JOURNAL MGIMS

ISSN - 0971 - 9903

THEJOURNAL OFMAHATMA GANDHI INSTITUTEOF MEDICAL SCIENCES

Volume 14, Number (i) March 2009

EDITORIAL

I Redesigning Self !OP Gupta

WORLD HEALTH DAY THEME, 2009

v “ Save Lives - Make Hospitals Safe In Emergencies”S Anwar & B S Garg

REVIEW ARTICLE

1 Migraine : A ReviewA Saxena, OP Gupta

7 Evaluation And Management Of The PatientWith Esophageal Varices.J Jain

12 Gastroesophageal Reflux In ChildrenA Taksande, KY Vilhekar

17 Face To Face With NontuberculousMycobacteria At SevagramDK Mendiratta, P Narang, R Narang

ORIGINAL ARTICLE

22 Effect Of Physiological Factors On SoleusH-Refles In Normal Human SubjectsB Ghugare, R Singh, AP Jain

26 Assessment Of Functional Capacity InElderly Population By Elderly Mobility Scale InWardha (District) Maharashtra IndiaSD Ganvir, SS Ganvir

38 Suicides In Elderly Age-Group In Wardha RegionOf Maharashtra In A Period Of Five Years,From 1st January 2001 To 31st December 2005.PN Murkey, BH Tirpude, VG Pawar, KS Singh.

CASE REPORT

43 Inability To Start Hemodialysis AfterA Smooth Dual Lumen HemodialysisCatheter Insertion Procedure : A Case ReportS Kumar, AP Jain

45 GENETIC STUDY - A HELPING HAND FORCLINICAL DIAGNOSISAM Tarnekar, JE Waghmare, P Bokariya,IV Ingole, AK Pal

49 I Want My Father Back - Child’s Destiny.BH Tripude, PN Murkey, VG Pawar,S Shende, A Keche, KS Singh

52 Dislocation Of First MetatarsalPhalangeal Joint : A Case ReportA Kumar, C Rathod, CM Badole, KR Patond

DRUG UPDATE

54 RENIN BLOCKERS - A Newer Therapy InRegulating HypertensionB Taksande, S Yelwatkar, UN Jajoo

BOOK REVIEW

57 Utopia Is Now Promised By Science!Book - Future Human Evolution : EugenicsIn Twenty First CenturyAnupama G.

OBITUARY

61 Dr Michael Ellis Debakey

NOBEL PRIZE IN PHYSIOLOGY OR MEDICINE

25 Year 200862 Year 1909

P O E M

63 The LiberationDr OP Gupta

64 Abstracts of The Papers Presented in TheNational and International ConferencesHeld During The Year 2008

91 Instruction To Authors

THE JOURNAL OF

MAHATMA GANDHI INSTITUTEOF MEDICAL SCIENCES

Vol. 14, No. 1, 2009

CHIEF PATRONSHRI DHIRU S MEHTA

PATRON

Dr P NARANG

Dr S CHHABRA

ASSOCIATE EDITORSDr A P Jain Dr P Chaturvedi

Dr B S Garg Dr S P Kalantri

Dr D K Mendiratta Dr M V R Reddy

ASSISTANT EDITORDr R Joshi

EDITORIAL ADVISORY BOARDDr B S Chaubey, (Nagpur) Dr G M Taori, (Nagpur)

Dr M Kothari, (Mumbai) Dr A B Vaidya, (Mumbai)

Dr N N Wig,(Chandigarh ) Dr J L Gupta, (New Delhi)

Dr K K Aggarwal,(New Delhi) Dr Robert A Ollar, (U.S.A.)

Dr Madhukar Pai, (U.S.A.) Dr Sunil Gupta, (Nagpur)

Dr Anil Narang (Chandigarh) Dr P S Shankar (Gulbarg)

Dr J Anbalagan (Pondichery) Dr M G Pillai (Bombay)

EDITORIAL CORRESPONDENCEThe Editor,JOURNAL OF MGIMSDepartment of Medicine,M.G.Institute of Medical Sciences, SEVAGRAM 442102 (MS)Tel : (07152) 284341 to 55 Extn : 327 - Ext. : 23, Fax : (07152) 284333E-mail : [email protected] Web Site : www.mgims.ac.inPrinted published & distributed by Dr OP Gupta for Mahatma Gandhi Institute of Medical Sciences, Sevagram 442102.

MGIMS FACULTYDr S Pande Dr K V Desikan

Dr R Narang Dr B C Harinath

Dr R K Gupta Dr N Gangane

Dr B H Tirpude Dr P B Behere

Dr A K Shukla Dr Ramji Singh

Dr A T Tayade Dr V Vyas

Dr P S Nagpure Dr R S Naik

Dr K R Patond Dr Dilip Gupta

Dr K Vilhekar Dr S Kar

Dr I Ingole

EDITOR IN CHIEFDr O P Gupta

REDESIGNING SELF!

Editorial

We celebrated bicentenary of Charles Robert Darwin (1809-1882) on 12th Feb 2009. Darwin’s

“On the Origin of Species by Means of Natural Selection” in late 19th century revolutionized the

whole concept of the origin of life. The theory of evolution put forth by him convinced people at that

time. Most people thought Drawinian science is a universal solvent that can sort out most recalcitrant

problems of the society, consciousness, politics, literature and more, they mislead them, writes Steve Jones

in an essay.

According to Darwin’s concepts, initially there was spontaneous generation of life by chance

from inanimate matter into unicellular form and through adaptation, conflict and environmental

influences it evolved in different species, including the present day man. Though in his own time

other scientist criticized and refuted his theories. Darwin himself acknowledged that only by making

a supreme effort of imagination to think about the vast stretches of time in which tiny changes in form

can take place. In moral terms, he accepted that ‘ homosapiens was something more—“of all the differences

between man and animals, the moral sense or conscience is by far the most important” (Steve Jones)

‘ Dr Hargovind Khorana and colleagues were awarded Noble prize for discovering the genetic

code-the DNA which is regarded as master molecule of life. The genes containing DNA molecules have

the growth plan and are capable of replicating and sustaining the growth of a creature. So are we

our genes? Or the proteins generated from DNA via RNA? Life is a mystery and for time immemorial

search is on to find the final answer.

Thus the ‘genes’ promote their self replication.Genes use individuals to make more genes.

When genes adopt the bodies it becomes their principal mode of transport. Every part of us is either

an adaptation or by-product of adaptation. Why we live, suffer or die is basic question! Answer is provided

again in the genetic concept—we live because by working together, the genes can build bigger and

better adaptation then they can by going alone. We suffer because our adaptations are designed to

promote not health or happiness but gene replication. And we die because we are built not to last but

J MGIMS, March 2009, Vol 14, No (i), i - iii

i

to be replaced by new gene-replicating machines. Thus the genes are potentially immortal, while the

vehicle they create—us—are not. (Helena Cronin, Oliver Curry)

It reminds me of shloka from Shrimadbhagvatgeeta —-

Oklkafl th.kkZfu ;Fkk fogk;]uokfu xzz.gkfr ujksijkf.k

rFkk ‘kjhjkf.k fogk; th.kkZU;U;kfula;kfr uokfu nsgh ¼2%22½

uSua fNUnfUr ‘kL+=kf.k uSua ngfr ikod%

u pSua Dysn;UT;kiks u ‘kks”k;fr ekjqr% ¼2%23½

The embodied soul casts away old and takes up new bodies as a man changes worn out

raiment for new, thus it uses the body as vechicle for its own transport The soul is indestructible,

and immortal. However it remains debatable whether the genes per say can be equated with that of

the soul.

The completion of human genome project by Francis Collins and Craig Venter in 1995 has

given rise to new ideology, and new thinking —Eugenics- “liberal vision for the improvement in the state of

all humankind”. In view of Dr glad, it is opening up new opportunities for the enhancement of both

the physical and mental conditions of human species. Here is an attempt to examine Darwinism

critically. Hansen NE et al write,”Common understanding of the naturalness of natural selection

appears to be fundamentally disconnected from the daily lived experience of the human species.

Impairment and disability are not commonly understood as natural variations in human biology but

as biology having gone wrong”.

The eugenic practices are on going since long. Sir Francis Galton (1883), Darwin’s cousin

coined the word eugenic in his book “Inquiries into Human faculties”. Individual efforts are already

in full swing, like sterilization or vasectomies for population control, permitted selective abortions on

health ground, one child norms of China.“How can we best protect the interest of still unborn generation?”

is the recent thinking. A close ended question is asked ‘do people have the right to give birth to babies

who in all probability will grow up feeble minded or who are likely to suffer from devastating genetic

illnesses? Or Do we not want our next generation to be genius and physically fit. And here is the crux of

the matter that is the ‘use and abuse of the eugenics. The eugenicists then ask that forced sterilization


ii

Editorial

of persons with genetically predetermined low IQ and major genetic illnesses should be reinstituted.

And many more such radical suggestions are put forth by them like, curbing reproductive rights of

criminals, insane, feeble minded & paupars, not to discourage female feticide, reducing age of

pregnancy, allowing polygynae, asexual in-vitro fertilization etc which are likely to be unpopular, and

unacceptable socially and morally (please read the book review’ on ‘Future Human Evolution’ in this

issue). This is so called the overall efforts to ‘redesign self’. It may be labeled as barbaric, inhumane, mad

idea or materialistic reductionism etc by the moralists. The society and the moralists react strongly to

oppose such proposals at the initial stages, but a time comes when their slogans lose the sharpness and

they themselves become insensitive to such issue, and the things like euthanasia are legalized and

later misused.

“We know what we are, but not what we may be”

HAMLET

Darwin wrote “man in distant future will be far more creative than he now is”. Life is

developed by primarily natural and sexual selection. Life was material and consciousness an

epiphenomenon. (Athar Yawar) The modern science has provided an apparently secure way for human

being to excel themselves. Though essence of excellence is material and not spiritual. All the human

behaviors, emotions, and morality could be explained by ultimately self-centered urge to survive and

reproduce. The era of evolution of species, or specifically homosapiens by genetic (artificial) selection

rather than natural selection is on the anvil.

Dr. O P GUPTA

1. Lancet, Darwin’s gifts, December ‘2008

2. Future of Human Evolution, John Glad (2006)

Hermitage publishers


iii

Editorial

" SAVE LIVES - MAKE HOSPITALS SAFE IN EMERGENCIES "

World Health Day Theme, 2009

SANAM ANWAR* & B S GARG**

* Associate Professor, ** Professor and Head,Address for correspondence : Dr. Sanam Anwar, Dept. ofCommunity Medicine, MGIMS, Sevagram, Wardha,MH-442102. Email : [email protected]

The World Health Day is one of WHO's

most visible opportunities to raise awareness in

global health priorities. On 7 April 2009, the

World Health Organization will mark World

Health Day (WHD), the theme of which being

"SAVE LIVES - MAKE HOSPITALS SAFE IN

EMERGENCIES." This theme underscores the

critical importance of ensuring health facilities

are built safely, possess the resilience to withstand

various crises and can deliver services in any

emergency scenario.

The health centres, staff and other health

care providers in the area are critical life-lines

for vulnerable people in disasters - treating

injuries, preventing illnesses and caring for

people's health needs. They are cornerstones for

primary health care in communities - meeting

everyday needs, such as safe childbirth services,

immunizations and chronic disease care that must

continue in emergencies. Often, already fragile

health systems are unable to keep functioning

through a disaster, with immediate and future

public health consequences. Many people are left

even without emergency care during and after

disasters when hospitals and health facilities fail

to perform.

Global Context

Globally, natural hazards and disasters

are set to increase. Increased frequency of hazards

such as floods, droughts and cyclones, are

worsening the impacts on lives and livelihoods.

Hundreds of hospitals and health facilities are

destroyed or damaged every year by disasters. The

number of people at risk has been growing by

70-80 million per year. According to global

statistics, Asia is the continent exposed to the

most hazards, and has the highest numbers

of people vulnerable to hazards, due to both

physical and socio-economic factors. The World

Disaster Report 2006 highlighted the discouraging

fact that around 58% of the total number of

people killed in natural disasters during the

decade 1996-2005 was from the Asia region.

In December 2004, the Tsunami in the

Indian Ocean destroyed 61% of the health facilities

in Banda Aceh, Indonesia. In August, 2007

within two minutes, the city of Pisco, Peru lost

97% of its hospital beds to an 8.0 magnitude

earthquake. In the October 2005 earthquake in

Pakistan, 50% of the health facilities in affected

areas were completely destroyed.

In this context, the importance of disaster

risk reduction and preparedness requires great

emphasis. The trend towards a focus on this area

began with the International Decade for Natural

Disaster Reduction (IDNDR) in 1990. At the

closure of the decade, the International Strategy

for Disaster Reduction (ISDR) was approved by

the United Nations General Assembly (UNGA)

in 1999 to coordinate action for disaster risk

reduction worldwide.

Hyogo Framework for Action 2005-2015 (HFA)

Less than one month after the tsunami,

at the January 2005 World conference on Disaster

J MGIMS, March 2009, Vol 14, No (i), v - x

v

Reduction, 168 nations endorsed the Hyogo

Framework for Action 2005-2015 (HFA). Among

other challenges, the HFA calls on countries to

"Integrate disaster risk reduction planning into

the health sector; promote the goal of HOSPITALS

SAFE FROM DISASTERS by ensuring that all

new hospitals are built with a level of resilience

that strengthens their capacity to remain func-

tional in disaster situations and implement

mitigation measures to reinforce existing health

facilities, particularly those providing primary

health care.

Later in 2005, disaster health professionals

primarily from SEAR countries took initial steps

towards filling the identified gaps and improving

the level of disaster preparedness region-wise by

developing benchmarks against which to measure

progress. One benchmark (Benchmark 11) calls

for health facilities to be built or modified to

withstand expected risks posed by natural

hazards. Issues to be ensured are :

multi-sectorality : there is a need for the

health system to include and engage

lawmakers and regulation enforcers,

especially for building codes, engineers

and architects ;

expansion beyond hospitals to include other

critical facilities such as blood banks and

laboratories is imperative; and,

hazards and risk assessment-based planning

for hospitals is essential so that plans remain

appropriate and stay within available

resources

Regional Context

The 11 member countries of WHO's

South-East Asia Region are highly vulnerable to

disasters. The diagram shows the situation in the

region.

(Source: The World Disasters Report 2006)

There are countless examples of health infra-

structure-from sophisticated hospitals to small

but vital health centres-that have suffered this

fate. A few are below:

2001, Gujarat (India) Earthquake

3812 health facilities were destroyed during

the earthquake. There was total collapse of

the health infrastructure in Kutch district,

which was the worst affected. Most difficulties

encountered during the response phase in

the Kutch district were due to the collapse

of the health infrastructure. The cost of

reconstruction for the health sector alone

was estimated at US$ 60 million.

Earthquakes and Tsunami of 26 December

2004

The earthquake and tsunami of 26 December

2004 was a watershed event for countries in

WHO's South-East Asia Region. Never before

had one single event affected such a large

number of countries so severely.

Aceh province (Indonesia) Indian Ocean

Tsunami

It damaged 61% of health facilities and

killed nearly a third of the area's midwives,

a major loss for women's health.

Figure I


vi

“ Save Lives - Make Hospitals Safe In Emergencies “ World Health Day Theme, 2009

Maldives

One regular hospital and 20 health

centers were destroyed. As many as 5000

people had to be evacuated from 13 is-

lands.

Sri Lanka

92 health facilities were destroyed. This

included 35 hospitals.

India

7 district hospitals, 13 primary health

centers and 80 sub-centers were damaged

in the southern Indian States of Tamil

Nadu, Andhra Pradesh, Kerala, the

Union Territory of Pondicherry and the

Andaman and Nicobar Islands.

2005 December, Jammu & Kashmir (India)

Earthquake

38 health facilities in the Kashmir were

completely damaged and 14 were partially

damaged. One such case is the Uri Hospital

in the Baramulla district, which serves a

population of 130,000 was totally destroyed.

Patients were shifted to buildings which

were under construction and those who were

in a position to be carried, were taken to the

temporary health care outlets set up by the

Directorate of Health Services.

2006 March, Bantul district (Indonesia)

Earthquake

One of the six hospitals in the district was

destroyed. This led to overcrowding in the

surrounding hospitals. Bantul was worst hit

by the earthquake.

2007 February, Indonesia Floods

49 health facilities were damaged by the flood

waters.

2008 May, China earthquake

More than 11 000 medical institutions were

damaged in China's Wenchuan earthquake

in May 2008, forcing tens of thousands of

people to seek treatment elsewhere.

Current conflicts in Ethiopia and Gaza are

interrupting primary health services, such

as immunizations.

Why focus on health facilities safe from

disasters?

Health facilities and health services are

the community's lifeline in normal times, but

especially so in times of crisis. It is the main

location for providing care for the injured and,

in many cases, a point for delivery of relief goods.

It is also the point where information on missing

people can be collected. Damage to the health

system can include the loss of services, human

resources and damage to health-related infra-

structure. This can create gaps in service

provision following the disaster and lead to

secondary disasters. Public health infrastructure

losses include damaged hospitals, drug stores,

cold rooms, preventive health care offices, health

staff accommodation facilities, district health

offices, vehicles, and medical equipment in

hospitals, stores, clinics. Disasters create an

intensive demand for health services. In addition

to treating disaster victims, hospitals must

quickly resume treatment of everyday emergencies

and routine care.

Hospitals provide a great social value to

communities and an essential sense of security.

Hospitals represent an enormous investment for

any country. In some regions of the world, the cost

of running hospitals consumes approximately

70% of the budget of the ministries of health; in


vii

S Anwar & B S Garg

remote areas and in small island nations,

frequently there is only one facility of this type;

losing this hospital represents a 100% loss.

Destruction or loss of functionality poses a major

economic burden. Direct economic losses involve

more than the structure; the value of non-structural

elements can be higher than the structure itself.

USD 350 million was the estimated amount for

projects and programmes to rebuild health

facilities in Aceh post tsunami; USD 60 million

to rebuild health facilities after the Gujarat

earthquake of 2001.

Certain factors put hospitals and health

facilities at risk during disaster :

Buildings: The location, design specifications

and resilience of the material used, all

contribute to a hospital's ability to withstand

natural hazards.

Patients : Damage to hospitals multiplies

patient vulnerability and increase in numbers.

Hospital beds : Increase in demands for

emergency care.

Health Workforce : The loss or unavailability

at the time of disaster, hiring outside personnel

to sustain response capacity - add to the over-

all economic burden.

Equipments : Damage to non-structural

elements can cost 80% of the total costs.

Basic lifelines and services : Electrical power,

water and sanitation, waste management and

disposal can affect the entire health facility.

Civil conflicts have also made it difficult for

health facilities to cope with a sudden influx of

injured people. In these situations, the problem

is usually not the physical or structural integrity

of a hospital or clinic, but understaffing, the lack

of access to supplies and essential utilities.

During mass demonstrations in Nepal in 2006,

WHO-led hospital assessments revealed that the

main problem was understaffing and the lack of

access to "lifelines" (eg. power, gas).

Several initiatives have been started to

reduce a health facility's risk of destruction in

an emergency. However, it is important to know

what we mean by safe health facilities.

Safe health facilities

The term 'safe health facilities' encom-

passes all health facilities - large or small, urban

or rural, complex or primary care centres. A

health facility can be classified as safe when three

aspects are in place :

Physical integrity - in accordance with the

hazards in its environment, allowing the

facility to remain intact and not collapse in

disasters, killing or injuring patients and staff;

Continued functionality - Installed capacities,

so that it will continue to function, providing

critical services and absorb extra needs when

there is an emergency

Contingency plans and a well-trained health

workforce that is ready and able to deal with

the health consequences of emergencies.

How to keep safe health facilities

The processes leading to the HFA represent

a significant change from the way disasters have

been dealt with in the past. Whereas previous

strategies were focused on emergency management,

humanitarian response and relief measures,

today there is strong recognition that risk and

vulnerability reduction are key in reducing the

negative impacts of hazards, and thus essential

to the achievement of sustainable development.


viii


Well-built or retrofitted hospitals have

remained functioning following disasters.

The health sector has excellent examples of

and substantial accumulated experience

contributing to in safe health facilities.

The knowledge exists to assess vulnerability

and reduce risk in health facilities. The cost

of protection is much less when included in

the design stage. Vulnerability assessments

for structural and non-structural aspects of

hospitals in Nepal was done with the goal to

keep hospitals in the Kathmandu Valley

physically intact and functioning in the

scenario of an earthquake. The work to keep

health facilities safe also entails training and

planning. The key technical issues that must

be addressed are hazard assessment, site

evaluation, appropriate conceptual design,

competent analysis, complete pre-construction

detailing, quality control during construction

and planned maintenance. Several countries

are working to keep hospitals safe, improving

preparedness to protect lives.

In Mexico, trained evaluators have

diagnosed the safety of 200 health

facilities, identifying which facilities

need improvements.

Multi-functional facilities for health,

education and agriculture were built in

Bangladesh to aid relief after cyclones

and floods - which saved thousands of

lives after Cyclone Sidr in 2007.

In Japan, Pakistan and Peru, health facilities

are now built to withstand earthquakes.

After the Gujarat earthquake in 2001, all

health facilities were rebuilt to interna-

tional standards to make this critical

infrastructure disaster resilient.

Activities to address the problem

The UN International Strategy for

Disaster Reduction (UN/ISDR) and the World

Health Organization (WHO) are partnering with

governments, international and regional organi-

zations, non-governmental organizations and

individuals worldwide to raise awareness about

how and why we must redouble efforts to protect

health facilities and ensure they can function

during and in the aftermath of disasters. The

theme of the World Disaster Reduction Campaign

2008-09 is HOSPITALS SAFE FROM DISAS-

TERS: REDUCE RISK, PROTECT HEALTH

FACILITIES, SAVE LIVES. The campaign is

implemented with support from the Global

Facility for Disaster Reduction and Recovery

(GFDRR) of the World Bank. The campaign's

objectives are :

Contribute to structural resilience of health

facilities.

Help hospital services continue to function

in the aftermath of emergencies and disasters

Assist health institutions to improve risk and

emergency management capability

Involve health professionals in identifying

and reducing risk.

Take steps to incorporate these priorities into

national development plans.

The campaign urges all those responsible

such as decision makers, politicians, architects,

engineers, public health professionals, development

banks and donors to come forward with required

policies, legislation, technical guidance and

public awareness to make hospitals and health

facilities safe from disasters.

A regional Consultation on keeping

Health Facilities Safe from Disasters was held

in New Delhi in April 2008. It recommended

the following key action points :


ix

S Anwar & B S Garg

Establish safe hospitals committees

Ensure new health facilities are safe at

planning and design stage

Conduct contingency planning and training

for existing health facilities

Obtain political and donor commitment

through advocacy.

The theme of World Health Day, 2009

"SAVE LIVES. MAKE HOSPITALS SAFE

IN EMERGENCIES" is an opportunity for

advocacy. This year on World Health Day WHO

and international partners will underscore the

importance of investing in health infrastructure

that can withstand hazards and serve people in

immediate need. They will also urge health

facilities to implement systems to respond to

internal emergencies, such as fires, and ensure

the continuity of care. Events around the world

will highlight successes, advocate for safe facility

design and construction, and build momentum

for widespread emergency preparedness - to save

lives and improve global health. In summary with

current knowledge, existing resources, and a

strong political commitment, it is possible to

stop disasters and reduce risk in the health

sector. Everyday problems in providing routine

health services can be looked for. However, in

large-scale emergencies, the backbone of lifesaving

health services must be preserved.

References :

1. Hospitals safe from disasters. World Disaster

Reduction Campaign, 2008-2009 (ISDR, WHO).

2008.[Online]. [Cited 2009 February 20].

Available from: http://www.unisdr.org/eng/

public aware/world camp/2008-2009/pdf/

wdrc-2008-2009-information-kit.pdf

2. Emergency and Humanitarian Action: FOCUS

(WHO) 2008. [Online]. [Cited 2009 February 20].

Available from: http://www.searo.who.int/

LinkFiles/Hospitals_Safe_from_Disasters_

EHAFOCUSnew30.pdf

3. Safe hospitals, a collective responsibility, a Global

measure of Disaster Reduction (PAHO, WHO)

2005. [Online]. [Cited 2009 February 20].

Available from: http://www.paho.org/english/dd/

ped/SafeHospitalsBooklet.pdf

4. World Health Day 2009: Save lives, make hospitals

safe in emergencies. [Online]. [Cited 2009

February 20]. Available from: http://

www.searo.who.int/worldhealthday2009/

World_Health_day.htm

5. Hospitals safe from disasters. World health day

2009. [Online]. [Cited 2009 February 20].

Available from: http://www.safehospitals.info/


x


MIGRAINE : A REVIEW

A SAXENA*, OP GUPTA**

**Professor, *Sr. Lecturer, Add. for correspondence :Dr Amrish Saxena, Deptt. of Medicine, MGIMS,Sewagram. Email : [email protected]

Headache is the commonest problem,

men have been enduring since the time immemorial.

Migraine, one of the more troubling cause of

headache, afflicts approximately 15% of women

and 6% of men, No age is immune but it generally

starts in younger generation.

Migraine is a markedly disabling condition,

and exerts a significant burden on the sufferer

in terms of pain, suffering and imparied quality

of life. This results in a large economic burden

on society, both in therms of direct medical costs

of care and indirect costs due to lost work time

and working at reduced productivity. It is a

common clinincal disorder that continues to

be underrecognised, underdiagnosed and

undertreated.

Migraine is a heterogeneous condition,

with headache attacks varying in frequency,

duration, symptomatology and associated

disability, both between sufferers and between

attacks in the same individual. It can be defined

as a benign and recurring syndrome of headache,

nausea, vomiting, tenderness around the face

and scalp and/or symptoms of neurologic

dysfunction in varying admixtures. It is a

neurovascular event the occurs in people with a

genetically susceptible sensitive nervous system.

Migraine is a complex disorder with polygenic

inheritance and a strong environmental

component.

Migraine Historical timeline :

Date Event

400 BC Hippocrates states that headaches

are derived from “humors” (fluidsor vapors) circulating in the body,

illness resulted from imbalances of

natural elements.

200 AD Galen introduces the term

“migraine”, which is derived from

the Greek world hemicrania.

1598 Charles Le Pois described premonitory

symptoms and migraine with aura

for the first time.

1938 Graham and Wolff demonstrate the

efficacy of ergotamine in aborting

migraine by constricting cerebralblood vessels.

1943 Stoll and Hoffman synthesize DHE

(dihydroergotamine).

1945 Horton, Peters, and Blumenthal use

DHE to treat acute migraine at the

Mayo clinic.

1976 Propranolol is reported to be

efficacious in migraine prevention.

1991 Pat Humphrey reports the efficacy

of Sumatriptan in aborting acute

migraine in human volunteers.

1993 Sumatriptan is first triptan to beFDA approved and marketed.

2002 Valproic acid is FDA approved for

migraine prevention.

2004 Topiramate is FDA approved for

migraine prevention.

Review Article

J MGIMS, March 2009, Vol 14, No (i), 1 - 6

1

Pathogenesis :

It was widely held for many years that

the headache phase of migrainous attacks was

caused by extracranial vasodilatation and that

the neurologic symptoms were produced by

intracranial vasoconstriction (i.e., the “vascular”

hypothesis of migraine).

Migraine is now considered to be a

neurovascualr disorder because its pathology

involves important interactions between the

cerebral nerves and blood vessels. A simple

clinical definition of migraine is “a referred

pain from duramater and blood vessels” It is a

clinical syndrome of self-limited neurogenic

inflammation. The concept of neurogenic

inflammation(NI), referring to both vasodilatation

and increased vascular permeability is mediated

by the peripheral release of neuropeptides such

as substance P(SP), neurokinin A(NKA),

endothelin-3 (ET-3), and calcitonin gene-related

peptide (CGRP).

The release of tachykinins and endothelin

-3(ET-3) from trigeminal neurons induces

dural vascular permeability and vasodilatation

via activation of tachykinin receptor (1 (Tacr 1)

and endothelin receptor type B (Ednrb) on

endothelial cells. Endothelial cell receptor

stimulation results in cellular contraction, leading

to plasma protein extravasation (PPE), which is

the most recognized physiological hallmark of

neurologic inflammation (NI), and NO-induced

vasodilatation. By contrast, the release of calcitonin

gene-related peptide (CGRP) from trigeminal

neurons- also a key physiological commponent

of NI- does not affect vascular permeability but

does induce neurogenic vasodilatation (NV) via

the direct, (Endothelium independent) relaxation

of vascular smooth muscle.

Fig - Mechanism of migrain. Migraine is probably

triggered through hypothalamic or cortical mechanisms.

Trigeminal innervation of pain sensitive intracranial

structures, dura mater, and blood vessels provides pain

input through trigeminal ganglion to trigeminal nucleus.

The nucleus extends from medulla to C2 (accounting for

commonly reported neck pain with migraine) and sends

fibres to thalamus. 5-Hydroxytryptamine receptors on

blood vessel (5-HT 1B) and neurone (5-HT1D) mediate

vasoconstriction and presynaptic inhibition, thus

antagonising vasodilator effects of calcitonin gene

related peptide. Peripheral transmission in blocked by

sumatriptan and ergotamine, while central transmission

is also blocked by zolmitriptan7.

Current theories propose that

(1) In genetically predisposed individuals

migraine-specific triggers promote

meningeal nociceptor activation, dilation of

meningial blood vessels and the activation

of trigeminovascular system.

(2) Sensitization of cells in the trigeminal nucleus

caudalis in the medulla (a pain-processing

center for the head and face region) results

in the release of vasoactive neuropeptides,

including substnace P and calcitonin gene-

related peptide,

(3) These peptide neurotransmitters induce a


2

Migraine : A review

Natural remidies for Migraine :

Recently, some good studies have

demonstrated the effectiveness of the herb

Butterbur (Petasites hybridus) in preventing

migraines. Another herb, Feverfew (Tanacetum

Parthenium), is also wodely used and some

studies have shown it to be safe and possibly

effective for migraine prevention.

A variety of other CAM (complimentary

& alternative medicine) techniques are not bolstered

by solid scientific data, but they may be perceived

to be of benefit to patients. A few techniques

commonly practiced for headache relief include

body work (eg, chiropractic, massage), creative arts

(eg, dance, music), nutritional/herbal supplements

(eg, vitamins, herbs), Eastern medicine (eg, yoga),

acupressure and acupuncture, and Ayurveda.

Pharmacologic Treatment of Acute Migraine :

The mainstay of pharmacologic therapy

is the judicious use of one or more of the many

drugs that are effective in migraine. Treat early.

This will not only reduce the total duration of

treatment but also the recurrence and redosing

of the drugs. Chances of treatment failure are

also reduced, since it has been observed that once

allodynia sets in triptans are not more effective.

The selection of the optimal regimen for

a given patient depends on a number of factors,

the most important of which are the severity of

the attacks co-morbid illness and emotional

background. Most drugs effective in the treatment

of migraine are members of one of three major a

pharmacologic classes : (1) anti-inflammatory

agents, (2) 5-HT1 agonists, and (3) dopamine

antagonists.

Migraine therapy must be individualized

for each patient; a standard approach for all

patients is not possible.

neurogenic inflammation that is characterized

by vasodilation, vessel leakage, and mast cell

degranulation causing peripheral nociceptor

sensitization.

(4) In addition, neuropeptides relay nociceptive

impulses to the CNS, leading to severe

migraine pain; to central sensitization, which

lowers the pain-responsive threshold. This is

responsible for cataneous allodynia11. The

non-nociceptive stimuli become painful.

Simple activities like brushing the hairs,

wearing the hat, even resting head on pillow

induces severe pain.

TREATMENT :

Nonpharmacologic Approaches :

Migraine can often be managed to some

degree by a variety of nonpharmacologic

approaches -

(1) Lessening one’s response to stress by various

techniques - yoga, transcendental meditation,

hypnosis, and conditioning techniques such

as biofeedback, behavioral therapy. However

for most patients, this approach is, at best,

an adjunct to pharmacotherapy.

Behavioral and psychological interventions

used for prevention include relaxation training,

thermal biofeedback combined with relaxation

training, electromyography (EMG) biofeedback,

and cognitive-behavioral treatment. Behavioral

approaches are particularly recommended for

patients who prefer nondrug interventions, who

tolerate drugs poorly, who have medical

contraindications to drug therapy, who have

insufficient response to specific drug treatments,

good options for patients who are pregnant,

nursing, or planning to become pregnant8.

(2) Avoidance of migraine trigger factors-provide

significant prophylactic benefit.


3

Saxena A, Gupta OP

Non Steroidal Anti-Inflammatory Agents :

Both the severity and duration of a migraine

attack can be reduced significantly by anti-inflam-

matory agents. NSAIDs are most effective when

taken early in the migraine attack. The combination

of acetaminophen, aspirin, and caffeine, or

indomethacin have been found to be effective for

the treatment of mild to moderate migraine. The

combination of aspirin and metoclopramide has

been shown to be equivalent to a single dose of

sumatriptan10.

5-HT1 Agonists :

Stimulation of 5-HT1 receptors can stop

an acute migraine attack. (a) Ergotamine and

dihydroergotamine are nonselective receptor

agonists, while the (b) series of drugs known as

triptans are selective 5-HT1 receptor agonists.

A variety of triptans (e.q., naratriptan, rizatriptan,

sumatriptan, zolmitriptan, almotriptan,

frovatriptan) are now available for the treatment

of migraine. Rizatriptan and almotriptan are

the fastest acting and most efficacious of the

triptans currently available. Sumatriptan and

zolmitriptan have similar rates of efficacy as

well as time to onset,

Unfortunately, monotherapy with a selective

oral 5-HT1 agonist does not result in rapid,

consistent, and complete relief of migraine in

all patients. In recent studies, a single-tablet

combination of sumatriptan and naproxen

sodium relieved migraine symptoms more

effectively than did either individual medication.

Triptans are not effective in migraiine with

aura unless given after the aura is completed and

the headache initiated. Similarly they are not

effective in patients having allodynia. Side effects,

although often mild and transient, occur in up

to 89% of patients. Moreover, 5-HT1 agonists are

contraindicated in individuals with a history of

cardiovascular disease.

Dopamine antagonists :

Copamine antagonists (eq. Metoclopramide,

chlorpromazine, prochlorperazine) should be

considered as adjunctive therapy in migraine.

Drug absorption is impaired during migrainous

attacks because of reduced gastrointestianl

motility. Therefore, when oral NSAIDs and/or

triptan agents fail, the addition of a dopamine

antagonist such as metoclopramide, 10 mg,

should be considered to enhance gastric

absorption. In addition, dopamine antagonists

decrease nausea/vomiting and restore normal

gastric motility.

Butalbital combinations :

Medications that combine the sedative

butalbital with aspirin or acetaminophen are

sometimes used to treat migraine attacks. Some

combinations also include caffeine or codeine.

These medications, however, have a high risk of

rebound headaches and withdrawal symptoms

and accordingly should be used infrequently.

Opioids :

Medications containing narcotics, particularly

codeine, are sometimes used to treat migraine

pain when people can’t take triptans or ergots.

These drugs are habit-forming and are usually

used only as a least resort.

CGRP antagonist BIBN 4096 SB :

A highly specific and potent neuropeptide

CGRP-receptor antagonist, is effective in treating

acute attacks of migrains. It blocks trigeminocervical-

induced vascular dilatation6. Telcagepant (oral

CGRP receptor antagonist) is effective and


4

Migraine : A review

generally well tolerated for actue migraine

treatment2.

Fixed drug combinations (FDCs) combine

standardized doses of two or more drugs in a

single tablet, injection, nasal spray or suppository.

FDCs may improve treatment compliance, efficacy

and /or tolerability through a variety of mecha-

nisms. Improved understanding of migraine

pathophysiology might now allow the development

of rational combination approaches to treatment,

based on manipulation of the three major

biological processes involved in migraine

pathophysiology: dopaminergic hypersensitivity,

neurogenic inflammation and serotonergic

disturbances.

In particular, the following combinations

are identified as being praticularly promising,

based on current beliefs about the biological

systems involved in migraine9.

(1) a dopamine antagonist + an anti-inflammatory

agent

(2) an anti-inflammatory agent + serotonin agonist

(3) a dopamine antagonist + serotonin agonist;

and

(4) a dopamine antagonist + an anti-inflammatory

agent + serotonin agonist.

The most consistent and impressive

evidence of benefit is for NSAID-containing

FDCs. Evidence suggests that NSAID-containing

FDSs perform as well or better than single agent

triptan comparators.

Other nonspecific therapies that have

been used to abort acute migraine attacks include

intranasal lidocaine (Xylocaine) and systemic

steroids. While limited studies report lidocaine

to be superior to placebo, the reported incidence

of recurrent headaches has been inconsistent.

Because the evidence is insufficient, a defined

role for intranasal lidocaiine as abortive migraine

therapy has yet to be established. Steroid therapy

may be the treatment of choice for patients with

status migrainosus (a severe, continuous migraine

that may last up to one week), but there are no

good studies documenting its efficacy int he

treatment of the acute migraine attack.

Prophylactic treatment of migraine :

The occurrence of at least three attacks

per month could be an indication for this

approach. Drugs must be taken daily, and there

is usually a lag of at least 2 to 6 weeks before an

effect is seen. The 3 classes of medications that

are effective for migraine prevention are (1)

antiepileptics, (2) antidepressants, and (3)

antihypertensives. The drugs that have been

approved by the FDA for the prophylactic

treatment of migraine include propranolol,

timolol, sodium valproate, and methysergide,

topiramater4,5. In addition, a number of other

drugs appear to display prophylactic efficacy.

This group of drugs includes amitriptyline,

nortriptyline, verapamil, phenelzine, gabapentin,

and cyproheptadine. Phenelzine and methysergide

are usually reserved for recalcitrant cases because

of their seriosu potential side effects. Other drugs

recently approved for preventive treatment are -

Tiagabine, Levetiracitam, Zonisamide.

Botulinum toxin A (BOTOX(R)) may be

beneficial in patients with intractable migraine

headaches that fail to respond to conventional

preventive medication. The injections are

administered to the scalp and temple. They may

reduce the frequency and severity of migraine

attacks after 2-3 months of injections. The injections

are expensive and must be administered every

2-3 months to maintain their effectiveness. The

most appropriate duration of prophylactic


5

Saxena A, Gupta OP

therapy has not been determined. In most patients

who are receiving prophylaxis, therapy must be

continued for at least 3-6 months. The mechanism

by shich Botox might prevent migraines is

unclear, although the drug may cause changes

in nervous system that modify the tendency to

develop migraines.

By understanding the pathophysiology of

migraine, the clinician can optimize therapeutic

options and therapeutic strategies for their

patients.

References :1. Goadsby PJ. Recent advances in the diagnosis and

management of migraine. BMJ. 2006 Jan 7; 332

(7532): 25-9.

2. Silberstein SD. Recent developments in migraine.

Lancet 2008; 372: 1369-71.

3. Bahra A, Matharu MS, Buchel C, Fracknowiak RSJ,

Goadsby PJ. Brainstem activation specific to

migraine headache. Lancet 2001;357:1016-7.

4. Brandes JL, Saper JR, Diamond M, Couch JR,

Lewis DW, Schmitt J, et al. topiramate for migraine

prevention: a randomized controlled trial. JAMA

2004; 291: 965-73.

5. Silberstein SD, Neto W, Schmitt J, Jacobs D.

Topiramate in migraine prevention: results of a

large controlled trial. Arch Neurol 2004;61:490-5.

6. Olesen J, Diener H-C, Husstedt I-W, Goadsby PJ,

Hall D, Meier U, et al. Calcitonin gene-related

peptide (CGRP) receptor antagonist BIBN4096BS

is effective in the treatment of migraine attacks. N

Engl J Med 2004;350:1104-10.

7. Goadsby PJ, Oleson J. Fortnightly Review:Diagnosis

and management of migraine. BMJ 1996 ; 312 :

1279-1283.

8. Campbell JK, Penzien D, Wall EM.Evidenced-based

guidelines for migraine headache: behavioral and

physical treatments. http://www.neurology.org,

2000.

9. Loder E. Fixed drug combinations for the acute

treatment of migraine: Review article. CNS Drugs

2005; 19(9): 769-784.

10. Tfelt-Hansen P, Venry P, Mulder LJ, et al. The

effectiveness of combined oral lysine acetylsalicylate

and metoclopramide compared with oral

sumatriptan for migraine. Lancet 1995;346:923-6.

11. Freitag, f, Saper, J., Silbersstein, SD., Diagnostic

and therapeutic challenges of acute migrain,

Medscape neurology 26th Dec. 2008.


6

Migraine : A review

EVALUATION AND MANAGEMENT OF THE PATIENT

WITH ESOPHAGEAL VARICES.

J JAIN

ABSTRACT

Esophageal varices are enlarged or swollen veins on the lining of esophagus which are

prone to bleeding and fatal in upto 50% of patients. Until recently, management of esophageal

varices is generally ineffective in alleviating symptoms or improving survival. However, past decade

has witnessed remarkable advances in under standing of the pathogenesis, development of

disease-specific treatments. Despite these achievements, esophageal varices remain a challenging

condition to manage. This article reviews recent developments in the diagnosis and highlight the

key management points of esophageal varices.

Esophageal Varices is a common disorder

that may complicate patients with Portal

hypertension (PHT). PHT is an elevation in

portal venous pressure (>10 mm Hg) that caused by

obstruction of portal venous flow. The anastomoses

connecting the portal and systemic circulation

may enlarge to allow blood to bypass the obstruction

and pass directly into the systemic circulation.

High portal pressure is the main cause of the

development of portosystemic collaterals. The

most important portosystemic anastomoses are

the gastroesophageal collaterals. Draining into the

azygos vein, these collaterals include esophageal

varices.

Recent studies have demonstrated the

role of endothelin-1 (ET-1) and nitric oxide (NO)

in the pathogenesis of PHT and esophageal

varices. ET-1 (vasoconstrictor) has been implicated

in the increased hepatic vascular resistance and

development of liver fibrosis. In the cirrhotic

liver, the production of NO (vasodilator) is

decreased, and endothelial nitric oxide synthase

(eNOS) activity and nitrite production are reduced.

Clinical & Endoscopic Finding

Although esophageal varices may be

asymptomatic, symptoms of anemia and sudden

massive bleeding with shock are the most

frequently encountered symptoms. Accordingly,

varices should be suspected in chronic liver

disease, family history of hereditary liver disease

such as Wilson disease, Alpha 1 antitrypsin

deficiency. Patients may have a history of

previous jaundice, alcohol abuse, blood

transfusion, administration of various blood

products or intravenous drug abuse(1).

Endoscopy is required at an early stage

to confirm the diagnosis. If active variceal

bleeding or an adherent clot is observed, variceal

hemorrhage can be diagnosed confidently.

Causes of PHT usually are classified as prehepatic,

intrahepatic, and posthepatic. (Table 1). To

establish a cause detailed history, clinical

examination, various laboratory tests (viral

markers, serum ceruloplasmin, alpha 1

antitrypsin) and radiological investigation

(ultrasonography, CT abdomen) are needed.

Review Article

* Assc. Prof., Dept. of Medicine, MGIMS, Sevagram


7

Table 1 : Causes of Portal Thrombosis

Prehepatic Intrahepatic Posthepatic

Splenic vein Congenital hepatic fibrosis, Idiopathic Budd-Chiari

thrombosis portal hypertension syndrome

Portal vein thrombosis Sclerosing cholangitis, Schistosomiasis Thrombosis of the

inferior vena cava

Extrinsic Primary biliary cirrhosis,Alcoholic cirrhosis

Hepatitis Band C virus-related cirrhosis, Chronic Constrictive

compression active hepatitis & Fulminant hepatitis pericarditis

of the portal vein Wilson disease & Hemachromatosis Venoocclusive

Alpha-1 antitrypsin deficiency disease of the liver

Risk Factors For Variceal Hemorrhage

Variceal size: larger the varix, the higher the

risk of bleeding.

Presence of endoscopic red color signs (eg,

red whale markings, cherry red spots)

Child classification-especially the presence

of ascites increases the risk.

Active alcohol intake in patients with chronic

alcohol-related liver diseases

Treatments

The objective of therapy is to stop

acute bleeding and manage persistent varices.

Approaches include pharmacotherapy, endoscopic

intervention, surgical therapy and, more recently,

radiologic shunting. All of these treatments are

limited by their inability to prevent or arrest

hemorrhage in a universal manner, extensive side-

effect profiles, and failure to improve long-term

survival rates. Availability of resources and expertise

is an important consideration in determining the

best approach.

Managment of Bleeding Esophageal Varices?I. Emergency treatment

Assess the rate, volume and severity of

bleeding (by inserting a nasogastric tube).

Establish airway protection in patients

with massive upper GI tract bleeding.

Measure the platelet count (Platelet

transfusions are reserved for counts <

50,000/mL), hematocrit (maintained in

the low 30% range), prothrombin time

and obtain a type.

Measure renal, liver function tests and

serum electrolytes.

Correct clotting factor deficiencies with

fresh frozen plasma, blood, & vitaminK-1.

Nephrotoxins should be avoided to prevent

renal failure as patients are volume-

depleted.

II. Pharmacologic Therapy

Currently, therapeutic endoscopy is the

definitive treatment for active variceal

hemorrhage. But on its non availability

somatostatin, or octreotide play an important

role. The advantages of vasoactive agents

include the ability to treat variceal bleeding

in emergency department, and offering

endoscopist a clearer view of varices(2).

a. Vasopressin : Vasopressin controls 60%

to 75% of variceal bleeding but increase


8

Evaluation And Management Of The Patient with Esophageal Varices.

the mortality rate because of vasoconstriction

in splanchnic, portal, coronary, cerebral,

and intrahepatic vessels. A meta-analysis

of three controlled trials has shown that

combination with Nitroglycerin is better

than vasopressin alone(3).

b. Terlipressin : Synthetic analog of vasopressin

and only pharmacologic agent shown to

reduce mortality. It has longer biological

activity, advantage of preserving renal

functions, beneficial when combined

with EST.

c. Somatostatin : Naturally occurring

tetradecapeptide which has similar effects

as vasopressin but does not cause coronary

vasoconstriction.

d. Octreotide acetate : Synthetic, long-acting

analogue of Somatostatin. Several studies

found octreotide to be more effective than

either placebo or vasopressin and soma-

tostatin in controlling both initial and

sustained bleeding. Because it has fewer

side effects than vasopressin, it has become

the drug of choice in acute variceal bleeding.

Unfortunately, like vasopressin, it does

not increase the survival rate.

III.Interventional therapies

a. Endoscopic Sclerotherapy (EST) - EST

remains first-line therapy. Obliteration of

varices by repeated injections arrests

acute bleeding. Injections may be directed

under direct vision into the veins

(intravariceal) or into the esophageal

wall (paravariceal). Several different

sclerosants are available-5% sodium

morrhuate,1% to 3% sodium tetradecyl

sulfate,5% ethanolamine oleate, Absolute

alcohol,N-butyl-2- cyanoacrylates (tissue

glue). Typically 1 to 2 mL and total of 10

to 15 mL of sclerosant is injected.

b. Endoscopic Variceal Ligation (EVL) - EVL

or variceal banding is an alternative to

EST, mainly because of fewer complications

and similar efficacy. Elastic O bands are

placed around varices by ensnaring

esophageal mucosa and the submucosa

using endoscope. Ischemic necrosis,

thrombosis, and fibrosis ensue, eradicating

the varix. Rebleeding occurs less frequently

with EVL than with EST (26% vs 45%)(4).

IV. Surgical Therapies - Approximately 5-10% of

patients with variceal bleed have conditions

that cannot be controlled by endoscopic

and/or pharmacologic treatment. Balloon

tamponade (eg, Minnesota tube, Sengstaken-

Blakemore tube,) may be used as a temporary

option. Definitive salvage options may include

the following :

1. Transjugular Intrahepatic Portosystemic

Shunt - TIPS is an angiographically created

shunt (expandable, implantable metallic)

between hepatic and portal veins first

conceived in the late 1960s.The potential

advantages include avoidance of general

anesthesia and surgery (nonsurgical

shunt), decreased morbidity and mortality

rates, less invasive. It controls active variceal

bleeding over 90% and achieving a

mortality rate of less than 10%, even in

critically ill patients(5).

Contraindications to TIPS are

polycystic liver disease, cholangiohepatitis,

primary pulmonary hypertension, biliary

obstruction, active intrahepatic or systemic

infection, severe hepatic encephalopathy,

portal vein thrombosis. Thus, it should

be considered as a bridge to subsequent

liver transplantation.


9

Jain J

2. Shunt Operations (Portosystemic shunt) -

Shunt operations traditionally have been

classified on the basis of their intended

impact on portal blood flow. Both shunts

were 100% effective in controlling

hemorrhage. However, the partial shunts

preserved hepatopetal flow in 90% of patients

and were associated with a significantly

lower frequency of encephalopathy.

a. Total shunts divert all portal blood

flow into the inferior vena cava. The

end-to-side portacaval shunt an

anastomosis between the end of the

portal vein and the side of the inferior

vena cava.

b. Partial shunts-A side-to-side anastomosis

is created between the portal vein and

inferior vena cava to divert only part

of the portal stream into the vena cava;

the remainder, would continue to

perfuse the liver.

c. Selective shunt (Distal splenorenal) -

Selectively decompresses variceal flow,

while preserving portal blood flow

thus avoid the high rate of encephal-

opathy. The varices are decompressed

by anastomosis of the splenic vein, to

the distal left renal vein.

3. Esophageal Devascularization - Direct

surgical devascularization of the lower 5

cm esophagus and upper two third of

stomach with staple gun. It may have a

role in patients with portal and splenic

vein thrombosis who are not suitable

candidates for shunt procedures.

4. Simple surgical variceal ligation with

esophageal transection is an effective

means of controlling acute variceal bleeding,

but bleeding frequently recurs. Improved

long-term control of bleeding has been

reported with the Sugiura operation, a

more extensive procedure consisting of

transthoracic paraesophageal devasculariza-

tion, esophageal transection, splenectomy,

esophagogastric devascularization,

pyloroplasty, and vagotomy.

5. Orthotopic liver transplantation - Treatment

of choice in patients with end-stage liver

disease. The selection of candidates is

dictated by the patient's clinical status,

etiology of cirrhosis, abstinence from

alcohol, and availability of a donor organ.

6. Percutaneous transhepatic embolization

(PTE) of gastroesophageal varices involves

catheterization of the gastric collaterals

that supply blood to varices via the

transhepatic route. This procedure is less

effective. Thus, it should be reserved for

situations in which other therapies has

failed or contraindicated.

Prognosis of Esophageal Varices ?

Rebleeding has poor prognosis

Occurrence of complications (eg, bacteremia

and/or endotoxemia, SBP, portosystemic

encephalopathy, hepatorenal syndrome)

Severity of portal hypertension

The location & number of the bleeding varices

The functional status of the liver and the

severity of liver disease.

Active alcohol intake in patients with chronic

alcohol-related liver diseases

References :1. Luketic VA, Sanyal AJ. Esophageal varices. I.

Clinical presentation, medical therapy and

endoscopic therapy. GI Clin North Am 2000; 29(2):

337-85.


10

Evaluation And Management Of The Patient with Esophageal Varices.

2. Sanyal AJ, Shiffman ML. Pharmacologic treatment

of portal hypertension. In: Lewis JH, Dubois A,

eds. Current clinical topics in gastrointestinal

pharmacology. London : Blackwell Scientific,

1997:242-75

3. Angelico M, Carli L, Piat C, et al. Effects of

isosorbide-5-mononitrate compared with

propranolol on first bleeding and long-term

survival in cirrhosis. Gastroenterology 1997; 113(5) :

1632-9

4. Laine L, Cook D. Endoscopic ligation compared

with sclerotherapy for treatment of esophageal

variceal bleeding: a meta-analysis. Ann Intern Med

1995;123(4):280-7

5. Luketic VA, Sanyal AJ. Esophageal varices. II.

Transjugular intrahepatic portosystemic shunt

and surgical therapy. GI Clin North Am 2000; 29(2):

387-421.


11

Jain J

GASTROESOPHAGEAL REFLUX IN CHILDREN

A TAKSANDE*, KY VILHEKAR**

* Senior Lecturer, ** Professor,Address for Correspondence : Dr. Amar M Taksande, Dept.of Pediatrics, MGIMS, Sevagram, Wardha, MS-442102E mail : [email protected]

Introductions :

Gastroesophageal reflux (GER) is the

common esophageal disorder and occurs when

stomach contents reflux into the esophagus

during a meal. Lower esophageal sphincter (LES)

at the bottom of the esophagus opens and closes

to allow food to enter the stomach. Reflux can

occur when the LES opens, allowing stomach

contents and acid to come back up into the

esophagus1. Transient LES relaxation (TLESR)

is the major primary mechanism allowing refluxe

to occur. A vagovagal reflux, composed of afferent

mechanoreceptor in the proximal stomach, a

brainstem pattern generators, and efferent in

the LES, regulates TLESR. Gastric distension

is the main stimulus for TLESR. There is a high

prevalence of GER in children with chronic

cough and asthma2.

GER is classified as follows :

Functional GER : patients have no underyling

predisposing factors. Growth and development

are normal, and treatment is typically not

necessary.

Pathogenic GER or Gastroesophageal reflux

disease(GERD) : Patients frequently experience

complications, including strictures, malnu-

trition, respiratory disorders, esophagitis,

bleeding, and changes in the normal epithelial

lining of the lower esophagus. Patients

require careful evaluation and treatment2,3.

Secondary GER : A case in which an underlying

condition predisposes to GER. Examples

include hiatal hernia and gastric outlet

obstruction.

Risk Factors: 4,5.

Anatomic factors that predispose to GER

include.

The angle of His (made by the esophagus

and the axis of the stomach) is obtuse

in newborns but decreases as infants

develop. This ensures a more effective

barrier against GER.

The presence of a hiatal hernia displaces

the LES into the thoracic cavity. The lower

intrathoracic presure may facilitate GER.

Resistance to gastric outflow raises

intragastric pressure and leads to reflux

and vomiting. Examples: gastroparesis,

gastric outlet obstruction, and pyloric

stenosis.

Other factors that predispose individuals to

GER include :

Medications 9eg. Valium Theophylline)

Smoking

Poor dietary habits (eg. overeating, eating

late at night, assuming a supine position

shortly after eating)

Food allergies

Certain foods (eg. greasy, highly acidic)

Short Review


12

Disorders of motility (postulated to

potentially cause reflux)

Antral dysmotility

Delayed gastric emptying

TLESR, accounting for 94% of reflux

episodes in children and adults.

Physiologic factors : Reflux is also facilitated

when an increase in intra-abdominal pressure

exists, but, the presence of a chronically lax

sphincter and a functional decrease in

sphincter tone determine the occurrence

of GER2.

Clinical Manifestation :

Infant reflux become symptomatic

during the first few month of life, peaking at

about 4 month and resolving in most by 12

month and nearly all by 24 months. Symptoms

in older children tend to be chronic, waxing

and waning, but completely resolving in more

than half, resembling adult pattern6.

When refluxed material rapidly returns

to the stomach, it does not harm the esophagus.

However, in some children, the stomach contents

remain in the esophagus and damage the

esophageal lining. In other children, the stomach

contents go up to the mouth and are swallowed

again. When the refluxed material passes into

the back of the mouth or enters the airways, the

child may have a raspy voice, or a chronic cough.

Other symptoms include7,8.

Recurrent pneumonia

Wheezing

Difficult or painful swallowing

Vomiting

Sore throat

Weight loss

Heartburn (in older children)

Investigation9,10,11.

Upper endoscopy, which involves the

direct visulization of the esophagus, stomach,

and a portion of the small intestines. Biopsies

can be obtained at the time of endoscopy to

determine whether there is inflammation due

to GERD or whether there are other problems

such as allergic esophagitis that are causing the

symptoms.

Contrast (usually barium) radiographic study of

the esophagus and upper GIT.

Esophageal pH probe monitoring : A thin, light

wire with an acid sensor at its tip is inserted

through the nose into the lower part of the

esophagus. This probe detects and records the

amount of stomach acid coming back up into

the esophagus and indicates whether acid is in

the esophagus when the child has symptoms such

as crying, coughing, or arching her back.

Radionucleotide scintography using technetium

may demonstrate aspiration and delayed gastric

emptying when these are suspected.

Esophageal manometry permits evaluation for

dysmotility.

Esophagography : In more seven cases, diagnosis

is made by barium esophagography under

fluoroscopic control. Strictures can be

demonstrated by esophagography.

MANGEMENT :

Medical Care11,12.

Functional GER - Reassurance is the only

treatment needed

Conservative measures:

Sleeping on the left side has been shown

to drastically reduce nighttime reflux

episodes in patients


13

Taksande A, Vilhekar KY

Upright positioning after feeding

Mild, uncomplicated cases: the prone

position with thickening of feeds with

cereal and burping after feeds is beneficial.

More severe cases : prone position in

addition to elevating the head of the bed

to 300 is recommended.

Providing small, frequent feeds thickened

with cereal.

Older children benefit from bland diet,

small, frequent feeds, and proper eating

habits.

The goals of medical therapy are to

decrease acid secretion and to increase gastric

emptying2,12.

Antacids :

- Rapid & transient relief of symptoms

- Acid neutralisation

Histamine 2 receptor antagonists:

- First line drugs for mild to moderate GER

- Ranitidine, Cimetidine, Famotidine

Proton Pump Inhibitors (PPIs): A second

class of medications often used to reduce

stomach acid is PPI, which block the production

of stomach acid. This class of drugs block

the hydrogen-potassium ATPase channels in

gastric acid secretion.

- Omeprazole & Lansoprazole

Prokinetic agents : These agents make the

LES close tighter so stomach acid cannot

reflux into the esophagus.

- Metoclopramide (dopamine 2 & 5HT 3

antagonist)

- Bethanecol (cholinergic agonist)

- erythromycin (motilin receptor agonist)

- Indcrease LES pressure, improve gastric

emptying & esophageal clearance

Surgery13:

Goal : Re-establish the antireflux barrier

without creating obstruction to the food

bolus.

Nissen Fundoplication : The stomach is

wrapped and sutured 3600 around the distal

esophagus.

Disadvantage : More episodes of dysphagia

and gas bloat than a partial wrap.

Complications of GERD2 :

Strictures occur in mid to distal esophagus.

Patients present with dysphagia to solid meals

and vomiting of nondigested foods.

Barrett esophagus occurs when goblet cell

metaplasia occurs.

Risk of adenocarcinoma is increased 30-40

times.

Failure to thrive because of caloric deficit.

Key Points :

GER disease includes all consequences of

reflux of acid or other irritants from the

stomach into the esophagus.

GER is common in infants, but most

children grow out of it.

GER may cause vomiting, coughing, hoarseness,

or painful swallowing.

Treatment depends on the child’s symptoms

and age and may incoude changes in eating

habits and taking medications. Surgery may

be an option.

References :

1. Monnier P, Ollyo JB, Fontolliet C. Epidemiology

and Natural History of Reflux esophagitis. Semin

Laparosc Surg. 1995, 2: 2-9.


14

Gastroesophageal reflux in children

2. Orenstein S, Peters J, Khan S, Youssef N, Hussain

SZ. Gastroesophageal Reflex disease. In: Behrman

RE, Kliegman RM, Jenson HB, editors. Nelson

Texibook of Pediatrics. 17th ed. Philadelphia: WB

Saunders, 2000; p. 1222-25.

3. Spechler SJ. Epidemiology and natural history

of gastro-esophageal reflux disease. Digestion.

1992; 51 Suppl 1: 24-9.

4. DeVault KR, Castell DO. Updated guidelines

for the diagnosis and treatment of gastrosophageal

reflux disease. The Practice Parameters Commit-

tee of the American College of Gastroenterolog.

Am J Gastroenterol. 1999: 94 (6): 1434-42.

5. Orenstein SR. Esophageal disorder in infant

and children. Current opinion in Pediatrics 1993;

5: 580-89.

6. Fernando HC, Schauer PR, Rosenblatt M, et al.

Quality of life after antireflux surgery compared

with nonoperative management for servere

gastroesophageal reflux disease. J Am Coll Surg.

Jan 2002; 194(1): 23-7.

7. Bremner RM, Bremner CG, DeMeester TR.

Gastroesophageal reflux: the use of pH monitoring.

Curr Probl Surg. Jun 1995; 32(6): 429-558.

8. Harding SM, Richter JE, Guzzo MR, et al Asthma

and Gastroesophageal reflux: acid suppressive

therapy improves asthma outcome. Am J Med. Apr

1996; 100(4): 395-405.

9. McCallum RW, Berkowitz DM, Lerner E. Gastric

emptying in patinets with Gastroesophageal reflux.

Gastroenterology. Feb 1981; 80(2): 285-91.

10. Vigneri S, Termini R, Leandro G, et al. A

comparison of five maintenance therapies for

reflux esophagitis. N Engl J Med. Oct 26 1995;

333(17): 1106-10.

11. Porro GB, Pace F, Peracchia A, et al. Short-term

treatment of refractory reflux esophagitis with

different doses of omeprazole or ranitidine. J

Clin Gastroenterol. Oct 1992; 15(3): 192-8.

12. Patti MG, Arcerito M, Feo CV, et al. An analysis

of operations for gastroesophageal reflux disease:

identifying the important technical elements. Arch

Surg. Jun 1998; 133(6): 600-6; discussion 606-7.

13. Abbas A, Deschamps C, Cassivi SD, et al. (2004).

“The role of laparoscopic fundoplication in

Barrett’s esophagus”. Annals of Thoracic Surgery

77(2): 393-396.


15

Taksande A, Vilhekar KY

FACE TO FACE WITH NONTUBERCULOUS

MYCOBACTERIA AT SEVAGRAM

DK MENDIRATTA *, P NARANG **, R NARANG ***

*Professor & Head., ** Director Professor & SecretaryKHS, *** Professor, Deptt. of Microbiology, MGIMS,Sevagram. Corresponding author : Dr Deepak KMendiratta, Prof & Head , Dept of Microbiology,MGIMS, Sevagram. Email:[email protected]

The non-tuberculous mycobacteria

(NTM), also known as atypical mycobacteria or

mycobacteria other than M. tuberculosis (MOTT)

have been recognized since Koch's time but being

opportunists they did not gain as much importance

as M. tuberculosis. Today, however, the recovery of

NTM from patient's specimens, where they can

cause infections called "other mycobacteriosis" 1

and from environmental sources is of concern

to microbiologists, epidemiologists and physicians.

There is a gradually shift in the focus from AFB

with rough, tough and buff colonies to AFB with

smooth and pigmented colonies , some of which

may be rapid growers. NTM infections are more

common in developed countries but have also

been documented in developing countries of

Latin America, Africa, and Asia2,3,4,5,6. Many a

times the NTM are found circulating in blood

(mycobacteremia) and this has lead to disseminated

infections. Among disseminated NTM infections,

most are caused by mycobacteria belonging to

Mycobacterium avium complex (MAC) and are

known as Disseminated MAC (DMAC). DMAC

infection decreases survival and worsens the

quality of life. DMAC was rare before the advent

of acquired immunodeficiency syndrome (AIDS)

and a steady rise has been observed after increase

in cases with AIDS. Between 1985 and 1990

DMAC occurred in 16% of AIDS patients at

Grady Memorial Hospital, Atlanta7. It was estimated

that most AIDS patients would develop DMAC

infection if they survive long enough to become

severely immunocompromised8. However, highly

active anti retro viral therapy (HAART) changed

the scenario and among patients in John

Hopkins cohort with advanced HIV disease, the

proportion developing DMAC had fallen from

16% before 1996 to 4% after 1996, and the rate

observed in 2004 was less than 1%9.

Clinically in AIDS patients it is not possible

to differentiate between M tuberculosis and other

mycobacteriosis. M tuberculosis causes majority of

pulmonary infections and the risk is largely

increased if the CD4 count falls below 300cell/

cumm10. In some cases disseminated infections

are also found11,12. NTM, on the other hand, may

colonize the gut or respiratory tract of HIV patients

but once the CD4 counts fall <100 cells/cumm,

they start multiplying rapidly, enter the blood

stream and cause disseminated infections. Patient

may succumb to these infections if not treated

in time. Horsburg in 1994 stated that persons

with HIV infection are like open culture plates

and AIDS related immunosuppression is the

single most important risk factor associated with

disseminated NTM infection especially MAC.

Laboratory support is a must to diagnose

these conditions and the clinical samples for

detection of various NTM species are blood,

Review Article


16

sputum, stool and other extra-pulmonary specimens.

Smear examination and isolation of Mycobacteria

are two important steps in laboratory diagnosis

of such infections. Only smear examination, as

recommended by RNTCP, may not be sufficient

in such conditions, especially in HIV/AIDS

patients, as NTM which are important organisms

causing disease in such cases need to be

differentiated from M. tuberculosis by culture,

since the treatment of the two differs.

Isolation of Mycobacteria from clinical

specimens other than blood is performed

routinely in many of the laboratories these days

using Egg based media, BACTEC media &

system, MGIT 960, BACTEC 9000MB system and

BacT/ALERT MB. Blood samples which need

special treatment and media are not routinely

cultured. However, since NTM cause bacteremia,

blood may be the only sample from where we can

isolate such organisms. Likewise, in some of the

TB patients with advanced HIV disease blood

may be the only sample yielding M. tuberculosis13.

The radiometric BACTEC 13A blood culture

bottle (Bectec Dickinson Diagnostic Instrument

System) or Isolator lysis centrifugation system

(E.I. Du Pont, de Nemours, Wilmington, Del) is

recommended for blood culture.

Lowenstein Jenson medium routinely

used for isolation of M. tuberculosis supports

growth of NTM from specimens other than blood,

but utilization of paraffin wax as sole carbon

source for growth by NTM and the inability of

Mycobacterium tuberculosis to do so, in a basal salt

media is a useful and often forgotten fact. The

paraffin system is a biphasic system which consists

of a liquid (Czapek Broth) phase and solid

(paraffin wax coated slide) phase. Non-motile

organisms such as Nocardia and NTM are carried

by Brownian movement to the paraffin wax, sole

carbon source. When these organisms attach to

the paraffin wax acting as sole carbon source

they begin to grow, since they now have all the

essential components for their growth cycle. When

positive, in situ growth is seen on the paraffin

slide and it appears as distinct points or spots

on the paraffin wax surface. One can also often

see the presence of a heavy growth at the meniscus

of the broth/slide. In some instances the heavy

growth can even display pigmentation. The

beauty of this system is that few pathogens

(NTM, Nocardia, Psuedomonas & C.tropicalis) can

grow in such a system and the growth of NTM

can not only be confirmed by Z N stain and

observed under the microscope in situ but also

used for molecular studies. Moreover, even the

least experienced member of a laboratory can

obtain quality results with this method. The system

could be made selective for NTM by adding

a cocktail of antibiotics like Polymyxin B,

Amphotericin B, Naladixic acid, Trimethoprim

and Azlocillin to the medium. This system has

been standardized and successfully used for

isolation of NTM from stool, sputum, blood

and environment as also speciation and drug

susceptibility testing in our laboratory14,15,16,17.

Identification of NTM species is important

as, not only does the treatment variy between the

species but geographical location may also be a

risk factor for certain species. Speciation is usually

done using conventional phenotypic and newer

genotypic methods. By conventional methods ie

rate & temperature of growth, pigmentation,

niacin & catalase (quantitative and qualitative)

production, tellurite and nitrate reduction,

tween-80, arylsulphatase & urea hydrolysis, TCH

sensitivity, growth on MacConkey agar, sodium

chloride tolerance etc, the identification of

mycobacterial strain requires 2 to 4 weeks for


17

Mendiratta DK, Narang P, Narang R

morphological and biochemical tests, in addition

to 4-6 weeks required for primary isolation.

Newer methods which include analysis of fatty

acids by chromatography, hybridization with gene

probe, gene amplification followed by restriction

analysis ( hsp65: heat shock protein, 16S rDNA,

ITS : internal transcribed spacer 16S-23S rDNA,

RNA polymerase beta sub unit: rpoB), LiPA

Mycobacteria( line probe assay) and gene

amplification analysis by sequencing are very

rapid and reduce the turn around time remarkably.

Kox et al18 for the first time used 16s rDNA based

gene amplification assay directly on clinical

samples containing mycobacteria. These new

alternative methods have limited the role of

conventional identification methods.

Speciation of mycobacteria using phenotypic

methods is still widely used in many of the

laboratories in the developing countries19 since

the genotypic methods are costly and not easily

available. The reference laboratories such as

Central JALMA Institute for Leprosy and other

Mycobacterial Diseases, Agra; Tuberculosis

Research Centre, Chennai (TRC); Centers for

Disease Control and Prevention, Atlanta, USA

(CDC) and National Mycobacteria Research

Laboratory, Bilthoven, The Netherlands are some

of the reference centers which help in identifying

the mycobacterial isolates by genotypic methods

to species level and beyond.

The mechanism of resistance in NTM

are quite distinct from M. tuberculosis and

mechanisms like permeability at cell wall and

efflux pumps appear to be more important than

targets like rpoB in M tuberculosis. Usual mutations

seen in M. tuberculosis are not frequently seen in

resistant NTM. Generally NTM are resistant to

low concentrations of various anti-tuberculous

drugs. The drugs to which NTM usually respond

and are modestly effective in controlling bacteremia

are macrolides (clarithromycin, azithromycin),

ethambutol, clofazimine and rifamycins (especially

rifabutin). However, the only antimicrobial agents

for which correlation between in-vitro susceptibility

test and clinical response has been demonstrated

in controlled clinical trials are macrolides

(Azithromycin & Clarithromycin) and that too

in MAC only. Drug susceptibility testing of the

mycobacterial isolate is an important aspect for

guiding the treatment. However, till recently

there were no approved guidelines for drug

susceptibility testing of mycobacteria, especially

NTM. In the year 2003, Clinical and Laboratory

Standards Institute (CLSI)20 published approved

standards for Mycobacteria, Nocardiae and other

aerobic Actinomycetes.

NTM are ubiquitous and majority are

present in the environment surrounding the

patient. AIDS patients may acquire infection

with multiple NTM species or multiple strains

of the same species21. It is thus important to type

mycobacterial strains if we wish to find the

relatedness of multiple isolates from a single patient.

If environmental samples from surroundings of

the patient suffering from NTM disease are

screened for NTM and the same species are

isolated from clinical and environmental samples,

typing of these isolates helps us to know if the

same strain has caused infection in such

patients22. A number of phenotypic techniques

viz. biotyping, antibiogram typing, serotyping,

multilocus enzyme electrophoresis (MEE) have

been used in the past. However, since in all these

methods measurement relies upon gene expression

which can be influenced by cultural conditions

their typeability, reproducibility and discrimination

may vary. Newer typing methods are based on

the analysis of DNA (and thus are unaffected by


18

Face To Face With Nontuberculous Mycobacteria At Sevagram

environmental conditions) and include plasmid

typing, restriction fragment length polymorphism

(RFLP), analysis of chromosomal DNA of rRNA

genes, rRNA spacer sequencing and large restriction

fragment (LRF) involving pulsed field gel

electrophoresis (PFGE).

In the department of Microbiology at

Mahatma Gandhi Institute of Medical Sciences,

Sevagram studies on NTM were initiated way

back in 1988 , when an ICMR sponsored project

to estimate the prevalence of pulmonary TB in

Wardha was underway in the early eighties.

Lowenstein Jensen medium was used for isolation

of mycobacteria and species were identified using

phenotypic methods - morphology and biochemical

reactions. A total 14 tests were performed and

150 NTM belonging to 16 species were recovered,

in addition to the principal pathogen , MTB.

HIV testing was not performed during this field

house to house survey14.

Later, during 1997-1998, we standardized

the paraffin slide culture (PSC) technique for

isolation, identification and drug susceptibility

testing of NTM15. Fifteen known species of NTM

along with Nocardia asteroides (positive control)

and M. tuberculosis H37Rv (negative control) were

used for this standardization. This PSC technique

was later used to isolate NTM from stool and

sputum samples of HIV seropositive subjects. Six

NTM species (4 MAC and 2 M. fortuitum) were

isolated from 80 stool samples and three NTM

species (2 MAC and one unspeciated) were isolated

from 42 sputum samples. Biochemical reactions

using PSC technique was used to speciate the

NTM. Drug susceptibility testing was performed

by MIC using PSC, LJ and Microtitre plates.

PSC results were comparable with that done on

LJ & Microtitre plates. The MAC isolates were

uniformly sensitive to Azithromycin and variably

sensitive to first line anti-TB drugs16. In another

study blood samples from 77 HIV seropositive

subjects were subjected to culture for mycobacteria

using BACTEC 13A medium followed by

subcultures on PSC and LJ medium. A total of 6

NTM isolates were recovered including 3 MAC

and 3 M. simiae6. In our initial studies on NTM

and HIV, CD4 counts were not performed and

thus the information of patients' HIV disease

status was not known and also that all the clinical

samples were not processed for the recruited

subjects.

A comprehensive study was undertaken

in 2005-0717 where in all the possible clinical

samples viz. blood, stool, sputum and other

extrapulmonary specimens were processed for

mycobacteria. CD4 counts were performed as

part of the protocol. A number of mycobacterial

species viz. M. tuberculosis, M. avium, M. simiae,

M. vaccae and M. wolinskyi were isolated. In two

patients, same species of NTM, M. avium in one

case and M. simiae in another, was isolated from

both blood and stool samples. In this study,

environmental viz. soil and water were also

processed for NTM using PSC technique. These

samples were collected from the environment of

patients with NTM disease. A large number of

species of NTM viz. MAC, M. fortuitum, M.

chelonae, M. abscessus, M. flavescens, M. phlei, and

M. thermoresistibile were isolated from such

samples. Drug susceptibility testing was performed

using MIC in microtitre plates and BACTEC

460TB system. Variable patterns of susceptibility

were obtained, the clinical isolates being more

resistant as compared to environmental isolates.

The clinical and environmental isolates of M.

avium were typed using PCR designed to amplify

DNA segments located between the insertion

sequences IS1245 and IS1311. Only two clinical


19


isolates from the same patient matched.

The NTM isolates obtained during

2005-07 were speciated using morphology and

biochemical reactions in our laboratory and

further confirmed using advanced techniques in

reference laboratories, by HPLC in CDC Atlanta,

InnoLiPA in Bilthoven the Netherlands, and

PCR-PRA & Gene Sequencing in National

JALMA Institute for Leprosy and other

Mycobacterial Diseases in Agra. The main

problematic NTM species showing discrepant

results was the M. simiae.

To conclude, NTM have started appearing

as important pathogens along with M. tuberculosis,

at least in AIDS patients. Paraffin slide culture

technique can be used as a selective medium for

NTM along with the routine LJ medium. The

laboratories can use phenotypic speciation

methods, which are available in most Medical

College laboratories and significant isolates from

important clinical samples may be sent to NRL

for confirmation. As per CLSI, MIC using

microtitre plate is acceptable method for drug

susceptibility testing of NTM.

Acknowledgement : The exhaustive work on NTM

has been possible due to contributions by Dr

Rahul Narang, Dr G M S Siddique, Dr Sangeeta

Dey, Dr Debashish Roy, Dr S Bhatacharya, Mr D

U Ingle, Mr Sunil Tiwari, Mr Sandeep Taksande

and Mr Siddharth Mendiratta)

References :

1. Anon (1989) Editor's note. Am Rev Respir Dis

140: 561

2. Grant AD, Djomand G, De Cock KM (1997)

Natural history and spectrum of disease in adults

with HIV/AIDS in Africa. AIDS 11(suppl B):

S43-S54.

3. McDonald LC, Archibald LK, Rheanpumikankit

S, et al (1999) Unrecognised Mycobacterium

tuberculosis bacteraemia among hospital inpatients

in less developed countries. Lancet 354:1159-1163.

4. Mohar A, Romo J, Salido F, et al (1992) The

spectrum of clinical and pathological manifesta-

tions of AIDS in a consecutive series of autopsied

patients in Mexico. AIDS 6:467-473.

5. Murillo J and Castro KG (1994) HIV infection

and AIDS in Latin America. Epidemiologic

features and clinical manifestations. Infect Dis Clin

North Am. 8(1):1-11.

6. Narang P, Narang R, Mendiratta DK, Roy D,

Deotale V, M. A. Yakrus, Sean T, and Kale V (2005)

Isolation of Mycobacterium avium complex and M.

simiae from blood of AIDS patients from Sevagram,

Maharashtra. Indian J Tuberc 52:21-26.

7. Joseph O, Falkinham,III (1996) Epidemiology of

Infection by Nontuberculous Mycobacteria Clin

Microbiol Rev 9(2);177-215

8. Bucher HC, Griffith LE, Guyatt GH, et al (1999)

Isoniazid prophylaxis for tuberculosis in HIV

infection: a meta-analysis of randomized controlled

trials. AIDS 13:501-507

9. Karakousis P C, Moore R D and Chasson R (2004)

Mycobacterium avium complex in patients with HIV

infection disease. Lancet 14:557-65.

10. Kumarswamy N,.Snigdha V, Timothy P (2005)

Clinical profile of HIV in India.Ind J Med Res

121: 377-394

11. David ST, Mukundan U, Brahmadathan KN and

John TJ (2004) Detecting mycobacteraemia for

diagnosing tuberculosis. Indian J Med Res

119(6):259-66.

12. Deodhar L (1999) Mycobacteraemia in AIDS

patients report of 2 cases. Ind J. Med. Microbiol

17 (4): 196-197.

13. Shafer RW, Goldberg R, Sierra M, Glatt AE (1989)

Frequency of Mycobacterium tuberculosis

bacteremia in patients with tuberculosis in an

Area endemic for AIDS. Am Rev Respir Dis 140;

I51I-1513.


20

Face To Face With Nontuberculous Mycobacteria At Sevagram

14. Siddiqi GMS (1989) Prevalence & characterization

of NTM among the symptomatics screned for

pulmonary tuberculosis in the community. A

thesis submitted to the RTN Nagpur University,

Nagpur for the degree of M.D. Microbiology.

15. Narang P, Dey S and Mendiratta DK (2000)

Paraffin slide culture technique for 'Baiting

Non-tuberculous Mycobacteria". Indian J Tuberc.

47:219-220.

16. Narang P, Narang Rahul, Bhattacharya S and

Mendiratta DK (2004) Paraffin slide culture

technique for isolating non tuberculous mycobacteria

from clinical specimens of stool and sputum of

HIV seropositive patients. Indian J Tuberc 51 :

23-26.

17. Narang R, Narang P, Jain AP, Mendiratta DK,

Wankhade A, Joshi R, Soolingen D van, van

Der Laan, Ollar RA. Isolation and speciation of

mycobacteria isolated from AIDS patients in a

rural teaching hospital in central India.

International Journal of Tuberc Lung Dis Nov 2007

(Supplement).

18. Kox LF, Leeuwen J van, Knijper S, Jansen, Kolk

AH (1995) PCR assay based on DNA coding for

16S rRNA for detection and identification of

mycobacteria in clinical samples. Journal of

Clinical Microbiology 33 (12): 3225-3233.

19. Paramasivan CN, Govindan D, Prabhakar R,

Somasundaram PR, Subbammal S and Tripathy

SP (1985) Species level identification of non-

tuberculous mycobacteria from South Indian

BCG trial area during 1981. Tubercle 66 : 9 - 15.

20. NCCLS. Suceptibility testing of Mycobacteria,

Nocardiae and other aerobic Actinomycetes :

approved standards. NCCLS document M24-A,

Wayne (PA): NCCLS ; 2003.

21. Arbeit, R.A., A. Slutsky, T.W. Barber, J.N. Maslow,

S. Niemczyk, J. O. Falkinham, G. T. O'Connor,

and C. F. von Reyn (1993) Genetic diversity

among strains of Mycobacterium avium causing

monoclonal and polyclonal bacteremia in patients

with AIDS. J. Infect. Dis. 167:1384-1390.

22. von Reyn, C.F., J.N. Maslow, T.W. Barber, J.O.

Falkinham III, and R. D. Arbeit (1994) Persistent

colonisation of potable water as a source of

Mycobacterium avium infection in AIDS. Lancet

343:1137-1141


21


EFFECT OF PHYSIOLOGICAL FACTORS ON SOLEUS

H-REFLES IN NORMAL HUMAN SUBJECTS

B GHUGARE *, R SINGH **, AP JAIN ***

ABSTRACT

Background : H reflex is a monosynaptic reflex elicited by percutaneous submaximal stimulation

of tibial nerve and recorded from the gastroe-soleus muscle. H reflex is affected by age, sex,

height, position of patient, sleep, vibration and Jendressik’s maneuver. With above background

current study was designed to collect the normative data of Soleus H reflex study and to evaluate

influence of age, height, weight on H reflex parameters.

Material and Methods : Following standard history taking, neurological examination and brief

electrophysiological examination 50 subjects, further divided age wise in two group from 21 to 35

and above 35 yrs, were enrolled, which underwent H reflex study on RMS-EMG-EP mark-II

machine in Clinical Neurophysiology Laboratory in Department of Physiology.

Results : Mean and SD were obtained for age, height, weight, H threshold, H latency and H amplitude. A

positive correlation was observed between H latency and age (r=0.41). Difference in H latency was

found to be statistically significant between two groups (p value<0.05).

Conclusion : Study concluded with the observation that age of the subjects and H latency shows

positive correlation i.e. as age advances latency also increases. Also our data is in accordance with

normative data of previous normative H reflex studies.

Key words : Soleus H reflex, Stretch reflex.

* Tutor ; **Professor and Head Department ofPhysiology. ***Director-Professor and Head Dept.of Medicine. MGIMS, Sevagram, Wardha- 442102

Background :

The H reflex is perhaps the most exten-

sively studies reflex in clinical neurophysiology.

The H reflex derives its name from Hoffman,

who first evoked the response on 1918. H reflex is

a monosynaptic reflex elicited by percutaneous

submaximal stimulation of tibial nerve and recorded

from the gastroe-soleus muscle.It is a true reflex

with Group Ia large sensory afferent, a synapse

with alpha motor neuron and a motor efferent

segment supplying muscle1. H reflex does not

include muscle spindle activation but rest of the

arc is similar to stretch reflex; therefore there is

a high correlation between Achilles reflex and

Soleus H reflex7.

H reflex is affected by various intrinsic

and extrinsic factors. Extrinsic factors like

temperature, electrical artifacts and poor recording

techniques and intrinsic factors like age, sex,

height, position of patients, sleep, vibration and

Jendressik’s maneuver. H reflex has the advantage of

evaluating proximal sensory and motor pathways.

It is helpful in the evaluation of plexopathies and

radiculopathies. It may be absent or delayed in

Original Article


22

GBS, absent in S1 radiculopathy. Flexor carpi

radialis H reflex may be absent in C6-C7

radiculopathy3.

If the extrinsic factors i.e. temperature,

electrical artifacts and poor recording techniques

are taken care of, effect of the physiological

factors on Soleus H reflex can be studied. With

above background current study was designed

to collect the normative data of Soleus H reflex

study and to evaluate influence of age, height,

weight on H reflex parameters.

Material and Methods :

We enrolled 50 volunteers to this study

after obtaining an informed consent. Following

a standard history taking, all of them underwent

physical examination and a brief electrophysiological

evaluation which comprises of bilateral tibial and

peroneal motor conduction, F wave and sural

sensory nerve conduction to rule out asymptomatic

polyneuropathy. We defined our exclusion

criteria as history of radiculopathy or diabetes

mellitus or any other disease with potential

to cause neuropathy or any abnormality in

neurological or musculoskeletal examination or

any of the abnormal electrophysiological findings

i.e. prolonged distal motor latencies, reduced

CMAPs, Sural SNAPs, conduction velocity and

prolonged F wave latencies (For comparison,

normative laboratory vlues were used). Age in years,

Height in centimeters and weight in kilograms

were noted prior study. All the included subjects

were further subdivided into two groups on the

basis of age - Group I: 21-35 yrs and Group II:>35

yrs. Temperature of laboratory was maintained

at 32 degree centigrade throughout study.

For obtaining Soleus H reflex study data

we used RMS-EMG-EP mark -II machine, the

sensitivity, sweep speed and duration were kept

at 0.2- 1mV/div, 5ms/div

We completed our study with 50 subjects.

The group consisted of 47 males (94%) and 3

females(6%). Findings of our study are summarized

in table 1 and H latency in two different age

groups is summarized in table 2.

Table No. 1

Variables Mean (SD)

Age (Yrs) 33.02 (9.1)

Height (Cm) 166(4.83)

Weight (Kg) 58.04 (8.6)

H-Th (mAmp) 3.98 (1.42)

H-lat (msec) 28.15(2)

H-Amp (mV) 5.49(3.24)

Figure : Mechanism of It refees in nerve co____chin velocity


23

Ghugare B, Singh R, Jain AP

Table No. 2

H Latency

Group I 27.68 (1.74)

(21-35 yrs) n=14

Group II 29.55 (2)*

(Above 35 yrs) n=36

A positive correlation was observed

between age of the patient and H-latency (r=0.41)

which can be tested in larger population for

better statistical significance.

*Difference in H latency was found to

be statistically significant between two groups

(p value <0.05).

There was no significant correlation

found between age and H-threshold, age and

H-amplitude; height and H reflex parameters;

weight and H reflex parameters.

Discussion :

In this study we found significant correlation

between age and H-latency, but there was no

such a relation between any other parameter.

Correlation between age and H latency as found

in our study was corroborative with the hypotheses

of neural structure remodeling, including

drop-out of largest fibers, and a segmental

demyelinisation and remyelinisation process with

a consequent reduction in internodal length4.

A comparison between current study and

previous studies is summarized in Table 3.

Table No. 3

H threshold (mA) H latency (ms) H amplitude (mV)

Current study (n=50) 3.98 (1.42) 28.15 (1.42) 5.49 (3.24)

Riccardo M 2001 (n=40) 8.1 (3.0) 30.6 (3.9) ---

David Preston 2005 (n=100) --- </=34 ---

Misra and pandey 1994 (n= ) --- 30.3(1.7) 9.8 (6.1)

It is evident from the available data that

H latency and H amplitude values obtained by

current study match with previous studies.

Larger difference in mean H threshold

in current and previous5 studies may be attrib-

uted to smaller sample size in both studies.

Limitations :

In this study we focused on age, height

and weight as potential contributing factors on

H reflex study. We did not control randomize

or obsrve other possible confounding factors with

potential to affect H reflex study. As sample size

is very small other factors affecting H reflex

study could not be correlated well. Physiological

variation in various parameters of H reflex

due to sex could not be assessed. Normal interleg

H-latency difference was not determined as study

was conducted unilaterally.

Abbreviations :

C M A P :Compound Muscle Action Potential

SNAP :Sensory Nerve action potential

H-Th :H wave threshold

H-Lat :H wave latency

H-Amp :H wave amplitude.

GBS :Guillain - Barre syndrome

References :

1. Braddom RI, Johnson EW. Standardization of H


24

Effect of Physiological Factors on Soleus H-Refles in Normal Human Subjects

reflex and diagnostic use in S1 radiculopathy.

Arch Phys Med Rehabil 1974; 55: 162.

2. David P, Barbara S. Electromyography and

Neuromuscular Disorders 2nd edition 2005. Late

responses; 47.

3. Fisher MA. AAEM minimonograph #13. H reflex

and F waves : physiology and clinical application.

Muscle Nerve 1992; 15: 1223.

4. Jacobs JM, Love S. Qualitative and quantitative

morphology of human sural nerve at different

ages. Brain 1985; 108: 897-924.

5. Riccardo M, Giovanni BS, Aldo Mariottni.

Recruitment curve of Soleus H reflex in chronic

low back pain and lumbosacral radiculopathy.

BMC Musculoskelet Disord. 2001; 2: 4.

6. UK Misra, J Kalita. Clinical Neurophysiology

2nd edition 2006. Late responses; 103.

7. Weintraub JR, Madalin K, yong M, et al. Achilles

tendon reflex and H response. Muscle Nerve 1988;

11: 972.

for his discovery of humanpapilloma viruses causing cer-vical cancer

Harald Zur HausenGermany

Born 1936

German CancerResearch CentreHeidelberg, Germany

The Nobel Prize in Physiology or Medicine 2008

Source : Noble Prize.Org.

for their discovery of

Francoise Barre-SinoussiFrance

Born 1947

Regulation of RetroviralInfections Unit, VirologyDepartment, Institut PasteurParis, France

humanimmunodeficiencyvirus

Luc MontagnierFrance

Born -1032

World Foundation forAIDS Research andPrevention Paris,France


25

Ghugare B, Singh R, Jain AP

ASSESSMENT OF FUNCTIONAL CAPACITY IN

ELDERLY POPULATION BY ELDERLY MOBILITY SCALE IN

WARDHA (DISTRICT) MAHARASHTRA INDIA

SD GANVIR* , SS GANVIR**

ABSTRACT

Background And Purpose : The rapid growth of the elderly population has resulted in a

corresponding rise in the number of elderly individuals who experience disability during their

lifetimes. The purpose of this study was to test the usefulness of (Tinniti scale-elderly mobility

scale ) four established clinical measures of balance, gait, and subjective perceptions of fear of

falling as screening methods for referring community-dwelling elderly individuals living in

residential care facilities for detailed physical therapy evaluation and possible intervention. The

number of persons over the age of 65 years has increased since the turn of the century, with the

most dramatic increase occurring in the number of persons 85 years of age and over. As the

number of elderly persons has grown, there has been a Corresponding rise in the number of

older persons with disability.

Subjects : The subjects were a convenience sample of 53 elderly individuals living in two

residential care facilities for the elderly.

Methods : Subjects were tested on each of four clinical measures of balance and mobility. Their

performance on these measures was compared with a physical therapist's brief evaluation of

disability and appropriateness for more detailed evaluation. The usefulness of these tools as

screening methods was determined by calculating sensitivity and specificity levels using the

physical therapist's evaluation as a standard.

Results : The sensitivity and specificity levels of the four clinical measures in their application as

screening tests for referral to physical therapy were as follows : Berg Balance Scale, 84% and 78%;

balance subscale of the Tinetti Performance-Oriented Mobility Assessment, 68% and 78%; gait

speed, 80% and 89%; and Tinetti Fall Efficacy Scale, 59% and 82%. The combination of two tests,

Berg Balance Scale and gait speed, yielded the highest sensitivity of 91% and the highest specificity of

70% when a subject tested positive on at least one test.

Conclusion And Discussion : These findings indicate the feasibility of developing screening methods

for referring community-dwelling elderly individuals for a detailed physical therapy evaluation

based on established clinical assessment measures, with a combination of tests measuring balance

and gait demonstrating the most promising results.

Original Article

* Professor, ** Assc. Professor, Ravi Nair PhysiotherapyCollege Sawangi Meghe Wardha India

Introduction :The number of persons over the age of 65

years has increased since the turn of the century,

with the most dramatic increase occurring in the

number of persons 85 years of age and over. As

the number of elderly persons has grown, there

has been a corresponding rise in the number of

older persons with disability. Based on data from


26

the 1987 National Medical Expenditure Survey,

an estimated 9.5 million non institutionalized

individuals experience difficulty in the performance

of basic life activities such as walking, self-care,

and home management activities1. Out of this total

of 9.5 million people, approximately 5.6 million

individuals (55%) are over the age of 65 years.1

The likelihood of having difficulty in carrying

out basic life activities increases as an individual

ages. In the 65- to 74-year-old age group, one in

nine individuals has difficulty performing basic

activities.1 This ratio rises to 1 in 4 individuals in

the 75- to 84-year-old age group and to 3 in 5

individuals aged 85 years of age and over1. As the

number of individuals with disability rises, there

will be a subsequent rise in the demand for

rehabilitation services to assist these individuals

in maintaining the highest functional level

possible. Despite this increase in demand for

services, many elderly individuals may not receive

needed care because of inconsistent referral to

physical therapists by primary care physician.2

The inability of elderly individuals to gain access

to physical therapy on a routine basis, and the

shortage of physical therapists to meet the growing

demand for services by community dwelling

elders.3 To alleviate this growing problem, screening

methods can be used in the community to identify

elderly individuals who have gross limitation in

mobility and who may be in need of referral to a

physical therapist for more detailed evaluation

and possible intervention.

In epidemiology, screening methods are

often used to identify a group of individuals with

a higher probability of having disease than the

general population.4 General characteristics of a

screening test include cost, convenience, reliability,

and safety. The most useful characteristics of a

screening test, however, are its sensitivity and

specificity. Sensitivity is defined as the chance

that a test will be positive when applied to

someone known to have the disease or disability

under consideration. Specificity is defined as

the chance that the test will be negative when

applied to someone known to be disease- or

disability-free. Higher sensitivity and specificity

indicate a better screening test. These measures

can therefore be used to determine how well a test

performs in screening a group of individuals for

a certain disability.4 Clinically based methods that

have been developed to measure physical function

may act as screening tests to identify older

individuals with limitations in mobility who

may benefit from physical therapy. Clinical

assessment methods may be particularly suitable

for screening because they can detect specific

impairments, have established reliability and

validity, and can be administered by medical or

non medical personnel who are trained in their

application.5 If a clinical assessment method

is demonstrated to have high sensitivity and

specificity in detecting mobility impairment in

the elderly, it could be administered by other

medical or trained non-medical personnel to

determine whether more detailed evaluation

by a physical therapist is warranted 6. Several

clinical assessment methods have been developed

to assess mobility and balance function in the

elderly. These methods measure different

domains of function such as physical performance

on specific tasks,7-12 gait mechanics,13,14 or the

patient's subjective perceptions of his or her

ability to balance.15,16 The validity of these

methods has been tested by

1. Determining the correlation between a

patient's performance and biomechanical

measures (such as measures of sway as

determined by force plates) 17, 18


27

Ganvir SD, Ganvir SS

2. Determining the assessment method's

ability to predict an event, such as whether a

patient will fall (predictive validity) l3

3. Determining the correlation of these

instruments with other established measures

of balance or mobility (concurrent validity).9

Further more, many of these instruments have

demonstrated test-retest and inter-rater

reliabilities on groups of elderly persons or

patients with specific medical conditions.

The aim of study is to test the ability

of four clinical assessment methods to act as

screening tests for detecting elderly individuals

with balance and mobility impairments who

should be referred for a detailed physical therapy

evaluation and possible intervention. These four

assessment methods were selected to correspond

to the three domains of mobility : Two of the

selected instruments measured functional

balance, one instrument measured gait, speed,

and one instrument measured subjective fear

of falling. The usefulness of each of these

assessment methods as a screening test for referral

to a physical therapist for detailed evaluation

and possible intervention was determined by

calculating sensitivity and specificity using a

physical therapist's brief evaluation of each

individual as the standard.

Method

Subjects

A convenience sample of elderly subjects

was obtained from residential care facilities

located in the Paloti ,wardha district Maharashtra

INDIA,. Prior to initiation of the study, the facility

administrator contacted conservators and

informed family members of the study. In addition,

the primary care physician of each potential

subject was contacted to determine whether there

were any medical problems that would preclude

participation in the study. Out of a total of 109

residents in two residential care facilities, 53 (40%)

consented to participate in the study. Subject

characteristics are presented in Table 1. The

mean age of the subjects was 83.3 years. The

majority (87%) of the subjects were female, with

an average length of stay in the facility of 2.3

years. Half of the sample required the use of

assistive devices for ambulation. There were

averages of 2.2 diagnoses per patient, with the

top five diagnostic categories being cardiovascular,

neurologic, psychiatric, musculoskeletal, and

endocrine. Specific diagnoses included hyperten-

sion, dementia, depression, stroke, arthritis, and

chronic obstructive pulmonary disease. The

mean score on the Folstein Mini Mental State

Examination was 21.2, indicating mild cognitive

impairment.

Clinical Measures

The clinical measures that were tested for

their feasibility as screening tests included the

following: (1) Berg Balance Scale,7,18-20 (2) balance

subscale of the Tinetti Performance-Oriented

Mobility Assessment (POMA),8,21-23 (3) gait

speed,l4 and (4) Tinetti Fall Efficacy Scale.15,16 24

The characteristics of each of these measures are

presented in Table 2. The Berg Balance Scale,

which measures "functional balance," has three

dimensions: maintenance of a position, postural

adjustment to voluntary movements, and reaction

to external disturbances.7,8, 20.Subject performance

on each of 14 activities is measured on a five-point

ordinal scale ranging from 0 to 4 (O=unable to

perform, 4=independent) so that the aggregate

score ranges from 0 to 56. Correlations between

the Berg Balance Scale and other measures of

balance have been determined to be moderate to


28

Assessment of Functional Capacity in Elderly Population by Elderly mobility scale In Wardha (MS)

high. The correlations between the Berg Balance

Scale and laboratory tests of postural sway,

Tinetti balance subscale, Barthel mobility

subscale, and timed "up and go" tests are -.55,

.91, .67, and - .76, respectively.18 Berg et al have

found high inter-rater and intra-rater reliabilities

(inter-rater and intra-rater reliability intra-class

correlation coefficients= .98 and .99, respectively)

and high internal consistency (Cronbach's alpha=

.%). The average time to administer the scale in

these studies was 10 to 15 minutes. Tinetti's

POMA balance subscale measures an individual's

position changes and ability to balance while

performing certain activities, and is usually used

in conjunction with a gait subscale to derive an

aggregate score of gait and balance.8, 12. The total

score on the POMA balance subscale can range

from 0 to 16, with a higher score indicating better

balance. Tinetti has reported both inter-rater and

test-retest reliability of .95 for the aggregate score

on the gait and balance subscale24. The POMA

gait and balance subscales have been shown to be

highly predictive of falls and fall related injuries

in community-dwelling elderly individuals and

residents of intermediate care facilities.22,23,25 In

addition, the POMA gait and balance subscales

have been shown to be predictive of nursing home

placement and mortality.26 The mean time to

administer the gait and balance subscales is 15

minutes. Gait speed was measured by an insole

footswitch system. This system measures gait

characteristics such as speed, cadence, stride

length, swing and stance times, single-limb support,

and double-limb support. As the subject walks a

specified distance, footswitches record foot-floor

contact, and these gait characteristics are timed

and automatically calculated.14 Speed was the

only gait characteristic to be considered as a

screening tool because decreased gait speed has

been associated with falling in elderly individual27.

Tinetti's Fall Efficacy Scale measures the degree

of confidence an individual has in performing

certain activities.17,18, 24. Tinetti suggests that

self efficacy may be an appropriate model to

investigate an individual's fear of falling. The

total score on the Fall Efficacy Scale can range

from 10 to 40, with lower scores indicating greater

confidence in walking. Test-retest reliability of

this scale in a sample of community-dwelling

elderly individuals was found to be.71(Pearson's

correlation)

Sample Characteristics : TABLE 1

N=53

Variable

Age(y)

X 83.3

SD 7.7

Range 62-96

Gender (%)

Male 13%(07)

Female 87%(46)

Length of stay (y)

X 2.3

SD 2.2

Range 0-9

Diagnosis (%)

Cardiovascular 36(41)

Neurologic 25(28)

Psychiatric 12(14)

Musculoskeletal 12(13)

Endocrine 8(9)

Respiratory 4(5)

Digestive 2(2)

Ophthalmalgic 1(1)

Folstein Mini Mental State

Examination score

X 21.2


29


SD 5.8

Range 29-May

Grip strength (kg)

Right

X 14.3

SD 5.6

Left

X 13.1

SD 5.5

ADL~(% )

Medication 70(37)

Bathing 21(11)

Dressing 4(2)

Feeding 2(1)

Toileting 0(0)

Walking aids (%)

No aid 5(27)

Canes 26(14)

Walkers 23(12)

Table 2. Characteristics of Clinical Measures

Measure Item Approximate Timeto Completes (min)

Berg Sit to stand 15

Balance Standing unsupported

Scale Sitting unsupported

Standing to sitting

Transfers

Standing, eyes Closed

Standing, feet together

Reaching forward with

outstretched arm

Pick up object from floor

Turn to look over shoulders

Turn 360"

Step touch stool

Standing unsupported with

one foot in front

Standing on one leg

Tinetti Sitting balance 10

P O M A Arise

balance Attempt to arise

subscale Immediate standing balance

Standing balance

Nudge

Standing, eyes closed

Turn 360"

Sit down

Stride Gait speed 10analyzer

Fall Subject's 10

Efficacy confidence in:

Scale 1.Cleaning the house

2.Getting dressed/undressed

3.Preparing simple meals

4.Taking a bath/Shower

5.Simple shopping

6.Getting in/out of a chair

7.Going up/down stairs

8.Walking in neighborhood

9.Reaching into cabinets

10.Answering the telephone

Physical Patient interview 10

therapist Observation of transfers;

Assessment walking on indoor and

outdoor level surfaces,

ramps, stairs, and curbs

Time to complete as determined in this study.

POMA = Performance-Oriented Mobility Assessment

The validity of the instrument is

suggested by the finding that total scores increase

progressively as subjects report an increase in fear

of falling.28

Data Collection

A "health fair" day was scheduled at each

facility to collect baseline data. The "health fair"


30


consisted of three stations at which residents

were interviewed and assessed on performance

based measures of gait and balance. Interested

residents could attend the health fair at any time

throughout the day. As each resident arrived, the

study was described, and, if informed consent

was obtained, the resident was entered into the

study. All subjects were initially tested for cogni-

tive impairment using the Folstein Mini Mental

State Examination. Those individuals who

achieved a score of 20 or higher were further

interviewed about their walking abilities and

administered the Fall Efficacy Scale to assess

their confidence in walking. A cutoff score of

20 was selected to allow individuals who were

moderately cognitively impaired to be evaluated

by the physical therapist. Following the interview,

each subject visited two measurement stations

to be evaluated on gait and balance/functional

activities.. The order of testing transfer was

variable. Three physical therapists assessed

balance and function by administering the Berg

Balance Scale and the Tinetti balance subscale

and by evaluating the subject's ability to transfer

and walk on level surfaces and ramps. These

therapists received prior training to standardize

their administration of these tests. Gait speed

was assessed by another physical and a research

assistant. Footswitches were inserted into the

subject's shoes, and a recorder was strapped onto

the subject's waist. Gait characteristics were

recorded as the subject walked a distance of 6.1

m (20 ft). The average time to prepare a subject

for testing and to test the subject on all activities

was 45 minutes. Two weeks following the initial

data collection, another physical therapist, who was

blinded to the results of the clinical measures,

visited each facility to briefly assess each subject's

functional level and the need for further evaluation

and possible intervention. The physical

therapist's assessment took between 5 to 10

minutes per subject and included an interview

followed by observation of the subject's ability to

transfer and walk on level surfaces, ramps, stairs,

and outdoors. The assessment was tailored to the

functional capacity of the subject. For example,

subjects who had difficulty walking a short

distance indoors were not assessed walking

outdoors. Subjects who exhibited difficulty while

performing any of these transfer and ambulation

activities were judged to be appropriate for

physical therapy intervention. To assess the degree

of agreement among physical therapists' judgments

of appropriateness for treatment, three of the

subjects were videotaped while performing the

transfer and ambulation activities. Ten physical

therapists, including the physical therapist

who performed the assessment on all patients,

subsequently rated each subject's appropriateness

for physical therapy based on their observation

of the videotaped performances. The level of

clinical experience of these physical therapists

ranged from 0.5 to 47 years, with a mean of 13

years. The physical therapists were asked to

Elaborate on their evaluation criteria by listing

each functional component included in their

assessment of subject performance.

Data Analysis

Distributions, frequencies, and measures

of central tendency were examined for each

clinical measure using the SAS statistical software

system. Next, the sensitivity and specificity levels

of each clinical measure of balance and mobility

were calculated using established methods.30,31.

In general, the number of subjects scoring above

and below a specified score (cutoff value) on each

measure were counted and categorized according


31


to whether they were true-positive, true negative,

false-positive, or false negative using the physical

therapist's brief assessment as the standard. The

selection of cutoff values by which to calculate

sensitivity and specificity is arbitrary; therefore,

optimal cutoff Values were determined by plotting

receiver operating characteristic (ROC) curves for

each assessment method to determine the point

that provided the best tradeoff between sensitivity

and specificity.32. The ROC curve plots sensitivity

on the y-axis and specificity (1-specificity) on the

x-axis for a range of score values. The point that

provides the best trade off between sensitivity and

specificity is determined by viewing the slope of

the ROC ~urve.3~ In this analysis, the optimal

point occurred where the slope of the curve was

the closest to 1. Finally, the sensitivity and specificity

levels achieved by using two clinical assessment

measures, gait speed and the Berg Balance Scale,

were determined in a parallel testing situation in

which a subject was labeled positive if diagnosed

as positive on at least one test.33 These two measures

were selected because they demonstrated the best

sensitivity and specificity levels when determined

individually. To assess the degree of physical

therapist agreement of appropriateness for

treatment based on observation of the videotaped

patient performances, the kappa statistic was

calculated using STATA statistical software. Kappa

is a chance-corrected measure of agreement that

can yield values ranging from - 1 to 1, depending

on the strength of agreement.34 The frequency

of items assessed by the physical therapists during

their assessment was also examined. The accept-

ability of each clinical measure, as determined

by the subject's ability to complete the test, was

the highest for the evaluation by the physical

therapist, followed by both tests of balance, gait

speed, and fear of falling. All 53 subjects

completed the evaluation by the physical therapist.

Forty three subjects (81%) completed both balance

tests, 44 (83%) completed the gait speed test, and

28 (53%) completed the Fall Efficacy Scale. For

both tests of balance, the most common reason

for non completion was subject refusal. The

majority of the subjects who failed to complete

the gait speed tests did so secondary to decreased

cognition. For the Fall Efficacy Scale, almost

one half of the subjects could not complete the

measure because of cognitive impairment or

communication difficulties. Table 3 provides

performance results for each clinical test. Frequency

distributions on both the Berg Balance Scale and

the Tinetti POMA balance subscale tended to

be skewed to the right. In this study, the Berg

Balance Scale required 15 minutes to administer,

whereas the POMA balance

Table: 3 Subjects performance on clinical tests

Test N x SD Median Range

Berg Balance Scale (0-56) 43 42.7 12.4 47 0-55

Tinetti POMAe balance subscale (0-1 6) 43 13 2.9 14 1-16

Gait speed (m/min) 44 33.6 15.6 33.3 9.1-68.5

Fall Efficacy Scaleb (10-40) 28 18.3 9.9 12 10-40

“POMA = Performance-Oriented Mobility Assessment.

Fall Efficacy Scale score reported only for those with a Folstein Mini Mental State

Examination SCORE of >20


32


Table 4: Best Sensitivity and Specificity for Each Screening Test

Measure Scale cut off score sensitivity specificity

Berg balance scale 48 84%(21/25) 78%(14/18)

Tinetti POMA balance subscale 14 68%(17/25) 78%(14/18)

Gait Speed 34 80%(20/25) 89%(17/19)

Fall Efficacy scale 16 59%(10/17) 82%(9/11)

Berg balance scale and Gait Speed 48&34 91%(21/23) 70%(12/17)

Based on physical therapist evaluation as the standard.

POMA=Performance-Oriented- Mobility- Assessment. Either testing positive.

Table 5. Item Included in a Brief Physicaltherapist Assessment

Item Assessed No. of PhysicalTherapists

Assessing Item

Difficulty with transfers 9

Difficulty with ambulation

on levelsurfaces 9


on stairs 9

Difficulty with balance 9


on ramps 8

Assistive device fit/use 7

Posture 6

Strength (functional) 6

Gait deviations 6

Range of motion 3

Cognitive impairment 2

.Ten physical therapists participated in the

videotaped patient ratings

. cognitive impairment could not be directly

assessed on videotape although two physical

therapists reported that they would assess this

in person.

Sub scale averaged 10 minutes. The gait

speed measurements were normally distributed,

with a mean of 33.6 m/min. The slowest speed

was recorded for a subject who had experienced

a severe stroke several years earlier. This subject

was walking with an ankle-foot orthosis and a

quad cane, and had severe left-side weakness. In

the 28 subjects who could be evaluated on the

Fall Efficacy Scale, the mean score was 18.3. Out

of 53 subjects,28 (53%) were judged by the

physical therapist to be appropriate for inclusion

in a physical therapy mobility training program

based on the brief assessment described previously.

The ROC curves for the Berg Balance Scale and

gait speed are plotted in Figures 1 and 2. The

optimal cutoff points, based on ROC curves for

each clinical assessment instrument and measure,

are presented in Table 4. At a cutoff score of 48,

the Berg Balance Scale demonstrated an equal

specificity level of 78% and a better sensitivity

level, 84% versus 68%, than the POMA balance

subscale at a cutoff score of 1.4. The measure of

gait speed demonstrated good sensitivity and

specificity levels (80% and 89%, respectively; at a

cutoff score of 34. The sensitivity and specific-

ity levels of the Fall efficacy Scale, using a cutoff

score of 16 and administered to cognitively intact

individuals, were 59% and 82%, respectively. Using

a combination of the Berg Balance Scale and gait

speed yielded a sensitivity of 91% and a specificity

of 70% when a subject was positive on at least

one test. Analysis of the physical therapists' ratings

of the videotaped patient performances yielded


33


moderate agreement beyond chance (K=.47,

P<.0001). The items assessed by the physical

therapists to arrive at their determination of

appropriateness for treatment are listed in Table

5. The most frequently reported items assessed

on videotape included difficulty with transfers,

difficulty with ability to balance, and difficulty

with ambulation on level surfaces and stairs

a physical therapist's judgment. The two clinical

measures that showed the strongest potential for

use as screening methods were the Berg Balance

Scale and gait speed. Our results showed that

the Berg Balance Scale was more sensitive than

the Tinetti POMA balance subscale and had

comparable specificity. The Berg Balance Scale,

however, takes longer to administer than the

POMA balance subscale (15 minutes versus 10

minutes). The strength of the Berg Balance Scale

lies in its detailed grading scale, which appears

to be better at detecting balance impairment than

the POMA balance subscale. Topper et a135 also

describe this limitation of the POMA in identifying

individuals who are at risk for falling In developing

the screening methods, we included individual

measures of balance, gait, and subjective percep-

tions of fear of falling. The combination of two

clinical measures, balance (as measured by the

Berg Balance Scale) and gait speed, yielded the

highest sensitivity level of 91%, suggesting that

a combination of clinical tests most accurately

reflects the physical therapist's judgment and

thus might be the best for developing screening

methods. In a screening situation involving the

Berg Balance Scale and gait speed, a subject

would be administered the second test only if the

first test did not indicate the need for further

evaluation. In this study, physical therapists were

used to conduct screening tests to maximize efforts

of ensuring that these tests were performed

consistently. The use of non-physical therapists to

perform these tests could decrease the likelihood

that the tests were performed consistently

because physical therapists are specially trained

to assess function. In a screening situation, these

screening tests could be administered by health

care personnel who are in constant contact with

elderly people, such as primary care physicians

Figure 1. Berg Balance Scale receiver operating characteristiccurve. Asterisk P) indicates cut off point; double asterisk (")

indicates optimal cut off point.

Figure 2. Gait velocity receiver operating characteristic curve.Asterisk (9 indicates Cutoff point ; double asterisk P) indicates

optimal cut off point.

Discussion

The results of this study show that clinical

assessment instruments that detect balance and

mobility impairments are useful for screening

elderly individuals who may be in need of a

detailed physical therapy evaluation and possibly

intervention. These screening methods demonstrated

good sensitivity and specificity for reproducing


34


during a routine office visit or facility personnel.

These individuals, however, would require in-depth

training to consistently administer the screening

tests. The next step is to have physical therapists,

or other individuals who are knowledgeable

about-these tests, educate other health care

personnel on how to conduct the tests for elderly

individuals. If physical therapists can teach

lower-level personnel to conduct these tests, the

screening procedure would be less costly. This

study showed that tests of balance and gait speed

had high sensitivity and specificity in screening

the older community dwelling population for

balance and mobility impairments. These specific

tests were selected because they have established

reliability and validity in the geriatric literature.

Other comparable, yet simpler, tests could be

used as screening methods for the detection of

balance and mobility deficits. For example, gait

speed could be measured by using a stopwatch

rather than the footswitch system, and balance

could be measured using the forward-reach

technique rather than the Berg Balance Scale.

The use of simpler tests would facilitate their

administration. Simpler methods, however,

would have to show acceptable sensitivity and

specificity to be able to identify appropriate

individuals. There are several limitations of this

study. First, the sample was relatively small and

drawn from the residential care facility population.

This study is therefore not generalize able to other

community-dwelling elderly individuals, such as

those living in their own homes. The residential

care facility population, however, represents a

sizable community-dwelling population with a

high prevalence of balance and mobility deficits

who often go undetected in their need for physical

therapy services. Second, there were only three

physical therapists to assess balance using the

Berg and Tinetti scales. These therapists, however,

received prior training to standardize the admin-

istration of these tests. Third, the standard for

identifying subjects with balance and mobility

deficits was limited to the assessment of one

licensed physical therapist, which was brief and

may not have been fully diagnostic. Subsequent

ratings of videotaped patient performances by

10-physical therapist including the rater, however,

yielded moderate agreement beyond chance,

indicating that therapists tend to evaluate patients

similarly. Finally, there was 2-week lag time

between testing and the physical therapists'

evaluations. There could have been some clinical

changes between the ratings, although such

changes should be minimal in a stable population.

Further studies be performed that incorporate

larger sample sizes and different sites in developing

screening methods to identify older persons with

balance and mobility deficits who may be in need

of more detailed physical therapy evaluation by a

skilled therapist. To facilitate the administration

of screening tests by clinicians or facility personnel,

further studies should be performed to identify

simpler and easier-to-administer methods with

comparable sensitivity and specificity in the

community based setting.

Conclusion

As the Indian population over the age of

65 years continues to grow, there will rise in the

level functional disability. Physical therapists can

.play. An important role in delaying the onset of

& ability and prolonging health into older ages,

it is there for imperative that appropriate screening

methods are developed to identify community-

dwelling elderly individual- with functional

impairment who should be referred for a detailed

physical therapy evaluation


35


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Geriatric rehabilitation: What do physicians

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3. Koska MT. Rehabilitation growth fuels PT

shortages. Hospitals 1989;63:32.

4. Rogan WI, Gladen B. Estimating, prevalence

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for the functional assessment of older patients. N

Engl J Med. 1990;322:1207-1214

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390

7. Berg K, wood-Dauphinee S, Williams JI,Measuring

balance in the elderly: validation of an instrument.

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9. Weiner DK, Duncan PW, Chandler J, Studenski

SA. Functional reach: a marker of physical frailty.

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in elderly people who have and who have not fallen.

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11. Mathias S, Nayak USL, Isaacs B. Balance in

elderly patients: the "Get-up and Go" test. Arch

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12. Studenski S, Duncan PW, Chandler J. Postural

responses and effector factors in persons with

unexplained falls: results and methodologic

issues, Geriatric Sot, 1991,33:229-234,

13. Feltner ME. MacRae PG. McNitt-Grav, J L

Quantitative gait assessment as a predictor of

prospective and retrospective falls in community-

dwelling older women. Arch Phys Med Rehabil.

1994,75:447-453

14. Peny J. Gait Analysis: Normal and Pathological

function Thorofare, NJ: SLACK Inc; 1992:431.

15. Tinetti ME, Richman D, Powell L. Falls caw as a

measure of fear of falling J Gerontol. 1990; 45:

p239-p243

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RG. Comparison of biomechanics platform

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J Gerontol. 45:M49-M54.

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D. Measuring balance in the elderly: preliminary

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37


"SUICIDES IN ELDERLY AGE-GROUP IN WARDHA REGION

OF MAHARASHTRA IN A PERIOD OF FIVE YEARS,

FROM 1ST JANUARY 2001 TO 31ST DECEMBER 2005."

PN MURKEY *, BH TIRPUDE **, VG PAWAR ***, KS SINGH ***.

ABSTRACT

The study was conducted at Mahatma Gandhi Institute of Medical Sciences (MGIMS),

Sevagram from 1st January 2001 upto 31st December 2005 i.e. 5 years on 99 cases of elderly suicide

which were received from in and around the district Wardha, Maharashtra. Cases included

victims greater than or equal to 50 years of age. Data was analyzed with regard to the age, sex,

methods of suicide, place of suicide, cause of suicide and time of the year components. There were

71 male (72%) and 28 female (28%) victims. The age range of the suicide victims was 50 to 85 years.

Commonest age group involved in our study was 50 - 59 years (n=47, 47.47%) in both sexes.

Poisoning (n= 62, 63%) was the most common method of suicide, followed by burning (n=27, 27 %)

and drowning (n=6, 6%). Maximum numbers of suicides were seen in the rainy and winter season

(n=54, 55%). Financial problem (n = 53, 53.5%) was the most common reason behind the suicide.

Key Words : Suicide, poisoning, burning, chronic illness.

Original Article

INTRODUCTION :

Aging is a natural phenomenon which is

inevitable to everyone. In the recent years, there

has been a considerable increase in the relative

or absolute numbers of the elderly people which

is due to decline in the fertility rates combined

with increase in life expectancy of people

achieved through medical interventions.1 In the

year 2002, there were an estimated 605 million

old persons in the world of which 400 millions

were living in the low income countries. It is

expected that by the year 2025, the number of

elderly people will rise to more than 1.2 billion,

with about 840 million of these living in low-income

countries. As per SRS estimates for the year 2003,

7.2 percent of total population were above the

age of 60 years.2

For most older people, their life is a time of

fulfillment, satisfaction with life's accomplishments.

For some older adults, however, later life is a time

of physical pain, psychological distress, and

dissatisfaction with present, and, perhaps, past

aspects of life. They feel hopeless about making

changes to improve their lives. Suicide is one of

the possible outcome. Life events commonly

associated with elderly suicide are: the death of

a loved one, physical illness, uncontrollable pain,

fear of dying a prolonged death that damages

family members emotionally and economically,

social isolation, lack of care from children and

loneliness and financial problems due to job

loss or retirement. The widowed, divorced, and

recently bereaved are at high risk. Others at high

* Associate Professor, ** Professor & Head, *** PostGraduate Students, Address for Correspondence :Dr.P.N.Murkey, Associate Professor, Dept. of FMT,MGIMS, Sevagram. E-mail : [email protected]


38

risk include depressed individuals and those

who abuse alcohol or drugs.3

In America, each year more than 6,300

older adults take their own lives, which means

nearly 18 older Americans kill themselves each

day. Although they comprise only 12 percent of

the U.S. population, people age 65 and older

accounted for 16 percent of suicide deaths in

2004.4 In India the rate of suicide among the

elderly in the year 2005 was 8.2 % (Male 5.8%, and

Female 2.4%) of the total suicides. According to

NCRB India report 2005, nearly 42.8% of the

elder age group committed suicide due to illness.5

In the present article, we have attempted

to study the incidences, patterns and modes of

suicides in the elderly persons brought for

medico-legal autopsy to MGIMS, Sevagram.

MATERIAL AND METHODS :

The Mahatma Gandhi Institute of Medical

Sciences (MGIMS), Sevagram, is one of the pioneer

rural based hospital in the country which was

established with the motive of providing the basic

medical needs to the rural population of India.

As in any other government medical hospitals,

here too the medico-legal autopsies are conducted

which covers the whole of Wardha district

(mainly) and also other nearby districts. We went

through all cases of elderly deaths on which

postmortems were done at MGIMS, Sevagram

(age of victim being 50 years and above, as

compared to 60 years and above in other studies)

over a period of 5 years, from 1st January 2001 to

31st December 2005. A total of 1306 autopsies were

done during this period, out of which 230 cases

were of elderly subjects (50 years and above). Out

of these 230 elderly autopsies, 99 cases were of

suicides, which constitutes about 7.58 % of all

the total autopsied cases which were done in the

above mentioned period of 5 years. The detailed

analysis of these cases was based on the medical

records and the evaluation of autopsy reports.

DISCUSSION :

In our study, out of total 1306 autopsy

cases, 312 cases were of suicides, which constitutes

about 23.89 % of all the autopsy cases. Out of

these 312 cases, 99 cases were in the elder age

group (50 years and above) which amounts to

31.73% of all the suicide cases.

In our study from 2001 to 2005, there

were almost an equal numbers of suicides in

each year with slight variation in the figures with

maximum incidence in 2002 (n=24) and minimum

incidence in 2004 (n=16). Kua et al, in a study

describing the trends of elderly suicide rates of

Chinese, Malays and Indians in Singapore from

1991 to 2000 reported that the suicide rates for

the elderly showed a decline, especially in elderly

Chinese.6

As for the pattern of age and sex wise dis-

tribution of suicide, Pritchard in a study of

changing patterns of suicide in the Western

World, examined changes in suicide rates between

1974 and 1992 in twenty-two countries. He found

a decrease in rate of suicide in 65-74 years olds of

both sexes in most countries and increases in

suicide rates in the population aged 75 years

and older, again in both sexes, but with a male

preponderance.7 But in our study, there is a

decrease in the rate of suicide with increasing

age with the commonest age group involved

was 50-59 years (n = 47, 47.47%) followed by the

age-group 60 - 69 years (n=31, 31.32%) and 70-79

years (n=15, 15.15%). Minimum cases of elderly

suicides were found in the age-group of 80-89

years (n=6, 6.06%). There is male preponderance

in all the age-groups except in the last one where

females are dominating. The highest rate of


39

Murkey PN, & et al.

elderly suicides in the age-group of 50-59 years

with male preponderance in our study may be

explained by the fact that there is high rate of

suicides among the farmers in the region of

Maharashtra.

Poisoning was the most common cause

of death (n=62, 62.6%) followed by burn injuries

(n=27, 27.3%). In cases of poisoning, the male :

female is 5.2 :1 whereas in cases of burns, females

predominated males with a male : female of 1:2.

Next to burn injuries the cause of death was

drowning which formed about 6.1% (n=6) with

male : female ratio of 1:5, followed by hanging

(n=2, M:F = 1:1)and railway cutting (n=2, both

males). Therefore, it was concluded that among

males poisoning was the most common cause of

death whereas among females burning was the

commonest mode of suicide. In a similar study

of 10 years (from 1996 - 2005) by C. Behera et al

at AIIMS, they found that hanging was the most

common cause of death which is quite different

from our study.1 This highlights the basic

difference of mode of suicide in rural and

urban areas where poisoning was most common

method in rural areas due to easy availability of

poisons (mostly pesticides and insecticides) in

each home of rural areas. Studies from most of

the western countries revealed firearms as the

most common method of suicide 8 which is quite

contradictory in our scenario where there was

not a single such case.

The highest number of suicides in the

elderly age groups was recorded in autumn and

winter (55%, n=54) followed by the rainy season

(28%, n=28) and spring and summer season (17%,

n=17) which is quite different from the findings

observed in the studies from eastern part of India

by S. Mohanty et al9 and from Northern India by

c.Behera et al1 where maximum cases were

recorded in the rainy season. Most of the suicides

occurred indoors (n=87, 88%), which is consistent

with the findings observed by S.Mohanty et al9

and c.Behera et al1.

The specific types of events most

pertinent to suicide in later life differ from

those of younger victims. Interpersonal discord,

financial and job problems, legal difficulties and

disputed romance etc. are more typical of suicides

in young and middle adulthood, whereas physical

illness and other losses including family

economical losses are the most common stressors

in older adults who end their own lives.

As per the findings of our study, financial

problem was the foremost reason behind the

high rates of suicide among the elders which

constituted 53.5 % (n=53) of the total cases. This

may be due to the below-poverty-line economy

of the poor rural populations combined with

high indebt from high-interest-money lenders.

This is followed by other family and personal

problems (n=26, 26.3 %) and chronic illness (n=11,

11.1%). This is quite contradictory to the findings

of most of the studies. Dorpat et al (1968)10 in a

study stated that physical illness directly contributed

to suicide in almost 70% of victims over 60 years

of age. Margda waern et al11in their study

mentioned that physical illness is a common

antecedent to suicide in elderly people, with

prevalent figures varying widely from 34% to

94% and higher risk factors in men than in

women. In 9.1% cases (n=9) the causes were unknown,

but here conditions like social isolation and

loneliness are important factors to be considered

(Barraclough 197112).

CONCLUSION :

Suicide is rarely, if ever, caused by any

single event or reason. Rather it results from


40

Suicides In Elderly Age-Group In Wardha Region Of MH In A Period Of Five Years, From 1st Jan. 2001 To 31st Dec. 2005.

many factors working in combination which

produce feelings of hopelessness and depression.

Elder suicide is usually associated with depression

and factors causing depression e.g. chronic illness,

physical impairment, unrelieved pain, financial

stress, loss and grief, social isolation and alcoholism

etc. However, suicide for the older is not an

impulsive act and so we can have a window of

opportunity to help the older persons get help

and we can prevent it by providing social welfare

measures like national assistance, supplementary

pensions, adult care centres, home care agengies,

hospices, assisted living facilities and nursing

homes etc.

FIGURES

Age-wise distribution of suicide cases in elderly

47

31

156

01020304050

50 - 59 60 - 69 70 - 79 80 andabove

Age-groups

No. o

f cas

es

Sex-wise distribution of elderly suicide cases

Males, 71, 72%

Females, 28, 28%

MalesFemales

Methods of suicide

Poisoning, 62, 63%

Burn, 27, 27%

Drowning, 6, 6%

Hanging, 2, 2%

Railway cut, 2, 2%

PoisoningBurnDrowningHangingRailway cut

E ld e rly s u ic id es in d iffe ren t seaso n s

A utum n and w inter, 54,

55%

Rainy s eas on, 28,

28%

S pring and s um m er, 17, 17%

A utum n and w inter

Rainy s eas on

S pring ands um m er

Place of suicide

Outdoor, 12, 12%

Indoor, 87, 88%

OutdoorIndoor

Reason for suicide

26

53

11 9

0

1020

30

4050

60

Family problems Financialproblems

Chronic Illness Causes notknown

Reason

No.

of c

ases

Figure : 1 - showing age-wise distribution. Figure : 2 - showing sex-wise distribution.

Figure :3 - showing methods of suicide. Figure : 4 - showing season-wise distribution.

Figure : 5 - showing place of suicide. Figure : 6 - showing reasons.


41

Murkey PN, & et al.

REFERENCES :

1) C. Behera, R. Rautji, R.K.Sharma, Suicide in

elderly : A study in South Delhi (1996 - 2005)

2) Park's text book of Prevention and social Medicine

: 19th Edition Feb 2007, Banarasidas Bhanot

Publishers,Page No. 476-477.

3) Suicide of older men and women - Elderly suicide

www.healthyplace.com/Communities/depression/

related/suicide_3.asp - 25k)

4) (Conwell Y, Brent D. Suicide and aging. I: patterns

of psychiatric diagnosis. International

Psychogeriatrics, 1995; 7(2): 149-64.)

5) Accidental deaths and Suicides deaths in India.

National Crime Record Bureau. Ministry of Home

Affairs, Govt. of India, RK Puram, New Delhi,2005.

6) Kua EH, Ko SM, NgTP, Recent trends in elderly

suicide rates in a multi-ethnic Asian city, Int J

Geriatr Psychiatry, 2003 Jun; 18 (6): 533-6.

7) Pritchard C.New patterns of suicide by age and

gender in the United Kingdom and the western

World 1974-1992, an indicator of social change ?

Soc Psychiatry Psychiatr Epidemiol 1996, 31 :227-234.

8) Katalin Szanto, Holly G Prigerson, charles F.

Reynolds III. Suicide in the elderly, Clinical

Neuroscience Research I (2001) 366-376.

9) S. Sachindananda Mohanty Geeta Sahu Manoj

Kumar Mohanty, Manju Patnaik, Suicide in India

- A four year retrospective study, Journal of Forensic

and Legal Medicine 14 (2007) 185- 189.

10) Dorpat TL, Anderson WF, Ripley HS (1968), The

relationship of physical illness to suicide. In:Resnik

HPL, editor, Suicidal behaviours : Diagnosis and

Management, boston : little, Brown, pp 209- 219.

11) Margda Waern, B runeson, K Wilhelson, Burden

of illness and suicide in elderly people : caee-

control study, BMJ 2002; 324 : 1355 (8 June).

12) Barraclough BM (1971), Suicide in the elderly :

Recent developments in psychogeriatrics. Br J

Psychiatry (suppl 6): 87 - 97.


42

Suicides In Elderly Age-Group In Wardha Region Of MH In A Period Of Five Years, From 1st Jan. 2001 To 31st Dec. 2005.

ERRATUM

JMGIMS Vol.13, No. ii, September 2008The Title of the article may please be read as -

“ Genome Sequencing of HPV- A Hope to Overcome Cervical Cancer”

Editor

INABILITY TO START HEMODIALYSIS AFTER

A SMOOTH DUAL LUMEN HEMODIALYSIS CATHETER

INSERTION PROCEDURE : A CASE REPORT

S KUMAR *, AP JAIN **

ABSTRACT

Cannulation of the central vein for placement of the temporary dual-lumen catheter

for hemodialysis is usually safe and reliable even when performed blindly. Here, we report a case of

aberrant catheter entry into the external jugular vein during an apparently smooth procedure.

Case Report

* Sr Lecturer, **Director - Prof. and Head Dept. ofMedicine, MGIMS, Sewagram. Corresponding Author :[email protected]

Case report -

A 36-year-old man known case of CKD

stage -5 who was on conservative management

because of financial problems. His symtomps

became refractory and also developed pulmonary

edema so planned for emergency hemodialysis.

His laboratory investigation revealed blood urea

- 250 mg%, serum creatinine - 14 mg%, serum

sodium - 128 mEq/L. and serum potassium - 7.6

mEq/L. However his ECG did not showed any

changes of hyperkalemia. A temporary dual

lumen standard 12 F, 13 cm long, hemodialysis

catheter (arrow) was inserted into the right

Subclavian vein using the Seldinger technique.

The Seldinger technique means that a blunt

guidewire is passed through the needle, and the

needle is then removed. A dilating device then

passed over the guidewire to slightly enlarge the

tract, and the catheter itself is then passed over

the guidewire, which is then removed. All the

lumens of the line are aspirated (to ensure that

they are all positioned inside the vein) and

flushed.The procedure was uneventful, and free

flow of blood from both lumens using a standard

20-mL syringe could be ascertained at the end

of the procedure. Hemodialysis, however, could

not be commenced due to a high negative ''arterial''

pressure. A post insertion chest X-ray was taken

(fig-1). We did Doppler sonography of this patient

which showed catheter in vein beside internal

jugular vein probably external jugular vein.

Fig - 1 : Double lumen catheter in upward directionprobably in external jugular vein.

Discussion -

In patients with end - stage renal disease,

cannulation of the central venous system with

large- bore double lumen catheters is often necessary

until a functioning vascular access can be created.

Double - lumen catheters are widely used for

temporary access to the circulation in patients


43

who require acute hemodialysis. Since HD requires

rapid extracorporeal blood flow, femoral, subclavian

and internal jugular veins are the sites most

commonly chosen. While cannulating the internal

jugular vein or subclavian vein their surface

anatomical landmarks are known to be inconsistent

and unreliable. Anomalies of the central veins

occur in 25%-35% of uremic patients,1 which

commonly include anatomic variation of the internal

jugular vein in relation to the carotid artery,

stenosis, total occlusion, and nonocclusive thrombus

formation. The hemodialysis catheter had not

followed the expected course of the right subclavian

vein into the right jugular vein that crosses the

midline to join the right brachiocephalic vein

to form the superior vena cava. The catheter had

most likely entered a tributary of the right

subclavian vein i.e. right external jugular vein,

(fig-2) which explains why there was free flow

of blood by syringe aspiration during catheter

insertion, but not by the blood pump of the

hemodialysis machine that generated a suction

force to execute a flow rate of 200 mL/min. Such

complication may happen in patients who had

previous catheter insertions. The external

jugular vein varies in size, bearing an inverse

proportion to the other veins of the neck. It is

provided with two pairs of valves, the lower pair

being placed at its entrance into the subclavian

vein, the upper in most cases about 4 cm. above

the clavicle.

To circumvent these problems, direct

real-time ultrasound guidance for the insertion

of temporary hemodialysis catheter has greatly

enhanced the safety and success rates of this

procedure,3 which is commonly performed by

the practicing nephrologist, intensivist, and

radiologist in major hospitals worldwide. However

at this centre we are doing blindly because of lack

of resources without any much complication and

inconvenience. Indeed, sonography does not

allow the operator to follow the course of the

guidewire and catheter beyond the subclavian

vein or internal jugular vein. So in addition to

an ultrasound survey, venography performed

during catheter insertion may detect unexpected,

clinically significant anatomical abnormalities or

variations of the central veins.

References -1. Lin BS, Kong CW, Tarng DC, Huang TP, Tang

GJ. Anatomical variation of the internal jugularvein and its impact on temporary haemodialysisvascular access : An ultrasonographic survey inuraemic patients. Nephrol Dial Transplant. 1998;13:134-138.

2. M.Moini, M.R.Rasouli, M.M.Kenari, H.R.Mahmoodi : Non-cuffed dual lumen cathetersin the external jugular veins versus other centralveins for hemodialysis patients. Saudi J KidneyDis Transpl 2009; 20:44-8.

3. Oguzkurt L, Tercan F, Kara G, Torun D, KizilkilicO, Yildirim T. US-guided placement of temporaryinternal jugular vein catheters: Immediatetechnical success and complications in normal andhigh-risk patients. Eur J Radiol. 2005;55:125-129.

Fig-2 : Major vein and their tributries(taken from internet)


44

Inability to start hemodialysis after a smooth dual lumen hemodialysis catheter insertion procedure : a case report

GENETIC STUDY - A HELPING HAND FOR CLINICAL DIAGNOSIS

AM TARNEKAR *, JE WAGHMARE **, P BOKARIYA ***, IV INGOLE ****, AK PAL *****

ABSTRACT

Genetic disorders have diverse modes of presentation. Some present with obvious features

and have strong clinical suspicion in order to make a clinical diagnosis. Many other genetic disorders

remain masked till a specific genetic test such as karyotype analysis or molecular analysis (FISH,

PCR) is carried out. Some routinely encountered genetic disorders such as Klinefelter's syndrome,

Turner's syndrome and Down's syndrome may present in a variant form. In such cases there is very

little clinical suspicion for a genetic disorder and diagnosis is entirely based on karyotype analysis.

Importance of genetic study in conditions of poor reproductive outcome, bad obstetric history

(BOH) and inheritance of Down's syndrome is highlighted.

Key words : karyotype, mosaicism, genetic counseling.

Case Report

*Associate Prof., ** Senior Lecturer, *** Lecturer,**** Prof. & Head *****Prof. (Cytogenetics) &corresponding author. Human cytogenetics unit, Dept.of Anatomy, MGIMS, Sevagram.

INTRODUCTION

With better control of infectious and

nutritional diseases more number of genetic

disorders are emerging1. People in general are

largely unaware of genetic disorders. Different

genetic disorders present in diverse manner and

manifest at different ages. Problems related to

fertility manifest much later than bodily deformities

(congenital anomalies) that manifest in neonatal

period. Many others manifest in adulthood or

may not reveal at all till a triggering signal is

received. Regardless of age of presentation, all

such conditions can however be identified at a

quite early age if specific genetic tests are applied

whenever clinically suspected.

Diagnosis of some of the genetic disorders

can be presumptively made on the basis of

presentation, signs and symptoms [e.g. Klinefelter's

syndrome, Down syndrome & Turner's syndrome].

However in many others a genetic test such as

Karyotype of peripheral blood lymphocytes or

molecular genetic tests such as PCR (polymerase

chain reaction) and FISH (fluorescent in situ

hybridization) are required to identify and

localise the abnormality. Most of the new world

diseases such as cancer, diabetes, hyperlipidaemia

etc have a genetic predisposition. This necessitates

carrying out a susceptibility test (e.g. human

leucocytic antigen 'HLA' typing) for the timely

diagnosis and proper management of such

conditions.

We have analysed some of the routinely

referred subjects to cytogenetics unit and categorized

some such cases where a clinical clue to point a

genetic abnormality was lacking. It reveals the

importance of carrying out Karyotype analysis

and subsequent genetic counseling for the

comprehensive management of such conditions.

Scenario 1 : An infertile married couple

is referred. No abnormality found in female

partner. Husband was azoospermic and found


45

to have deletion of Y chromosome (46,XYq-); OR

mosaic of Klinefelter's syndrome (46,XY /

47,XXY) OR some other structural abnormalities

of 'Y' chromosome.

Fig 3 : Karyotype of the child with translocatedDown syndrome: Karyotype: 46,XY,t(14;21)

Scenario 4 : a couple presents with a child

who was born after series of pregnancy losses.

His parents want to rule out any genetic disorder

in child. Karyotype of the child reveals

traslocated type of Down's syndrome.

DISCUSSION :

The case scenarios suggest the modes

of presentation of some genetic disorders. The

existing myths about disease causation can be

removed by proper counseling and the scientific

background of such conditions be explained to

the family members in order to regain the peace

of the family.

In scenario 1, gentleman did not know

that he might have an abnormality till seminal

analysis and karyotype was performed. Mosaics

of Klinefelter's syndrome may not be azoospermic

and some sperms or round spermatids may be

obtained by MESA (micro epididymal sperm

aspiration) or TESA (Testicular sperm extraction)

for invitro fertilization (IVF) such as ICSI (intra

cytoplasmic sperm injection)2. Such persons have

chromosomally imbalanced gametes that may

lead to birth of an abnormal child. It is therefore

most undesirable for such couples to try their

Fig 1 : Karyotype of an azoospermic individual :karyotype 46,XYq-

Scenario 2 : Another infertile married

couple, male partner found normal, female

partner has mosaic pattern of Turner's syndrome

(45,X0 / 46,XX or 47,XXX / 45,X0) OR other

structural abnormalities of an 'X' chromosome.

Scenario 3 : A childless couple with history

of several pregnancy losses (bad obstetric history

'BOH'). Karyotype reveals autosomal structural

abnormality e.g. 46, XY, t(6;13) (p24; q21) in male

OR 46, XX, t(9;15)] in female partner.

Fig 2 : G banded Karyotype of male partner ofa couple with BOH: 46, XY, t(6;13)(p24;q21)


46

Genetic Study - A Helping Hand For Clinical Diagnosis

luck with assisted reproductive techniques

(ARTs), the ideal option is adoption. It is quite

unfortunate on part of lady when we here about

husband's second marriage, separation of the

couple or continued harassment of the lady3 by

family members in such circumstances.

In scenario 2, a lady in whom onset of

menses (menarche) occurs as usual, secondary

sex characters are developed, clinical examination

may not reveal any abnormality but the lady is

infertile due to a constitutional chromosomal

abnormality - 'X' chromosomal abnormality

[structural or numerical] such as mosaic

Turner's syndrome and fragile 'X' syndrome4. 'X'

mosaicisms cause premature ovarian failure

(POF) or polycystic ovary syndrome (PCOS) ren-

dering a lady primarily or secondarily infertile5.

In conditions of reciprocal balanced

autosomal translocations [scenario 3] phenotypic

abnormalities may not be there. However the

particular structural abnormality of autosomes

leads to improper segregation of chromosomes6

during gametogenesis rendering the gametes

chromosomally imbalanced and therefore

pregnancy either does not occur or results in

miscarriage (BOH)7.

The occurrence of abnormal karyotype

as 'translocated Down' in child [scenario 4] was

the result of inheritance of Robertsonian

translocation from one of the parents, which

happens in 3-4% cases of Down's syndrome8. In

such cases usual phenotypic features of Down's

syndrome are lacking so there is no clinical

suspicion. Though such children might lead an

apparently normal life as their parents do, but

their reproductive outcome will be poor. 'Trisomic'

Down's syndrome, which is the usual form of the

syndrome, occurs de novo and is never inherited.

Karyotype analysis is a basic investigative

tool for diagnosis of a genetic disorder. The

drastic features of genetic disorders are hereby

summarised for a proper and ethical approach

towards their management.

Genetic disorders may arise either de

novo or familial, so they are not always predictable;

only by genetic tools they can be identified; they

provide no option for treatment, any attempt of

treatment or further investigation will be

wastage of resources.

Pre marital counseling is must when a

genetic disorder is suspected in families of

marriageable candidates9. If already married,

child should be planned only after proper

genetic counseling. If an expert advice is seeked

when already pregnant, pre natal diagnosis is a

measure to rule out birth of baby with congenital

anomaly10.

On realizing that there is no treatment

option left, people might raise doubts about

feasibility of carrying out a genetic test. It can

clearly be stated that to have a safe future

generation genetic study should be carried out

today.

Acknowledgements : Authors gratefully acknowledge

the technical assistance of MR V P Kavinesan

and Mr. Satish Shingare.

REFERENCES :

1. Verma IC. The challenge of genetic disorders

in India : Molecular genetics and gene therapy.

The New Frontier. In Proceedings of First Annual

Ranbaxy Science Foundations Symposium, New

Delhi 1994: 11-20.

2. Lanfranco F, Kamischke A, Zitzmann M and

Nieschlag E. Klinefelter's syndrome. Lancet 2004;

364: 273-283.


47

Tarnekar AM & et al

3. Phadke SR. and Agarwal SS. Adverse effects of

genetic counseling on women carriers of disease:

The Indian perspective. The National Medical

Journal of India 2001; 14, (1).

4. Pal A K, Waghmare JE, Tarnekar A, Rawlani S

and Ingole I. Genetic aspects of human infertility.

Perspectives in Cytology and Genetics (Eds. Giri

AK, Ghosh PD and Mukherjee A; AICCG

publication) 2007; 13: 106-114

5. Anasti JN. Premature ovarian failure: an update.

Fertility and Sterility 1998; 70: 1-15.

6. Sadler TW. Gametogenesis: conversion of germ

cells into male and female gametes. In Langman's

Medical Embryology (Lippincott Williams and

Wilkins Publ.), 10th Edition : 2008 : 11- 29.

7. Chandley AC, Edmond P, Christie S, Gowans L,

Fletcher J, Frackiewicz A and Newton M.

Cytogenetics and infertility in man. I. Karyotype

and seminal analysis. Results of a five year survey

of men attending a sub fertility clinic. Annals of

Human Genetics 1975; 39: 231-252.

8. Hamerton JL, Cowie VA, Gianneli F, Briggs SM,

Polani PE. Differential transmission of Down's

syndrome (Mongolism) through male and female

translocation carriers. The Lancet 1961 (ii): 956-958

9. Abdel MN, Zaki MS and Hammad SA. Premarital

genetic investigations: effect of genetic counseling.

East Mediterr. Health J. 2000; 6 (94):652-60.

10. Jackson LG. Prenatal genetic counseling. Primary

care Dec 1976; 3(4): 701-16.


48

Genetic Study - A Helping Hand For Clinical Diagnosis

I WANT MY FATHER BACK - CHILD’S DESTINY.

BH TRIPUDE *, PN MURKEY **, VG PAWAR ***, S SHENDE ***, A KECHE ***, KS SINGH ***

ABSTRACT

A 50 years / male, rural farmer in Wardha district, Vidarbha region of Maharashtra,

cultivated cotton on his eight acres (3.2 heactares) of land, and the returns were good until a

couple of years ago. On August 11, 2007, he had consumed some unknown poison in his farm and

admitted in Kasturba Hospital, Sewagram and died during treatment. As the body comes to the

postmortem examination the children’s were crying agonizingly and shouting as “majhe baba mala

parat daya”. On postmortem examination, a visceral examination indicated the presence of a

pesticide. He had apparently taken the step as he is unable to face the local bankers and

moneylenders who had loaned him money. Two successive failed monsoons, coupled with the

non-payment of dues by an apathetic State Government, left him with barely enough to feed his

family and repay a debt of Rs. 50,000. It is a situation that thousands of farmers in the cotton belt

of Maharashtra are familiar with, and increasingly they are reaching for the pesticide can as a way

out of the misery. As this is one of the case filed as farmer suicide from the institute.

Key words - Poison, Pesticide, Cultivation.

Case Report

Introduction -

Rig Veda mentions laws and regulations

regarding poisoning. Poisoning is prevalent in

all over the world since ancient times. Meera was

killed by giving “Charanamrit” by king Rana.

Cleopatra committed suicide by inducing snake

bite by her own. Nepolean Bonaparte of France

was killed by slow arsenic poisoning. Ala-Uddin

Khilagi and General Romel were also killed by

poison. Greece and Rome also practiced medical

laws and ethics regarding poisoning since 600

B.C.

Today the social scenario has changed the

face of poisoning. India being an agricultural

country, uses insecticides very commonly to pro-

tect the crops, fruits and vegetables from insects.

There is no check on the supply, sale and uses of

the insecticides; hence incidence of poisoning

cases is increasing rapidly. Instructions about the

use of the insecticides regarding concentration

and protective measures are not followed by the

users as the instructions written in very small

letters by manufacturers are Toxic substances are

mostly manufactured in developed countries and

banned in their own countries, but they are to

the developing countries.

Case Report :

The following information was brought

from the inquest made by the police, case paper

study and relatives.

A 50 yrs. old male, was brought by police

constable, in the casualty of KHS, Sevgram on

11/08/07 at night, with the history of consumption

of insecticides in his farm as he is unable to face

the local bankers and moneylenders who had

loaned him money.

* Prof. & Head, ** Associate Professor, *** PostGraduate Students, Dept. of Forensic Medicine &Toxicology, MGIMS, Sevagram


49

Then he was referred to medicine ICU

for further treatment but he died during the

treatment. Postmortem was done on 12/08/07.

Postmortem Examination -

General Examination -

The body was averagely built and

nourished, height of 5”6’, was wrapped with

white cotton bed sheet.

On external examination, face was

congested, both eyes were open, pupils were

dilated, lips shows blusih purple colour, tongue

within the oral cavity, no bite marks on tongue,

subconjunctival hemorrhages present in both

eyes, no oozing from mouth, nostrils, ears

neigher any evidence of dribbling of saliva

present. Finger nails were bluish purple in colour.

No injuries to external genitalia seen but evidence

of purging of the stool as well as semen present.

No sign of decomposition seen postmortem

lividity was present and fixed on the back. Rigor

mortis well developed all over the body.

Internal Examiantion -

Head

The scalp was opened, no injuries under

the scalp were seen. The skull and meninges

appeared normal, brain matter edematous and

small petechial hemorrhages seen on cut section

of the brain. No pus or excessive cerebrospinal

fluid was noted, Circle of Willis and other vessels

were normal.

Respiratory system -

1) Walls, ribs, cartilages- No injuries fracture

of the ribs, cartilages, pleura were intact and

adherent to both sides of thoracic cavity.

2) Airway - The larynx appears normal, trachea

and major bronchi contained minute

haemorrhages, mucosa appears slightly

hyperemic.

3) Parenchyma and lungs- both lungs were

congested and collapsed, minute haemorrhages

were present on the surface. On cut section,

both lungs were congested and show minute

pin point petechial haemorrhages severaly

and kerosene like smell present.

Cardiovascular system -

1) Heart- The pericardium was empty and intact.

The heart was normal in size and shape and

weighs about 230 gms. both the chambers

were filled with fluid blood, no evidence of

infarction, no thickening of cusps of valves,

no hypertrophy seen. Coronary arteries were

patent.

2) Arteries - Aorta show mild atherosclerotic

changes.

Alimentary syswtem -

Esophagus was normal, mucosa congested, no ul-

cers seen. All organs in situ. No free fluid in the

peritoneal cavity.

Stomach contaiins greenish colour fluid about

700 cc. with kerosene like smell to the contents.

Mucosa shows multiple haemorrhagic spots.

Food particles like rice and dal were partially

digested.

Liver and gall bladder - was of normal appearance,

on cut section, pale and easily friable and weighted

1350 gms. no gall stones found.

Kidneys - congested, on cut section the right

kidney weight about 120gms. And left kidney

weights about 110gms. Kidneys Cortico medullary

ratio normal.

Urinary bladder - filled with about 20cc urine.


50

I want my Father Back - Child’s Destiny

Pancreas - appears normal and haemorrhages

seen. On cut section, soft in consistency.

Spleen - appears congested on cut section and

weighted 110gms.

Spine and spinal cord - Intact. No fracture of

the spine

As this is a case of poisoning, Blood and

viscera have been preserved and sent to RFSL,

Nagpur for chemical analysis.

Cause of death -

Taking the reference from the case

paper study, from treating doctor’s opinion and

postmortem examination we conclude that cause

of death was insectide poisoning.

Discussion -

Toxicology is a science which deals with

properties action, toxicity, fatal dose, detection,

estimation, treatment of poisons and medico

legal importance of poisons(1).

Poison is derived from the Latin word

pouts which means, poison is a substance which

when introduced in any form by any route in

to the body will produce by its local or and

constitutional effect or both any harmful effect

on the body leading to disease or death(2).

The highest rate of poisoning is in

Srilanka where death due to poisoning which

stands next to total number of death by war due

to LTTE. Unfortunately India is not lagging

much behind. About 50,000 deaths occur in

India due to poisoning every year(3).

Poisoning is the commonest method of

committing suicides in Vidarbha region of

Maharashtra. Organophosphorus, Organochlorus

compounds and zinc Phosphide are commonly

used poisons to commit suicide. Zinc Phosphide

due to its odorless and tasteless character is

commonly used for homicide (4).

People in the rural area are more prone

to poisoning due to occupational hazards, poverty,

illiteracy unemployment and easy availability.

August and November are the months

when suicidal poisoning was common due to

crop failure and repeated sowing process as a

result of scanty or heavy rain in most of the areas.

Hence the debt -ridden farmers, unable

to support their famili4es suffers from mental

stress and develop suicidal tendency very often.

Most commonly used poison is Organophosphorus

compound followed by ethyl alcohol and

combination of insecticides.

Organophosphorus is most commonly

responsible poisoning for accidental and suicidal.

Ethyl alcohol poisoning is mostly accidental

in nature due to its adulteration; it is prohibited

in as Wardha district.

Conclusions and Suggestions -

a. Suicidal and accidental poisoning can be

prevented to some extent by improving

social, economical, educational and moral

status of the people.

b. Prevention is better than cure hence the

farmer should be demonstrated and educated

regarding proper use of protective devices

while spraying insecticides through TV,

media and by the government agencies

working in the villages like gramsevak should

be provided.

c. Marital conflict is the most common cause

of suicidal poisoning so proper marriage

counseling should be provided at all levels

of society.

d. Government must ensure availability of

proper drugs needed for treatment of cases

of poisoning at affordable cost and at village

level dispensaries.


51

Tripude BH & et al

DISLOCATION OF FIRST METATARSAL

PHALANGEAL JOINT : A CASE REPORT

A KUMAR *, C RATHOD **, CM BADOLE ***, KR PATOND ****

Case Report

*Sr. Lecturer, **Registrar, ***Professor, ****Director- Professor and Head. Address for Correspondence -Dr. Ashok Kumar *, Dept. of Ortho. & Traumatology,M.G.I.M.S., Sewagram – 442102, Wardha (M.S.)

Introduction:

A rare injury consisting of an irreducible,

closed dorsal dislocation of the metatarsopha-

langeal joint of the great toe was encountered

in 25 year old man. An open reduction of the

metatarsophalangeal joint dislocation was

performed through midline medial approach

and fixed with K-wire

Case report :

A 25 years old man was involved in a road

traffic accident. He had Gr-IIIB compound

fracture Left Tibia and closed dorsal dislocation

of first metatarsal phalangeal joint on the same

side. He was taken to the operation theatre where

debridement of the wound and external fixator

was applied for fractured Tibia. Attempted

closed reduction of the metatarsophalangeal

joint dislocation was unsuccessful. Hence open

reduction of the metatarsophalangeal joint

dislocation was performed through midline

medial approach and fixed with K-wire. The

Patient postoperative course was uncomplicated.

At four weeks K-wire removed. There was full

range of movement and no evidence of metatar-

sophalangeal joint instability.

Discussion

Dislocations of first metatarsophalangeal

joint are rare and results from high energy

trauma and are frequently associated with

multiple fractures of the lower extremity. Most

dislocations are dorsal through the plantar plate

and seasemoid complex with only occasional

reports of plantar , lateral or medial dislocations.

The mechanism of injury is hyperextension of

the proximal phalange on the first metatarsal

when the toes are forcibly dorsiflexed, results in

the metatarsal head being pushed through the

plantar capsule between the medial and lateral

tendons of the flexors hallucis brevis muscles.

The plantar capsule is disrupted at its proximal

attachment to the metatarsal. The proximal

phalange comes to lie dorsally with the metatarsal

head trapped between the one flexors hallucis

brevis tendon, the abductor hallucis tendon, the

adductor hallucis, and their associated sesamoid

laterally. The metatarsal head is fixed between

the plantar capsule and deep transverse metatarsal

ligaments dorsally and the longitudinal portion

of the plantar Aponeurosis on its plantar surface.

The tendon of the flexor hallucis longus is

displaced laterally to the dislocated metatarsal

head. Thus, the head of the metatarsal is locked

in the dislocated position, rendering closed

reduction impossible.

Jahss classified the First metatarsopha-

langeal dislocation into two types.

Type : I - In which the proximal phalange and

both sesamoids dislocate dorsally without

disruption of the sesamoid complex, are

invariably irreducible by closed manipulation


52

Type : 2 - Dislocation in which the phalange

dislocates dorsally with disruption of the

sesamoid complex,. are usually reducible by

closed manipulation.

There are different approaches for

open reduction of first metatarsophalangeal joint

dislocation like transverse plantar approach,

midline longitudinal approach but we chose the

midline medial approach for open reduction of

the joint.

The advantages of this approach is that

it does not lead to formation of painful scar on

the weight bearing aspect of metatarsal head and

at the same time avoids the damage to the planter

neurovascular bundle.

References :

1. Eric C. YU. Steven R: Closed dorsal dislocation

of the metatarsophalangeal joint. On the great toe.

A surgical approach and case re open reduction

of the metatarsophalangeal joint dislocation

was performed through midline medial approach

and fixed with K-wire port. Clin. Orthop. 185:

237-240,1984.,

2. Jacques AB: Pathomechanics of complex

dislocation of the first metatarsophalangeal

joint. Clin. Orthop. 332:126-131,1996.

3. Peter B, Salamon MD, Richarts HG, James MH:

Dorsal dislocation of the metatarsophalangeal

joint of the great toe. J. bone and joint Surg 56.

No-5: 1073-1075, 1974"

4. Alans G, Lewis. Jesse C, Delee: Type I complex

dislocation of the first metatarsophalangeal

joint- open reduction through dorsal approach

a case report. J. bone and joint Surg 66A No-7:

1120-1123. 1984.

5. Osep E. Armagan , MD, and Michael J. Shereff,

MD : Injuries to the toes and metatarsals. The

Orthopaedic clinics of North America Volume

32 : 7-8 ; Jan 2001.

Pre-operation

Post-operation


53

Kumar A & et al

RENIN BLOCKERS - A NEWER THERAPY IN

REGULATING HYPERTENSION

B TAKSANDE *, S YELWATKAR *, UN JAJOO **

ABSTRACT

Though various drugs starting from beta blockers to the thaizides are used for regulating

hypertension, the ACE inhibitors are the widely used. Newer therapy for the control of hypertension

that is rennin blockers have come into picture. Only one drug of this group has come into the

market. Here is a review of the rennin blocker(aliskiren).

Key words : hypertension, reninblockers, drug.

Drug Update

*Lecturer, **Professor. Address for Corresponence : Dr.Bharti Taksande, Dept. of Medicine, MGIMS,Sevagram, MH. Email : [email protected]

HYPERTENSION

Hypertension clinically is defined as that

level of blood presuure where the institution of

antihypertensive drugs will lower the hypertension

related morbidity and mortality(1).

Blood Pressure Classification

Blood Pressure Classification Systolic, mmHg Diastolic, mmHg

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 hypertension 140-159 or 90-99

Stage 2 hypertension 160 or 100

Isolated systolic hypertension 140 and <90

Hypertension is broadly classified into

2 categories primary(essential) and secondary.

The secondary causes for hypertension are fully

understood. However, those associated with

essential hypertension are far less understood.

What is known is that cardiac output (determined

by stroke volume and heart rate) is raised early in

the disease course, with total peripheral resistance

(determined by functional and anatomic changes

in small arteries and arterioles) is normal; over

time cardiac output drops to normal levels but

TPR is increased.

Three theories have been proposed to

explain this :

Inability of the kidneys to excrete sodium,

resulting in natriuretic factors such as Atrial

Natriuretic Factor being secreted to promote

salt excretion with the side-effect of raising

total peripheral resistance.

An overactive renin / angiotensin system leads

to vasoconstriction and retention of sodium

and water. The increase in blood volume

leads to hypertension.

An overactive sympathetic nervous system,

leading to increased stress responses.


54

Role of Renin

Renin may play a critical role in the

pathogenesis of most hypertension, a view long

espoused by Laragh(2). The renin- angiotensin

system is the most important of the endocrine

systems that affect the control of blood pressure.

Renin is secreted from the juxtaglomerular

apparatus of the kidney in response to :

Glomerular underperfusion

Reduced salt intake.

It is also released in response to stimulation

from the sympathetic nervous system.

Renin is responsible for converting renin

substrate (angiotensinogen) to angiotensin I, a

physiologically inactive substance which is rapidly

converted to angiotensin II in the lungs by an-

giotensin converting enzyme (ACE). Angiotensin

II is a potent vasoconstrictor and thus causes a

rise in blood pressure. In addition it stimulates

the release of aldosterone from the zona

glomerulosa of the adrenal gland, which results

in a further rise in blood pressure related to

sodium and water retention. The circulating

renin-angiotensin system is not thought to be

directly responsible for the rise in blood pressure

in essential hypertension. In particular, many hy-

pertensive patients have low levels of renin and

angiotensin II (especially elderly and black

people), and drugs that block the renin-angiotensin

system are not particularly effective. There is,

however, increasing evidence that there are

important non-circulating "local" renin-angiotensin

epicrine or paracrine systems, which also control

blood pressure. Local renin systems have been

reported in the kidney, the heart, and the arterial

tree. They may have important roles in regulating

regional blood flow.

Action

Renin blockers works by inhibiting a

enzyme called renin which helps in regulating

the blood pressure. Renin is the first step of a

complicated hormone system called the Renin-

Angiotensin-Aldosterone-System (RAAS). By

blocking the action of renin in the RAAS, these

drugs can decrease the production of angiotensin

and aldosterone, which are both potent agents

that raise blood pressure. Tetkurna inhibits the

renin release from the kidney and thereby is

powerful for controlling high blood pressure.

This Renin blockers have similar characteristics

as that of and ACE inhibitors and Angiotensin

receptor blockers(3).

Approved by FDA :

On 9 march 2008 FDA approved a new

drug called Tekturna, for the control of high blood

pressure the mechanism of which was completely

different from the rest of antihypertensives(4).

Indications

At present available to treat only high blood

pressure in combination with other drugs

especially thaizides.(5)

Certain clinical trials are going to find its

use in congestive heart failure and diabetic

neuropathy.

Dose :

The usual daily dose is 150 mg, to be

increased up to 300 mg if necessary

Renin Blockers

Currently, only one renin blocker is

available. The drug Tekturna (generic name

Aliskiren), manufactured by Novartis Pharma-

ceuticals. Three agents are currently in FDA

clinical trials which are thought to be renin

blockers and are to be released on to the market

soon Tekturna is available by prescription

throughout the United States and Canada.


55

Taksande B & et al

Adverse Effects :

Some side effects of renin blockers

include :

Gastrointestinal: Stomach Upset and Diarrhea

Dermatology: Swelling of the Face and/or

Neck

Respiratory system: Cough

Metabolic: Rarely hyperkalemia

The effectiveness of frusemide is reduced

if used in combination with reninblocker(6).

Contraindications :

Pregnant women should not take renin

blockers.

Limitations :

Expensive ,as they do not have any other

generic equivalent

No data on long term effects on end organ

damage and cardiovascular outcomes

References :

1. Chobanian AV et al: The Seventh Report of the

Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High

Blood Pressure : The JNC 7 Report. JAMA 2003;

289:2560.

2. Laragh JH. The renin system and four lines of

hypertension research. Hypertension 1992 ; 20 :

267- 68.

3. Scheen AJ, Piérard L, Krzesinski JM. [Aliskiren

(Rasilez), direct renin inhibitor] Rev Med Liege.

2008 Sep;63(9):564-9.

4. Krop M, Garrelds IM, de Bruin RJ, van Gool JM,

Fisher ND, Hollenberg NK, et al. Aliskiren

accumulates in Renin secretory granules and binds

plasma prorenin. Hypertension 2008;52(6):1076-83.

5. Musini VM, Fortin PM, Bassett K, Wright JM.

Blood pressure lowering efficacy of renin

inhibitors for primary hypertension. Cochrane

Database Syst Rev. 2008 Oct 8;(4):CD007004

6. Vaidyanathan S, Bartlett M, Dieterich HA, Yeh

CM, Antunes A, Howard D, Dole WP. Pharmaco-

kinetic interaction of the direct Renin inhibitor

aliskiren with furosemide and extended-release

isosorbide-5-mononitrate in healthy subjects.

Cardiovasc Ther 2008 ;26(4):238-46.


56

RENIN BLOCKERS - a newer therapy in regulating hypertension

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democrats, have ever found the key to the much

dreamed and promised UTOPIA i.e. happiness

to every living creature and perfect harmony

between man and nature. John glad, an American

Jewish scholar in his recent book proclaims to

find solution to all social, political, cultural,

financial, moral human problems through

genetic engineering. The book is acclaimed

highly by academicians, researchers and readers

alike(downloaded more than1 million times from

the site till date) advocates a eugenic movement

towards creating a new human species Homo

autocatalyticus, and making a highly intelligent,

altruistic, nonpredatory and loving society which

will pursue the goal of intellectual enrichment

and not of materialistic gains. The flip side of

the coin is, to give the new much better man its

deserved place, the present Homo sapiens species

has to accept its selective disappearance from the

planet!

The book is a detailed account of history

and post- World War II Renaissance of eugenic

movement and insists that success of the movement

is the only hope of ever sustainable life on mother

planet. The Eugenics (Greek-eu 'well'+genes 'born')

is a branch of genetics dealing with improvement

of a population by controlled breeding to increase

the occurrence of desirable and inheritable

characteristics. All animal and plant breeders

know its utility very well, while practicing it in

human race suffered a near lethal blow by racial

killings and Nazi holocaust in early part of

twentieth century. Revival of interest in this

direction is evident from the number of books

written on the topic in recent years and worldwide

scientific deliberation going on. Out of total

3200 books listed on 'online computer library

center/OCLC/Worldcat', 473 are published

within last five years apart from innumerable

online discussions.

Author makes it clear in the beginning

itself that it is not the therapeutic eugenics he

is proposing, for eugenics to prevent genetic

diseases by pre- and post marital counseling,

antenatal diagnosis and selective abortion of

affected fetus is already more or less accepted by

most of us except few religious groups. It is the

new socio-political aspect of reproductive eugenic

movement which has been pondered over in the

book. Molecular biologists as prophets of this

new religion of genetics have following basic

concepts -

1. In the role of a species on earth, we behaved

in utter indisciplined way, in fact just like a

malignant disease - freeing ourselves from

regulatory constraints of natural selection

and limitations of natural resources. Our

invasive development started to wreak havoc

not only on our fellow species and on the


57

host we parasitize- the planet but now also

endangering our own survival.

2. Evolutionary selection process which created

the human species on earth is almost stopped

by development of civilization, science in

general and Medicine in particular. Almost

everyone who is born, however genetically

weak he/she is, lives full life today thanks to

power of medical sciences. As a result, natural

selection by differential mortality is replaced

largely by differential fertility patterns of

communities.

3. Moreover fertility is decreasing fast in high

IQ individuals and groups (procreation is not

their ambition) while it is still high in low IQ

groups, world wide. This dysgenic phenomenon

is leading to deterioration of quality of human

life as a race. Not only we stopped evolution

on earth, we are going backwards in

evolutionary chain. This can be evidenced by

less and less numbers of masterminds and

geniuses with every passing generation.

4. Different ethnic populations on the earth are

not one Homo sapiens, the myth purposefully

woven by egalitarians, but are different species

with separate gene map of their own and so

their IQ, abilities and capabilities

5. Almost all physical, mental, behavioral, moral

and social characteristics are determined by

genes and are inheritable. 'Nurture' has trivial

role in defining the personality, unlike the

popular thinking. The author is troubled that

we continue to apply moral criteria of behavior

in spite of knowing that we are about to

decipher behavioral patterns scientifically,

after mapping of human genome.

6. Humanity is defined not as only the currently

living population, but as the total number of

people who will potentially ever live on earth.

Since the unborn constitute a vastly greater

potential population than do currently

living, their rights prevail (though in present

political - social sphere future generations

represent a zero political constituency).

Emboldened by recent mapping of human

genome, new breakthroughs in biotechnology,

animal cloning and stem cell research, Glad with

other proponents of eugenics predicts that areas

of health and behavior up till viewed through a

moral prism are going to be explained by genes

in a few years time. "The genie of enlightenment

can not be squeezed back into the bottle of

ignorance" whoever tries to do it now. They propose

that we should start working for artificial selection

of fertility by joining hands with genetics to make

human race evolving further and this time also

to save ecology of the mother planet. "Eugenics

views itself as the fourth leg of the chair of

civilization, the other three being a thrifty

expenditure of natural resources, mitigation of

environmental pollution and maintenance of a

human population not exceeding the planet's

carrying capacity." Eugenicists believe that "while

our social conduct, like that of all other animal

species, is necessarily centered around the mating

ritual, our perception of this process is governed

by a myriad of camouflaging taboos and fetishes.

The gap between reality and fantasy could not

be more crass." The goals advised by the author

for twenty first century are

A. to reduce fertility of low IQ groups from

each ethnic community by

1. curbing their reproductive rights, along with

criminals, insane, feebleminded and paupers

2. removal of or severe constraints on help

provided to welfare mothers


58

Utopia is now promised by science! Book - Future Human Evolution : Eugenics in twenty first century

3. not to discourage female feticide in countries

with increasing population and thus

reducing number of reproducing females

B. to increase high IQ groups fertility in each

ethnic community by

1. reducing the age of first pregnancy in the

females of these groups so they can bear more

children

2. polygynae /artificial insemination to make

best use of high quality sperms

3. asexual procreation by low IQ females using

high quality ova and sperms fertilized in vitro

4. asexual cloning of high IQ individuals

It is evident that the first and foremost

prerequisite to achieve these goals is to release

sex from its procreative duty and also from

number of myths encasing it. The speed at which

we are depleting the natural resources for our

mainly dysgenic and huge species, makes it very

clear that sooner or later we are bound to agree

to above proposals or accept our inevitable

extinction from the face of the earth.

But are we ready to consider the eugenic

movement our saviour? It is hard to accept the

following notions in the first place that :

1. Different ethnic communities are separate

species. Few like Jews are genetically privi-

leged than others. Moreover gene mapping

can answer all our questions regarding

biodiversity in human race.

2. IQ can be the sole criteria to decide the

worth, progeny and fate of an individual on

the earth.

3. Not only physical but behavioral and social

negative traits as violent behavior, criminal

attitudes, cruelty, consumerism, addictions,

even marriage and divorce are not correctable

as determined by nature and not nurture.

4. Success stories of breeding of health animals/

plants which did not take any socio-politico-

cultural issues in to consideration, suffice to

proceed for human breeding program

5. We have to surrender our beliefs in all other

socio-political movements if want to achieve

equality.

6. The basis of morals, emotions and relationships

can be entirely different in next era.

Even if we try to believe that the goal of

an advanced human species working in harmony

with nature is achievable through eugenics,

innumerable questions still remain -

1. Advantages of eugenic practices will take at

least ten generations to surface if we start

action from the current reproducing popu-

lation (which is impossible as we just started

to explore genome, to use it we have to go a

long way) but abuse of eugenics is already very

well known to us in form of racial hatred,

Nazi holocaust and forced sterilizations. We

have to be absolutely ruthless and honest just

as nature, if we play god. Our history doesn't

assure us regarding this quality in us. How can

we trust the purity of intentions of eugenicists

and the politicians guiding them, this time?

2. Even if we trust them, who will decide which

characteristic is desirable up to what extent?

The world is not black and white; it has

innumerable shades of grey in between which

are angelic but intolerable to others.

3. According to Glad we must be dispassionate

(towards loss of reproductive freedom to

current population, morals) when talking

of scholarly discussion over eugenics! Perhaps

he forgot that being passionate must also

be a genetically determined trait in us which

can not be changed.


59

John Glad

4. In an all highly intelligent society who will

do the manual labor, need for which will

always be there? It means the future

generations will have lord-slave system

again or else, have to live with robots.

5. If low IQ persons are more involved in crime

then what do we label all white collar scams

and scandals? Perhaps eugenics does not

count them in criminal activities.

6. Can we afford the total collapse of judiciary

in an already threatened world? The new

system would not lay responsibility on the

individuals for their own criminal acts and

crimes will no more be punishable. Concept

of Marriage will be irrelevant; and so also

the concept of adultery and incest as children

of same biological parents (who will be very

few selected individuals) but different legal

parents may make couples. Though all these

complications may look unreal or perverse in

present socio-cultural setting, this in fact is

the future being written for us by eugenic

movement

7. It is the fact that people prefer their own

biological children at any cost. Reproductive

rights of a couple will no more be a personal

property in the new regime. Author himself

expressed fear of inability to pass this hurdle.

Moreover the love and natural bond formed

between a biological child and parents is

necessary for psychosocial development of

the child. Perhaps emotional security is also

considered here inherited! Which government

will risk its viability by this intrusion into

personal sphere when the promise of every

government is to give as much as freedom is

possible to its citizens?

8. Will concern over issues of reducing male :

female ratio and woman's rights to career and

development be absurd forever? The high IQ

females will be forced to enter the reproductive

pool at early age and thus the personal

freedom partially obtained just in last

century through a long feminist movement

to will be snatched away again.

9. Even if we are different genetically, we are

extremely intimately related species and if

reproductive rights of one community are

favored over other owing to genetic superiority,

will it not reflect into even more intense

intergroup conflicts than today?

Eugenics is proposing that there will be

no more stories of miracle from dust to sky; no

more families; no more interethnic marriages.

Or it is just another type of 'fantasies plucked

from the air' as J Bauer, a Viennese physician once

said about Nazi concept of race. Some of these

questions are addressed by Glad in the book very

intelligently but without satisfactory answers. A

book for rights of future generations and for that

of the earth is indeed a holy mission but as he

indicates, both of these clients have no say in the

matter and present population have to be forced

only, to act in such direction questioning its

feasibility.

If still you are ready to buy the idea, you

are welcome to dream once again of the Eugenic

Utopia.

By

DR. ANUPAMA GProfessor Dept., of PathologyMGIMS, Sevagram


60

Utopia is now promised by science! Book - Future Human Evolution : Eugenics in twenty first century

DR MICHAEL ELLIS DEBAKEY

(Sept’ 1908-July 2008)

Obituary

“Dr Debakey, a pioneering surgeon whose

carrier spanned 70 years, was one of the creator of

cardiovascular surgery. His death has brought to

an end almost a century of tireless work for

improvement of surgical treatment of major

cardiovascular disorders.” writes The Iris Medical

Times.

Dr Michael Debakey was born on 7th Sept

1908 at Lake Charles, Louisiana to Lebanese

immigrant parents. Interestingly, his father had a

Farmacy and his mother taught him to sew and knit

which resulted in his joining the medical school

and developing the surgical skills. He completed

his medical degree from Tulane University in

New Orleans. Later he continued his studies at the

University of Strassbourg in France and University

of Heidelberg in Germany.

In that era “there was virtually nothing you

could do to a patient of heart disease, If a patient

came with heart attack it was up to God” so said

Dr Debakey. He developed a roller pump which

subsequently became an important component of

heart-lung machine necessary today for any open-

heart surgery. The development of bypass surgery

for coronary heart disease made a medical history.

In 1953 for the first time he used a dacron graft for

blood vessel replacement allowing the repair of

Aortic Aneurysm. He with Dr Denton Cooley was

the first to introduced cardiac transplant in USA in

1968, after the very first transplant carried out by

Dr Christian bernard in South Africaq in 1967.

He developed the artifical heart for the patients

waiting for cardiac transplant. His innovations have

helped developing several newer surgical instru-

ments and surgical techniques Hundreds of heart

surgeons trained by him are working around the

world. He was totally dedicated to his work and his

patients without any

discrimication. He has been

tirelessly working almost 12

hours a day, performed

1000 operations per year

totalling about 60000. He continued to operate

till the age of 90 years. He remained active and

have been moving for delivering lectures and

attending conferences. He has over 1300 published

medical articles besides several chapters, and

books on surgery and medicine “The living heart”

is one of his best sellar publication.

He worked in army during second world

war initially as captain. Later he was made director

of surgical consultants division at Office of the

Surgeon General in Europe. His innovative mind

helped here also in developing ‘Mobile Surgical

Hospital. He has been medical advisor to five

presidents of United States of America. This

political support resulted in creation of Medicare

Health Insurance Scheme. In such a long carrier

he received innumerable awards. The few prominent

ones are President Medal for Freedom (1969 given

by President Lyndon Johnson), National Medal for

Science (1987, given by President Ronal Regan) and

the latest Cogressional Gold Medal (2008, given by

President George W Bush).

In leisure time he liked shooting and fishing.

He was Episcopalian by faith. In 2006 he had

himself undergone an aortic surgery. He passed

away at the age of 99 year on 11th July 2008. He has

improved the human conditions and touched the

life of generations to come. The medical world will

always remain indebted to him.

(Sources- Net reports of Irish medical times, the telegraph

and Houston Chronicle)

J MGIMS, March 2009, Vol 14, No (i), 61

61

THE NOBEL PRIZE IN PHYSIOLOGY OR MEDICINE 1909

EMIL THEODOR KOCHER

(August 25, 1841 - July 27, 1917)

Emil Theodor Kocher was a Swissphysician, medical researcher, and Nobel laureatefor his work in the physiology, pathology andsurgery of the thyroid.

Theodor Kocher was born on August 25,1841, at Berne Switzerland. His father, was a Chief-Engineer. He studied in Zurich, Berlin, London andVienna, and obtained his medical doctorate in Bernein 1865. His teachers of surgery were Demme, Lucke,Billroth, and Langenbeck. In 1872, he succeededGeorg Albert Lucke as Ordinary Professor ofSurgery and Director of the University SurgicalClinic at the Inselspital in Berne.

In 1883 Kocher announced his discoveryof a cretinoid pattern in patients after total excisionof the thyroid gland, when a portion of the glandwas left intact, however, there were only transitorysigns of the pathological pattern.

When Kocher began his surgical activitiesthe transition from the septic to the antiseptictreatment of wounds, works on the antiseptictreatment of wounds with weak chlorine solutions,Kocher was one of the first to go over to pureasepsis processes he sought to advance.

He published works on a number ofsubjects other than the thyroid gland includinghemostasis, antiseptic treatments, surgical infectiousdiseases, on gunshot wounds, acute osteomyelitis,the theory of strangulated hernia, and abdominalsurgery. His new ideas on the thyroid gland wereinitially controversial but his successful treatmentof goiter with a steadily decreasing mortality ratesoon won him recognition and the Nobel prize. Theprize money he received, he donated to his Universitythe sum of 200,000 Swiss francs which helped himto establish the ‘Kocher Institute’ in Berne.

His Chirugische Operationslehre (Theoryon surgical operations) reached six editionsand was translated into most modern languages. Itdescribed many operations, mostly in abdominalsurgery and the surgery of joints. His book

Erkrankungen derSchilddruse ( Diseasesof the thyroid gland )discussed the etiology,symptology and treatmentof goitres.

Kocher was an honorary member ofnumerous academies and medical scoeities, e.g. theGerman Surgical Society. An Honorary Fellow ofthe Royal College of Surgeons; Honorary Member ofthe Royal Society of Sciences, Uppasala; HonoraryMember of the American Surgical Society; theNew York Academy of Medicine & the College ofPhysicians, Philadelphia; the Imperial MilitaryMedical Academy, the Royal Medical Society ofVienna; Royal Medico-Surgical Society, London;He was a Corresponding member of the SurgicalSociety of Paris, Brussels : Belgiam Academy ofMedicine; the German Society of Neurologists andof the Hufeland Society of Berlin; Honorary M.D.of the Free University of Brussels.

In 1902 he was President of the GermanSociety of Surgeons in Berlin and President of theFirst International Surgical Congress, 1905, in Brussels.

A number of instruments and surgicaltechniques (for example, the Kocher manoeuvre)are named after him, as well as the Kocher-Debre-Semelaigne syndrome, Kocher zonde Spoon-shapedprobe for goitre operations, Kocher’s arced incisionOblique incision for opening the knee joint.,Kocher’s incision II Tranverse incision over glandulathyreoidea in the neck for thyroidectomies, Kocher’ssign Eyelid phenomenon in hyperthyreosis andBasedow’s disease, Kocher’s syndrome Splenomegalywith or without lymphocytosis and lymphadenopathyin thyrotoxicosis etc.

Kocher married Marie Witchi (1851-1921).They had three sons, the eldest of whom, Albert(1872-1941) became Assistant Professor of Surgeryand gave his father considerable help in his work.Theodor Kocher died at Berne on July 27, 1917.


62Source - Noble prize.org

THE LIBERATION

Poem

Representative of the summit of creation,

The man,

Utopia remains his dreams, his imagination

Possessing consciousness, the supramental ability,

Prays and crave for immortality !!

About to slip in another world

Away from the wearying regimen of __

Pokes, prods, and pinches__

Endured since diagnosed as Acute leukemia

Curly haired

Cherub faced, reserved

Prone to one word answer

Behind his shy exterior

Lurked a creative spirit

Endowed with the capacity to endure

In the material universe, ever unsure

Eventide follow even the brightest day

Like the epilogue of life’s romance in a way

Plunging in to gloomy incertitude

‘Death’! No terror but the life’s prelude

Inevitably inseparable, intertwined

An evolutionary march for the new one, it reminds

No thanatophobia,

But a feeling of liberation from bondages

Carried on through the ages

Dr OP GUPTA


63

A N A T O M Y

1. EFFECT OF CELLPHONE ON DEVELOPING

LENS OF CHICK EMBRYO. IV Ingole, JE Waghmare,

P Bokariya, BR Sonatakke, Tapti Das. 56 NATCON of

ASI, BHU Varanasi, Dec 27-29, 2008.

Magnitude of the problem of exposure to

Cellphone radiation is self evident from a vast number of

mobile phone users where the whole atmosphere gets

charged with the radiation acting as an environmental

pollutant. The radiation emitted by the Cellphone has been

incriminated to adversely affect the biological tissues. The

embryonic tissues are the most sensitive as the processes of

division and differentiation of the cells are crucial to its

development and are most sensitive to any type of insult at

this stage. Various effects on the developing visual system

have been reported as a result of exposure to cellphone

radiation case of congenital cataract have been frequently

reported as a result of prenatal exposure to certain teratogens.

None theless the reports of the adverse effects of radiation

emitted by cellphone on the developing lens have been

contradictory. The present study is aimed at investigating

direct effect if any on the developing lens. Fertile hen eggs

were incubated in 2 batches. Each batch comprised 18 eggs.

Out of 18 eggs, 9 eggs were incubated in a standard egg

incubator without giving any exposure to radiation and

treated as control. Remaining 9 eggs were incubated in a

special incubator exposing them to radiation from

cellphone. Total exposure of 4 hours duration was given to

the experimental group of both the batches. One batch was

sacrificed at the completion of 4 days and the other at the

completion of 6 days. Embryos were procesed for histological

examination. 5 micron thick sections were cut and stained

with H & E. The lens epithelial cells from experimental

groups showed increased number of mitotic figures in the

form of metaphase and anaphase as compared to that of

controls. This points towards increased proliferation of

cells which may be compensatory phenomenon in response

to increased destruction of cells.

2. NEED OF GENETIC COUNSELING IN

INFERTILE COUPLES. DOES A GENDER BIAS

EXIST?. AM Tarnekar, JE Waghmare, IV Ingole &

AK Pal. 56th NATCON of ASI, BHU Varanasi, Dec

27-29, 2008.

It is a social stigma to be carrier of a disorder and

infertility is a lifelong suffering. It is a globally accepted

fact that both the partners be investigated simultaneously if

a couple is infertile. In India, especially, it is seen that women

have to undergo traumatic experiences of investigations

first. Unfortunately medical men too sometimes neglect

this issue and do not ask for examination of male subjects

simultaneously. Genetic counseling is essential at the very

beginning of the management of infertility. Karyotype

analysis is the most basic of the genetic tests and is usually

employed as a screening test in infertility. The best policy

from our point of view is to have a pre marital counseling

done by a geneticist. Or else prenatal diagnosis be done if

a couple wishes to got for assisted methods of reproduction.

Measures can also be taken to identify genetic abnormality

in the foetus in order to prevent the birth of an abnormal

child if clinically suspected. When it is evident that a couple

can not conceive the best way out is to adopt a child.

On interrogation with the infertile subjects

referred for Karyotype analysis, some facts revealed pointing

to a possible gender bias in management of infertile couples.

Some scenario that we have identified as the most common

prevaling situations in India, causing unnecessary delay in

investigations, wastage of money & manpower and ultimately

some untoward consequences to the extent of separation of

couple or remarriage, will be presented.

3. NEED OF MORE CAPABLE TECHNICIANS TO

SUIT THE ANATOMY DEPARTMENT. Pradeep

Bokariya, Ruchi Kotheri, S Rawlani, AM Tarnekar, S

Kakde, IV Ingole. 56th NATCON of ASI, BHU

Varanasi, Dec 27-29, 2008.

Most of the diploma courses after XII (like DMLT,

BMLT) make a candidate suitable for working in Pathology

labs but not in Anatomy Dept. These courses do not provide

the candidates with the appropriate knowledge of embalming,

museum up keeping, organ identification. Most of them

are unaware with basic know how of Anatomy.

Considering paucity of suitable candidates for

Anatomy Department, there should be a provision of

Diploma course in Anatomy after XII.

Some recommendations for the same are as follows -

1) Such a course should be conducted in a Medical College.

2) It can be for duration of 9-12 months.

3) Evaluation at the end of term should be more practical

based.

4) The course can be named as “DALT - Diploma in

Anatomy lab Technology”


64

ABSTRACTS OF THE PAPERS PRESENTED IN THE NATIONAL ANDINTERNATIONAL CONFERENCES HELD DURING THE YEAR 2008

Few bottlenecks are also there in implementing

such a course but they can be overlooked considering the

benefit of the department of Anatomy.

4. DERMATOGLYPHIC STUDY OF

SCHIZOPHRENIC PATIENTS - A CASE

CONTROL STUDY. BR Sontakke, IV Ingole, PB

Behere, SS Rawlani, AM Tarnekar, JE Waghmare.

56th NATCON of ASI, BHU Varanasi, Dec 27-29, 2008.

Dermatoglyphics is a scientific study of epidermal

ridges and their configuration on volar aspect of hands,

fingers, feet and toes. Eighty (80) clinically diagnosed

patients of schizophrenia (48 males & 32 females) were

selected from out patient department of Psychiatry and

compared them with 76 (44 males and 32 females) healthy

controls. Palm and finger prints were taken by ink method.

Both qualitative and quantitative analysis of finger tip,

palmar pattern and atd angle was done. We found statistically

significant increased total whorl composite, total arches

and tur palmar pattern at hypothenar area in male

schizophrenics as compared to male controls.

5. A HISTOLOGICAL STUDY OF THE EFFECT

OF MONOSODIUM GLUTAMATE IN LIVER OF

ALBINO MICE. T Das Bhattacharjee, AM Tarnekar,

IV Ingole. 56th NATCON of ASI, BHU Varanasi,

Dec 27-29, 2008.

Monosodium glutamate popularly known as

Azinomoto is used as flavouring agent in Chinese cuisines.

It is responsible for creating the fifth basic type of taste

sensation ‘Umami taste’ in brain. Receptors for Umami

taste sensation are found in Chorda tympani as well as

Glossopharyngeal nerve. It is powerful neurotransmitter -

both excitatory and inhibitory. MSG is reported to cause

damage in brain and reduced reproductive function in

adults. Present study was carried out with 25 albino mice

after exposing the animals to MSG (2mg/g body weight

subcutaneous injection) in neonatal period. Total 5 injections

were given at the interval of 48 hours starting 48 hours

after birth. Animals were sacrificed 75 days after birth and

liver was isolated and processed for histological study.

Histological findings were compared with same number

of control animals. The findings will be discussed.

6. VARIANT ARTERIAL PATTERN IN UPPER

LIMB WITH PERSISTANT MEDIAN ARTERY. AD

Kannamwar, AM Tarnekar, SJ Kakde, T Das, P

Bokariya, IV Ingole. 56th NATCON of ASI, BHU

Varanasi, Dec 27-29, 2008.

During the routine dissection of the right and left

upper limbs of a middle aged male cadaver, we encountered

mixed vascular pattern. We observed variant arterial

pattern in arm, forearm and hand which was present

bilaterally but not exactly similar.Most striking feature

was persistence of median artery which had significant

contribution in formation of superficial palmar arch

bilaterally. Details of this case along with its embryological

basis and clinical significance will be presented in conference.

POSTER PRESENTATIONS :

1. ANTHROPOMETRIC STUDY OF FEMUR IN

CENTRAL INDIAN POPULATION. Pradeep

Bokariya, S Rawlani, JE Waghmare, A Kannamwar,


Dec 27-29.

Anthropometric provides scientific method and

technique for taking various measurements in different

geographic regions and races. The femur itself is a complex

anatomic unit so anthropometric study was devised on the

same. In the present study 106 (58 right and 48 left) intact

adult femora were obtained from the bone bank of Anatomy

department of MGIMS, Sevagram. For this purpose a sliding

caliper, osteometric board, tapeline and gonometer were

used.

The study was aimed at determining measurements

for obtaining platymeric index, robusticity index and

foraminal index for both right and left femur. The details

of data obtained with relevant review of literature will be

discussed.

2. EVALUATION OF SAFETY OF ASPARTAME

AS A FOOD ADDITIVE BY EXPERIMENTATION

OF NEONATAL SWISS - ALBINO MICE. SJ Kakde,

AM Tarnekr, A Kannamwar, SS Rawlani and IV Ingole.

56th NATCON of ASI, BHU Varanasi, Dec 27-29, 2008.

Aspartame is used in many baby products like baby

food, vitamin solutions etc. Present study was conducted

in Department of Anatomy at MGIMS, Sevagram with 30

control and 30 experimental neonatal Swiss-albino mice.

Aspartame was injected intra peritoneally at a strength of

100 microgm per gm body wt into experimental mice at an

interval of 48 hours for 6 doses starting from 72 hours of

life. Control group received same amount of normal saline

with same dose schedule. Animals were kept in cages and

were fed with standard rat feed free from aspartame with


65

cool drinking water ad libitum under ideal conditions. Body

weights were taken at birth and at 28th day of life. Body weights

were reduced in exposed group compared to controls.

Significant number of exposed animal had seizures during

experiment and subsequently death in few. Mortality rate

was significantly high in experimental group as compared

to control group. Details with be presented.

3. BILATERAL ABSENCE OF EXTENSOR

INDICIS MUSCLE - A CASE REPORT. SJ Kakde,

AM Tarnekar, A Kannamwar, JE Waghmare, P Bokariya,


Dec 27-29, 2008.

During routine dissection in a middle aged male

cadaver we found absence of Extensor indicis muscle

bilaterally. There was no scar mark or external deformity

over forearm. Literature suggests it as a rare variation in

the form of congenital absence of extensors of forearm.

It is reported to be associated with polyneuropathy.

Reconstructive interventions of hand require knowledge

of such variations. Details of this case with its ontogeny

and clinical significance will be presented.


66

COMMUNITY MEDICINE

PAPER PRESENTED IN XVII WORLD CONGRESS

OF EPIDEMIOLOGY AT PORTO ALEGRE, RS Brazil :

20-24 September 2008

1. PERCEPTIONS AND HEALTH CARE SEEKING

ABOUT NEWBORN DANGER SIGNS AMONG

MOTHERS OF RURAL WARDHA. Dongre AR,

Deshmukh PR, Garg BS.

Abstract : Objectives : The objectives of the present study

were to know mothers' knowledge and explore their

perceptions about newborn danger signs and health care

seeking behaviors.

Material and Methods : In December 2003, a cross-sectional

study was undertaken in three of the 27 Primary Health

Centres of Wardha district; namely Anji, Gaul and Talegaon

with a population of 88187. Out of 1322 such mothers, 1160

mothers in the area were interviewed by house-to-house

visits. Data was entered and analyzed in SPSS 12.0.1. In

order to explore mothers' perception of danger signs and

actions taken, a triangulation of formative research methods

like chapatti diagram and Focus Group Discussion (FGD)

was undertaken. The analysis of free list and pile sort

data obtained was undertaken using Anthropac 4.98.1/X

software.

Results : About 67.2 % mothers knew at least one newborn

danger sign. Majority of mothers (87.4%) responded that

the sick child should be immediately taken to the doctor

but only 41.8% of such sick newborns got treatment either

from government hospital (21.8%) or from private hospital

(20%) and 46.1% of sick babies received no treatment. The

reasons for not taking actions even in presence of danger

signs/symptoms were ignorance of parents, lack of money,

faith in supernatural causes, non availability of transport,

home remedy, non availability of doctor and responsible

person not at home. For almost all the danger signs/

symptoms supernatural causes were suspected and remedy

was sought from traditional faith healer (vaidu) followed

by doctor of Primary Health Centre and private doctor.

Conclusions : The present study found gap between mothers'

knowledge and their health seeking behavior for sick newborn

and explored their deep perceptions, constraints and

various traditional treatments. Comprehensive intervention

strategies are required to change behaviour of caregivers

along with improvement in capacity of Government health

care services and National Health Programs to ensure

newborn survival in rural area.

2. EFFECT OF USE OF SOCIALLY MARKETED

FAUCET FITTED EARTHEN VESSEL / SODIUM

HYPOCHLORITE SOLUTION ON DIARRHEA

PREVENTION AT HOUSEHOLD LEVEL IN

RURAL INDIA. Dongre AR, Deshmukh PR, Garg BS.

Abstract : Objective : To evaluate the effect of socially

marketed faucet fitted to earthen vessel/sodium hypochlorite

solution on diarrhea prevention at rural household level

as a social intervention for diarrhea prevention under

'Community Led Initiatives for Child Survival (CLICS)

program.

Methods : Unmatched case-control study was carried out in

10 villages of Primary Health Centre, Anji, located in rural

central India. During the study period, 144 households used

either faucet fitted earthen vessel to store drinking water

or used sodium hypochlorite solution (SH) for keeping

drinking water safe. These served as case households for

the present study. 213 neighborhood control households

from same locality who used neither of the methods were

also selected.

Results : Odds ratio for households who used faucets fitted

to earthen vessel was 0.49 (95% CI= 0.25 - 0.95). Odds ratio

for households who used sodium hypochlorite solution

was 0.55 (95% CI= 0.31 - 0.98). Use of these methods by

the community, would prevent about 27 percent and 22

percent cases of the diarrhea (Population attributable risk

proportion = 0.25 by faucets fitted to earthen vessels and

0.22 by use of sodium hypochlorite solution) respectively.

Conclusion : To ensure safe drinking water at household

level, the effective and cheap methods like fitting faucet

to traditionally used earthen vessel and/or use of sodium

hypochlorite solution must be promoted through

community participation at household level for cost and

culture sensitive rural people in India.

PAPER PRESENTED IN INTERNATIONAL

CONFERENCE OF THE NETWORK - TOWARDS

UNITY FOR HEALTH AT BAGOTA: 27th September 2008

- 2nd October 2008

1. FORMATIVE EXPLORATION OF STUDENTS'

PERCEPTION ABOUT COMMUNITY MEDICINE

TEACHING AT MAHATMA GANDHI INSTITUTE

OF MEDICAL SCIENCES, SEWAGRAM, INDIA.

Garg BS, Dongre AR, Deshmukh PR.

Abstract: Objective : The objectives of the present formative

research were to explore medical undergraduates' study

problems and their perceived effective teaching approaches

in currently practiced teaching framework of Community

Medicine.

Methods : The present formative research was undertaken

at Dr. Sushila Nayar School of Public Health incorporating

Department of Community Medicine, MGIMS, Sewagram.

The respondents were 17 (26.5%) conveniently selected

final year exam appearing medical undergraduates from

2004 regular batch of 64 students. A triangulation of

qualitative research methods like structured free listing

and pile sort exercise and semi structured Focus Group

Discussion (FGD) were used. A two dimensional scaling

and hierarchical clustering analysis was completed with the

pile sort data. The data was analyzed by using software

Anthropac.

Results : The medical undergraduates could understand

the subject matter and learn skilled based topics like

IMNCI, PHC, Cold chain system, Immunization and Health

education, Dietary survey and Survey methods in community

based camp approaches. Students found it difficult to

comprehend the core of subject from scattered lecture

series over long time especially using lengthy OHP/LCD

presentations. The major problems encountered in studying

Community Medicine were difficulty in understanding con-

cepts of Biostatistics, confusions due to apparently similar

text in National Health Programs, concepts of Epidemiology,

difficult to recall subject, understanding Health planning

and Management and problems due to vast syllabus.

Conclusions : Students perceived community based camp

approach of teaching as a best method to understand the

subject, which is an integration of task oriented assignments,

integration of social sciences within medical domain and

active community involvement. The community based

camp approach can be scaled up as a best Community

Medicine teaching approach. Lectures and Clinics need

to be more interactive and problem based.

2. AN APPROACH TO MONITOR AND INITIATE

COMMUNITY LED ACTIONS FOR ANTENATAL

CARE IN RURAL INDIA - A PILOT STUDY. Garg

BS, Dongre AR, Deshmukh PR.

Abstract : Background & Objective : Utilization of antenatal

care in rural India is far from universal. It requires monitoring

and identification of specific needs at field levels for timely

corrective actions. To pilot test the triangulation of rapid

quantitative (Lot Quality Assurance Sampling) and qualitative

(Focus Group Discussion) monitoring tools for timely and

locally relevant information for decision making and

facilitating participatory community actions for ensuring

antenatal care in a community based program.

Methods : The present study was undertaken in surrounding

23 villages of Kasturba Rural Health Training Centre

(KRHTC), Anji, which is also a field practice area of

Mahatma Gandhi Institute of Medical Science (MGIMS),

Sewagram. The monthly monitoring and action system of

the study was based on the rapid quantitative monitoring

tool (Lot Quality Assurance Sampling, LQAS) to find out

poor performing supervision areas and overall antenatal

service coverage and the qualitative methods (Focus group

discussions (FGDs), and free listing) for exploring ongoing

operational constraints in the processes for timely decision

making at program and community level. A trained

program supervisor paid house visit to 95 randomly

selected pregnant women from 5 supervision areas by

using pre-designed and pre-tested questionnaire. For

poor performing indicators, semi structured FGDs and

free listing exercise were undertaken to identify unmet

service needs and reasons for its poor performance.

Results : Over three months period, the overall antenatal

registration improved from 253 (67%) to 327 (86.7%). The

proportion of pregnant mothers reporting farm work as

their current occupation, declined from 41.1% to 31.6%.


67

Registration of pregnancy within 12 weeks improved from

24.2% to 29.5%. The consumption of 100 IFA tablets

during pregnancy also improved from 6.9% to 16.4%. There

was significant improvement in awareness regarding

pregnancy danger signs and symptoms.

Interpretation & Conclusion : To summarize, the present

field based monitoring and action approach constructively

identified the reasons for failures and directed specific

collective actions to achieve targets.

PAPER PRESENTED IN 9TH SOUTH EAST ASIA

REGIONAL SCIENTIFIC MEETING OF

INTERNATIONAL EPIDEMIOLOGICAL

ASSOCIATION AT DHAKA : 9-12 February 2008

1. CORRELATES OF OVERWEIGHT/OBESITY

AMONG SCHOOL GOING CHILDREN OF

WARDHA CITY. Bharati DR, Deshmukh PR, Garg BS.

Abstract: Background & objectives : Overweight and obesity

are important determinants of health leading to adverse

metabolic changes and increases risk of non-communicable

diseases. Following the increase in adult obesity, the

proportion of children and adolescents who are overweight

and obese has also been increasing. To halt the epidemic,

it is important to understand the epidemiology. Hence,

the present study was undertaken to study the magnitude

of overweight/obesity and its correlates among school

going children of Wardha city in central India.

Methods : The cross-sectional study was carried out in all

the 31 middle-schools (5th to 7th standard) and high-schools

(8th to 10th standard) of Wardha city. Probability proportionate

to size of population technique (PPS) was used to decide

the number of children to be studied from each school,

each class and then each section of the class. Systematic

random sampling technique was used to select the children

from each section. Pre-designed and pre-tested questionnaire

was used to elicit the information on family characteristics

and individual characteristics. Height and weight was

measured and BMI was calculated. Overweight and obesity

was assessed by BMI for age using CDC 2000 reference.

Student who had BMI for age =85th and < 95th percentile

of reference population were classified as overweight and

BMI for age = 95th percentile of reference population were

classified as obese. Data was analyzed by using epi_info

2002 v 3.3 and SPSS 12.0.1.

Results : In the present study, overweight and obesity was

found to be 3.1% (95% CI: 2.5%-3.8%) and 1.2% (95% CI:

0.8%-1.8%) respectively; together constitute 4.3% (95% CI:

3.6%-5.2%) for overweight/obesity. Final model of the

multivariate logistic regression showed that the important

correlated of overweight/obesity were urban residence, joint

family, father and/or mother involved in service/business,

English medium school and child playing outdoor games

for less than 30 minutes.

Interpretation & conclusion : The magnitude of overweight/

obesity among school going children of Wardha city was

found to be 4.3%. Family characteristics play important role

in predisposing the children to overweight/obesity and

hence the interventions need to be directed towards the

families.

2. THE EFFECT OF COMMUNITY BASED

HEALTH EDUCATION INTERVENTION ON

MANAGEMENT OF MENSTRUAL HYGIENE

AMONG RURAL INDIAN ADOLESCENT GIRLS.

Dongre AR, Deshmukh PR, Garg BS

Abstract : Objective : To study the effect of a community-based

health education intervention on awareness and behavior

change of rural adolescent girls regarding their management

of menstrual hygiene.

Material & Methods : A participatory-action study was

undertaken in Primary Health Centres in 23 villages in

Anji in Wardha district of Maharashtra state. Study

subjects were unmarried rural adolescent girls (12-19years).

We conducted a needs assessment for health messages with

this target audience, using a triangulated research design

of quantitative (survey) and qualitative (Focus Group

Discussion) methods. Program for Appropriate Technology

for Health (PATH) guidelines were used to develop a

pre-tested, hand made flip book containing need based

key messages about the management of menstrual

hygiene.The messages were delivered at monthly meetings

of village based groups of adolescent girls, called Kishori

Panchayat.After three years, the effect of messages was

assessed using a combination of quantitative (survey) and

qualitative(Trend Analysis) methods.

Results : After three years, significantly more adolescent

girls (55%) were aware of menstruation before its initiation

compared with base line(33%).The practice of using

readymade pads increased significantly from 5% to 25%

and re-use of cloth declined from 85% to57%. The trend

analysis showed that adolescent girls perceived a positive

change in their behavior and level of awareness.

Conclusion : The present community health education

intervention strategy could bring significant changes in the

awareness and behavior of rural adolescent girls regarding

management of their menstrual hygiene.


68

PAPER PRESENTED IN 26 TH ANNUAL

CONFERENCE INDIAN SOCIETY FOR MEDICAL

STATISTICS AT NAINITAL : 7-9 Nov. 2008.

1. NEONATAL MORTALITY DIFFERENTIALS

IN RURAL AREAS IN CENTRAL INDIA,

DISTRICT WARDHA MAHARASHTRA. Bharambe

MS, Gupta SS, Deshmukh PR, Garg BS.

Abstract : Neonatal mortality is a very important component

of the Infant mortality, which contributes almost 50% of

the total infant mortality. The neonatal mortality is mostly

affected by endogenous causes and partly by the antenatal

care and the availability of obstetrics and neonatal care

services. These determinants of neonatal mortality are

largely depends upon national health policy and the

availability and utilization of the health care services. In

the present paper and attempt has been made to compare

the neonatal mortality as is achieved by the use of usual

health services and a specific model claimed to reduce

the neonatal mortality by around 25%.

The material used for the study has been taken

from the data about neonatal mortality collected from the

PHCs and the two large research projects supported by

USAID and Government of India in rural areas of districts

Wardha and Yeotmal of the Vidharbha region of

Maharashtra State. The study is based on 6207 neonates;

comprised of 3143 subjects from Government of India (ICMR)

project claiming 25% improvement in the neonatal mortality

and 3064 neonates from the CLICS study, the study period

is from July 2006 to June 2008, and the data has been

collected on the parameters of the child, mother, socio-

economic variables and the health services parted in the

two schemes. The neonates delivered outside the study

area have been excluded from the analysis.

The factor analysis has been done to study the

multi-collinearity in the maternal parameters viz. age,

parity, weight, education, caste/religion etc. Two principal

components comprising of i) age, parity and weight, and ii)

education, caste/religion etc. have been extracted, contributing

more than 70% of the variation of these variables.

The very young and mothers of age 30+ years,

and the primi-mothers and of parity more than 4 along

with no education were associated with the higher neonatal

mortality. The neonatal mortality decreased with increasing

baby weight, however, showing a reverse trend after the

birth weight more than 4 kg.

PAPER PRESENTED IN 52 ND NATIONAL

CONFERENCE OF INDIAN PUBLIC HEALTH

ASSOCIATION AT MAMC, New Delhi : 7-9 March 2008

1. EPIDEMIOLOGICAL CORRELATES OF

NUTRITIONAL ANEMIA AMONG CHILDREN

(6-36 MONTHS) IN RURAL WARDHA. Sinha N,


Abstract : Background and objectives : Nutritional anemia

is associated with impaired performance on a range of

mental and physical functions in children along with

increased morbidity. Iron supplementation at a later age

may not reverse the adverse effects. National Nutritional

Anemia Control Program was launched in India in 1970

failed to make any impact. The present study was undertaken

to find out prevalence of anemia and its correlates in rural

Wardha in children 6-35 months.

Methods : 772 children between 6-35 months were studied

for anemia by cluster sampling method. The hemoglobin

was estimated in the child by "Filter Paper Cyanmethemo-

globin method". Pre-designed and pre-tested questionnaire

was used to collect data on socio-demographic and other

variables. Data was analyzed by SPSS 12.0.1.

Results : Mean hemoglobin level was 98.5±12.9 gm/L.

Prevalence of anemia was 80.3%. Only 1.3% children had

severe anemia (hemoglobin < 70 gm/L). The univariate

analysis showed that anemia is significantly associated with

age of the child, education of mother and father, occupation

of father, socio-economic status, birth order and nutritional

status as measured by weight for age. The final model

suggested that only educational status of the mother,

occupation of the father, birth order and nutritional status

of the child were significantly associated with anemia.

Interpretation & conclusion : For short term impact,

appropriate nutritional interventions remain the only

operational intervention as only the nutritional status

(weight for age) is modifiable factor. But for long term

sustained impact, policy makers need to focus on improving

maternal education and reducing family size.

2. NUTRITIONAL STATUS AND AGE AT

MENARCHE IN ADOLESCENT GIRLS IN AN

URBAN SCHOOL OF WARDHA. D.G. Dambhare,

M.S. Bharambe, S.S. Gupta, B.S. Garg.

Research Question : What is the relationship between age at

menarche and nutritional status? Objectives : 1. To access

the nutritional status of adolescent girls. 2. To determine

the association between age at menarche and nutritional

status. Study Design : Cross sectional study. Setting : Kamla

Nehru School, Wardha. Participants : All 360 female students

in the age group 10-19 years studying in high school.


69

Results : The mean age was 13.76 years (SD. 2.35). The mean

age at menarche in those who had attained menarche was

15.45 years (SD. 1.75). Menarche was attained by 51.94% of

the adolescents. A statistically significant relation between

menarcheal age and socioeconomic class is found

(P<0.0001). The overall level of malnutrition was very high

84.44%. However, in 10-14 years age group malnutrition

was significantly high 70.06% compared to 29.83% in 15-19

years age group (p <0.001). Among the adolescent of age

group 10-14 years, 28.94% attained menarche compared

to 95.2% adolescent of 15-19 years age (p <0.001). The

difference between the mean BMI of those girls who had

attained menarche 17.15 compared to those who had not

attained menarche 14.83 was statistically significant (p<

0.001). Conclusion : In this study, the adolescents from the

upper social class were attained menarche earlier than

those whose belong to lower social class. The rate of under

nutrition amongst adolescent girls was very high 84.44%.

The nutritional status was associated with age at menarche.

The higher the nutritional status, the lower is the age at

menarche.

3. MORBIDITY STATUS OF UNDER THREE

CHILDREN IN RURAL WARDHA. Thaware Preeti,


Background and Objective : Pre-school children, especially

under three children constitute the most vulnerable segment

of any community. Their morbidity status is a sensitive

indicator of community health.. Hence the present study

was undertaken with the following objective:

Objective : To assess the morbidity status of under three

children in villages under field practice area of Department

of Community-Medicine, M.G.I.M.S, Sewagram.

Materials & Methods : A cross-sectional study was conducted

in 3 PHC areas of Wardha District; namely Anji, Talegaon

and Gaul. 30-cluster sampling technique was used for

selection of study subjects. 33 respondents from each

cluster [11 from each of (0-11) months, (12-23) months, and

(24-35)month's age group] were selected for study purpose.

Thus, total 990 children were studied. Basic information

was collected by using a pre-designed and pre-tested

questionnaire. Data was entered and analyzed by using

epi_info 6.0

Results : In the study area; more then 50% children are in

the morbid condition. There is no difference in the morbid

status among male and female children in under three

children. According to the socioeconomic condition, the

children from low socioeconomic status are more morbid

then the children in high or middle socioeconomic status

family. There is considerable less morbidity in the children

in open group. Whereas almost no variation in morbidity

status in the children of other cast.i.e they are more morbid.

More morbidity is present in under weight and anemic

children (56%,54% respectively).The children with muac of

12.5 are more more morbid (55%) as compare to other

group The children with the parents of higher education

are less morbid.

Conclusion and Recommendation : Widespread prevalence

of morbidity among under three children and highlight a

need for a integrated approach towards improving the

child health by increasing the education,socio-economic

status of parents, at the same time nutritional status of

the children in this area.

4. ROLE OF VILLAGE COORDINATION

COMMITTEE (VCC) IN DECENTRALIZED

HEALTH CARE. Datta SS, Garg BS.

Research Question : To assess the effectiveness of Village

Coordination Committee (VCC) in decentralized health

care delivery in rural area. Objectives: 1. To develop and

test Institutional Maturity Index (IMI) for the VCC. 2. To

assess the effectiveness of VCC with emphasis on various

dimensions of health interventions. Study Design: Process

documentation vis. a vis. quasi experimental study. Setting:

Villages of three PHC areas: Anji, Gaul and Talegaon in

Wardha district of Maharashtra state. Participants: 64 VCCs

formed in these villages of atleast one year old. Results:

The IMI for the VCC was developed in a participatory man-

ner including various activities of VCC specially those

which are vital for sustainability. The IMI already devel-

oped by Aga Khan Rural Support Program (AKRSP) at

Gujarat was utilized as reference. Gradation of all VCCs

has been done using the IMI scoring mechanism and each

VCC promises of heading towards ownership of village

level activities. All VCC have village health plan in place

and majority has prepared their sustainability plan. The

average IMI score of the VCCs is 58 out of 100. Once any

VCC achieves score of 80 out of 100 and reaches a five star

VCC status, will also achieve ownership of health activities

at village level. Conclusions: The VCC has synergy with

'Village Health and Sanitation Committee' in NRHM and

the experience gained in the process will have long term

repercussion in the implementation of NRHM and at the

same time can guide into assessing maturity of these

committees in near future.


70

PAPER PRESENTED IN 35TH ANNUAL NATIONAL

CONFERENCE OF INDIAN ASSOCIATION OF

PREVENTIVE & SOCIAL MEDICINE AT JIPMER,

Puducherry : 23-25 January 2008

1. STUDY OF CHEST SYMPTOMATICS AT A

TEACHING RURAL HOSPITAL. Nimbarte SB,

Mehendale AM*, Garg BS.

Abstract : Introduction : Pulmonary Tuberculosis contributes

to around 85% of total TB cases and these cases serve as

main reservoir of infection. So it is important to reduce the

transmission by diagnosing them and putting them on

treatment as early as possible. The present study was

planned in general out-patient department of Kasturba

Hospital, Sewagram with the following objective.

Objective : To study the sputum positivity of chest symptom-

atic with cough for diagnosis of pulmonary tuberculosis

Methodology : Cross-sectional study was carried out among

chest symptomatic who presented at General Hospital

out-patient department of Kasturba Hospital, Sewagram

with productive cough based on history. Three sputum

samples were collected from each of them and subjected

to sputum microscopy. Data thus collected was entered

and analyzed by EPI.Info.6 program me.

Results : Out of the 845 chest symptomatic, 104 had sputum

positive results with sputum positivity 12.3%. Sputum

positivity among females was more than males in the age

group 15-19 years. Sputum positivity was higher among

patients with chest pain and haemoptysis than those

without these symptoms.

Conclusion : The detection of smear- positive TB cases can

be substantially improved by actively eliciting history of

cough from all out-patients with related symptoms.

2. HOUSEHOLD & COMMUNITY IMNCI

THROUGH VILLAGE HEALTH WORKER.

Sanam Anwar, Garg BS

Abstract : Background : One of the MDG goal is reducing

child mortality by two third by 2015. In view of emphasis

on newborn illness and health, the child survival interventions

under CLICS Program are delivered using the Household/

Community IMNCI framework.

Objectives : To develop skills of Village Health Workers to

identify illnesses among children & communication skills

for guidance and counseling.

Materials and Methods : The study was conducted in 67

villages of 3 PHC areas of rural Wardha. 8 days skill

based IMNCI training through case demonstration in

hospital & community visits, Lecture and Group Discussion,

Video Demonstration, Role plays and case studies.

Results : 88 VHW trained on IMNCI. 16 key family

practices for child health and nutrition targeted.

Implementation of Community Pharmacy using Essential

Drugs managed by VHW.

Conclusion : VHW act as effective tools for Household &

Community IMNCI.

3. A COMPARISON OF HIV/AIDS AWARENESS

BETWEEN SELF HELP GROUP LEADERS

AND OTHER WOMEN IN THE VILLAGES OF

PRIMARY HEALTH CENTRE, ANJI. Dongre AR,

Deshmukh PR, Garg BS, Boratne AV. Department of

Community Medicine, Mahatma Gandhi Institute of

Medical Sciences, Sewagram, Wardha (MS)

Abstract : Objective : To compare the level of awareness

about HIV/AIDS between women's self-help group leaders

and other women in the villages of primary health centre

area, Anji, Wardha District, Maharashtra.

Material & Methods : A cross sectional study was undertaken

in the month of May 2004 to compare the level of awareness

regarding HIV/AIDS between two group comprised of two

leaders (president and secretary) from each of 41 women's

SHGs promoted by Kasturba Rural Health Training Centre,

Anji in the area of PHC, Anji & second group comprised of

98 randomly selected women other than the leaders of

women's SHGs from the same villages. The women were

interviewed on per-designed and pre-tested questionnaire

by house to house visit. The data was analyzed by using the

software package epi_info 6.0.

Results : The level of awareness regarding the modes of

transmission of HIV/AIDS was higher among the leaders

of women's SHGs as compared with the other women. The

difference was statistically significant (p<0.05). Most of the

leaders of women's SHGs knew even at least one preventive

measure. 16% of women other than the leaders did not

know even a single preventive measure. The difference was

statistically significant (p<0.05). Most of the leaders of

women's SHGs had heard about HIV/AIDS. Majority (70%)

of them received information from television and most of

them (76%) had discussed about HIV/ AIDS with someone.

However 17 % of women other than leaders of women's

SHGs received information from health worker and only

24 % of them discussed about HIV/AIDS with someone.

(Table 1)


71

Conclusion : The leaders of women's SHGs can act as potential

resource persons for the delivery of the health education

about HIV/ AIDS to other women in the villages.

4. BEST PRACTICES IN INVOKING COMMUNITY

PARTICIPATION: LESSONS FROM CLICS

PROGRAM. Chetna Maliye, BS Garg.

Background : Community participation, a movement in the

public health field that respects the rights and responsibility

of community members to actively engage in designing,

implementing and evaluating strategies to address their

health problems.

The key strategy of CLICS (Community led

initiatives for Child Survival) is to build the capacity of the

target communities to develop, manage and ultimately

achieve 'ownership' of village based child survival and

health services.

Objectives : To study the best practices of community

participation in villages of rural Wardha.

Material and Methods : Study was conducted in 67 villages

of rural Wardha. The Village Coordination Committee

was trained in PLA techniques, planning, supervision,

monitoring and evaluation of community based activities.

Monthly one day training was conducted.

Results : Empower community to identify problems and

take decisions. Delegate responsibilities to make everyone

participate. Let community mobilize its own resources;

it gives them ownership. Train them in participatory

monitoring and self- evaluation.

Conclusion : Community organization is a prerequisite

for making community participate actively.

5. COST BENEFIT ANALYSIS OF "KIRAN

CLINICS" UNDER CLICS PROGRAM IN

RURAL WARDHA. Thaware Preeti, Deshmukh PR,

Garg BS.

Background and Objective : With increasing level of costs,

the health benefits are not increasing up to the mark.

Government of India spends 0.9 % total GDP on health, but

the result remain the same. For the best use of the scared

resources, analysis and accurate information is necessary,

to make health service efficient and effective, by using

alternate method of the health financing.

Objective : To find out cost recovery of Kiran clinics & to

study the expenditure pattern of Kiran clinics.

Methodology : Kiran clinics have been established so far

in 18 villages under CLICS program "Community Led

Initiatives for Child Survival (CLICS)" support from


72

Department of Community Medicine, MGIMS, and

Sewagram. Costing was for fixed assets at set up and

subsequently, training the manpower, personnel, drugs and

surgical, administration, Supplies, cost recovery it was from

user fees and drug sold. Information on monthly amount

was collected from the records.

Results : During the analysis period, total of 591 clinics

were held and the average attendance of patients was 21.3

per clinic. Out of this, 41.6% cost was incurred on personnel,

30.4% on administration, which mainly includes transport,

and 25.3% on drugs and surgicals. Average cost incurred

per patient served was Rs. 45.50. The variation in personnel

cost ranged from 29.4%-52.7%. Similarly, cost on transport

(administration) ranged from 15.5% -48.6%. Overall, the

cost recovery was 37.9%.

Conclusion and Recommendation : For more cost recovery,

sector-wise strategy needs to be evolved to cut down the

manpower cost and the transport cost. On the other hand,

user fees may be increased gradually in consultation with

Village Coordination Committee considering the above

cost distribution.

6. TO ASSESS THE EFFECTIVENESS OF VILLAGE

COORDINATION COMMITTEE (VCC) IN

DECENTRALIZED HEALTH CARE DELIVERY

IN RURAL AREA. Datta Shib Sekhar, Garg BS.

Background : Village Coordination Committees (VCCs)

are being promoted under the Community Led Initiatives

for Child Survival program (CLICS) at MGIMS, Sewagram.

The ultimate aim of the program is to achieve 'Community

Ownership', a stage where the VCC is able to independently

manage key health activities and sustain health gains at

village level.

Objectives : To develop and test Institutional Maturity

Index (IMI) for the VCC.

Materials and Methods : The present study was undertaken

in 64 VCCs from three PHC areas namely Anji, Gaul and

Talegaon in Wardha district of Maharashtra state. The IMI

for the VCC was developed in a participatory manner including

various activities of VCC specially those activities which

are vital for sustaining the VCC. The IMI already developed

by the Aga Khan Rural Support Program (AKRSP) at

Gujarat was utilized as reference.

Results : Gradation of all the VCCs has been done using the

IMI scoring mechanism and each VCC promises of heading

towards the ownership stage. The average IMI score of the

VCCs in the program area is 58 out of 100. Once any VCC

achieves a score of 80 out of 100 and reaches a five star

FORENSIC MEDICINE & TOXICOLOGY

A) PAPERS PRESENTED IN XXIX ANNUAL

CONFERENCE OF INDIAN ACADEMY OF

FORENSIC MEDICINE, HELD ON 23RD TO 25TH

FEBRUARY 2008 AT MUMBAI.

1) EARLY CHEMICAL ANALYSIS OF POISONING

CASES ADMITTED TO THE HOSPITAL FOR

TREATMENT AND IMPORTANCE OF CLINICAL

TOXICOLOGY IN MEDICAL COLLEGE. AN

ASSET TO CLINICIAN, INVESTIGATING

AUTHORITY AND JUDICIARY. Presenting Author -

Dr.Bipinchandra Tirpude

Study was conducted at Mahatma Gandhi Institute

of Medical Sciences, Sewagram, Wardha in the year 2002

to 2006 in the department of Forensic Medicine and

Toxicology where clinical toxicology laboratory is available.

During this period, 1223 cases of poisoning were analyzed

by in Clinical Toxicology Laboratory. Out of this,1188 cases

were admitted with history of poisoning for treatment

and 35 cases were brought dead as medico-legal case for

postmortem examination. Present study was undertaken

with the purpose of determining how the toxicology

laboratory was contributing in clinical work, medico legal

work and research work. The toxicology laboratory has

provided a reliable data bank of poisoning cases, which can

be utilized for various purposes like diagnosing the cases

of poisoning, where the analysis report can be conveyed

within time to clinician so that they can start proper

treatment and fixing charges against the accused by

investigating authority and submit the case, for further

disposal to the judiciary. Judiciary is again known for

taking long time for giving final verdict in such cases, so

overall purpose is to help the clinician for proper diagnosis

and trement, investigating authority y visiting scene of

crime and judiciary for disposing the cases.


73

VCC status, it will be offered with the prize to sign the

ownership agreement of the program and interventions

related to program activities. The IMI is so far proving to

be acting as lever to motivate the VCC to strive forward in

order to achieve sufficient maturity to be the owner of the

program.

Conclusions : The program has synergy with NRHM and

the experience gained in the program will have long term

repercussion in the implementation of NRHM and at the

same time can guide into assessing maturity of 'Village

Health and Sanitation Committee' in near future.

2) EUTHANASIA. Presenting Author : Dr.P.N.Murkey

The term euthanasia, also known as mercy killing,

was derived from the Greek words "eu" and "thanatos"which

means "good death". It literally means putting a person to

painless death especially in cases of incurable suffering or

when life haws become purposeless as a result of mental or

physical handicap. It is deliberately bringing about a gentle

and easy death making the last few days of the patient as

comfortable as possible. This is to be ensure a calm and

peaceful death, within the context of relieving incurable

suffering in terminal illness or disability. Euthanasia is

voluntary, when requested by the sufferer, involuntary or

compulsory if it is against the will of the patient, passive

when the death is hastened by deliberate withdrawal of

effective therapy of nourishment. Various ethical contra-

dictions exist regarding its practice in different religions

and in different societies. Laws around the world also

vary greatly with regard to its practice, and are constantly

subject to change as cultural values shift and better

palliative care, or treatments become available. It is legal

in some country and criminalized in others.

3) QUALITY OF POSTMORTEM EXAMINATION

IN INDIA. Presenting Author :-Dr.Indrajit Khandekar

In India any registered Medical practitioner

irrespective of his/her training or experience is allowed to

conduct medico-legal postmortems. The question that needs

answer is, on what basis government is allowing untrained

doctors to conduct medicolegal postmortem eaminations.

As per MCI norms any student after passing Final MBBS

examination and completion of one year rotatory internship

is allowed to do general practice. However, in the most of

universities there is no compulsory internship in the subject

of Forensic Medicine. WHO has said that in many countries,

where the allocation of scarce resouserces is at theissue,

it should be realized that it is unreasonable to expect

reliable & valid result from autopsies conducted by

medical practitioner without the benefit of further

substantial supervised post graduate training & experience

in pathology in general, forensic pathology in particular.

4) MODIFICATION OF FORMAT OF POSTMORTEM

REPORT: REQUIRED OR NOT ? Presenting Author

:- Dr.Indrajit Khandekar

Presently in Maharashtra we use a printed proforma

for writing postmortem report, as per the Govt of

Maharashtra, Bombay letter No.FRM/1462/19357, dated

4-7-62. Like government of Maharashtra various states

that this case may contribute to the establishment of actual

incidence of the above said condition.

8) SUICIDES IN THE ELDERLY AGE GROUP

IN WARDHA DISTRICT OF MAHARASHTRA

IN A FIVE YEARS PERIOD, FROM1ST

JANUARY 2001 TO 31ST DECEMBER 2005.

Presenting Author - Dr.P.N. Murkey

Ageing is a natural phenomenon which is inevitable

to everyone. For most old people, their life is a time of

fulfillment and satisfaction with life's accomplishment. For

some older adults, however, later life is a time of physical

pain, psychological distress & dissatisfaction with present.

Suicide is one of the possible outcomes. The present study

was conducted in Mahatma Gandhi institute of Medical

Sciences from 1st January 2001 to 31st December 2005 which

is one of the pioneer rural based hospitals in the country

B) PAPERS PRESENTED IN XVI ANNUAL STATE

CONFERENCE OF KARNATAKA MEDICOLEGAL

SOCIETY. 23RD & 24TH AUGUST 2008

1) UNDETERMINED DISEASE CAN CAUSE

MYSTERY-A CASE REPORT. Presenting Author -

Dr.A.S. Keche

2) "CHIELOSCOPY" EVERYTHING IN NATURE

IS UNIQUE. Presenting Author: - Dr.V.G.Pawar

3) "CONTRIBUTORY NEGLIGENCE" A CASE

REPORT. Presenting Author- Dr.V.G.Pawar

4) SUICIDAL HANGING IN RURAL HOSPITAL

AROUND WARDHA. Presenting Author :-

Dr.V.G.Pawar

5) HISTOPATHOLOGY REVEALS - HIDDEN

DISEASE. Presenting Author- Dr.A.S. Keche

6) CONCEPT OF MOMENT OF DEATH. Presenting

Author -Dr.K Suken Singh

7) AN UNUSUAL WAY OF ASSAULT?. Presenting

Author - Dr.S.T.Bhowate

8) IMPORTANCE OF FORENSIC MEDICINE

EXPERT IN DEALING WITH MEDICOLEGAL

CASES. Presenting Author - Dr.Aloke Mazumder

9) PRESENT: DOCTOR PATIENT RELATIONSHIP.

Presenting Author - Dr.Aloke Mazumder


74

have their own format of postmortem report. This paper

is presented by keeping in mind that there should be

uniform guidelines at national level regarding format of

post mortem report.

5) NARCOANALYSIS. Presenting Author :- Dr. K.

Suken Singh

Criminal investigation is one of the most challenging

issues of the present era with the number of crimes increasing

day by day, and to know weather a person who is being

investigated on is speaking truth or not is most crucial

areas of the criminal investigation. Forensic scientist have

kept on developing newer techniques to fulfill this goals.

The present article discuses the pros & cons of Narcoanalysis

& their validity in the court of law as per the law of the

country.

6) PARENTAL NEGLIGENCE - A CASE REPORT.

Presenting Author-Dr.Atul Keche

A 5 years old male child was brought to the

Kasturba Hospital, Sewagram with the history ingestion

of poison on 19/12/05 along with bottle containing some

poison which he was ingested. On asking relatives, it was

revealed that the child was operated for inguinal hernias

on 13/12/05 & was given regular medicine in the form of

syrupOn19/12/05 at around 11 AM, his grandmother gave

medicine to him but the child said that syrup was given

in less quantity and demanded for more but grandmother

denied & kept the bottle on sajja.Unfortunately on same

sajja by the side of medicine bottle another bottle containing

poison was already present wrapped in piece of paper.

After grandmother left the room that child stood on the

stool & tried to get the bottle but rather than taking

bottle of medicine he had taken bottle containing poison

& ingested it & died on 21 December 2005.

7) PENTALOGY OF FALLOT WITH

NEUROFIBROMA OF HEART: AN AUTOPSY

CASE AND REVIEW OF THE LITERATURE.

Presenting Author:-Dr.Sumeet Shende.

The teratology of Fallot is a congenital heart

defect which classically has four anatomical components. It

is most common cyanotic heart defect and a most common

cause of blue baby syndrome. The four characteristics of

Fallot's teratology syndrome, plus a patent foramen ovale

or atrial septal defect is known as pentalogy of Fallot. It

occurs rarely. we are reporting this case which is relatively

rare condition found on forensic autopsy, and considering

C) PAPER PRESENTED IN FIFTH ANNUAL

CONFERENCE OF SOUTH INDIA

MEDICOLEGAL ASSOCIATION FROM 31ST

OCTOBER TO 2ND NOVEMBER 2008

1) CAUSE OF DEATH AND ITS RELATION

WITH TOTAL BODY SURFACE AREA (TBSA) IN

CASES OF BURNS. Presenting Author- Dr.P.R.Zopate

626 autopsies were performed in Kasturba Hospital

Sevagram during the period 1st July 2005 to 31st July 2007.

Out of these 626 cases 343(54.79) cases died because of

burn injuries. The study cohort was comprised of 68.80%

females and 31.19% males. The mortality in cases of burn is

directly related to TBSA.

MEDICINE

1. GERICON - 2008 - TO STUDY OF PREVALENCE

OF SLEEP APNEA IN ELDERLY PATIENTS

WITH CHRONIC OBSTRUCTIVE AIRWAY

DISEASE. AP JAIN***, A BHATT**, N PATIL*.

Introduction : Patients with chronic obstructive airway

diseases [COAD] are noted to have a high prevalence of

sleep disordered breathing including not only obstructive

sleep apnea syndrome but also episodes of hypoventilation

associated with oxygen desaturation. Pulse oximetry has

been proposed as useful diagnostic and screening tool for

obstructive sleep apnea syndrome. We investigated the

patients with chronic obstructive airway disease developing

sleep apnea syndrome and utility of pulse oximetry as a

screening tool for sleep apnea syndrome in a COAD patient.

Methods : The study was conducted in Kasturba Hospital

and Mahatma Gandhi Institute of Medical Sciences,

Sewagram. COAD was confirmed on basis of history, clinical

examination and pulmonary function tests. The total

number of patients that were taken for the study was 124

out which 62 patients had COAD and rest 62 were controls.

A detailed clinical history was obtained regarding age,

chronicity of symptoms, cough, sputum production, wheezing,

dyspnoea, smoking and number of admissions for acute

exacerbations. Assessment of severity was based on clinical

examination, chest radiograph and mainly spirometry

measurement of FEV1 [ forced expiratory volume in 1

second] and ratio of FEV1/FVC [forced vital capacity].

These patients were subjected to Epworth sleepiness scale

[ESS]. Pulse oximetry probe was attached to finger of the

patient and recording of Trans cutaneous SaO2 was


75

done manually during the night. These patients were

prospectively evaluated for episodes of oxygen desaturation,

apnea, hyperpnoea and arousals by overnight pulse

oximetry. The study was done to predict the prevalence

of sleep apnea syndrome in COAD patients.

Results : Prevalence of sleep apnea syndrome in COAD pa-

tients was 5% by pulse oximetry, 4% by Apnea Hyperpnoea

index - AHI [>10/hour] and 8% by Epworth sleepiness scale

[ESS]. We found that oxygen desaturation of >4% by pulse

oximetry is a cost effective screening tool for detection of

sleep apnea syndrome. Screening oximetry is most successful

in detecting patients with a high likelihood of having sleep

apnea syndrome, those with more severe disease and ESS

score>10. Excessive daytime sleepiness was found to have

56% sensitivity and 66% specificity for diagnosis of sleep

apnea syndrome. For pulse oximetry [O2 desaturation >4%],

there was 82% sensitivity and 69% specificity for diagnosis

of sleep apnea syndrome. Apnea Hyperpnoea index [AHI]

was 94% sensitive and 70% specific for diagnosis of sleep

apnea syndrome while ESS>10 was 96% sensitive and 82%

specific.

Conclusion : To conclude, the present study observes the

prevalence rate of 5% of sleep apnea syndrome in COAD

patients by overnight pulse oximetry. Oxygen desaturation

of >4% by pulse oximetry is a cost effective screening tool

for detection of sleep apnea syndrome. Screening oximetry

is most successful in detecting patients with a high

likelihood of having sleep apnea syndrome, those with

more severe disease and ESS score >10.

2. TITLE : THE DIAGNOSTIC SENSITIVITY

OF F-WAVE LATENCY IN DIABETIC

POLYNEUROPATHY. BHARTI TAKSANDE, AP

Jain, UN Jajoo (IMACON-DUBAI; OCT 2008).

Background & Aim : Diabetic patients have a 12 times higher

risk of amputations when compared with non-diabetic

subjects, due to diabetic neuropathy. Diabetic polyneuropathy

is characterized by a combined axonal loss and demyelinating

sensorimotor peripheral neuropathy. NCV- primarily CV

are considered one of the most sensitive indices of the

severity of neuropathy. To investigate this condition, NCV

with the determination of latency and velocity, are

commonly used as they are considered to be the most

sensitive, reliable, nonnoninvasive, and objective means.

Materials and Methods : This was a prospective study of 30

subjects of Type 2 DM admitted in medicine ward during

a period of 6 months. All patients underwent a detailed

neurological examination Nerve Conduction Velocity (NCV)

measurements were made using the standard RMS EMG

EP machine. Nerve conduction studies of the bilateral

median, ulnar, tibial and peronial nerves are performed.

DML, CMAP Amplitude, FWL were recorded. In total 240

motor nerves of 30 diabetic patient (60 limbs) were studied.

Statistical analysis was performed using SPSS, version 10

Results : The 30 diagnosed patients of type 2 DM were

taken. The minimum F wave latency had a larger Z score

than the MCV of the median, ulnar, peroneal or tibial nerves

and was larger than z score for the amplitude of the CMAP

in all the four motor nerve (Table 1). There was a significant

correlation between the minimum F wave latency and

MCV in all the four motor nerve. The bivariate correlation

coefficients were y = -0.41(p<0.05), y = -0.757 (p<0.05), y = -

0.759 (p<0.05) and y = - 0.74 (p<0.05), for the median, ulnar,

peroneal and tibial nerve, respectively.

Conclusion : Abnormal NCV is a common finding in NDD

subjects. Although F-response latency was considered a

sensitive indicator of peripheral neuropathy, amplitude and

duration in ulnar nerve F response were the other sensitive

parameters of the detection of mild diabetic neuropathy

in type 1 diabetes.

3. PULMONARY HYPERTENSION IN

HEMODIALYSIS PATIENTS – SEWAGRAM

STUDY. Sunil Kumar, AP Jain.

About half the death in dialysis patients is due

to cardiovascular disease, one of them is pulmonary

hypertension which usually develops secondary to

pulmonary artery calcification. Prevalence of pulmonary

hypertension ranges from 30-40 % as detected by Doppler

echocardiography in patient on chronic hemodialysis.

The aim of this study was to evaluate the prevalence

of primary pulmonary hypertension(PHT) among

hemodialysis patients and search for possible etiologic

factors. We studied 92 patients who were on long term

regular hemodialysis therapy by AV fistula 2 times per week

in Kasturba hospital of MGIMS, SEWAGRAM from

October 2007 to may 2008. The prevalence of PHT was

prospectively estimated by Doppler echocardiogram in 92

hemodialysis patients on the day post dialysis. PHT (> 35

mm Hg) was found in 32 (34.8%) patients with a mean

systolic pulmonary artery pressure of 39.6 ± 13.3 mmHg.

The hemoglobin and albumin levels were significantly

lower in the PHT subgroup (10.5 ± 1.86 vs 7.8 ± 1.97 g/dL

and 3.75 ± 0.44 vs 2.38 ± 0.32 g/dL, p = 0.01 and 0.02,

respectively). Our study demonstrates a surprisingly high

prevalence of PHT among patients receiving long-term

hemodialysis. Early detection is important in order to avoid

the serious consequences of the disease.

MICROBIOLOGY

1. MYCOTIC KERATITIS DUE TO

NODULISPORIUM GRISEOBRUNNEUM :

FIRST CASE REPORT : DK MENDIRATTA. DC

Thamke, P Narang : (Microcon-2008) 32nd National

Conference of Indian Association of Medical

Microbiologists. AFMC, Pune, 21st - 25th Oct. 2008.

Nodulisporium sp. occurs worldwide in nature often

as accompanying conidial anamorphs to wood decaying

fungi of family Xylariaceae. Human infections due to this

fungus are rare. Previously it has been reported from

patients of allergic fungal sinusitis (North Carolina), chronic

sinusitis (Brazil) and cerebral phaeohyphomycosis (India).

We here in report the first case of mycotic keratitis due to

Nodulisporium griseobrunneum from a female agricultural

worker of Vidarbha region, Maharashtra, Central India

following injury with vegetative matter. The fungus was

demonstrated on direct microscopy and grown on SDA

with Chloramphenicol after one week of incubation. It was

confirmed by Dr. Joseph Guarro, Professor of Microbiology,

University of Rovira i Virgili, Reus, Spain.

2. WORM IN THE EYE OF A CHILD - A CASE

REPORT : D K MENDIRATTA. Rahul Narang,

Vijayashri Deotale, A Shukla, N Gangane, Pratibha

Narang : (Microcon-2008) 32nd National conference

of Indian Association of Medical Microbiologists,

AFMC, Pune, 21st - 25th Oct., 2008.

A live 3.2mm x 0.8mm worm was extracted from

the anterior chamber of the eye of a 7 year old boy who

presented with history of repeated episodes of headache

and loss of vision since last 8 months. Son of a dairy farm

worker at Chandrapur, Maharashtra, the child did not

give any other significant history including that of travel

outside the district. The blood counts were within normal

limits, no microfilaria was observed in the blood and serology

(detection of Ag, Ab, Ag-Ab complex) for filaria was negative.

Repeated stool examination did not show presence of any

ova or larvae. The worm was extracted and the patient was

treated with DEC. After extraction, the headache was


76

be presumptive as strains negative for AmpC b lactamases

production may also show resistance to this drug due to

other mechanisms. CLSI gives no guidelines for AmpC

detection but according to other studies M3DT has been

taken as Gold Standard as it has 100% correlation with

isoelectric focusing and molecular methods. We observed

100% correlation between M3DT and Cefoxitin resistance

indicating thereby that in our 135 strains tested the

resistance was due to AmpC b lactamases and not due to

any other mechanisms. Thus in our hospital out of a total

1555 Klebsiellae and 1378 E. coli, 4.18% and 5.07% isolates

respectively were AmpC b lactamases producers.

4. INDUCIBLE CLINDAMYCIN RESISTANCE IN

STAPHYLOCOCCUS AUREUS ISOLATED FROM

CLINICAL SAMPLES : VS Deotale, DK Mendiratta,

UC Raut, SC Sharma, Prathibha Narang: (Microconf -

2008), XIV Maharashtra Chapter Conference of

Indian Association of Medical Microbiologists, GMC,

Akola, 23rd-24th Aug. 2008.

Introduction : Clindamycin is commonly used for treatment

of erythromycin resistant Staphylococcus aureus causing

skin and soft tissue infections. In vitro routine tests for

clindamycin susceptibility may fail to detect inducible

clindamycin resistance due to erm genes resulting in

treatment failure. Thus obviating the need to detect such

resistance by a simple D test on routine basis. The present

study used Erythromycin (15 mg) and clindamycin (2 mg)

discs to detect inducible (MLSBi phenotype), constitutive

resistance (MLSBi phenotype) and MS phenotype with

respect to clindamycin.

Methods : 247 Staphylococcus aureus isolates recovered from

various clinical specimens between February to May 2008

were subjected to routine antibiotic susceptibility testing

including that to Clindamycin (2 mg) by Kirby Bauer disc

diffusion method. Inducible Clindamycin resistance was

detected by disc approximation test (DAT) commonly

reffered as D test, as per CLSI guidelines. Isolates were also

screened for methicillin resistance using Oxacillin (1 mg)

disc.

Results : 80 (32.3%) isolates were erythromycin resistant.

Out of these 71 (28.7%) were sensitive to Clindamycin. 36

(50.7%) showed inducible clindamycin resistance (MLSBi

phenotype), 9(3.6%) constitutive resistance (MLSBi phenotype)

while remaining 35(49.3%) showed MS phenotype. Both

inducible as well as constitutive resistance was found to be

higher in MRSA (94.4% & 100%) as compared to MSSA

(5.6% & 0% respectively).


77

relieved, however, loss of vision continued. The worm was

examined in great detail and photographs of the worm,

cut section and also a portion of the worm for molecular

identification was sent to Parasitology Division, CDC,

Atlanta and NIH, Bethesda. However no definite diagnosis

could be made by these Institutions. On the basis of absence

of cephalic papillae & irregular small bosses on cutile

(features of Loa loa) but presence of blunt anterior end

with spicule and copulatory bursa at the posterior end, we

strongly feel that it is a late stage larva of Angiostrongylus

cantonensis. The poster is being presented before the

August Scientific fraternity for their views and comments.

3. DETECTION OF AMP-C BETA LACTAMASES IN

KLEBSIELLA AND E.COLI ISOLATES FROM A

RURAL HOSPITAL, IN CENTRAL INDIA USING

THREE TEST METHODS: D Maraskolhe, VS Deotale,

P Narang, DK Mendiratta: (Microconf-2008),

XIV Maharashtra Chapter Conference of Indian

Association of Medical Microbiologists, GMC, Akola,

23rd-24th Aug. 2008.

The production of extended spectrum b lactamases

in gram negative organisms has evolved as a major mechanism

of drug resitance, Chromosomally encoded AmpC enzymes

i.e, Class C b lactamases also confer resistance to variety

of b lactams including Oxyamino cephalosporins,

Cephamycins, and Monobactams and have been reported

from some part of the country. However, there are no such

reports so far from ‘Central India. Klebsiella species and

E.coli are the commonest isolates from clinical specimens

in our hospital and therefore this study was undertaken

to detect the presence of AmpC b lactamases mediated

resistance in these organisms.

Method : A total of 1555 Klebsiella and 1378 E. coli isolates

from the clinical samples identified as per standard

methods were studied for 3rd GC resistance and production

of ESBL as per CLSI guidelines. The non ESBL isolates(165)

detected amongst the resistance strains further screened

for AmpC b lactamases production by using- Cefotoxin(Cn)

30 mg disc, Disc Potension Test(DPT), Double Disc Synergy

Test (DDST) and Modified Three Dimensional Test (M3DT).

Result : Presumptive screening by Cefoxitin revealed 135

out of 165 isolates (65 klebsiella and 70 E.coli) to be AmpC

producers. All these presumptive isolates were further tested

by 3 confirmatory tests. DPT detected 54(83.07%) Klebsiella

and 63(90%) E. coli, DDST detected 57(87.69%) Klebsiella

and 67(95.71%) E. coli and M3DT were positive for all the

135 isolates (100%). Cefoxitin resistance is considered to

Conclusion : Study showed that D test should be used as an

auxillary method to routine disc diffusion testing in order

to detect inducible clindamycin resistance.

5. DETECTION OF AMP-C BETA LACTAMASES

IN KLEBSIELLA AND E.COLI FROM A RURAL

HOSPITAL IN CENTRAL INDIA. VS Deotale,

Deepashri Maraskolhe, P Narang, DK Mendiratta :

(Microcon-2008) 32nd National Conference of Indian

Association of Medical Microbiologists, AFMC, Pune,

21st-25th Oct. 2008.

Introduction : The production of extended spectrum b

lactamases in Gram negative organisms has evolved as a major

mechanism of drug resistance. Chromosomally encoded

AmpC enzymes i.e. Class C b lactamases also confer

resistance to variety of b lactams including oxyamino

cephalosporins, cephamycins and monobactums and have

been reported from some part of the country. CLSI gives

no guidelines for AmpC detection but many studies have

considered the M3DT test to be the gold standared as it

has shown 100% co-relation with isoelectric focusing and

molecular methods. Cefoxitin resistance has been used as

a screening test for AmpC production, but reports of

cefoxitin sensitive AmpC positive isolates have been

encountered. Detection of AmpC in ESBL producers by

phenotypic methods is difficult. Considering the paucity

of data on AmpC production, the present study was

conducted in klebsiellae sp and E. coli, the common

isolates in our rural hospital, where different phenotypic

methods were compared in both cefoxitin resistant and

sensitive non ESBL producers for AmpC detection.

Methods : A total of 1555 Klebsiella and 1378 E. coli isolates

from the clinical samples identified as per standard methods

were studied for 3rd GC resistance and production of ESBL

as per CLSI guidelines. The non ESBL isolates(165) detected

amongst the resistance strains further screened for AmpC

b lactamases production by using- Cefotoxin (Cn) 30 mgms

disc. Confirmation was done by Disc potentiation (DPT)

using boronic acid and closacillin in the concentration of

300 and 500 mgms, Double Disc Synergy (DDST) with

boronic acid and cloxacillin and Modified Three

dimensional Tests (M3DT).

Results : Amongst the 3rd GC resistant isolates 165 were

non ESBL producers. All these isolates were confirmed by

confirmatory tests. The sensitivity of DPT was 86.66%, for

DDST it was 91.85%. M3DT detected AmpC production in

both cefoxitin resistant and cefoxitin sensitive isolates where

as the other confirmatory tests detected only in cefoxitin

resistant isolates.


78

Conclusion : AmpC b lactamase production in Klebsiellae

and E. coli is prevalent in our area. Though cefoxitin

resistnace aws a good screening test, using M3DT a

confirmatory phenotypic test as M3DT detected AmpC even

in cefoxitin sensitive isolates in our set up.

ORTHOPAEDICS

1. ENDOSCOPIC LUMBAR DISCECTOMY BY

DESTANDU TECHNIQUE. Author : KR Patond,

Roshan Bhaisare. SICOT/SIROT Triennial

conference, HONGKONG. 22nd - 30th August.

Introduction : Traditionally lumbar prolapsed disc with

radicular symptoms in lower limb, not responding to

conservative management were treated with Laminectomy

and Discectomy. There is significant post operative morbidity

associated with these techniques, since there is a lot trauma

to the posterior elements.

Over last 10 yrs Endoscopic techniques develops

to accomplish a much smaller scar and early return to

activity. Foley and Smith (METRx system) and Destandu

(Karl Storz system) are among the most commonest of these

endoscopic techniques. We are presenting here the series

with Destandu’s Technique for Endoscopic Lumber

Discectomy.

Materials and Method : In this series 20 Endoscopic

Discectomy were performed using paraposterior technique

described by Dr. Destandu. There were 13 males and 7

females. Age averages from 20-55 yrs. L4-L5, L5-S1 disc

were the most common sites of disc herniation as assessed

on details neurological examination and MRI scans.

Patients were selected on the inclusion and exclusion

criteria. Only single level disc was operated. We use Prolo’s

criteria for out come assessment.

Results : Mean follow up period was 1 1/2 year. Excellent

and good results were found in 19 patients (95%), fair in 1

patient(5%). No poor result was seen. Discitis was developed

in one patient which was managed with antibiotics, no

further detoriation in neurological outcome. Most patients

were operated on day care basis, ambulated the next day

after surgery and discharge on 2nd or 3rd day post-op day.

Conclusion : Endoscopic discectomy by Destandu technique

for lumbar prolapsed intervertebral disc is a safe and

minimally invasive technique. Patients are mobilized early

and are very comfortable after surgery because of less pain.

Hospital stay is significantly reduced and they can go back

to work ealry.

Over last 10 yrs Endoscopic techniques develops

to accomplish a much smallear scar and early return to

activity. Foley and Smith (METRx system) and Destandu

(Karl Storz system) are among the most commonest of these

endoscopic techniques. We are presenting here the series

with Destandu’s Technique for Endoscopic Lumber

Discectomy.

Materials and Method : In this series 20 Endoscopic

Discectomy were performed using paraposterior technique

described by Dr. Destandu. There were 13 males and 7 females.

Age averages from 20-55 yrs. L4-L5, L5-S1 disc were the

most common sites of disc herniation as assessed on

details neurological examination and MRI scans. Patients

were selected on the inclusion and exclusion criteria. Only

single level disc was operated. We use Prolo’s criteria for

out come assessment.

Results : Mean follow up period was 1 1/2 year. Excellent

and good results were found in 19 patients (95%), fair in 1

patient(5%). No poor result was seen. Discitis was developed

in one patient which was managed with antibiotics, no

further detoriation in neurological outcome. Most patients

were operated on day care basis, ambulated the next day

after surgery and discharge on 2nd or 3rd day post-op day.

Conclusion : Endoscopic discectomy by Destandu technique

for lumbar prolapsed intervertebral disc is a safe and

minimally invasive technique. Patients are mobilized early

and are very comfortable after surgery because of less pain.

Hospital stay is significantly reduced and they can go back

to work ealry.

4. CORRLATION OF CLINICAL FINDINGS AND

MRI FINDINGS IN LOW BACKACHE. Authors :

Ashok Kumar. CM Badole, KR Patond. VOSCON,

Akola. 9th - 10th Oct. 08.

Introduction : Low backache is a common complain and

a majro cause of work disability. MRI is the choice of

diagnosis in low backache.

Aim : To correlate the clinical findings and MRI in low

backache.

Material and Method : 100 patients with low backache with

radiculopathy underwent MRI lumbar spine to find out

correlation of clinical findings with MRI findings. Patient

between age group 20-45 yrs were selected for the study.

Detail clinical history comprising of type, onset, duration

of pain, sensory loss with or without motor loss, bladder


79

2. TITLE : ARTHROSCOPIC DEBRIDEMENT OF

THE ARTHRITIC KNEE. Authors : Ashok Kumar,

CM Badole , KR Patond. Annual Conference of

Indian Arthroscopic Society, Goa. 25th-28th September.

Introduction : Osteoathritis is present radiographically

in the weight bearing joint of 90% of the people over the

age group of 40 years and the commonly affected joint

is the knee. Arthroscopic debridement is the accepted

procedure for the treatment of symptomatic osteoartheritos

of knee.

Material and Method : 30 patients with symptomatic

osteoarthritis of knee joint underwent Arthroscopic

debridement of knee after failure of medical management

and physiotherapy. Radiographic findings were classified

as mild, moderate and severe. Patients with inflammatory

or traumatic type of osteoarthritis were excluded. Age

group was 40-70 yrs. Arthroscopic debridement includes

resection of unstable chondral flaps and meniscal tears.

Observations and Results : Out of 30 cases 17 were male and

13 were females. Age ranges from 40-70 yrs. Results of

surgery were graded on a nine point scale based on pain

reduction, functional improvement and overall patient

satisfaction. Patients were followed up at 6 months and

final follow up a 1 years, At 6 months the result were excellent

in 15 (50%) patients, good in 10(33%) patients, fair in 3(10%)

patients, failure in 2(7%). At the final follow up at 1 years

the results were excellent in 12 (40%) patients good in

10(33%) patients, fair in 6(20%) patients, failure in 2(7%).

Conclusion : Arthroscopic debridement can be used to

prolong the time for knee Arthroplasty since it is having

few contraindications, minimal risk, and low morbidity,

moreover it can be repeated and does not complicte future

Arthroplasty or realingement. to reach the final outcome,

long term follow up and large number of patients are

required since the disease is progressive.

3. ENDOSCOPIC LUMBAR DISCECTOMY BY

DESTANDU TEACHNIQUE. Author : Roshan

Bhaisare, KR Patond. Annual Spine Conference,

Rajkot. 25th - 28th September 08.

Introduction : Traditionally lumbar prolapsed disc with

radicular symptoms in lower limb, not responding to

conservative management were treated with Laminectomy

and Discectomy. There is significant post operative morbidity

associated with these techniques, since there is a lot trauma

to the posterior elements.

or/bowel disturbance was taken. Clinical examination in

the form of range of spine movements, gait, SLRT, sensory

or motor deficit, ankle and knee reflexes was recorded, AP

and lateral view of lumbar spine was taken. MRI lumbar

spine was done and findings were recorded as level and

type of disc prolapse like protrusion, extrusion, sequestration

and bulge with indentation. Bulge without indentation

was considered normal MRI fingings.

Observations and Results : There were 70 males and 30

females. In 38 patients there was bulge without indentation.

30 had extrusion disc, 18 had bulge with indentation, 8 had

protruded disc and 6 had sequestrated disc. L4-L5 level

was commonly involved. 70% of patients with positive

SLRT, 74% of patients with motor deficit, 80% with sensory

loss and 66% of patients with absent deep tendon reflex

had abnormal MRI Finding.

Conclusion : To diagnose intervertebral disc prolapse

detail clinical history and clinical examiantion should be

done. MRI must be correlated with clinical finding.

5. MANAGEMENT OF DISPLACED DIAPHYSEAL

FRACTURE OF FEMUR IN CHILDREN WITH

INTRAMEDULLARY KIRSCHNER WIRES.

Author : Ashok Kumar, CM Badole, KR Patond.

Conference : ARISCON, Sevagram. 15th-17th Nov. 08.

Introduction : Femoral shaft fractures account for 1.6% of

all pediatric bony injuries. Traction from non operative

(Plaster spica) to operative treatment (Intra medullary

osteosynthesis) in childhood has been accepted universally.

Complications such as malunion, rotational deformity, joint

stiffness, plaster sores & psychological problems can be

avoided

Methods : Study was conducted in the Kasturba Hospital

Sevagram Wardha, int he department of Orthopaedics, 25

childrens with a mean Age of 8-15 yrs (Range 4-14 yrs), 16

males and 9 females presented with closed displaced

diaphyseal fracture of femur were included in the study.

Closed reduction done under C-ARM control and K wires

fixation done using 3 point fixation principle. Follow up was

done monthly upto 6 months and Implant used was stainless

steel 316 L Kirschner 2.0, 2.5, 3.0, 3.5, 4.0mm X 30cm.

Results : Evaluation of Results was done using Flynn et al

(2001) criteria as Excellent, Satisfactory and Poor results.

Present study had 18 Excellent 7 Satisfactory results no poor

results.

Conclusion : Intramedullary fixation with K wires for

diaphyseal fracture femur gives predictably good results

with minimal infection rates. Complication of conventional

traction & spica are avoided. Early ambulation & decreased

hospital stay for the patients. No joint stiffness. Maintenance

of rotational & logitudinal stability.

6. DECOMPRESSION IN MULTILEVEL CERVICAL

SPONDYLOTIC RADICULOMYELOPATHY.

Author : CM Badole, KR Patond. Conference :

MOACON, Mahabaleshwar. 21st- 23rd Nov. 08.

Introduction : Various techniques and approaches have been

established for the surgical management of multilevel cervical

spondylotic radiculomyelopathies. Though there is an

increasing success of anterior decompression & laminoplasty,

however en block laminectomy is still the best and reliable

option for symptomatic multilevel cervical spondylotic

radiculomyelopathy not responding to non operative line

of management.

Method : The study was conducted in KHS, Sevagram

between Jan 2005 and May 2008 Patients having significant

neurological symptoms suggestive of cervical canal stenosis

were screened clinically and radiographically. Patients with

multilevel compression in the MRI were selected for the

study. Study group consisted of 27 patients, 24 males and 3

females with mean age of 61 years. Patients were admitted

and evaluated preoperatively and postoperatively using the

“Japanese Orthopaedic Association score.” Positioned in

prone with neck in neutral position. through posterior

midline approach, En block Laminectomy was done from

C3-C7. A fine, high speed burr was used to create troughs

at the facet-lamina junction on both sides. Laminas and

spinous processes are lifted off en block. Postoperatively

soft cervical collar given. Patients were discharged on 7th to

10th day and called for follow-up after 3 weeks.

Results : Results of surgery were decided based on the

comparison of preoperative and postoperative “Japanese

Orthopaedic Association score.” 23 patients had good results, 3

patients had fair result and 1 had post operative complication

but neurological improvement was significant.

Conclusion : Cervical en block laminectomy is safe, easy

and reliable technique. It is technically simpler than anterior

corpectomy as a means to address multiple levels of

pathology. This approach also avoids the increased

pseudoarthrosis rates of multiple level fusion procedures.

This technique also avoids incomplete decompression,

recurrent stenosis and neck restriction with are common in

laminoplasty procedure. No spinal instability or deformity

has been documented in the study so far.


80

PATHOLOGY

1. ROLE OF OXIDATIVE STRESS AND

ANTIOXIDANT LEVELS IN TUBERCULAR,

REACTIVE AND METASTATIC

LYMPHADENOPATHY. P Magdum, S More, K Mehra,

NS Ingole, N Gangane. MAPCON 2008, Annual

Conference of Maharashtra Chapter of Indian

Association of Pathologists and Microbiologists,

Sawangi Meghe, 19-21 Sept. 2008.

Introduction : Oxidative stress is implicated in the

etiopathogenesis of a variety of human diseases including

tuberculosis and cancer. Mycobacteria can induce reactive

oxygen species (ROS) production by activating phagocytes

resulting into inflammation and tissue injury. ROS are

also involved in carcinogenesis. This study was carried out

to determine if there is difference in free radical and

antioxidant levels in patients of tubercular, reactive and

metastatic lymphadenopathies.

Aim : To evaluate the serum levels of malondialdehyde,

nitric oxide, ascorbic acid, reduced glutathione and

Key words : En block Laminectomy, spondylotic

radiculomyelopathy, cervical spine.

7. MANAGEMENT OF DISPLACED FRACTURE

SHAFT HUMERUS BY INTERLOCKING NAIL.

Author : CM Badole, R Chasnal, KR Patond.

Conference : MOACON, Mahabaleshwar. 21st - 23rd

Nov. 08.

Introduction : Various types of devices have been used

for fixation of fracture shaft of humerus. Rigid plate

osteosynthesis carries disadvantages including extensive

soft tissue trauma, significant blood loss and risk of intra

operative radial nerve injuries. Intramedullary stabilization

of humeral shaft fractures avoids some of these disadvantages,

but the nails are not without complications. However, locked

nails provide good rotational stability with good results.

Methods : Study was conducted in the Kasturba Hospital

Sevagram, Wardha May 2006 to May 2008. Patients presenting

with displaced diaphyseal fractures of shaft of humerus

5cm proximal to the distal metaphysis, Closed or Grade II

compound fractures were included in the study. Of the 31

patient treated with humerus Interlocking nail, 23 were

included in the study. Passive ROM movements were allowed

from third postoperative day. Assessment of shoulder

function was done by Constant - Murley Shoulder Score at

follow up visits.

Results : Assessment of shoulder function was done at

follow up in which 78.2% of the study has 81-100% score,

13% has 61-80% score and 8.6% has 41-60% score.

Complications like iatrogenic fracture, broken drill bit,

delayed union, shoulder stiffness and implant failure, were

encountered in 6 cases.

Conclusions : Intramedullary nailing offers the benefits

of anatomical alignment, rigid fixation, with limited soft

tissue dissection and early rehabilitation. Although shoulder

stiffness is a common problem it can be treated by making

entry point at correct site and with active physiotherapy.

8. NEURENTERIC CYST, A CASE REPORT.

Author : CM Badole, KR Patond. Conference :

IOACON, Bangalore. 4th-7th Dece., 2008.

Introduction : Benign epithelial lined cystic structures in

the Intraspinal - lower cervical or upper thoracic may be

Intradural and extramedullary along with spinal deformities,

resembling that of alimentary canal also known as

‘Enterogenous cyst’. We are reporting 2 such cases.

9. MINIMAL INVASIVE PERCUTANEOUS PLATE

OSTEOSYNTHESIS FOR PROXIMAL TIBIAL

FRACTURES. Author : Devashis R Barick, KR Patond.

Conference : IOACON, Bangalore. 5th December 08.

Introduction : Proximal tibial fractures pose many problems

in their treatment specially related to skin condition & tissue

equilibrium around the proximal tibia. Open reduction and

internal fixation may pose problems with wound healing

at the operative site with high chances of post-op infection.

Minimally Invasive Percutaneous Plate Osteosynthesis is

a safe, technically easy & equally effective in addition to

being cosmetically better.

Methods : 20 patients were treated with this modality

for closed fractures of the proximal tibia over a period

of 3 years at the department of Orthopaedics MGIMS,

Sevagram.

Results : The mean follow up was 2.8 yrs. All patients had

favourable results with no incidence of wound complications,

with minimal restriction of joint mobility.

Conclusion : Percutaneously introduced tibial condylar

plates in appropriately chosen cases give a good functional

outcome without additional procedures. Post-op. skin

necrosis is minimal with a significantly reduced infection

rate.


81


82

superoxide dismutase in patients with tubercular, reactive

and metastatic lymphadenopathy.

Methods : Fine needle aspiration cytology (FNAC) was

performed on 120 subjects presenting with lymphadenopathy.

The study included 40 cases each of tubercular lymphadenitis,

non specific reactive lymphadenopathy and metastatic

lymphadenopathy. Levels of malondialdehyde, nitric oxide,

superoxide dismutase, reduced glutathione (GSH) and

ascorbic acid were evaluated in all three categories and in

the control group comprising of 30 healthy controls.

Results : Levels of malondialdehyde and nitric oxide were

significantly raised in patients of tubercular and metastatic

lymphadenopathy as compared to controls. The antioxidant

levels (superoxide dismutase, glutathione reductase and

ascorbic acid) were significantly lower in tubercular and

metastatic lymphadenopathy when compared to patients

with reactive lymphadenopathy and controls.

Conclusions : We found rise in reactive oxygen species

and lipid peroxidation products in patients of tuberculosis

and malignancy. There was significant decrease in the

values of antioxidants in both metastatic and tubercular

groups. This study provides new insights on their role in

pathogenesis of various diseases and could have therapeutic

significance.

2. A HISTOMORPHOLOGICAL STUDY OF

BENIGN VASCULAR LESIONS WITH SPECIAL

REFERENCE TO ELASTING STAINING AND

MAST CELL DENSITY (SECOND PRIZE: BEST

PAPER AWARD). P Pawane, D Dhumal, R Gode,

Anshu, N Gangane. MAPCON 2008, Annual




Introduction : The diagnosis and management of benign

vascular lesions continue to present diagnostic and the

therapeutic challenges to surgeons, radiologists, and

histopathologists. This is in part due to lack of agreement

regarding the nosology and classification of these lesions.

In 1982, Mulliken and Glowacki introduced a new

classification based on the clinical and histological

characteristics of vascular lesions. They classified vascular

lesions into hemangiomas and vascular malformations.

Aim : This study was carried out of classify benign vascular

anomalies using Mulliken and Glowacki’s simple two-tier

classification. We also tried to see whether presence of

arteries and arterioles can be used as diagnostic criteria to

differentiate between hemangiomas and arterio-venous

malformations. We also sought to explore diagnostic clues

that may help in the diagnosis and differentiation of these

lesions. We studied mast cells using toluidine blue stain

in these lesions.

Materials and Methods : Cases reported as benign vascular

lesions were retrived from the Surgical Pathology records

of the Department of Pathology, MGIMS Sevagram. All

lesions were reclassified using Mulliken and Glowacki’s

classification into hemangiomas and arterio-venous

malformations. Sections were stained by routine haematoxylin

and eosin stain, Verhoeff’s method and 1.0% toluidine blue.

Lesions were also evaluated for presence or absence of

intralesional nerves.

Results : Lesions which showed presence of arteries and

arterioles on elastin stain were classified as arteriovenous

malformations. Intralesional nerves were found to be

significantly higher in arteriovenous malformations than

in hemangiomas. Mast cell density was high in proliferating

hemangiomas compared to involuting forms which showed

fibrosis.

3. CARDIAC PARAGANGLIOMA ASSOCIATED

WITH PENTALOGY OF FALLOT: A CASE REPORT.

S Deshmukh, R Sougaijam, R Sinha, SM Sharma, N

Gangane. MAPCON 2008, Annual Conference of

Maharashtra Chapter of Indian Association of

Pathologists and Microbiologists, Sawangi Meghe,

19-21 Sept. 2008.

Introduction : Primary cardiac tumors are rare. The majority

are benign and 75% are atrial myxomas. One of the more

unusual tumors affecting the heart is a cardiac paraganglioma.

We report an unusual case of cardiac paraganglioma which

was associated with Pentalogy of Fallot.

Case Report : A 22 year old woman succumbed to sudden

death within two hours of admission. Autopsy was conducted.

On examination the heart was enlarged. The heart showed

the presence of ASD, VSD, overriding of aorta, dilatation

and hypertrophy of the right ventricle, left ventricular

hypertrophy and origin of pulmonary trunk from left

ventricle. Pulmonary trunk was dilated. Apart from these

congenital defects, the heart also showed a nodular swelling

on posterior wall of the left ventricle just below the

atrio-ventricular groove.

Sections from the nodule showed the presence

the typical ‘Zellenballen pattern’ around an elaborate

vasculature. A diagnosis of paraganglioma was made.

Conclusion : Tetrology of Fallot is one of the most common

congenital cardiac defects causing cyanosis. It is characterized

by biventricular origin of the aorta above a large VSD,

obstruction to pulmonary blood flow, and right ventricular

hypertrophy. Tetralogy when associated with ASD is called

Pentalogy of Fallot, and is not distinguishable clinically.

Pentalogy of Fallot and transposition of pulmonary trunk

to the left ventricle along with cardiac paraganglioma is a

very rare combination which was seen in the present case.

4. CYTODIAGNOSIS OF AMYLOIDOSIS OF LIVER

IN A PATIENT OF MULTIPLE MYELOMA : A

CASE REPORT. V Rao, C Nalinimohan, R Singh, VB

Shivkumar, N Gangane. MAPCON 2008, Annual




Introduction : Amyloidosis occurs in less than 15% of cases

of multiple myeloma. We report a case of amyloidosis of

the liver which was diagnosed on fine needle aspiration

cytology (FNAC). The cytological diagnosis of amyloidosis

prompted a search for the cause and multiple myeloma was

discovered.

Case Report : A 60 year woman presented with lump in

right hypochondrium of 4 years duration. The patient had

massive hepatomegaly which was progressive and painless.

Fine needle aspiration cytology was performed from the

liver. The smears showed thick deposits obscuring the

hepatocytes. These dense fragments were homogenous and

appeared reddish purple on the Giemsa stained smears and

pale green on the Pap smears. There was scalloping of the

margins of these deposits. The deposits were Caongophilic

and confirmed the presence of amyloid. A diagnosis of

amyloidosis of liver was made on cytology.

The cytologic diagnosis of amyloidosis prompted

a search for its cause. Radiographs from the skull showed

multiple punched out lesions. Serum electrophoresis was

done and showed the presence of M band. Bone marrow

aspiration was also performed. It showed mature and

immature plasma cells diagnostic of multiple myeloma.

Conclusion : Multiple myeloma can evolve into amyloidosis.

Primary amyloidosis occurs due to the tissue deposition

of AL protein which is derived from monoclonal light

chain fragments of the immunoglobulins. As our case

demonstrates, FNAC can be a useful minimally invasive

procedure in diagnosing amyloidosis. Further diangosis of

amyloidosis should prompt search for the cause.

5. EUMYCOTIC MYCETOMA - REPORT OF FOUR

CASES (SECOND PRIZE : BEST POSTER AWARD).

M Quadri, N Tatkare, S Gabhane, A Gupta, N Gangane.

MAPCON 2008, Annual Conference of Maharashtra

Chapter of Indian Association of Pathologists and

Microbiologists, Sawangi Meghe, 19-21 Sept. 2008

Introduction : Mycetoma is a late stage clinical manifestation

of a subcutaneous infection produced by either bacteria

(actinomycetoma) or fungi (eumycetoma). Only few articles

have described the morphological appearance of this

uncommon pathology on cytology. We report four cases

of Eumycotic mycetoma due to fungi where FNAC was

instrumental in diagnosis.

Case reports : Our cases include three men and women with

age range of 18 to 41 years and a history of a swelling with

discharging sinuses of six months to three years duration.

In three of them the foot was affected and one exceptional

case showed left side chest wall involvement. FNAC was in

all cases. Smears showed inflammatory infiltrate comprising

of mainly neutrophils, along with lymphocytes, plasma

cells, histiocytes and foreign body type of giant cells. A

prominent feature noted was presence of thick, septate,

branching fungal hyphae. Dark brown-black granules

were also seen in the macrophages and extracellularly in

smears. Hence the diagnosis of eumycotic mycetoma was

entertained.

Conclusion : Mycotic mycetoma can be accurately diagnosed

by FNAC, when there is high index of suspicion. Awareness

amongst cytopathologists for the possibility of eumycotic

or actinomycotic mycetoma in proper clinical context may

lead to rapid and economic diagnosis for the patient and

will be helpful in early treatment.

6. CYTOMORPHOLOGICAL FEATURES OF

MIXED INVASIVE PAPILLARY CARCINOMA

AND CRIBRIFORM CARCINOMA BREAST : A

CASE REPORT. S Chaukade, Y Bhiogade, Y

Zonunfawni, D Joshi, N Gangane. MAPCON 2008,

Annual Conference of Maharashtra Chapter of Indian



Introduction : Special types of mammary carcinoma are

collectively responsible for about 25% of invasive breast

cancers, and their recognition may often be of prognostic

importance. Though Fine-needle aspiration (FNA) is a

reliable method for the diagnosis of breast carcinoma, but

difficulties exist for the cytopathologist to determine the


83

tumor subtypes. We hereby report the cytomorphological

features of a case of mixed invasive papillary carcinoma

and cribriform carcinoma breast.

Case - Report : A 62 years old female presented with a recurrent,

gradually progressive painless lump in right breast for six

months. Previous lumpectomy was done around the same

site one and half years back. FNA was performed and a

diagnosis of ductal carcinoma with degenerative change

was made and biopsy was advised for confirmation. Patient

then underwent modified radical mastectomy, histological

examination revealed presence of invasive papillary and

cribriform carcinoma breast extending upto the overyling

skin. Retrospective examination of the cytological smears

showed presence of papillary sheets, columnar cells,

vacuolated cells and macrophages more characteristic of

papillary carcinoma. Micro-acinar groupings denoting

areas of cribriform carcinoma were also noted. Presence of

micro-acinar groupings and background macrophages led

to the erroneous diagnosis of ductal carcinoma with

degenerative change.

Conclusion : Invasive papillary and cribriform carcinoma

are rare tumors of the breast and since their prognosis

differs from conventional ductal carcinomas, cytological

recognition of these entities is important. We have not only

described the specific cytological features of these rare

tumors but also the features which can cause diagnostic

confusion of these entities with ductal carcinoma.

7. DOES HPV TESTING HELP WHEN HIGH-GRADE

CYTOLOGY IS NOT CONFIRMED AT

COLPOSCOY? (BEST PAPER AWARD). Anshu,

Amanda Herbert, Gillian Holdsworth, Hilda

Dunsmore, Ali Kubba. CYTOCON 2008, Annual

Conference of Indian Academy of Cytologists,

Ahmedabad, 15-16 Nov 2008.

Introduction : At Guy’s and St Thomas’ NHS Foundation

Trust(GSTFT), high risk HPV(HRHPV) testing with Hybrid

Capture 2(HC2) is carried out during post-colposcopic

follow-up of women with high-grade dyskaryosis or

‘bordeline, high-grade not excluded’ cytology found not to

have at least CIN2. The aim of this study was to find out

whether HPV testing helped with the clinical management

of these non-concordant cases.

Material and Methods : Cases comprise 98 non-concordant

cases among 627 cases in which HC2 tests were conducted

at the Colposcopy Unit at Guy’s Hospital from September

2006 to September 2007. In these women, HC2 was carried

out because initial colposcopy did not confirm a high-grade

dyskaryosis or ‘borderline, high-grade not excluded’ cytology

report. The screening histories of these 98 women were

retrived and colposcopy, cytology, biopsies and HC2

results were recorded. These were analyzed according to

their final management protocols and outcomes and their

original slides were reviewed.

Results : Of the 98 cases, the index smear was high-grade

dyskaryosis in 94, “bordeline, high grade not excluded’ in

four. Of 94 high-grade reports, eight had been reported as

mildmoderate dyskaryosis, 20 as ‘ungraded dyskaryosis,

probably high-grade’, 42 as moderate dyskaryosis and 24

as severe dyskaryosis or?glandular neoplasia. 50 were

positive for HC2 and 48 were negative.

Slides from 93 cases were reviewed. These were

reviewed as benign (4-tubal metaplasia, tubo-endometrioid

metaplasia, squamous metaplasia and reactive), borderline

change in glandular cells(1), atypical immature metaplasia

(24), ‘borderline, high-grade not excluded’ (3), mild

dyskaryosis or borderline (13). High-grade dyskaryosis was

confirmed on review in 33.

At least CIN2 was found in subsequent biopsies

of 20 women. Eighteen were HC2 positive. In 35 cases, the

outcome was considered more likely to be potentially

reversible low-grade disease. Of these, 21 were HC2 positive

and 14 negative. Excisional treatment has been avoided in

all these women, at least in the short term, but 21 remain on

colposcopy follow-up, either because of persistent low-grade

changes or positive HC2, while 14 have been discharged to

cytological surveillance.

Conclusion : HC2 adds a useful parameter to cytology

review in management of these women but is rarely used

on its own to decide treatment. The whole process of slide

review and HC2 testing allows a high proportion of these

women to avoid ablative or excisional treatment. However,

clinical judgement is needed to decide management of

women with positive HC2 in whom no lesion is found,

especially when previous high-grade cytology is confirmed

on review. HC2 proved to be useful in detecting persistent

disease in women previously treated for high-grade CIN.

8. PREVALENCE, TREND AND CO-INFECTION

OF INFECTIOUS DISEASE MARKERS IN

BLOOD DONORS. NS Ingole, A Thakre, D Joshi,

N Gangane. Transcon, SGPGI Lucknow, 5-7 Dec 2008

Introduction : Transfusion trasmitted diseases (TTD) are a

major challenge to transfusion services all over the world.

The problem of TTD is directly proportional to the

prevalence of the infection in blood donor community.


84

Aim : The aim of the study was to find out the prevalence,

trend and correlation between HIV, HBsAg, HCV and

VDRL positivity in the blood donor population in Wardha

district.

Materials and Methods : Study was undertaken at Kasturba

Hospital, Sevagram which is a tertiary care hospital catering

health services to the patients of central provinces of

Maharashtra. Data was obtained from blood bank registry

of TTD positive donors at MGIMS, Sevagram. All such

cases between the periof of 1st January 2001 to June 2007

were selected. The screening for anti HIV I and II, HBsAg,

and anti-HCV was done by ELISA. VDRL testing was done

by Rapid Plasma Reagin test marketed by Tulip diagnostics.

Results : The percent prevelence rate of HIV, HBsAg, HCV

and VDRL reactivity was found to be 1.1, 2.3, 0.87 and 0.84

respectively amongst total 26,603 donors held during this

period. The statistical analysis of co-occurrence of TTD

markers showed highly significant positive correllation of

HIV with VDRL but not with HBsAg and HCV. There was

significant decrease in the prevalence of HBsAg from 2001

to 2005 (3.06 to 1.7) but it again increased in the last two

years (2.14 and 2.94).

Conclusion : In spite of rigid donor selection criteria and

screening of TTD markers, there remains some risk of

post transfusion infection, hence transfusion of blood or

its products should be done when atmost indicated.

9. A PILOT OF HPV TESTING FOR TRIAGE OF

LOW-GRADE CYTOLOGY AND MANAGEMENT

OF DISCORDANCE IN A COLPOSCOPY CLINIC

SETTING. Eva Lysova1, Anshu2,4, Tamara Kubba3,

Ruhi Jawad1, Hilda Dunsmore2, Amanda Herbert2,

Gillian Holdsworth1, Aggie Jokhan2, Michael Kidd2,

Ali Kubba2. Annual Scientific meeting, Birmingham,

10-11 April 2008.

Aims : To use hybrid 2 (HC2) for HPV triage in colposcopy

(i)to allow more women with lowgrade cytology to be returned

to cytological surveillance and (ii) improve the management

of women with non-concordant cytology/colposcopy.

Methods : HC2 testing was carried out on residual material

in ThinPrep vials after obtaining consent for the tests to

be carried out. New referrals with-low grade cytological

abnormalities and cases in which high-grade cytology was

not confirmed.

Results : Results are currently available on 374 women

referred with mild dyskaryosis (most were referred on

second occurrence) and 131 with borderline change. Of 505

women, HC2 was negative in 38.2%. In women with negative

HC2, management was altered by the test result in 29%

(67 of 231 women) who were returned to cytological

surveillance. In the non-concordance group, CIN2 or worse

was not confirmed in 81 women originally referred for

investigation of high-grade cytology. Of these, 46.9% were

HC2 negative. HC2 was more likely to negative in women

referred for moderate or ungraded dyskaryosis (34.6%)

compared with severe dyskaryosis or worse (12.4%). HC2

results provided a useful parameter in these cases alongside

slide review at multidisciplinary meetings.

Conclusion : Repeat colposcopy could be avoided in women

with low-grade cytology if their HPV status is known. HC2

added a useful parameter to the management of women

with highgrade cytology when not confirmed at colposcopy.

10. AUDIT OF INVASIVE CERVICAL CANCER

DURING THE INTRODUCTION OF ORGANIZED

SCREENING : HOW INTERVAL CANCERS

BECAME RELATIVELY MORE FREQUENT

WHILE THEIR INCIDENCE DECLINED. A

Herbert1, Anshu1,2, S Gupta2, M Gregory3 and N

Singh3,1Guy’s & St Thomas’. 47th Annual Scientific

Meeting, Dublin, 7-10 Sep. 2008.

Introduction : A 12-year study of invasive cervical cancer

was analysed to investigate the significance of screen-detected

cancers defined in clinical terms, the reasons why screening

does not prevent all cancers and to provide a baseline for

current audits.

Methods : A database of 382 invasive cancers diagnosed

between 1985 and 1996 was re-examined to analyse screen-

detected cancers and interval cancers in terms of four

3-year periods, age band, histological type and stage of

cancer. Incidence was calculated for the local population

of total women and, for the more recent years in which the

data were available, for previously screened and unscreened

women eligible for screening.

Results : There was a significant fall in symptomatic

cancers per 100 000 total female population form 13.0 in

1985-1987 to 6.4 in 1994-1996 (P = 0.00005) while screen-

detected cancers, both fully invasive and microinvasive,

became relatively more frequent (P=0.002). Interval cancers

increased as a proportion of all cancers from 34.1% in 1985-

1987 to 48.6% in 1994-1996 and showed a peak during the

third period of the study (1991-1993). Incidence among

eligible women aged 25-64 years screened within 5 years

fell in 1994-1996, when the overall incidence in SSWH


85

was the same as for England as a whole (10.4/100 000),

and could provide a baseline for current audits. Interval

cancers were significantly more likely to be seen in younger

age bands and in screen-detected cancers, especially

when microinvasive. Factors other than or in addition to

previous negative smears were recorded in 52.8% of

interval cancers and showed the importance of accurate

cytology, appropriate follow-up, prompt investigation and

effective treatment.

Conclusion : Interval cancers should be considered in

relation to the number of eligible women screened during

that period of time and not as a proportion of all cancers.

They were more likely to be screen-detected early cancers

in young women.

11. ANALYSIS OF PREDICTIVE VALUE OF

CYTOLOGIC FEATURES IN DIAGNOSIS OF

PAPILLARY CARCINOMA OF THYROID. Anshu,

Yvonne Zonunfawni, Ranjeeta Sougijam, Nitin

Gangane. APCON 2008, Annual National Conference

of Indian Association of Pathologists & Microbiologists,

Kattankulathur, Chennai, 15-17 Dec 2008.

Introduction : Papillary carcinoma is routinely diagnosed

on the basis of its characteristic features on fine needle

aspiration cytology(FNAC). However these cytologic features

are not unique to papillary carcinoma and are also seen in

other thyroid lesions. Further compounding the diagnostic

dilemma is the variable cytologic picture seen in variants

of papillary carcinoma. We followed up cases of papillary

carcinoma on cytology and compared it with their histologic

outcome. Further, each cytologic feature was statistically

analyzed to see how useful it was in predicting the

diagnosis of papillary carcinoma of the thyroid.

Material and Methods : 75 consecutive cases diagnosed as

either definite or probable cases of papillary carcinoma on

FNAC were studied. Histologic follow-up was available in

36 cases. We reviewed the Papanicolaou and Giemsa stained

smears of all the cases. The smears were graded on the

basis of their architectural features (cellularity, presence of

papillary fragments, monolayered sheets, single cells,

microfollicles, cellular swirls), cytoplasmic features (presence

of oxyphilia, vacuoles, fireflares), neclear features (presence

of nuclear grooves, intranuclear cytoplasmic inclusions,

pleomorphism, dusty chromatin, micronucleoli, nuclear

overlapping) and background changes (presence of thick

colloid, psammoma bodies, metaplastic cells, giant cells,

elongated cells, tall cells, lymphocytes and cyst macrophages).

The usefulness of each feature in diagnosing papillary

carcinoma on FNAC was statistically analyzed.

Results : Of the 18 cases where a definite diagnosis of

papillary carcinoma was offered on FNAC, 13(72.2%) were

confirmed on histology. Of the 5 false positive cases, 3

were hashimoto’s thyroiditis and 2 were colloid goiter with

cystic change. Of the 18 cases where a probable diagnosis

of papillary carcinoma was given, only 8 (44.4%) were

confirmed on surgery. The 10 false positive cases were

Hashimoto’s thyroiditis (1), hyalinizing trabecular adenoma

(3) and multinodular goiter with hyperplasis (6). The features

which helped most in diagnosis of papillary carcinoma on

FNAC were the combined presence of papillary fragments,

intranuclear inclusions, metaplastic cells and thick colloid.

Cytology was not effective in correctly predicting variants

of papillary carcinoma including tall cell varient and

columnar variant.

12. LEUKOCYTE ALKALINE PHOSPHATASE

ACTIVITY IN NON-HAEMATOLOGICAL

MALIGNANCIES AND ITS UTILITY AS A

PROBABLE PREDICTOR OF METASTASIS

WITH EMPHASIS ON BREAST AND COLON

CANCER. Ingole NS, Deshmukh S, Dhumal D,

Gangane N. APCON 2008, Annual National

Conference of Indian Association of Pathologists and

Microbiologists, Kattankulathur, Chennai,15-17 Dec 2008

Introduction : Human alkaline phosphatase has been

demonstrated in different tissues of the body like liver,

pancreas, thyroid, bone marrow and peripheral blood

leukocytes. Assessment of LAP activity has many clinical

applications. It is found to be altered in physiological as

well as pathological states including haematological and

non-haematological malignancies.

Aims and objectives :

1. To establish the normal range of LAP score in healthy

controls in our laboratory.

2. To find out the LAP score in patients of non

haematological malignancies at the time of diagnosis.

3. To evaluate the differences in LAP score between

non-metastatic and metastatic cancer patients at the

time of diagnosis.

Materials and Methods : The ‘study’ group included total

100 patients with histologically or cytologically proven

non-haematological malignancies of different sites and

organs with particular emphasis on breast and colon

cancer. The histochemical staining technique used for

LAP scoring was by Rutenberg et al, (1965).

Observations :

LAP score in the patients with non-haematological


86

malignancies is lowere than in the control group

irrespective of the organ or site.

Irrespective of the mode of treatment, LAP score

gradually increased with treatment of malignancy.

Metastatic cases showed higher LAP values than in

non-metastatic patients. With metastasis, there is

marked increase in LAP score as compared to regular

values for that patient.

13. INCREASING THROMBOCYTOPENIA AS

A EARLY MARKER OF SEPTICEMIA IN BURN

CASES. A Gupta, V Rao, C Nalinimohan, N Gangane.

APCON 2008, Annual National Conference of Indian


Kattankulathur, Chennai, 15-17 Dec 2008.

Introduction : Infection is the most common, as well as

serious complication of a major burn injury. Sepsis accounts

for 50-60% of all deaths in burn patients today, despite

improvements in antimicrobial therapies. Diagnosis of

sepsis in burn patients can be difficult because it needs to

be distinguished from usual hyperdynamic, hyperthermic,

hypermetabolic post burn state. Fever spikes are not

proportional to degree of infection in such cases. Again

cultures are reported to be negative in many cases.

Aim :

1. To study changes in platelet count and increasing

thrombocytopenia if any, in cases of burn cases

2. To study the relationship between increasing

thrombocytopenia and incidence of septicemia in

these patients.

Materials and Methods : The current observational study

was carried out in the Dept.of Pathology, MGIMS, Sevagram

after receiving approval from institutional ethical committee.

All burn patients (Total of 498 patients) admitted in burn

wards between Jan ‘06 - May’08 were the study cases. After

taking informed consent complete blood count and

peripheral smear examination of all cases was done at regular

intervals. If sepsis was suspected, relevant investigations

were carried out to ascertain the diagnosis including

criteria given by Astone et al.

Results : The analysis of finding confirms that increasing

thrombocytopenia is an early indication of septicemia in

burn patients. Other related findings and their significance

will be presented.

14. CLINICOPATHOLOGICAL CHARACTERISTICS

OF INFILTRATING DUCT CARCINOMA

OF BREAST WITH MICROPAPILLARY

CARCINOMA COMPONENT. S Chaukade, SM

Sharma, Y Bhiogade, N Gangane. APCON 2008,

Annual National Conference of Indian Association of

Pathologists and Microbiologists, Kattankulathur,

Chennai, 15-17 Dec 2008.

Introduction : Micropapillary carcinomas(MPC) are described

as carcinomas with predominant papillary clusters, devoid

of fibrovascular core, surrounded by empty lacunar speces.

They have been reported to be associated with high incidence

of axillary lymph node metastases and poor outcome.

This study was carried out to determine if

infiltrating duct carcinomas (IDC) with micropapillary

component are prognostically different from tumors

without micropapillary component.

Aims and Objectives : This study is being carried out

(a) to determine the percentage of cases of IDC which

have a micropapillary component and

(b) to compare clinicopathological features of IDC of

breast showing micropapillary component with cases

of IDC without micropapillary component

Materials and Methods : All cases of IDC reported between

2000-2007 were retrieved from Surgical Pathology files.

Clinical and gross findings were recorded. Slides of all

cases were reviewed. Tumors were classified into a) those

with micropapillary component and b) those without

micropapillary component. Tumors with MPC were also

assessed to percentage of this component. Both the groups

were compared using Chi square test and linear regression

analysis to investigate the possible relationship between

their clinicopathological parameters.

Results : Of the 361 cases of IDC diagnosed in 8 years, 43

(11.9%) showed a micropapillary component. 60.4% of MPC

tumours were larger than 5 cm in size. None of the MPC

tumours were grade 1 tumours. Tumours with MPC had a

significantly higher DCIS component, number of metastatic

lymph nodes and lymphovascular invasion compared to

non-MPC tumours. Significantly higher proportions of

MPC tumours were of higher stage compared to non-MPC

tumours.

15. MAMMARY FIBROMATOSIS AS A MIMIC OF

CARCINOMA ON FINE NEEDLE ASPIRATION

CYTOLOGY. Anshu, N Shende, Y Bhiogade, N

Gangane. APCON 2008, Annual National Conference

of Indian Association of Pathologists and

Microbiologists, Kattankulathur, Chennai, 15-17 Dec

2008.


87

Introduction : Smears obtained from aspiration of

mammary fibromatosis have classically been described as

cellular. They have shown presence of numerous stromal

cells without atypia in a background of granular amorphous

material, with presence of collagen fragments

Case Report : We encountered a case of fibromatosis of the

breast in a 33 year old female where the cytologic aspirates

were dominated by ductal cells with mild atypia. This led

to an erroneous diagnosis of low grade malignancy.

Conclusions : Careful sampling and multiple aspirations may

help in reaching a correct diagnosis in cases of fibromatosis

where stromal cells predominate. However in the absence of

these characteristic findings; and a presence of predominance

of epithelial elements, it may be wise to recommend tissue

confirmation, to avoid mutilating surgery.


88

PAEDIATRICS

1. Amar Taksande, STUDY OF RISK FACTOR FOR

CONGENITAL HEART DISEASES IN CHILDREN

AT RURAL HOSPITAL OF CENTRAL INDIA.

(International Saudi Heart Association Conference

SHA, RIYADH 11-14 Feb. 2008).

Objectives : To determine the risk factor for the development

of congenital heart disease (CHD)in children at Rural

hospital of Central India.

Settings : Study was conducted in the Department of

Pediatric, MGIMS, Sevagram, Maharashtra, India.

Design : Hospital based case control study conducted from

March 2004 to April 2007.

Methods : The children up to twelve year of age with clinical

suspicion of congenital heart disease were subjected to

chest x-ray and electrocardiography, and final diagnosis

was confirmed by echocardiography (n=209) as cases. The

control group (n=418) were randomly selected from children

without congenital heart disease who were admitted during

the same period. The etiological factors like environmental,

tertogens, infections, drugs, and maternal factors were

analyzed by using EPI 6 version.

Results : In cases group, 56% were male and 44% female

children, 82% cases presented at age of less than 5 years

and 18% after 5 year of age. Exposure to smoking

(OR=10.45, 95% CI 2.13; 69.71), tobacco intake by mother

(OR=8.28, 95% CI 1.62; 56.93) and family history of

congenital heart disease (OR=7.21, 95% cI 1.48; 35.01) were

the significant risk factor present in cases.

Conclusion : The risk factors which are present in congenital

heart disease child are exposure to smoking and tobacco

intake by mother, family history of congenital heart disease,

antenatal infection in 1st trimester and history of diabetic

mother.

2. Amar Taksande. PREVALENCE OF HYPERTENSION

IN SCHOOL GOING CHILDREN IN RURAL

AREA OF WARDHA DISTRICT, MS (Annual

conference of International Medical Science Academy,

12-13 Oct. 2008, DUBAI).

Objectives : To study the blood pressure level in the children

at rural area and its relationship with the anthropometric

indices. Also to know the prevalence of hypertension in

the school children in rural areas of Wardha Districts of

Central India.

Material and Methods : A prospective, cross-sectional study

was carried out from November 2006 to December 2007

on school children between the ages of 6-17 years, drawn

from 8 different schools in the rural areas of Wardha District.

The height, weight, systolic and diastolic blood pressure

were recorded for both sexes followed by complete clinical

examination with special stress on cardiovascular system.

Hypertension was defined as the arterial BP above the 95th

percentile with reference to age, sex and height. Coefficient

correlation tests were employed to see the relation between

blood pressure (BP) and anthropometric variables.

Result : Of 2643 school children, 1416 were girls and 1227

boys with a male to female ratio of 1:1.16. In boys, SBP &

DBP increased with age groups except at a) 17 year of age,

slight declination in SBP i.e. -0.09 and b) -1.29 declinations

in DBP at 16 year. In girls, SBP and DBP also increases with

age groups except at a) 11 year of age, slight declination in

SBP i.e. -0.09 and b) -0.24 declinations in DBP at 11 year

age. Correlation coefficient analysis showed positive and

significant correlation of age, height, weight, and body

mass index with each SBP and DBP. The prevalence of

hypertension was 6.73% (i.e. 3.90% for systolic HT and

2.83% for diastolic HT).

Conclusion : We recommend that the need for regular

check up of BP in the children to find out the hidden

cases of hypertension in children.

PHARMACOLOGY

1. PAPERS PRESENTED IN 41ST ANNUAL

CONFERENCE OF INDIAN PHARMACOLOGICAL


89

SOCIETY & INTERNATIONAL CONFERENCE

ON TRANSLATIONAL PHARMACOLOGY 2008

AIIMS ANSARI NAGAR, NEW DELHI. Comparative

study of chlorpromazine and resperidone on positive

and negative symptoms of schizophrenia. RK Gupta,

AP Singam.

Introduction : Schizophrenia is a devastating mental

disease that affecting human population worldwide with

prevalence of about 1%. Typical and atypical antipsychotics

are mainly used to treat schizophrenia. The typical

antipsychotic have autonomic side effects and EPS but

the drugs are cheaper and was found to more effective in

treating positive symptoms. Atypical antipsychotic takes

care of both positive and negative symptoms. Still there is

need for research in pharmacological intervention to treat

symptoms of the disease both positive and negative. Therefore

it was decided to conduct the study to assess the efficacy of

typical (chlorpromazine) I and atypical antipsychotic

(Resperidone).

Material and Method : It was a longitudinal single blind

prospective study 100 patients attending Psychiatry OPD

at KHS Sevagram, with Schizophrenia were selected (50

receiving Chlorpromazine and 50 receiving Risperidone).

They were interviewed and were administered test drug &

were followed up every 3 monthly for 1 year. Scoring was

done according to PANSS (Positive and Negative Symptom

Scale for Schizophrenia).

Results : Typical antipsychotics are better to treat positive

symptoms but not much effective in treating negative

symptoms of Schizophrenia. Atypical antipsychotics take

care of both positive and negative symptoms. Compliance

is better with atypicals

Discussion and Conclusion : After assessing the patient,

whether he has predominant positive or negative symptoms

the psychiatrist can decide either of typical or atypical

antipsychotic and this might be helpful for the better

treatment of the patient.

2. EFFECTS OF PANCHAGAVYA GHRITA (PG) ON

PARACETAMOL INDUCED HEPATOTOXICITY

IN ALBINO RATS. DD Gosavi1, J Premendran1,

D Sachdev1.

Introduction : Sushtrut Samhita mentions use of

Panchagavya Ghrita (PG) in the treatment of mania,

epilepsy, fever and hepatitis. In an effort to correlate the

ancient knowledge with the modern concepts of reasearch

int he Pharmacology, we decided to study the effects of PG

on paracetamol induced hepatotoxicity in rats.

Material and methods : The animals were divided into four

groups of 6 rats each. First two groups received PG in the

dose of 1 (PG1), 2(PG2),) ml per Kg of body weight for

thirty day. Third group received normal saline 2 ml per Kg

orally. The fourth group acted as a standard control and

received LIV 52 2ml/Kg body weight daily. Hepatotoxicity

was induced with Paracetamol 1gm/Kg body weight orally

once. Blood samples were collected and analyzed for liver

enzymes and bilirubin. Liver was separated and estimated

for Anti-oxidants (AO) in the liver tissue.

Results : PG prevented the increase in the liver enzymes

like AST, ALT and alkaline phosphatase produced by the

paracetamol. There was no significant effect on bilirubin.

It also has AO activity in vivo as shown by the changes in the

MDA, GSH and Catalase leveis.

Conclusion : Hepatoprotective action of PG can be due to

AO activity of PG. PG is a mixture of cow milk, ghee, urine,

dung, and curd milk. Cow milk contains minerals and vita-

mins. Cow urine contains minerals, urea, vitamins, enzymes,

and a large amount of free volatile acids with AO activity.

Of these which component is responsible for AO action is

difficult to comment.

3. EFFECT OF PANCHAGAVYA GHRUTA ON SOME

PARAMATERS IN ALBINO RATS. DD Gosavi, D

Sachdev, J Premendran.

Introduction : Sushrut samhita an authentic ayurvedic

text mentions the use of Panchagavya Ghruta (PG) in the

treatment of mania, epilepsy, fever and hepatitis. In an

effort to correlate the ancient knowledge with the moder

concepts of research in the pharmacology, we decided

to study the effects of Panchagavya Ghruta on some

parameters including anticonvulsant activity in rats.

Material and methods : For all the experiments the animals

were divided into three groups of 10 rats each. First three

groups received Panchagavya Ghruta in the dose of 1(PG1),

2(PG2), ml per Kg of body weight respectively and the fourth

group received normal saline 2ml per Kg orally twice daily

(9am-9pm) for 30 days. 1. Maximal electroshock induced

convulsions : After screening convulsions were induced by

maximal electroshock method. A current of 150mA was

delivered for 0.2sec using Techno convulsiometer. 2.

Spontaneous motor activity (SMA) : animals were screened

for SMA using Actophotometer. Animals were allowed to

adjust to the test chamber of the instrument for 30 minutes

and then activity was counted using the digital counter


90

for 5 minutes. 3. Pentobarbitone induced sleep time : Test

and control animals both were injected with injection

Pentobarbitone in the dose of 40-mg/Kg body weight. The

animals were observed for loss and recovery of righting

reflex for the calculation of duration of sleep. 4.

Haloperiodol induced catalepsy : Catalepsy was induced

by inj. Haloperiodol 1mg/kg i.p. and animal assessed with

catalepsy scale.

Results : In our study to study the effect of Panchagavya

Ghruta (PG) on some neurological parameters in rats we

found that, 1) PG protected rats from maximal electroshock

induced convulsions 2) had no effect on spontaneous motor

activity as measured by actophotometer. 3) Inhibited the

pentobarbitone induced sleep time in rats while 4) there

was no effect on the general behavior of the rats 5) PG

significantly potentiated the Haloperidol induced catalepsy.

Conclusions : To conclude it can be said that PG offers

protections against the MES induced convulsions without

producing any sedation in rats and also does not effect

the normal behavior of the animals. Potentiation of

catalepsy is an indicator of anti-psycotic action and

further studies are planned in this direction.

The animals were observed for loss and recovery

of righting reflex for the calculation of duration of sleeep

4. haloperidol induced catalepsy: catalepsy was induced

by inj. Haloperidol 1mg/kg i.p. and animal assessed with

catalepsy scale.

Results : In our study to study the effect of Panchagavya

Ghruta (PG) on some neurological parameters in rats we

found that, 1) PG protected rats from maximal electroshock

induced convulsions 2) had no effect on spontaneous motor

activity as measured by actophotometer. 3) Inhibited the

pentobarbitone induced sleep time in rats while 4) there

was no effect on the general behavior of the rats 5) PG

significantly potentiated the Haloperidol induced catalepsy.

Concludions : To conclude it can be said that PG offers

protections against the MES induced convulsions without

producing any sedation in rats and also does not effect the

normal behavior of the animals. Potentiation of catalepsy

is an indicator of anti-psycotic action and further studies

are planned in this direction.

4. TITLE : STUDY OF COMBINED EFFECT OF

CALCIUM CHANNEL BLOCKERS WITH

ANTIEPILEPTIC DRUGS IN MAXIMAL ELECTRIC

SHOCK AND PENTYLENETETRAZOL INDUCED

CONVULSIONS. R Brahmane, S Dahat.

Introduction : Present antiepileptic drugs unable to control

seizures effectively. Limitations highlighted need for

developing newer agents for epilepsy.

Materials and Methods : Effect of Phenytoin sodium

15mg/kg, sodium valproate 300mg/kg and carbamazepine

8mg/kg alone and in combination with cinnarizine

30mg/kg, Nimodipine 21mg/kg and Nifedipine 5mg/

kg studied in albinomice i.e. 12 mice in each group.

Seizures were induced by maximal electric shocks (MES)

by using electroconvulsionmeter and by Pentylenetetrazol

(PTZ) induced seizures. Abolition of hind limb tonic

extension was an index of anticonvulsant activity in MES.

Failure to observe even a single episode of tonic spasm for

5 second duration for 1 hour was an index of PTZ seizures.

With this percentage protection calculated. Combined

drugs are compared with antiepileptic drug alone to which

they are combined. For analysis formula of critical ratio

applied.

Results : In MES Seizures augmented effects obtained when

Cinnarizine and Nifedipine added to phenytoin sodium i.e.

66.66%; Nimodipine added to Carbamazepine i.e. 66.66%;

Cinnarizine and Nimodipine are combined with sodium

valproate i.e. 100%. In PTZ induced seizures augmented effects

obtained when Nimodipine combined with phenytoin

sodium i.e. 66.66%; Cinnarizine and Nifedipine combined

with carbamazepine i.e. 66.66%; Nifedipine and

Nimodipine combined with sodium valproate i.e. 100%.

Discussion and Conclusion : Cinnarizine given concurrently

with sodium valproate produces significant protection

against MES seizures. Nimodipine along with sodium

valproate produces significant protection against both MES

and PTZ induced seizures. Nifedipine along with sodium

valproate produces significant protection against PTZ

induced seizures. The results provide potential benefit

of combining calcium channel blockers with sodium

valproate in refractory epilepsy.


91

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