeFranceandheadoftheMedical

Clinic at Hospital de la Charite.• In1823,hewaselectedafullmemberoftheAcademyofMedicine.• HewasmadeaknightoftheLegionofHonorin1824.• ReneLaennecwashonoredbythegovernmentwithFirstPrizeinMedicineandSolePrizeinSurgeryin1903.• AttheUniversiteClaudeBernardLyon,oneofthefourmedicalschoolsisnamedafterLaennec.

Tragic End

Laennec’s teachings were widely known and had gained respect all over the Western world. Unfortunately, Laennec was unable to accomplish his widely acclaimed masterpiece in good health. The writing of the book had fully exhausted him, and a month before publication, he was forced to resign his hospital post and give up his practice.

Never having enjoyed the robust health, Rene Laennec was diagnosed with tuberculosis in April 1826. The person who could hear the abnormal sound from his own chest through his own invention, the stethoscope, died of cavitat-ing tuberculosis on August 13, 1926, aged just 45 years. (Those whom God loves die young. Good men also die, but death cannot kill or erase their names.)

REFERENCES

1. Roguin A. Rene Theophile Hyacinthe Laennec (1781–1826). The man behind the stethoscope. Clin Med Res 2006 Sep;4(3):230-235. 2. Billimoria AR. Rene Laennec. JAPI 2012 Jul;60:62. 3. Jay V. The legacy of Laennec. Arch Pathol Lab Med 2000 Oct;124(10):1420-1421. 4. Lachmund J. Making sense of sound: auscultation and lung sound codification of 19th century French and German medicine.

Science, Technol Human Value 1999 Oct;24(4):419-450. 5. Daniel T. Rene Theophile Hyacinthe Laennec and the founding of pulmonary medicine. Int J Tuberc Lung Dis 2004 May;8(5):517-518. 6. Pasterkamp H, Kraman SS, Wodicka GR. Advances beyond the stethoscope. Am J Resp Crit Care Med 1997 Sep;156(3 Pt 1):974-987. 7. Denkder K, Johnson J. A lost piece of melanoma history. Plast Reconstr Surg 1999 Dec;104(7):2149-2153. 8. Karamanou M, Stratigos AT, Saridaki Z, Tsoucalas G, Androustjus G. Rene Theophile Hyacinthe Laennec (1781–1826) and the

description of metastatic pulmonary melanoma. J BUON 2015 Jan-Feb;20(1):354-356. 9. Duffin JM. Why does cirrhosis belong to Laennec. CMAJ 1987 Sep;137(5):393-396.

VK TiwariProfessor

Department of Pulmonary Medicine Rohilkhand Medical College and Hospital,

Bareilly, Uttar Pradesh, India

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