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Volume 30, Number 1, June 2019 From the desk of THE group editor-in-chief

Nipah Emerges Again in Kerala: Nipah Virus Update KK Aggarwal

CLINICAL STUDY

Correlation of Paroxysmal and Persistent Cardiac Arrhythmias with Clinical and Echocardiographic Parameters in Patients of Rheumatic Fever and Rheumatic Heart Disease Sarah Alam, Mu Rabbani, Ms Zaheer, Muhammad Uwais Ashraf, S Hasan Amir

Tropical Spastic Paraparesis Management with Herbal Neurogenic: A New Hope Avinash Shankar, Amresh Shankar, Anuradha Shankar

Diagnostic Utility of GeneXpert (CB-NAAT) and BACTEC (960) and Socio-clinical Profile of Children with Tuberculous Meningitis Satish Joharwal, Dhan Raj Bagri, JN Sharma

Prevalence of Inducible Clindamycin Resistance among Staphylococci in an Urban Tertiary Care Hospital of Jalandhar, Punjab

Sheevani, Jaspal Kaur, Kailash Chand, Gomty Mahajan, Shashi Chopra

A Simple Inexpensive Surface Applicator for High Dose Rate Intraluminal Brachytherapy of Anal Cancer

Meena J Shah, Rakesh K Vyas

Wooden Sticks as Object of Ocular Injury: Anti-infective Profile Mehul Shah, Shreya Shah, Pramod Upadhyay

A Study to Evaluate Safety and Efficacy of Postpartum Intrauterine Contraceptive Device Insertion

Mamta Rani, Parneet Kaur, Khushpreet Kaur, Gurdip Kaur, Satinder Pal Kaur

Case Report

Stroke in Hanging: Ischemic or Thrombotic? KA Vivek, N Vijayakumar, R Umarani

Lingual Thyroid: A Case Report Ponnathpur Lakshmi, Meena L

Ptosis in Poisoning: An Interesting Partnership S Saravana Moorthy, N Vijayakumar, R Umarani

Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com

Case Report

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Anjani Dixit, Monica Vohra Pandit

Amebiasis Mimics Malignancy in the Transverse Colon and Transpires in Liver Abscess BV Nagabhushana Rao, BVS Raman, Sailesh Modi, M Umamaheswara Rao

Complete Hydatidiform Mole Coexisting with a Live Fetus in Twin Pregnancy

Avishek Bhadra, Pallab Kumar Mistri, Bandana Biswas, Shilpa Kumari, Sudip Mukherjee

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INDIA LIVE 2019 Around the globe

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From the desk of THE group editor-in-chief

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Dr KK Aggarwal

Group Editor-in-Chief, IJCP Group

Nipah Emerges Again in Kerala: Nipah Virus Update

n June 4, the Kerala Health Minister confirmed that a 23-year-old college student admitted to a hospital in Kochi had been infected with the Nipah virus. The results of blood samples of the student, which were tested at the National Institute of Virology (NIV) in Pune confirmed Nipah. Earlier, blood samples examined at two virology institutes - Manipal Institute of Virology and Kerala Institute of Virology and Infectious Diseases - had indicated Nipah. It was around the same time last year, when the Nipah outbreak was reported from two districts of Kerala Kozhikode and Malappuram. The Indian Council of Medical Research (ICMR) had then confirmed that fruit bats were the primary source of the virus that killed 17 persons in the two districts. In 2015 and again last year, the World Health Organization (WHO) had cautioned about Nipah as one among eight emerging pathogens likely to cause severe outbreaks in the near future, and for which few or no medical countermeasures exist.

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Nipah outbreaks have been also reported in India: Siliguri outbreak in 2001: 45 deaths, Nadia-West Bengal outbreak in 2007: 5 deaths, Kerala outbreak in 2018: 17 deaths and Kerala 4th June 2019: 1 case.

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Agent: Nipah virus is a highly pathogenic paramyxovirus.

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Natural reservoir: Large fruit bats of Pteropus genus are the natural reservoirs of Nipah virus. Presumably, pigs may become infected after consumption of partially bat eaten fruits that are dropped in pigsties.

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Seasonality: All of the Nipah virus outbreaks have occurred during the months of winter to spring (December-May).

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Incubation period: 6-21 days.

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Mode of transmission: Direct contact with infected bats, infected pigs or from other Nipah virus infected people, especially by contact with body fluids; in hospital setting if appropriate personal protective equipments or standard infection control measures are not used; drinking of raw date palm sap or toddy contaminated with Nipah virus or through infected bat secretions during fruit tree climbing, eating/handling contaminated fallen fruits.

Nipah is not an airborne infection; the virus can persist on surfaces. Infection can spread through droplets and objects contaminated by secretions (urine, saliva, etc.) of infected animals or humans (fomite-borne Nipah virus transmission).

All about Nipah virus infection ÂÂ

The Nipah virus infection is a newly emerging zoonotic disease that takes its name from Sungai Nipah, the Malaysian village where it was first identified in 1998.

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Nipah virus infection is a notifiable disease.

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There is no National Program for Surveillance of Nipah virus. It is a part of Integrated Disease Surveillance Program (IDSP).

IJCP Sutra: "Achieve and maintain a healthy weight for your height."

from the desk of THE group editor-in-chief ÂÂ

Clinical features: Initial symptoms include fever, vomiting and severe headaches; some patients may have acute respiratory syndrome. Disorientation, drowsiness and mental confusion appear later on. Coma and death may occur within a day or two.

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Case-fatality rate: 40-75%; however, this rate can vary by outbreak and can be up to 100%.

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Diagnosis: Identification of Nipah virus RNA by polymerase chain reaction (PCR) from respiratory secretions, urine or cerebrospinal fluid and/or isolation of Nipah virus from respiratory secretions, urine or cerebrospinal fluid. In India, testing facility is available at NIV, Pune and NIV Alleppey.

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Treatment: Currently there is no known treatment or vaccine available for either people or animals. Intensive supportive care (bed rest, fluids) with symptomatic treatment is the main approach to managing the infection in people. Early treatment with ribavirin, an antiviral, may have a role in reducing mortality among patients with encephalitis caused by Nipah virus disease.

zz Distribute triple layer surgical masks to each household and keep sufficient stock (but avoid misuse/unnecessary use, as as it may create fear/panic). zz IEC on Nipah virus infection, symptoms and importance of contact tracing and home quarantine/isolation. zz Give his telephone number and number of control room/nearest health facility. zz Have location and details of dedicated ambulance and availability of disinfectant. ÂÂ

The case can transmit the disease from the development of first symptoms (which may be cough and/or fever with headache) till 21 days have passed from the last contact.

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During contact tracing, the person should be visited daily and/or enquired about telephonically about any fever, cough, headache (and/or other symptoms like altered sensorium, shortness of breath, etc.), or keeping a self-watch on developments of symptoms. If a contact develops symptoms, then he/she becomes a suspect case and should:

Isolation: The infected persons are kept in isolation in a room in the house or in isolation wards in designated hospital/s to prevent spread of the virus. Standard infection control protocol must be strictly adhered to. After the suspected case is transferred to the hospital, the room must be disinfected in accordance with prescribed SOPs by Lysol/5% sodium hypochlorite or any other disinfectant.

zz Immediately wear a triple layer mask and put him under self-isolation (means should not go near/maintain a distance of around 3 m to any other person). zz Inform concerned health worker (and or nearby doctor) and not to move by himself (unless there is delay and symptoms are getting worse). zz Dedicated ambulance (with driver and accompanying health staff having full protective gears) to be used for transporting all such suspects.

Prevention: Avoid exposure and contact with infected persons and animals, practice hand hygiene and use appropriate personal protective equipment, avoid consuming half eaten fruits lying on the ground, avoid abandoned caves and wells, avoid consuming raw date palm sap or toddy, follow government advisory when handling dead bodies of the infected persons.

zz Enlist all possible contacts since the time he/she has developed symptoms and inform health worker. zz Health worker has to put all such persons in contact list for further doing contact tracing for 21 days, since the time of last contact with a person having symptoms or till the time, the person's test for Nipah virus comes negative.

Contact tracing A contact is any person who has a history of contact with a case (person who is laboratory confirmed). Contact tracing must be done up to 21 days from the last case in the area within 5 km radius from the periphery of the affected area. ÂÂ

Each worker or person responsible for contact tracing should: zz Enlist all the contacts for tracing.

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All households and close contacts of a suspect case should be under home quarantine till the time test results of symptomatic comes negative. If test result comes positive then all such persons become contacts and have to be put under contact tracing for next 21 days.

IJCP Sutra: "Exercise regularly."

from the desk of THE group editor-in-chief

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

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The area/district/state can be declared free after 42 days from the date of last positive case reported from the district/state.

cure, it should be first submitted to the government for review. ÂÂ

The primary source should be traced - pig, bat or human.

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There should be guidelines and effective system for contact tracing and their management.

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There should be a standard protocol for case handlers and probable case spreaders.

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National surveillance in all cases of encephalitis for the cause, Nipah or any other.

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There should be a protocol for spread of encephalitis to contacts.

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A government advisory should be issued for handling of dead bodies of people who die due to the infection.

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The role of police, military and media should be well-defined.

Time for action and not reaction ÂÂ

Public health problems such as Nipah require a multilateral effort. So, any action taken involves education along with participation of all stakeholders, including the general public.

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A district, state, national and international plan of action should be in place.

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The public health information should include standard relevant messages for everyone and innovations in research. This information should include all Dos and Don’ts.

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There should be a uniform protocol for all systems of medicine.

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Doctors from all systems of medicine should refrain from any claims of cure. If they possess any such

Source: National Center for Disease Control, Recommended Community level Public Health Measures for Nipah virus infection; Nipah FAQs. ■■■■

90% Deaths Due to Cancer Caused by Tobacco Intake Nine out of 10 deaths caused by cancer are due to consumption of tobacco. In India, 7300 people die every year because of passive smoking, said Dr Arvind Pancholia, a member of Indian Medical Association (IMA) Indore Chapter. He was addressing a symposium in the city ahead of World No Tobacco Day. Pancholia said smoking is not only harmful for smokers, but also deadly for fetus. The doctors associated with IMA Indore Chapter stressed on sensitizing people. “Cigarette manufacturing cannot be stopped since it generates a lot of revenue, there can be a control on the consumption by spreading awareness,” Govt. Dental College principal Dr Deshraj Jain said. (ET Healthworld)

Hard-to-Treat Uterine Corpus Cancers on the Rise Among all US women, rates of more aggressive non-endometrioid cancer subtypes have been rising rapidly. And trends show marked racial differences and disparities, with higher rates of uterine corpus subtypes and poorer survival among non-Hispanic black women, reported a new study in the Journal of Clinical Oncology. The analysis, conducted by Megan A Clarke, PhD, and associates from the National Cancer Institute (NCI) in Bethesda, Maryland, found that hysterectomy-corrected uterine cancer incidence rates increased by approximately 1% per year from 2003 to 2015, with the most rapid increases occurring in non-white women, including Hispanic, Asian and especially black women. The study used data from the Surveillance, Epidemiology, and End Results (SEER) database to calculate rates of uterine corpus cancers in women ages 30-79 overall and by histologic subtype, 5-year age groups, and geographic region.

IJCP Sutra: "Eat a diet that is rich in fruits, vegetables and whole grains."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Correlation of Paroxysmal and Persistent Cardiac Arrhythmias with Clinical and Echocardiographic Parameters in Patients of Rheumatic Fever and Rheumatic Heart Disease SARAH ALAM*, MU RABBANI†, MS ZAHEER‡, MUHAMMAD UWAIS ASHRAF#, S HASAN AMIR#

Abstract Introduction: Acute rheumatic fever (ARF) is a multi-system disease caused by an abnormal immunological response after Group A β-hemolytic streptococcus (GABHS) infection. Arrhythmias, atrial fibrillation (AF) occurring in patients of rheumatic heart disease (RHD) are associated with increased risk of stroke. In the Framingham Heart Study, patients with RHD and AF had a 17-fold increased risk of stroke compared with age-matched controls, and the attributable risk was 5 times greater in those with nonrheumatic AF. Material and methods: A total of 92 patients of ARF and RHD from Medicine OPD, Medicine IPD, CCU, Cardiology OPD, Pediatrics OPD, Pediatrics IPD of a tertiary care hospital in North India were recruited in this study. A detailed history, physical examination and routine investigations were carried out. Ambulatory 24-hour Holter recordings were obtained in a standard fashion with 3-channel PC card recorders in all patients. Results: Of the 92 patients studied, 84 had RHD and 8 had rheumatic fever (RF). Maximum number of patients was in the age group 31-40 years. On echocardiography, range of left atrial diameter was 32-81 mm with mean of 50.45 ± 11.27 mm. Thirteen patients were found to have paroxysmal AF detected on Holter monitoring. Thirty-nine patients were found to have pauses detected on Holter monitoring. Out of these, 25 patients were found to have pauses >2.5 seconds. Forty-eight had episodes of paroxysmal supraventricular tachycardia (PSVT) detected on Holter. Seventy-two patients were found to have premature ventricular contractions (PVCs) on ambulatory ECG monitoring. Twenty-five patients had Holter detected episodes of bigeminy; 29 patients had episodes of nonsustained ventricular tachycardia (NSVT) detected on Holter. The association of arrhythmias with age was evaluated. Pauses, PSVT, AF and NSVT were found to have a significant association with advanced age. Severity of mitral stenosis was significantly associated with presence of AF and PVCs. Severity of mitral regurgitation was significantly associated with AF. Eight patients had acute RF and all patients were in New York Heart Association (NYHA) Class I. The PR interval was prolonged in 2 patients and was within normal limits in 6 patients. Pauses >1.5 seconds were detected in 2 patients. The duration of the longest pause was 1.60 seconds. Conclusion: RHD is a significant health problem in our region. It commonly affects young patients, compromising the workforce of a country. Only more symptomatic, severe cases belonging to higher functional classes report to hospital. Around one-third of patients are already in AF when they first seek treatment. Even in those patients who are in sinus rhythm, various arrhythmias can be detected on Holter monitoring.

Keywords: Acute rheumatic fever, arrhythmias, atrial fibrillation, rheumatic heart disease, echocardiography

*Senior Resident Dept. of Endocrinology All India Institute of Medical Sciences (AIIMS), New Delhi †Professor Centre for Cardiology ‡Professor #Assistant Professor Dept. of Medicine JN Medical College, AMU, Aligarh, Uttar Pradesh Address for correspondence Dr Muhammad Uwais Ashraf Assistant Professor Dept. of Medicine JN Medical College, AMU, Aligarh, Uttar Pradesh E-mail: uwaisashraf@gmail.com

cute rheumatic fever (ARF) is a multi-system disease caused by an abnormal immunological response after Group A β-hemolytic streptococcus (GABHS) infection. In 30-50% of cases, recurrent episodes of rheumatic fever (RF) may lead to chronic rheumatic heart disease (RHD), with progressive and permanent damage of the cardiac valves. The associated cardiac morbidity of RF with possible sequelae of heart failure, development of atrial fibrillation (AF), systemic embolism, transient ischemic attacks, strokes, endocarditis, the need for interventions

IJCP Sutra: "Limit sodium intake to under 2,300 mg a day (one teaspoon of salt)."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

including cardiac surgery and impaired quality-oflife, and shortened life expectancy, impose a heavy burden and has major implications for the individual. Arrhythmias, AF occurring in patients of RHD are associated with increased risk of stroke. In the Framingham Heart Study, patients with RHD and AF had a 17-fold increased risk of stroke compared with age-matched controls, and the attributable risk was 5 times greater in those with nonrheumatic AF. Holter monitoring is one of the most effective noninvasive clinical tools in the diagnosis and assessment of cardiac symptoms, prognostic assessment or risk stratification of various cardiac populations and in the evaluation of many cardiac therapeutic interventions. Data are limited regarding prevalence of arrhythmias in RHD patients and Holter monitoring is not part of their routine diagnostic work-up. The present work aims to study cardiac arrhythmias by Holter monitoring in patients of RF and RHD. Material and Methods This was an open-label, cross-sectional, hospital-based study. A total of 92 patients of ARF and RHD from Medicine OPD, Medicine IPD, CCU, Cardiology OPD, Pediatrics OPD, Pediatrics IPD of a tertiary care hospital in North India were recruited in this study. A detailed history and physical examination were carried out. Investigations carried out included, complete hemogram, blood urea, serum creatinine, urine analysis, liver function test, chest X-ray, electrocardiography (ECG), echocardiography and Doppler study. In patients of RF, additional investigations carried out were erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), serological examination for streptococcal antibodies (antistreptolysin-O, antideoxyribonuclease B), throat culture or rapid antigen test for Group A streptococcus. Ambulatory 24-hour Holter recordings were obtained in a standard fashion with 3-channel PC card recorders in all patients. All Holter recorders were subsequently analyzed using specialized software. All results were then visually analyzed to correct for artefact and any erroneous analysis. Statistical Analysis All statistical data were analyzed by using SPSS software version 20. Continuous variables were expressed as mean ± standard deviation (SD, Gaussian distribution) or range while proportions were expressed as percentages. Chi-square test was used for comparison of categorical variables between the groups, while unpaired t-test

for independent samples was used for comparing continuous variables between two groups. Values of p < 0.05 were considered statistically significant. Results Of the 92 patients studied, 84 had RHD and 8 had RF. Maximum number of patients was in the age group 31-40 years. Mean ± SD of age of RHD patients was 34.52 ± 14.47 years (range 13-76 years). Median age was 35 years. Twenty-eight patients (33.33%) were males and 56 (66.67%) were females. Among the 56 females, 26.8% were seen in 31-40 years age group and around 8% were seen in more than 50 years age group. The most common valvular lesion in RHD patients was mitral stenosis seen in 73 (86.9%) patients, followed by mitral regurgitation seen in 64 (76.2%) patients. Almost equal number of patients had aortic regurgitation and tricuspid regurgitation, which was seen in 25 (29.8%) and 24 (28.6%) patients, respectively. Aortic stenosis was seen in 3 (3.54%) patients. None of the patients had tricuspid stenosis or involvement of pulmonary valve. On echocardiography, range of left atrial diameter was 32-81 mm with mean of 50.45 ± 11.27 mm. Maximum mitral valve area was 4.40 cm2 and minimum was 0.60 cm2 with mean of 1.41 ± 1.15 cm2. Range of ejection fraction was 18-76% with mean of 58.79 ± 10.44% (Table 1). Figure 1 depicts scatter diagram showing plot of age and left atrial diameter on Echo of RHD patients. Among the 53 patients who had sinus rhythm on baseline ECG, 13 patients were found to have paroxysmal AF detected on Holter monitoring. Out of 84 RHD patients, 39 patients were found to have pauses detected on Holter monitoring. Out of these 39, 25 patients were found to have pauses >2.5 seconds. Among 39 patients who had pauses detected on Holter monitoring, 26 had chronic AF. Presence of pauses was strongly associated with AF (p < 0.001). Among 13 patients who had pauses and were in sinus rhythm, 2 were found to have paroxysmal AF (Table 2). Table 1. Echocardiography Findings Minimum

Maximum

Mean

LA diameter (mm)

32.00

81.00

50.45

11.27

MVA (cm2)

0.60

4.40

1.41

1.15

EF (%)

18.00

76.00

58.79

10.44

LA = Left atrial; MVA = Mitral valve area; EF = Ejection fraction.

IJCP Sutra: "Get adaquate of potassium (at least 4,700 mg/day) from fruits and vegetables."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Table 3. Arrhythmias Seen in RHD Patients

Arrhythmia

Present Absent

Pauses

LA Diameter (mm)

70 60

39 (46.7)

PSVT

48 (57)

31 (37)

Paroxysmal AF

30 (35.7)

PVC

72 (86)

Couplets

52 (62)

Bigeminy

25 (30)

Trigeminy

17 (20)

NSVT

29 (35)

30 20

Age (years)

Figure 1. Scatter diagram showing plot of age and left atrial diameter on Echo of RHD patients.

Table 2. Presence of Atrial Fibrillation in Relation to Pauses on Holter Monitoring Atrial fibrillation

Pause Total

Total

Table 4. Association of Arrhythmias with Different Parameters Parameter

Association

P value

Age

Yes

<0.001

NYHA class

Yes

0.032

Severity of MS

Yes

0.007

Present

Absent

Present

Severity of MR

0.110

Absent

Severity of TR

0.06

Severity of AS

0.596

Severity of AR

0.209

Out of 84 patients, 48 had episodes of paroxysmal supraventricular tachycardia (PSVT) detected on Holter. Seventy-two patients were found to have premature ventricular contractions (PVCs) on ambulatory ECG monitoring. Twenty-five patients had Holter detected episodes of bigeminy and 29 patients had episodes of nonsustained ventricular tachycardia (NSVT) detected on Holter (Table 3). The association of arrhythmias with age was evaluated. Pauses, PSVT, AF and NSVT were found to have a significant association with advanced age. There was an appreciable increase in these arrhythmias after the age of 40 years. Association of arrhythmias with increasing New York Heart Association (NYHA) class was found to be significant for pauses, PSVT, AF, couplets, bigeminy and trigeminy. Severity of mitral stenosis was significantly associated with presence of AF and PVCs. Severity of mitral regurgitation was significantly associated with AF. Severity of tricuspid regurgitation was found to have significant association

No. of patients, n (%)

MS = Mitral stenosis; MR = Mitral regurgitation; TR = Tricuspid regurgitation; AS = Aortic stenosis; AR= Aortic regurgitation.

with presence of bigeminy and NSVT. No association was found between severity of aortic stenosis/aortic regurgitation and cardiac arrhythmias. Arrhythmias significantly associated with left atrial diameter >45 mm were pauses, AF, PVCs, bigeminy, trigeminy and NSVT (Table 4). Paroxysmal AF was found to have a statistically significant association with advanced age, higher NYHA functional class and severity of mitral stenosis. In our study, 8 patients had ARF. All patients were in 11-20 years age group. Mean ± SD of age of RHD patients was 13.25 ± 1.17 years with range of 12-15 years. Out of 8 patients in the RF group, 5 were females and 3 were males. Fever was the commonest clinical manifestation seen, being present in 7 (87.5%) patients. Among the major manifestations, polyarthritis and carditis were the commonest, both being present in 6 (75%) patients. One patient had chorea. None of the

IJCP Sutra: "Reduce stress."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

patients had erythema marginatum or subcutaneous nodules. Two out of 8 patients gave prior history of sore throat infection 1-5 weeks before disease onset. Six out of 8 patients had mild mitral regurgitation, which was confirmed on echocardiography. No other valvular involvement was seen. All patients were in NYHA Class I. The PR interval was prolonged in 2 patients and within normal limits in 6 patients. No advanced degree atrioventricular block was observed. None of the patients had junctional rhythm. Two patients had ventricular premature contractions in 24-hour ECG. In none of the patients, ventricular couplets were present and no ventricular runs were detected. Pauses >1.5 seconds were detected in 2 patients. The duration of the longest pause was 1.60 seconds. No patient had AF, PSVT or ventricular tachycardia. Discussion Rheumatic heart disease is the world’s most common acquired cardiovascular disease. Worldwide, this disease is the leading cause of heart failure in children and young adults, resulting in disability and premature death and severely affecting the workforce in the developing nations. Because secondary prevention can prevent adverse outcomes, early echocardiographybased identification of silent RHD (showing no clinical signs) with minimal valve lesions by active surveillance programs might be of major importance. In the present study, the commonest valvular lesion among RHD cases was combined mitral stenosis with mitral regurgitation, seen in 22 (26.2%) RHD cases, which was similar to the findings of Joseph et al and Melka A where this pattern was seen in 25.4% cases. However, other studies have reported mitral regurgitation to be the commonest valvular presentation in RHD cases. The differences in the pattern of involvement of valvular lesion could be possibly due to the difference in the age of subjects in various studies. The mean left atrial diameter in our study was 50.45 ± 11.27 mm which was similar to the findings of Banerjee et al who found it to be 54.25 ± 1.48 mm. In current study, AF was present in 31 (37%) RHD patients on baseline ECG. Other studies have found rates ranging between 5.9% and 40%. Paroxysmal AF was detected on Holter in 13 out of 53 patients who had sinus rhythm on baseline ECG. This finding of 24% in our study was similar to the findings of 27% by Karthikeyan et al and 22.2% by Ramsdale et al. PVCs occurred in 72 (85.7%) RHD patients, with couplets in 52 (62%) patients, bigeminy in 25 (29.7%)

and trigeminy in 17 (20.2%) patients. This was similar to the findings of Ramsdale et al who found PVCs in 87.3% patients in a study done in Liverpool, UK. In our study, pauses were found in 39 (46.7%) patients detected on Holter monitoring. In a study done by Uebis et al to study asystolic pauses in 100 patients having AF by Holter monitoring, pauses longer than 2 seconds occurred in 57% of patients, but longer than 4 seconds only in 6 cases. They also found that a statistically higher frequency was seen in patients with permanent (78.3%) than in those with paroxysmal (24.5%) AF, and in patients with rheumatic valve disease (82.4%) in comparison with the rest (54.3%). They noted asystoles of up to 4 seconds duration in AF can be regarded as “normal” and longer asystoles must be anticipated particularly in patients with rheumatic valvular disease. It is only here that permanent pacemaker therapy appears to be indicated. Pauses, PSVT, AF and NSVT were found to have a significant association with advanced age and were found to be more common in patients over 40 years of age. Paroxysmal arrhythmias were also found to be more common in advanced age by Ramsdale et al. Significant association of arrhythmias was found with increasing NYHA class for pauses, PSVT, AF, couplets, bigeminy and trigeminy. The possible explanation could be that patients who are having paroxysmal arrhythmias are more symptomatic and thus belong to higher NYHA functional class. Besides, the presence of arrhythmias not only indicates chronicity and severity of lesions but could also be contributing factor for higher NYHA functional class. In our study, subclinical AF detected on Holter was associated with increasing age, higher NYHA functional class and severe mitral stenosis. In our study, presence of PVCs was associated with severity of mitral stenosis. Also, AF was found to be strongly associated with severity of mitral stenosis. Similar findings were noted in earlier studies. Presence of AF was also associated with severity of mitral regurgitation. This may be due to the reason that majority of patients in our study had combined mitral stenosis and mitral regurgitation. A study done by Diker et al noted that the highest frequency of AF in RHD occurs in those with mitral stenosis, mitral regurgitation and tricuspid regurgitation in combination. In patients of ARF, prior history of sore throat infection 1-5 weeks before disease-onset was found in 2 out of 8 cases and has ranged between 14% and 45.9% among cases in other studies. This wide variation in infection rates could be because of differing immunity

IJCP Sutra: "Monitor your blood pressure regularly, and work with your doctor to keep it in a healthy range."

Clinical Study status and living conditions among patients in different parts of the world. Cases with sore throat reported at schools and villages should be immediately referred to health centers for confirmation. PR prolongation in many ARF patients has been a well-known finding since 1920. In the present study, a pause >1.5 seconds on ECG was detected in 2 patients. The duration of the longest pause was 1.60 seconds. In the study by Karacan et al, on standard ECG, the frequency of the first-degree atrioventricular block was found to be 21.9%. ECG at 24 hours detected three additional and separate patients with a long PR interval. Mobitz type 1 block and atypical Wenckebach periodicity were determined in one patient (1.56%) on 24-hour ECG. Lower incidence of conduction abnormalities in our study could be due to small number of cases in our study. However, our results point towards the need of further Holter-based studies in patients of ARF. The prevalence of rhythm and conduction abnormalities may be much higher than determined on standard ECG. Conclusion Rheumatic heart disease is a significant health problem in our region. It commonly affects young patients, compromising the workforce of a country. Only more symptomatic, severe cases belonging to higher functional classes report to hospital. Around one-third of patients are already in AF when they first seek treatment. Even in those patients who are in sinus rhythm, various arrhythmias can be detected on Holter monitoring. Detection of paroxysmal AF on Holter can identify high-risk patients in which anticoagulation can be started and may prevent morbidity and mortality from stroke in such patients. Very few cases of RF report to hospital. Rhythm and conduction can be seen in RF patients also, although they are less common as compared to RHD patients. Very few Holter-based studies exist in literature to detect arrhythmias in patients of RHD and RF. Our study provides new insights as such a study has not been conducted previously in our region. More such studies are needed in future, so that high-risk patients can be identified and strategies can be formulated to improve outcomes in such patients. Suggested reading 1. Smith MT, Zurynski Y, Lester-Smith D, Elliott E, Carapetis J. Rheumatic fever - identification, management and secondary prevention. Aust Fam Physician. 2012; 41(1-2):31-5.

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019 2. Delunardo F, Scalzi V, Capozzi A, Camerini S, Misasi R, Pierdominici M, et al. Streptococcal-vimentin cross-reactive antibodies induce microvascular cardiac endothelial proinflammatory phenotype in rheumatic heart disease. Clin Exp Immunol. 2013;173(3):419-29. 3. White H, Walsh W, Brown A, Riddell T, Tonkin A, Jeremy R, et al. Rheumatic heart disease in indigenous populations. Heart Lung Circ. 2010;19(5-6):273-81. 4. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983-8. 5. Kennedy HL. The history, science, and innovation of Holter technology. Ann Noninvasive Electrocardiol. 2006;11(1):85-94. 6. Hegazy RA, Lotfy WN. The value of Holter monitoring in the assessment of pediatric patients. Indian Pacing Electrophysiol J. 2007;7(4):204-14. 7. Jackson SJ, Steer AC, Campbell H. Systematic Review: Estimation of global burden of non-suppurative sequelae of upper respiratory tract infection: rheumatic fever and post-streptococcal glomerulonephritis. Trop Med Int Health. 2011;16(1):2-11. 8. Carapetis JR. Acute rheumatic fever. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J (Eds.). Harrison’s Principles of Internal Medicine. 18th Edition, New York: The McGraw-Hill Companies; 2012. pp. 2752-7. 9. Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Jani D, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med. 2007;357(5):470-6. 10. Joseph N, Madi D, Kumar GS, Nelliyanil M, Saralaya V, Rai S. Clinical spectrum of rheumatic Fever and rheumatic heart disease: a 10 year experience in an urban area of South India. N Am J Med Sci. 2013;5(11):647-52. 11. Melka A. Rheumatic heart disease in Gondar College of Medial Sciences Teaching Hospital: socio-demographic and clinical profile. Ethiop Med J. 1996;34(4):207-16. 12. Fadahunsi HO, Coker AO, Usoro PD. Rheumatic heart disease in Nigerian children: clinical and preventive aspects. Ann Trop Paediatr. 1987;7(1):54-8. 13. Banerjee T, Mukherjee S, Ghosh S, Biswas M, Dutta S, Pattari S, et al. Clinical significance of markers of collagen metabolism in rheumatic mitral valve disease. PLoS One. 2014;9(3):e90527. 14. Chockalingam A, Gnanavelu G, Elangovan S, Chockalingam V. Clinical spectrum of chronic rheumatic heart disease in India. J Heart Valve Dis. 2003;12(5):577-81. 15. Karthikeyan G, Ananthakrishnan R, Devasenapathy N, Narang R, Yadav R, Seth S, et al. Transient, subclinical atrial fibrillation and risk of systemic embolism in patients with rheumatic mitral stenosis in sinus rhythm. Am J Cardiol. 2014;114(6):869-74.

IJCP Sutra: "Walk 80 minutes a day; brisk walk 80 minutes a week with a speed of 80 (at least) steps per minute."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019 16. Ramsdale DR, Arumugam N, Singh SS, Pearson J, Charles RG. Holter monitoring in patients with mitral stenosis and sinus rhythm. Eur Heart J. 1987;8(2):164-70. 17. Uebis R, Merx W, Fritzsche V. Asystolic pauses in atrial fibrillation. Incidence, dependence on the underlying disease and significance for pacemaker therapy. Dtsch Med Wochenschr. 1985;110(30):1157-60. 18. Moreyra AE, Wilson AC, Deac R, Suciu C, Kostis JB, Ortan F, et al. Factors associated with atrial fibrillation in patients with mitral stenosis: a cardiac catheterization study. Am Heart J. 1998;135(1):138-45. 19. Diker E, Aydogdu S, Ozdemir M, Kural T, Polat K, Cehreli S, et al. Prevalence and predictors of atrial fibrillation in rheumatic valvular heart disease. Am J Cardiol. 1996;77(1):96-8.

20. Arora R, Subramanyam G, Khalilullah M, Gupta MP. Clinical profile of rheumatic fever and rheumatic heart disease: a study of 2,500 cases. Indian Heart J. 1981;33(6):264-9. 21. Clarke M, Keith JD. Atrioventricular conduction in acute rheumatic fever. Br Heart J. 1972;34(5):472-9. 22. Hoffman TM, Rhodes LA, Pyles LA, Balian AA, Neal WA, Einzig S. Childhood acute rheumatic fever: a comparison of recent resurgence areas to cases in West Virginia. W V Med J. 1997;93(5):260-3. 23. Karacan M, Işıkay S, Olgun H, Ceviz N. Asymptomatic rhythm and conduction abnormalities in children with acute rheumatic fever: 24-hour electrocardiography study. Cardiol Young. 2010;20(6):620-30.

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Mumps and Measles Cases in England Prompt Vaccine Call A significant increase in mumps cases and continuing outbreaks of measles in England have led to calls for people to ensure they are immunized. Public Health England said even one person missing their vaccinations was “too many”. There were 795 cases of mumps in the first 3 months of 2019, compared with 1,031 in the whole of 2018. Most mumps cases are linked to teenagers mixing when they go to university. A large outbreak was centred on Nottingham Trent University and the University of Nottingham at the beginning of the year and similar increases in cases have been reported in Wales and Northern Ireland. (BBC)

FDA Approves First PI3K Inhibitor for Breast Cancer The US FDA approved alpelisib tablets, to be used in combination with the FDA-approved endocrine therapy fulvestrant, to treat postmenopausal women and men, with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, PIK3CA-mutated, advanced or metastatic breast cancer (as detected by an FDA-approved test) following progression on or after an endocrine-based regimen. The FDA also approved a companion diagnostic test, PIK3CA RGQ PCR Kit, to detect the PIK3CA mutation in a tissue and/or a liquid biopsy. Patients who are negative by the test using the liquid biopsy should undergo tumor biopsy for PIK3CA mutation testing. (FDA)

It Might Take 2 More Years to Contain Congo Ebola Outbreak, WHO Official Says In a "worst-case scenario," the current Ebola outbreak in the Democratic Republic of Congo may take up to 2 years to end, a World Health Organization (WHO) official said. The outbreak, which began on August 1, is "not under control," Dr Mike Ryan, Executive Director of WHO Health Emergencies Program, said during a press briefing. "We may end up dealing with this outbreak for a long time." Ryan said that numbers have stabilized and even fallen in the last 2 weeks, yet he also said there's still "substantial transmission" in some health zones. While there is a smaller geographic footprint, the spread of disease is rampant within affected zones, he added. (CNN)

IJCP Sutra: "Keep kidney and lung function more than 80%."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Tropical Spastic Paraparesis Management with Herbal Neurogenic: A New Hope AVINASH SHANKAR*, AMRESH SHANKAR†, ANURADHA SHANKAR‡

Abstract Tropical spastic paraparesis (TSP), a disease of the nervous system, is caused by human T-lymphotropic virus type 1, thus also known as HTLV-1 associated myelopathy. It is common among females of age group 30-50 years. In spite of advancement in diagnostic procedures, i.e., CT scan, MRI, etc., its treatment with α-interferon, steroids, antiviral drugs, neuro-vitamin supplementation, physiotherapy fails to ensure cure or improve quality-of-life except transient pain relief with analgesics and muscle relaxants. Thus, a therapeutic regime composite consisting of a proven herbal neurogenic has been evaluated. Objective of the study: To assess the herbal neurogenic and immune boosting composite in ensuring clinical relief and improving quality-of-life in patients deterred from various medicenters without any relief. Material and methods: Sixty-three diagnosed and already treated cases of tropical spastic paraparesis, attending the Centre for Critical Care, National Institute of Health and Research, Warisaliganj (Nawada), Bihar, were selected, interrogated, examined clinically, assessed and analyzed for their previous investigation reports, therapy taken and their effect. Irrespective of their clinical severity, all patients were advocated the prescribed regime and were followed for 2 years post-therapy for which patients were given a follow-up card to record the changes. Result: Approximately 88.9% patients had Grade I clinical response while rest 11.1% had Grade II clinical response without any untoward effect or any withdrawal during post-therapy 2 years follow-up. Conclusion: The present regime constituting intravenous calcium gluconate, intravenous methylcobalamin + pyridoxine + niacin, self-blood (2 mL) and intramuscular betamethasone 2 mg, capsule cholecalciferol 60K, syrup herbal neurotonic proved its worth in the management of TSP even in chronic and long-term treated cases.

Keywords: Tropical spastic paraparesis, human T-lymphotropic virus type 1, CT, MRI, herbal neurogenic, quality-of-life

ropical spastic paraparesis (TSP), a chronic and progressive clinical condition affecting the nervous system, remained of obscure etiopathogenesis for long, but nowadays, an important association of this condition has been established with human retrovirus (Human T-cell lymphotropic virus type 1), thus this condition is also termed as HTLV-1 associated myelopathy (HAM). As per World Health Organization (WHO) estimate, worldwide 10-20 million people are carrying HTLV-1 and

*Chairman National Institute of Health and Research, Warisaliganj (Nawada), Bihar †Director (Hon) Aarogyam Punarjeevan, Patna, Bihar ‡Ex-Director, Centre for Indigenous Medicine and Research and Senior Research Fellow, Regional Institute of Ayurveda, Itanagar, Arunachal Pradesh Address for correspondence Dr Avinash Shankar Chairman National Institute of Health and Research Warisaliganj (Nawada), Bihar E-mail: dravinashshankar@gmail.com

5% of them are affected with TSP in the age group of 30-50 years. TSP is very common in Latin America, the Caribbean Basin, sub-Saharan Africa and Japan, but these days, incidence of this clinical state is increasing even in India. Common presentation of the clinical condition is: ÂÂ

Gradual weakening and stiffening of lower extremity

ÂÂ

Radiating back pain down to legs

ÂÂ

Burning and pricking sensation (paresthesia)

ÂÂ

Urinary and bowel function disturbances

ÂÂ

Erectile dysfunction in males

ÂÂ

Inflammatory skin condition, like dermatitis or psoriasis

ÂÂ

Rarely may present with eye inflammation, arthritis and muscle inflammation.

The common mode of transmission of this virus is through: ÂÂ

Breastfeeding

IJCP Sutra: "Eat less; not more than 80 g/80 mL of caloric food in one meal."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

ÂÂ

Sharing infected needles during intravenous drug use

ÂÂ

Sexual activity

ÂÂ

Blood transfusions.

In spite of advancement in diagnostics (computed tomography [CT] scan and magnetic resonance imaging [MRI]) and its established etiopathogenesis, till date, no established therapeutic regime has ensured its reversal but only symptomatic relief through α-interferon, intravenous immunoglobulin, antiviral drugs and muscle relaxants is available. Signs and symptoms vary but may include slowly progressive weakness and spasticity of one or both legs, exaggerated reflexes, muscle contractions in the ankle and lower back pain. Other features may include urinary incontinence and minor sensory changes, especially burning or prickling sensations and loss of vibration sense. Considering the poor quality-of-life with present therapeutics, a clinical study was planned to evaluate the clinical efficacy of proved neurogenic herbal composite with neuromodulator at National Institute of Health and Research and Centre for Research in Indigenous Medicine.

Based on clinical presentation, patients were classified as summarized in Table 1. Patients were investigated for hemoglobin concentration, total and differential leukocyte count, erythrocyte sedimentation rate (ESR), peripheral smear, fasting and postprandial blood sugar, renal and liver function tests and serological test for syphilis. Common presentation of TSP is summarized in Table 2. All patients underwent conventional myelography, CT and MRI scans. The serum samples of all the patients were tested for HTLV-1 antibodies by the Serodia technique. All patients presenting with this crippling disease were advised and administered the following therapeutic regime after due awareness counseling and encouragement: ÂÂ

Injection calcium gluconate 1 amp every 15th day intravenous, very slow

ÂÂ

Injection methylcobalamin + pyridoxine + niacinamide + pantothenic acid + betamethasone every week

Table 1. Clinical Presentation-based Classification

Objective of the Study To evaluate the clinical efficacy and safety profile of herbal neurogenic with neuromodulator in TSP.

Duration of Study

Severity Grade

Characteristics

Mild

Patients presenting with back pain, tingling and numbness in the leg

Moderate

Patient presenting with back pain, tingling and numbness, tendency to fall, heaviness in the lower extremity, leg weakness

Severe

Back pain, gait disturbance, stumbling, leg weakness, hyperreflexia and extensor plantar reflex, overactive bladder, constipation and sexual dysfunction

January 2014 to December 2018. Material and Methods

Material Proved and treated cases of TSP without any clinical response, attending the Centre for Critical Care, National Institute of Health and Research, Warisaliganj (Nawada), Bihar were considered for evaluation of the herbal neurogenic constituting therapeutic regime.

Disturbances Symptoms

Signs

Methods

Motor

Gait disturbance, tendency to fall, stumbling and leg weakness

Spastic paraparesis, weakness hyperreflexia lower limb, clonus, extensor plantar reflex

Sensory

Pain, numbness at lumbar level and backache

Feet paresthesia, loss of light touch sensory level at lower thoracic level

Autonomic

Urinary dysfunction, Neurogenic or constipation, sexual overactive bladder, dysfunction diminished peristalsis, erectile dysfunction

Patients of spastic paraparesis diagnosed by myelogram, CT and MRI were interrogated thoroughly for the onset, duration and evolution of the disease, family history of neurological illness, history of extramarital sexual exposure, abortion, blood transfusions, dietary choices with emphasis on strict vegetarianism, Lathyrus sativus use, socioeconomic status, housing, sanitary conditions, treatment taken and their response. A detailed general examination and a meticulous neurological assessment were done.

Table 2. Common Presentation of Tropical Spastic Paraparesis

IJCP Sutra: "Do not eat refined carbohydrates 80 days in a year."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

ÂÂ

Injection self-blood + betamethasone 2 mg every 10th day intramuscular

ÂÂ

Capsule vitamin D3 60K every week orally

ÂÂ

Syrup herbal neurogenic 10 mL every 12 hours/ Capsule herbal neurogenic 1 cap every 12 hours

ÂÂ

Active and passive exercise of the extremity

ÂÂ

Diet: High protein vegetarian diet.

Herbal composite neurogenic capsule 500 mg or syrup 5 mL constitutes 100 mg each of Acorus calamus (rhizome), Nardostachys jatamansi (flower), Herpestis monniera (leaf), Convolvulus pluricaulis (flower) and Cassia acutifolia (seed).

Table 4. Distribution of Patients as per Age and Sex Age group (years)

Number of patients Male

Female

Total

30-35

35-40

40-45

45-50

Male

Female

Patients were assessed for improvement in tone and power of the muscle, tingling and numbness, gait and autonomic function (passage of stool and urine) for which patients were given a follow-up card to mention date of achievement and any untoward manifestation experienced. Patients were advised to visit the center on any unusual manifestation or contact on helpline for needful redresses. To adjudge the safety profile of the regime practiced, basic bio-parameters were repeated every month for first 3 months and then every 3 months. Based on the clinical outcome and safety profile therapeutic response was graded as Table 3.

Result Sixty-three identified, diagnosed and treated patients of TSP were considered for the study and out of them, majority (30/63) were in the age group 30-35 years with female dominance (Table 4 and Fig. 1) and all were from rural background. The community representation is depicted in Figure 2.

Figure 1. Pie diagram showing distribution as per sex.

Dalit

Majority of the patients was nonvegetarian and none had any history of taking Lathyrus sativus (Fig. 3). The age of onset of clinical presentation varied from 20 to 40 years and duration of illness from 1 to 12 years (Fig. 4). Symptoms at the onset were difficulty

Muslim

Other

Table 3. Grade of Therapeutic Response Clinical Grade

Characteristics

Grade I

Complete recovery of power and tone without any residual neurological deficit and adversity

Grade II

Improvement in power and tone with residual paresis and sensory deficit without any adversity

Grade III

No alteration in status

Figure 2. Pie diagram showing distribution of patients as per community.

IJCP Sutra: "Take vitamin D through sunlight 80 days in a year."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

in walking, stiffness of legs, back pain, weakness of legs, leg pain and urinary discomfort (Table 5) while presentation at our center included disturbed gait, leg stiffness, back pain, leg pain, urinary discomfort, urinary retention, tingling and numbness and erectile dysfunction in males (Table 5). No history of blood transfusion, abortion, delivery or surgery prior to onset of the disease was evident but serum samples tested positive for HTLV-1 in 49 cases out of 63 (Fig. 5). In addition, all the bio-parameters (hepatic, hematological and renal profile) were normal. No patients were positive for tuberculosis, any sexually Vegetarian

Nonvegetarian

transmitted disease. In terms of clinical severity, out of 63Â patients, 13 were of moderate and 50 were of severe status (Fig. 6). Patients had taken treatment with Îą-interferon, muscle relaxants, neuro-vitamin supplementation at various medicare centers without any positive therapeutic outcome (Table 6). Symptomatic relief started from 4th week of therapy and by 24th week, all had symptomatic relief (Fig. 7). The minimum and maximum duration of therapy required for complete reversal of clinical presentation Table 5. Distribution of Patients as per their Clinical Presentation Clinical presentation

Number of patients

Difficulty in walking

Leg stiffness

Back pain

Weakness of the legs

Leg pain

Tingling and numbness

Gait disturbance

Urinary discomfort

Sexual weakness

History of surgery, abortion and blood transfusion Figure 3. Pie diagram showing distribution of patients as per dietary status. 18

None

HTLV-1 positive

HTLV-1 negative

Number of patients

14 12 10 8 6 4 2 0

1-2

2-3

3-4

4-5

Duration (years)

Figure 4. Bar diagram showing distribution of patients as per duration of illness.

Figure 5. Pie diagram showing HTLV-1 status of the patients.

IJCP Sutra: "Do 80 cycles of Pranayama in a day with a speed of 4 breaths/minute."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

60 50

Number of patients

30 20

40 30 20

13 10

10 0

Mild

Moderate

Severe

7 0 Grade I

Grade II

Grade III

Clinical grades

Degree of severity

Figure 6. Bar diagram sowing clinical severity of illness.

Figure 8. Bar diagram showing grades of clinical response.

Discussion Table 6. Treatments Taken in Past Therapy taken

Number of patients

α-interferon

Antiviral drug

Muscle relaxants

Neuro-vitamin supplement

Active and passive exercise

Pain relief

Gait

Tingling and numbness

70 Number of patients

60 50 40 30 20 10 0

4th

8th

12th

16th

20th

24th

Duration (week)

Figure 7. Graph showing duration required for improvement in presentation.

(both symptom and sign) was 9 months and 2 years, respectively. In all, 56 patients achieved Grade I clinical improvement and 7 achieved Grade II improvement (Fig. 8). No patients had shown any adversity, recurrence of presentation or any alteration in bio-parameters in 2 years of post-therapy follow-up (Table 7).

Tropical spastic paraparesis is becoming a common neurological disorder in India though it is common in different parts of the world including Jamaica, Martinique, Seychelles, Colombia and Japan. While it was considered as a neurological disorder of obscure etiology, these days, it is proved to be caused by HTLV-1. In spite of advancement in diagnostics like CT, MRI, cerebrospinal fluid (CSF) and serum for HTLV-1 antigen, the therapeutics used, i.e., α-interferon, muscles relaxant and neuro-vitamin supplement, fail to ensure cure or improve quality-of-life, except for transient symptomatic relief. The current study showed clinical supremacy in terms of marked improvement in pain, sensation and gait of the already treated patients with other regime and achieving Grade I clinical response in 88.9% patients and Grade II in rest 11.1%. No patients had any withdrawal or drug adversity in 2 years post-therapy follow-up. This clinical efficacy can be explained considering the pathogenesis and causation due to HTLV-1 infected T cells (Fig. 9). Self-blood with betamethasone intramuscular induces antibody formation against the released toxin and ensure their neutralization, while betamethasone, acting as anti-inflammatory agent, reduces neural edema, which is synergized by intravenous calcium administration. Methylcobalamin, pyridoxine, niacin and pantothenic acid support neural cells in its normal neural conduction and a herbal neurogenic, by its neurogenic activity helps in restoration of neural viability and vitality which combinely ensure relief in pain, neuropathic

IJCP Sutra: "Avoid exposure to >80 dB of noise pollution."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Table 7. Outcome of the Study Particulars

Number of patients

Duration in months

Clinical relief

Back pain

Tingling numbness

Pain in legs

Autonomic disturbance

Gait

SGOT (<35 IU)

SGPT (<35 IU)

Alkaline phosphatase (<100)

Blood urea (<26 mg%)

Serum creatinine (<1.5 mg%)

Albumin-Negative

RBC-Negative

Post-therapy bio-parameters Hepatic profile:

Renal parameters

Urine

Hematological Hemoglobin (>10 gm%) Clinical grade Grade I

Grade II

Grade III

manifestation, gait and autonomic function and provide better quality-of-life to all.

HTLV-1 infected T-cell Proinflam matory cells

HTLV-1

Conclusion

Invasion

Peripheral blood

Spinal cord

Present regime constituting calcium gluconate intravenous, methylcobalamin + pyridoxine + niacin intravenous, self-blood (2 mL) and betamethasone 2Â mg intramuscular, capsule cholecalciferol 60K, syrup herbal neurogenic proved its worth in the management of TSP even in chronic and long-term treated cases. Suggested reading

HTLV-1 Chronic inflammation

Destruction and degeneration of CNS tissue

Figure 9. Pathogenesis and causation due to HTLV-1 infected T cells.

1. World Health Organization (WHO). Report of the scientific group on HTLV-1 and diseases, Kagoshima, Japan, December, 1988. Virus Diseases, Human T-lymphotropic virus type 1, HTLV-1.Â Wkly Epidemiol Rec. 1989;64:382-3.

IJCP Sutra: "Avoid prolonged exposure to sun when the temperature is high."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

2. Orland JR, Engstrom J, Fridey J, Sacher RA, Smith JW, Nass C, et al; HTLV Outcomes Study. Prevalence and clinical features of HTLV neurologic disease in the HTLV Outcomes Study. Neurology. 2003;61(11):1588-94. 3. Blattner WA, Gallo RC. Epidemiology of human retroviruses. Leuk Res. 1985;9(6):697-8. 4. Oomman A, Madhusoodanan M. Tropical spastic paraparesis in Kerala. Neurol India. 2003;51(4):493-6. 5. Román GC. The neuroepidemiology of tropical spastic paraparesis. Ann Neurol. 1988;23 Suppl:S113-20. 6. Arango C, Concha M, Zaninovic V, Corral R, Biojo R, Borrero I, et al. Epidemiology of tropical spastic paraparesis in Columbia and associated HTLV-1 infection. Ann Neurol. 1988;23 Suppl:S161-5. 7. Richardson JH, Newell AL, Newman PK, Mani KS, Rangan G, Dalgleish AG. HTLV-I and neurological disease in South India. Lancet. 1989;1(8646):1079. 8. Gessain A, Barin F, Vernant JC, Gout O, Maurs L, Calender A, et al. Antibodies to human T-lymphotropic virus type-I in patients with tropical spastic paraparesis. Lancet. 1985;2(8452):407-10. 9. Rubin M. Tropical spastic paraparesis/HTLV-1–associated myelopathy (TSP/HAM). Merck Manual. October, 2016. Available at: http://www.merckmanuals.com/professional/ neurologic-disorders/spinal-cord-disorders/tropicalspastic-paraparesis-htlv-1%E2%80%93associated-mye lopathy-tsp-ham. 10. Tropical spastic paraparesis information page. National Institute of Neurological Disorders and Stroke. Available at: https://www.ninds.nih.gov/Disorders/All-Disorders/ Tropical-Spastic-Paraparesis-Information-Page. Accessed on Dec 7, 2017. 11. Iwasaki Y. Pathology of chronic myelopathy associated with HTLV-I infection (HAM/TSP). J Neurol Sci. 1990;96(1):103-23. 12. Izumo S, Umehara F, Osame M. HTLV-1 associated myelopathy. Neuropathology. 2000;20:565-8. 13. Osame M. Pathological mechanisms of human T-cell lymphotropic virus type I-associated myelopathy (HAM/ TSP). J Neurovirol. 2002;8(5):359-64.

14. Lezin A, Olindo S, Oliere S, Varrin-Doyer M, Marlin R, Cabre P, et al. Human T lymphotropic virus type I (HTLV-I) proviral load in cerebrospinal fluid: a new criterion for the diagnosis of HTLV-I-associated myelopathy/tropical spastic paraparesis? J Infect Dis. 2005; 191(11):1830-4. 15. Matsuzaki T, Nakagawa M, Nagai M, Usuku K, Higuchi I, Arimura K, et al. HTLV-I proviral load correlates with progression of motor disability in HAM/TSP: analysis of 239 HAM/TSP patients including 64 patients followed up for 10 years. J Neurovirol. 2001;7(3):228-34. 16. De Castro-Costa CM, Araújo AQ, Barreto MM, Takayanagui OM, Sohler MP, da Silva EL, et al. Proposal for diagnostic criteria of tropical spastic paraparesis/ HTLV-I-associated myelopathy (TSP/HAM). AIDS Res Hum Retroviruses. 2006;22(10):931-5. 17. Bagnato F, Butman JA, Mora CA, Gupta S, Yamano Y, Tasciyan TA, et al. Conventional magnetic resonance imaging features in patients with tropical spastic paraparesis. J Neurovirol. 2005;11(6):525-34. 18. Scadden DT, Freedman AR, Robertson P. Human T-lymphotropic virus type I: Disease associations, diagnosis, and treatment. Waltham, MA: UpToDate; February 16, 2016. Available at: http://www.uptodate.com/ contents/human-t-lymphotropic-virus-type-i-diseaseassociations-diagnosis-and-treatment. 19. Sandbrink F. Tropical myeloneuropathies treatment & management. January 2015. Available at: http://emedicine. medscape.com/article/1166055-treatment. 20. Arimura K, Nakagawa M, Izumo S, Usuku K, Itoyama Y, Kira J, et al. Safety and efficacy of interferon-alpha in 167 patients with human T-cell lymphotropic virus type 1-associated myelopathy. J Neurovirol. 2007;13(4):364-72. 21. Croda MG, de Oliveira AC, Vergara MP, Bonasser F, Smid J, Duarte AJ, et al. Corticosteroid therapy in TSP/ HAM patients: the results from a 10 years open cohort. J Neurol Sci. 2008;269(1-2):133-7. 22. Taylor GP, Goon P, Furukawa Y, Green H, Barfield A, Mosley A, et al. Zidovudine plus lamivudine in human T-lymphotropic virus type-I-associated myelopathy: a randomised trial. Retrovirology. 2006;3:63.

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Estrogen a Possible Treatment Option for Women with Schizophrenia Adjunctive estrogen may be effective in reducing symptoms in women with schizophrenia and offers a potential new treatment option, suggests new research. A systematic literature review conducted by investigators at the University of Maryland in Baltimore revealed that the addition of estrogen reduced schizophrenia symptoms in a dose-dependent, and statistically significant, manner compared with stand-alone antipsychotic treatment. The findings were presented at the American Psychiatric Association (APA) 2019 annual meeting.

IJCP Sutra: "Use an umbrella if you need to go out when the temperature is high."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Diagnostic Utility of GeneXpert (CB-NAAT) and BACTEC (960) and Socio-clinical Profile of Children with Tuberculous Meningitis SATISH JOHARWAL*, DHAN RAJ BAGRI†, JN SHARMA‡

Abstract Introduction: Tuberculosis has always remained puzzling to diagnose. Many children with tuberculous meningitis are diagnosed late due to non-availability of rapid and sensitive diagnostic tests. This study examines the diagnostic utility of GeneXpert test and BACTEC (960) and compares of the sensitivity and specificity of these newer tests. Material and methods: This hospital-based prospective study was conducted in the Dept. of Pediatrics, Sir Padampat Mother and Child Health Institute, SMS Medical College, Jaipur, Rajasthan. Seventy children of >6 month and <18 years age, presenting with fever of >2 weeks duration, headache, signs of meningeal irritation, altered consciousness level and focal neurological deficits were included in the study. Results: Out of 14 patients detected positive by GeneXpert, BACTEC (960) was detected positive in only 4 patients. Out of 56 negative patients detected by GeneXpert, 2 patients were detected positive by BACTEC (960). The sensitivity was 66.67%, specificity was 84.38%, positive predictive value was 28.57%, negative predictive value was 96.63% and accuracy was 82.86%. Conclusions: The GeneXpert has higher sensitivity compared to other currently available diagnostic modalities including liquid culture BACTEC.

Keywords: Tuberculosis, tuberculous meningitis, GeneXpert, BACTEC (960), sensitivity, specificity

uberculous meningitis (TBM) due to Mycobacterium tuberculosis is a dreaded consequence. Early diagnosis and treatment for TBM is the best predictor of survival.1-4 However, many children are diagnosed late because of vague initial signs, paucibacillary nature and lack of rapid and sensitive diagnostic tests. Various laboratory tests such as microscopy and culture of cerebrospinal fluid (CSF) have poor yield. Ziehl-Neelsen (ZN) microscopy staining of CSF is the most widely applied rapid diagnostic technique; however, sensitivity for TBM rarely exceeds 20%.5 Liquid culture techniques,

including the mycobacterial growth indicator tube (mycobacterial growth indicator tube [MGIT]; BACTEC) and the mycobacterial observation drug susceptibility assay (MODS) culture, offer improved sensitivity over solid culture, to a sensitivity of almost 60%.5 The present study was conducted to assess the diagnostic utility of GeneXpert test and BACTEC (960) in detection of M. tuberculosis in TBM and to assess and compare the sensitivity and specificity of GeneXpert (Catridgebased nucleic acid amplification test [CB-NAAT]) and BACTEC (960) molecular diagnostic test. Material and Methods

*Senior Resident †Assistant Professor ‡Professor Dept. of Pediatrics Sir Padampat Mother and Child Health Institute (JK Lon Hospital), SMS Medical College, Jaipur, Rajasthan Address for correspondence Dr Dhan Raj Bagri Assistant Professor Dept. of Pediatrics Sir Padampat Mother and Child Health Institute (JK Lon Hospital), SMS Medical College, Jaipur, Rajasthan E-mail: meena.drdhanraj6@gmail.com

This hospital-based prospective study was conducted in the Dept. of Pediatrics, Sir Padampat Mother and Child Health Institute, SMS Medical College, Jaipur, Rajasthan, after getting requisite clearance from the research review board of the institute. All children >6 month and <18 years age, presenting with fever of >2 weeks duration, headache, signs of meningeal irritation, altered consciousness level and focal neurological deficits were considered for study and were diagnosed on the basis of Indian Academy of Pediatrics (IAP) 2015 guidelines. Sample size was calculated at 95%

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Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

confidence level (-error of 0.05) assuming 38.2% sensitivity of GeneXpert in suspected TBM cases. At the prevalence of 61% of suspected TBM among clinically suspected TBM, the required sample size will be 68 clinically suspected TBM cases, which were further rounded of to 70 cases. Patients already on antituberculosis drugs and patients having comorbid disease and patients with negative consent were excluded from the study. The Xpert MTB/RIF (resistance to rifampicin) is a CB-NAAT, an automated diagnostic test that can indentify M. tuberculosis DNA and RIF by nucleic acid amplification test (NAAT). BACTEC MGIT (960) produced by Becton Dickinson (BD) is specially designed to accommodate MGIT and incubate them at 37°C. Results are obtained within 2 hours. The instrument scans the MGIT every 60 minutes for increased fluorescence. Analysis of the fluorescence is used to determine if the tube is instrument positive; i.e., the test sample contains viable organisms. Culture tubes which remain negative for a minimum of 42 days (up to 56 days) and which show no visible signs of positivity are removed from the instrument as negative and discarded.6 Observations and Results

Demographic Patterns of Study Population In our study, maximum patients (64.29%) were in the 6 months to 6 years age group followed by 24.29% patients aged 6-12 years and 11.43% patients aged 12-18 years (Fig. 1). Nearly 58.57% patients were male and 41.43% patients were female. 6 months to 6 years

6-12 years

Approximately 68.57% patients belonged to rural area and 31.43% patients were from urban area. Nearly 92.86% patients were Hindu and 7.14% patients were Muslim. Most of the patients (38.57%) were from lower socioeconomic strata and 28.57% patients were from upper lower socioeconomic strata, 15.71% patients were from lower middle socioeconomic strata. About 8.57% patients were from lower middle and upper socioeconomic strata. In our study, all patients presented with fever, 54 patients presented in altered sensorium, 34 patients presented with headache, 22 patients presented with vomiting and 21 patients presented with seizure (Fig. 2). We observed that 41.43% patients presented with positive family history of tuberculosis and 47.14% patients presented positive history of bacillus CalmetteGuérin (BCG) vaccination. Out of 42 confirmed cases of TBM, BCG scar was positive in 2 cases; so other factors like malnutrition may be attributable for depressed immunity in BCG vaccinated children.

Nutritional Status Indicators of Affected Children In our study, 30% patients had weight-for-age between -3 and -2 SD followed by 28.57% patients with weightfor-age -2 to -1 SD, 8.57% patients weight-for-age was below -3 SD and 22.85% patients weight-for-age normal (Table 1). Mantoux test: In the study, 31.43% patients tested tuberculin positive with Mantoux test (MT) >10 mm. MT >10 mm was considered positive and presence of BCG scar did not affect interpretation. Most of the

12-18 years 70

11.43

Number of Cases

24.29

64.29

20 10

ap p

eti

mo ti se

kn es

izu

We a

itin g Vo m

se Alte ns re ori d um He ad ac he

ve r

Figure 1. Age distribution of study population.

Figure 2. Clinical profile of study population.

IJCP Sutra: "Make sure that you are properly hydrated before you step out in the heat."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Table 1. Nutritional Status Indication of Affected Children Weight-for-age according to WHO growth chart Yes

Below -3 SD

8.57

-3 to -2 SD

30.00

-2 to -1 SD

38.57

Normal

22.85

Total

100.00

Table 2. Sputum - AFB (ZN-staining) GA/Sputum-AFB (ZN-staining)

Number of patients (n = 70)

Percentage (%)

Present

5.71

Absent

94.29

Total

100.00

unvaccinated children (without BCG scar) developed invasive tuberculosis. GA/Sputum for AFB (ZN-staining): Sputum for acidfast bacilli (AFB) test was positive in only 5.71% patients (Table 2). Sputum CB-NAAT (GeneXpert): Sputum CB-NAAT was positive in 4.29% (3) patients. CSF for AFB (ZN-staining): CSF for AFB was positive in 15.71% (11) patients. CSF for BACTEC (960): CSF for BACTEC (960) was positive 8.57% patients. CSF for GeneXpert (CB-NAAT): CSF for GeneXpert (CB-NAAT) was positive in 20% (14) patients. Comparison b/w GeneXpert and CSF AFB: Comparison of results between GeneXpert and CSF AFB suggested that out of 14 positive patients detected by GeneXpert, CSF for AFB was positive only in 6 patients. Out of 56 negative patients detected by GeneXpert, 3 patients were positive by CSF for AFB (Table 3). When comparing GeneXpert and CSF AFB, the sensitivity was 72.73%, specificity was 89.83%, positive predictive value was 57.14%, negative predictive value was 93.64% and accuracy was 87.14% with Chi-square P value = 0.001. Comparison b/w GeneXpert and BACTEC (960): Out of 14 patients detected positive by GeneXpert, BACTEC (960) was detected positive in only 4 patients. Out of

Table 3. Comparison b/w GeneXpert and CSF AFB GeneXpert

Total

CSF AFB Yes

Yes

Table 4. Comparison b/w GeneXpert and BACTEC (960) GeneXpert

Total

BACTEC (960) Yes

Yes

56 negative patients detected by GeneXpert, 2 patients detected positive by BACTEC (960) (Table 4). The sensitivity was 66.67%, specificity was 84.38%, positive predictive value was 28.57%, negative predictive value was 96.63% and accuracy was 82.86% with Chisquare = P value = 0.0124. Summary and Conclusions Maximum patients (64.29%) were in 6 months to 6 years age group followed by 24.29% patients of 6-12 years of age and 11.43% patients aged 12-18 years. Approximately 47.14% patients presented positive history of BCG vaccination and only 7.14% patients presented with history of measles and pertusis. In 30% patients, weight-for-age was -3 to -2 SD, followed by 28.57% patients with weight for age -2 to -1 SD. In 8.57% patients, weight-for-age was below -3 SD and 22.85% patients’ weight-for-age was normal. Nearly 31.43% patients’ tuberculin test was positive and 5.71% patients’ sputum for AFB test was positive. Additionally, 4.29% patients’ sputum CB-NAAT was positive; 15.71% patients’ CSF for AFB was positive; 8.57% patients’ CSF for BACTEC (960) was positive. In 20% patients, CSF for GeneXpert (CB-NAAT) was positive. The sensitivity was 72.73%, specificity was 89.83%, positive predictive value was 57.14%, negative predictive value was 93.64% and accuracy was 87.14% observed while comparing GeneXpert and CSF AFB. The sensitivity was 66.67%, specificity was 84.38%, positive predictive value was 28.57%, negative predictive value was 96.63% and accuracy was 82.86% observed while comparing GeneXpert and BACTEC (960). The GeneXpert has higher sensitivity compared to other currently available diagnostic modalities7 including

IJCP Sutra: "Summer drinks should be refreshing and cool such as panna, khas khas, rose and lemon water, bel sharbat and sattu sharbat."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

liquid culture BACTEC. In 2015, the World Health Organization (WHO) also endorsed the Xpert MTB/RIF for use in TB endemic countries.8 References 1. Terzi HA, Aydemir O, Karakece E, Koroglu M, Altindis M. Comparison of the GeneXpert® MTB/RIF test and conventional methods in the diagnosis of Mycobacterium tuberculosis. Clin Lab. 2019;65(1). 2. Kohli M, Schiller I, Dendukuri N, Dheda K, Denkinger CM, Schumacher SG, et al. Xpert® MTB/RIF assay for extrapulmonary tuberculosis and rifampicin resistance. Cochrane Database Syst Rev. 2018;(8): CD012768. 3. Agrawal M, Bajaj A, Bhatia V, Dutt S. Comparative study of GeneXpert with ZN stain and culture in samples of suspected pulmonary tuberculosis. J Clin Diagn Res. 2016;10(5):DC09-12.

4. Misra UK, Kalita J, Roy AK, Mandal SK, Srivastava M. Role of clinical, radiological, and neurophysiological changes in predicting the outcome of tuberculous meningitis: a multivariable analysis. J Neurol Neurosurg Psychiatry. 2000;68(3):300-3. 5. Nhu NT, Heemskerk D, Thu do DA, Chau TT, Mai NT, Nghia HD, et al. Evaluation of GeneXpert MTB/RIF for diagnosis of tuberculous meningitis. J Clin Microbiol. 2014;52(1):226-33. 6. Chinedum OK, Ifeanyi OE, Stanley MC, Nwandikor UU. Comparative assessment of five laboratory techniques in the diagnosis of pulmonary tuberculosis in Abuja. South Am J Acad Res. 2015;2(2). 7. Tortoli E, Russo C, Piersimoni C, Mazzola E, Dal Monte P, Pascarella M, et al. Clinical validation of Xpert MTB/RIF for the diagnosis of extrapulmonary tuberculosis. Eur Respir J. 2012;40(2):442-7. 8. World Health Organization. Global Tuberculosis Report 2015. World Health Organization, Geneva; 2015a.

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ICMR Head Balram Bhargava Wins Dr Lee Jong-Wook Prize for Public Health “When I work with patients, I think about how to apply science to alleviate their suffering. This gives meaning to everything else I do,” said Director General of the Indian Council of Medical Research (ICMR), Professor Balram Bhargava after jointly winning the 2019 Dr Lee Jong-Wook Memorial Prize for Public Health at the 72nd World Health Assembly in Geneva earlier this week. “I did not study medicine to make money! I did it to help people. Indians do not need to go abroad for treatment—we have the health solutions here,” he affirms. “Unfortunately, they are not accessible for everyone. This is a huge unfinished agenda that policy makers must address.” “While the responsibility of providing quality, affordable health care lies with everyone, the policy makers must take the lead.” “A doctor treats only one patient at a time. A researcher helps larger groups, as his knowledge and innovation can spread to many patients. A policy maker brings it all one step farther when taking decisions to ensure that the whole population of the country benefits.” “I was 14 years old when my father had a heart attack, that was when I decided to become a doctor. Ever since, my goal in life has been to treat people and the goal remains my driving force.” (The Hindu).

International Statistical Classification of Diseases and Related Health Problems (ICD-11) Adopted The World Health Assembly member states have agreed to adopt the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), to come into effect on January 1, 2022. ICD11 has been updated for the 21st century and reflects critical advances in science and medicine. It can be well integrated with electronic health applications and information systems. This new version is fully electronic, allows more detail to be recorded and is significantly easier to use and to implement, which will lead to fewer mistakes and lower costs, and make the tool much more accessible, particularly for low-resource settings. (WHO) FDA OKs Two Self-administered Options for Mepolizumab The US Food and Drug Administration (FDA) has approved two new methods for administering mepolizumab, an autoinjector and a prefilled safety syringe, which patients or caregivers can administer at home once every 4 weeks, the company announced. Mepolizumab is the first anti-interleukin-5 biologic to be licensed in the United States for at-home administration, and the first respiratory biologic to be approved for administration via an autoinjector. (Medscape)

IJCP Sutra: "Any drink with more than 10% sugar becomes a soft drink and should be avoided."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Prevalence of Inducible Clindamycin Resistance among Staphylococci in an Urban Tertiary Care Hospital of Jalandhar, Punjab SHEEVANI*, JASPAL KAUR†, KAILASH CHAND*, GOMTY MAHAJAN†, SHASHI CHOPRA*

Abstract Introduction: Clindamycin (CL) is a lincosamide antibiotic used in staphylococcal infections. It is highly bacteriostatic against Staphylococcus aureus. Clinical failure of clindamycin therapy has been reported due to multiple mechanisms that include resistance to macrolide, lincosamide and streptogramin antibiotics. In vitro routine tests for CL susceptibility may fail to detect inducible clindamycin resistance, thus necessitating the need to detect such resistance by a simple D-test on routine basis. Material and methods: The present study was a prospective study undertaken with the objective to know the prevalence rate of inducible CL resistance in the Staphylococcus species. Method used for the detection of inducible CL resistance was D-test as recommended by CLSI guidelines. Results: Out of 237 isolates of staphylococci, 194 were found to be S. aureus. Of these 194 strains, 106 were methicillin-resistant S. aureus (MRSA) and 88 were sensitive to it. Amongst MRSA strains, only 15 (18.75%) were found to be positive for inducible CL resistance, while overall prevalence rate was 17.98% (16/89). Conclusion: The inducible resistance can be easily missed by routine in vitro susceptibility tests, when the ER and the CL disks are placed in nonadjacent positions, which may result in clinical failure. Implementation of the D-test for iMLSB detection on a routine basis in the hospital laboratory should be practiced.

Keywords: Clindamycin, staphylococcal infections, bacteriostatic, inducible clindamycin resistance, D-test

ultidrug-resistant pathogens are increasing at a great pace, limiting the therapeutic options. Methicillin-resistant Staphylococcus aureus (MRSA) is one such pathogen that is cross-resistant to all beta-lactams, including penicillins and cephalosporins. It is a frequently isolated pathogen from hospital- and community-acquired infections worldwide. Increasing frequency of MRSA infections and changing patterns in antimicrobial resistance have led to renewed interest in the use of macrolide-lincosamide-streptogramin B (MLSB) antibiotics to treat such infections. The MLSB antibiotics are similar in their modes of action, but structurally these are unrelated. They inhibit protein synthesis by binding to the 23S rRNA. Clindamycin (CL), an antimicrobial belonging to the MLSB family, is

frequently used for treatment of infections caused by S. aureus. However, the widespread use of the MLSB family of antimicrobials has led to the emergence of resistance. The common mechanism of resistance is mediated by erm genes that encode enzymes conferring inducible (iMLSB) or constitutive (cMLSB) resistance to MLSB agents by reducing binding by these agents to the bacterial ribosome. In this study, we have attempted to determine the prevalence of iMLSB type of resistance to CL among S. aureus isolates in our hospital. No previous data regarding the prevalence rate of iMLSB is available from either this Institution or this part of the state. This study was therefore undertaken to close this gap in our knowledge. Material and Methods

*Professor †Associate Professor Dept. of Microbiology Punjab Institute of Medical Sciences, Jalandhar, Punjab Address for correspondence

Dr Sheevani 144, Gurjeet Nagar, Garha Road, Jalandhar - 144 022, Punjab E-mail: drsheevani@yahoo.com

A total of 237 nonduplicate, consecutive clinical isolates of Staphylococcus species were obtained from pus/ wound swab, respiratory tract, high vaginal swab, urine and body fluids derived from both outdoor and indoor patients of our hospital over a time period of 6 months (January 2013 to June 2013).

IJCP Sutra: "A sign of adequate hydration is passing urine at least once in 8 hours."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

All the Staphylococcal species were identified by conventional microbiological methods including colony morphology, Gram stain, catalase, slide coagulase and tube coagulase test. Antibiotic susceptibility testing was performed by Kirby-Bauer disk diffusion method. Antibiotic disks used were ampicillin (10 μg), amoxiclav (20/10 μg), cephalexin (30 μg), cefadroxil (30 μg), cefuroxime (30 μg), ceftriaxone (30 μg), cephotaxime (30 μg), cefoxitin (30 μg) cefoperazonesulbactam (75/30 μg), cefepime (30 μg), ciprofloxacin (5 μg),) doxycycline (30 μg), erythromycin (ER) (15 μg), azithromycin, linezolid (30 μg), netilmicin (30 μg), piperacillin-tazobactam (100/10 μg) and vancomycin (30 μg) and teicoplanin (30 μg). Methicillin resistance was detected by cefoxitin disk diffusion test as per Clinical and Laboratory Standards Institute (CLSI) guidelines. All the isolates were subjected to cefoxitin disk diffusion test using a 30 µg disk. A 0.5 McFarland standard suspension of the isolate was lawn cultured on Mueller-Hinton agar (MHA) plate. Plates were incubated at 37oC for 24 hours and zone of inhibition diameters measured. An inhibition zone diameter of <19 mm was taken as cefoxitin-resistant and >19 mm was considered as cefoxitin-sensitive. Disk approximation testing (D-test) was performed for each isolate according to CLSI method. A 0.5 McFarland suspension was prepared in normal saline for each isolate and inoculated on MHA plate. CL-2 μg and ER-15 μg disks were placed 15 mm apart edge-to-edge manually. Plates were incubated at 37°C for 24 hours and zone diameters were recorded. Results

blunting of the zones (MS phenotype). Eighteen (22.50%) isolates showed ER and CL resistance (cMLSB phenotype) (Table 2). No hazy D (HD) zone or D+ phenotype was observed. Out of 43 CoNS, only two (4.65%) were methicillin-resistant CoNS (MRCoNS), Table 1. Comparative Percentage Antibiotic Susceptibility Pattern of MRSA and MSSA Antibiotic

MRSA (%) (n = 106) ⃰

MSSA (%) (n = 88)

Cephalexin

3.77 (4)

76.93

Cefoxitin

0 (0)

100

Cefadroxil

23.58 (25)

73.07

Cefuroxime

32.08 (34)

84.62

Ceftriaxone

28.30 (30)

61.54

Amoxicillin + Clavulanic acid

35.85 (38)

96.16

Tigecycline

69.23

Amikacin

100

Ciprofloxacin

65.38

Ofloxacin

80.78

Vancomycin

100

Linezolid

100

Azithromycin

92.30

Erythromycin

24.53

89.77

Clindamycin†

68.78

98.86

Teicoplanin

100

Nitrofurantoin‡

100

*Total number in the parenthesis. †True sensitivity percentage. ‡Antibiotic tested only in urinary isolates.

Out of 237 isolates, 194 (81.86%) were found to be S. aureus (coagulase-positive), while 43 (18.14%) were coagulase-negative staphylococci (CoNS). Of 194 S. aureus, 106 (54.64%) were cefoxitin-resistant i.e., MRSA and 88 (45.36%) were cefoxitin- or methicillinsensitive S. aureus (MSSA). Antimicrobial susceptibility pattern showed that MSSA isolates were relatively more susceptible to most of the groups of antimicrobial agents when compared to MRSA strains (Table 1). Out of 106 MRSA strains, 80 (75.47%) were found to be resistant to ER in contrast to only 9 (9/88; 10.23%) of MSSA isolates. Eighty-nine (45.88%) clinical isolates of S. aureus, which showed ER resistance were tested for inducible resistance by double disk approximation test. Out of 89 ER-resistant strains 16 (17.98%) were iMLSB phenotypes (18.75% MRSA, 11.11% MSSA [1/9]) (Fig. 1). Forty-seven (58.75%) of MRSA isolates showed ERresistant and CL-susceptible zone diameters with no

Figure 1. D-test positive strain.

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Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Table 2. Phenotypic Characterization of ER-resistant Staphylococcal Isolates Isolates (Number)

ER-R;CL-S MS phenotype Percentage in parentheses

ER-R; CL-S D-test positive iMLSB

ER-R; CL-R cMLSB

MRSA (80)

47 (58.75)

15 (18.75)

18 (22.50)

MSSA (9)

8 (88.89)

1 (11.11)

MRCoNS (2)

1 (50)

MSCoNS (12)

8 (66.67)

4 (33.33)

while remaining were methicillin-sensitive. Resistance to ER was observed in 14 isolates; out of these 14 strains only one (7.14%) showed D-zone phenotype. D-zone phenotype was MRCoNS. Eight isolates showed MS phenotype with no blunting of the zones, while five strains were resistant to both EL and CL. Discussion Our study aimed at finding the incidence of inducible CL resistance in staphylococcal isolates. CL, a lincosamide, has long been an option for treating staphylococcal skin, soft tissue and bone infections because of its proven efficacy, low cost, the availability of its oral and parenteral forms, tolerability, excellent tissue penetration, its good accumulation in abscesses and because no renal dosing adjustments are required. It also directly inhibits the staphylococcal toxin production and is a useful alternative for patients who are allergic to penicillin. Its good oral absorption makes it an important option in the therapy of the outpatients or as a follow-up after an intravenous (IV) therapy (de-escalation). This reduces the burden of prolonged hospitalization as well as the risks associated with it. It is effective against both the methicillin-resistant and the methicillin-sensitive staphylococcal infections. The increased frequency of the staphylococcal infections, along with the changing drug-susceptibility patterns, have led to a renewed interest in CL usage, but the possibility of an inducible resistance to CL remains a major concern and this could limit the use of this drug. In vitro and in vivo susceptibility of S. aureus to CL may vary especially when the strain is resistant to ER. This may be due to the presence of iMLSB. This kind of resistance can be missed out by conventional susceptibility testing methods unless specifically looked for using disk approximation D-test, which is easy to perform though it can also be detected using molecular methods. To report the CL susceptibility accurately, the staphylococci which are isolated from the clinical specimens should first be subjected to the D-test, to exclude the isolates with an induced CL resistance (iMLSB); as such isolates,

when treated with CL, can undergo a rapid in vitro conversion to a constitutive resistance (cMLSB) and this may result in the CL treatment failure. Many cases of CL therapy failures due to the iMLSB phenotype have been reported in the past. Overall prevalence rate of 16.51% (S. aureus and CoNS) of inducible CL resistance with 18.75% in MRSA and 11.11% in MSSA was observed in our study. Our findings are in coherence with the findings of other authors with the prevalence rate of 19.4%, 20%, 24.82% and 27% of iMLSB in MRSA strains in four different studies conducted in different parts of the country. Prevalence rate of iMLSB in MSSA strains in above mentioned studies was 6.3%, 1.6%, 1.66% and 6.2%, respectively, while it was 11.1% in our study. Higher prevalence of iMLSB - 35.33%, 38.46%, 72% and 74% in MRSA strains has been quoted in other studies by various authors. Vast variation in the prevalence rates of iMLSB is a known fact. It varies with geographical area, environmental conditions and even from hospital to hospital. Extensive variability in the prevalence of ER-induced CL resistance further emphasizes on the significance of knowledge of local prevalence rate of iMLSB. This study determined the prevalence of the inducible resistance among staphylococci from the upcoming medical institute and hospital and this is the first study in this region. Since our hospital is an upcoming medical institute and as molecular laboratory facilities were unavailable, so, the molecular diagnosis of these isolates was not possible. Also, the molecular markers for the erm genes are costly and inconvenient for everyday use. Patients coming to our hospital belong to rural as well as urban background and majority of them are below poverty line and hence are not able to bear the heavy expenditures. In the Indian context, with the high burden of the staphylococcal infections, where the health-associated expenditures are borne by the patients, D-test is a simple, economical and reliable test, which can be easily inculcated in the routine antimicrobial susceptibility testing. It helps to guide empiric therapy.

IJCP Sutra: "Monitor your blood pressure before, during and after pregnancy."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Conclusion The inducible resistance can be easily missed by routine in vitro susceptibility tests, when the ER and the CL disks are placed in nonadjacent positions, which may result in clinical failure. Implementation of the D-test for iMLSB detection on a routine basis in the hospital laboratory should be practiced. Consequently, early detection helps in the use of CL only in infections caused by truly CL-susceptible staphylococci and thus helps to avoid treatment failures. It is very important that the clinical microbiologists and the infectious disease experts keep a close watch on the developing patterns of drug resistance, which will help in guiding the therapy effectively. Suggested reading 1. Saiman L, O’Keefe M, Graham PL 3rd, Wu F, Saïd-Salim B, Kreiswirth B, et al. Hospital transmission of communityacquired methicillin-resistant Staphylococcus aureus among postpartum women. Clin Infect Dis. 2003;37(10):1313-9. 2. Mallick SK, Basak S, Bose S. Inducible clindamycin resistance in Staphylococcus aureus: A therapeutic challenge. J Clin Diagn Res. 2009;3(3):1513-8. 3. Lim HS, Lee H, Roh KH, Yum JH, Yong D, Lee K, et al. Prevalence of inducible clindamycin resistance in staphylococcal isolates at a Korean tertiary care hospital. Yonsei Med J. 2006;47(4):480-4. 4. Lowy FD. Antimicrobial resistance: the example of Staphylococcus aureus. J Clin Invest. 2003;111(9):1265-73. 5. Fiebelkorn KR, Crawford SA, McElmeel ML, Jorgensen JH. Practical disk diffusion method for detection of inducible clindamycin resistance in Staphylococcus aureus and coagulase-negative staphylococci. J Clin Microbiol. 2003;41(10):4740-4. 6. Angel MR, Balaji V, Prakash J, Brahmadathan KN, Mathews MS. Prevalence of inducible clindamycin resistance in gram positive organisms in a tertiary care centre. Indian J Med Microbiol. 2008;26(3):262-4. 7. Schreckenberger PC, Ilendo E, Ristow KL. Incidence of constitutive and inducible clindamycin resistance in Staphylococcus aureus and coagulase-negative staphylococci in a community and a tertiary care hospital. J Clin Microbiol. 2004;42(6):2777-9. 8. Clinical Laboratory Standards Institute (CLSI). “Performance standards for antimicrobial susceptibility testing.” In Proceedings of the 22nd International Supplement (M100-S22). National Committee for Clinical Laboratory Standards: Wayne PA, USA; 2012.

treatment of acute hematogenous osteomyelitis. Pediatrics. 2006;117(4):1210-5. 11. Frank AL, Marcinak JF, Mangat PD, Tjhio JT, Kelkar S, Schreckenberger PC, et al. Clindamycin treatment of methicillin-resistant Staphylococcus aureus infections in children. Pediatr Infect Dis J. 2002;21(6):530-4. 12. Jadhav SV, Gandham NR, Sharma M, Kaur M, Misra RN, Matnani GB, et al. Prevalence of inducible clindamycin resistance among community- and hospital-associated Staphylococcus aureus isolates in a tertiary care hospital in India. Biomed Res. 2011;22(4):465-9. 13. Lewis JS 2nd, Jorgensen JH. Inducible clindamycin resistance in Staphylococci: should clinicians and microbiologists be concerned? Clin Infect Dis. 2005;40(2):280-5. 14. Levin TP, Suh B, Axelrod P, Truant AL, Fekete T. Potential clindamycin resistance in clindamycin-susceptible, erythromycin-resistant Staphylococcus aureus: report of a clinical failure. Antimicrob Agents Chemother. 2005;49(3):1222-4. 15. Drinkovic D, Fuller ER, Shore KP, Holland DJ, EllisPegler R. Clindamycin treatment of Staphylococcus aureus expressing inducible clindamycin resistance. J Antimicrob Chemother. 2001;48(2):315-6 16. Siberry GK, Tekle T, Carroll K, Dick J. Failure of clindamycin treatment of methicillin-resistant Staphylococcus aureus expressing inducible clindamycin resistance in vitro. Clin Infect Dis. 2003;37(9):1257-60. 17. Juyal D, Shamanth AS, Pal S, Sharma MK, Prakash R, Sharma N. The prevalence of inducible clindamycin resistance among staphylococci in a tertiary care hospital: A study from the Garhwal Hills of Uttarakhand, India. J Clin Diagn Res. 2013;7(1):61-5. 18. Prabhu K, Rao S, Rao V. Inducible clindamycin resistance in Staphylococcus aureus isolated from clinical samples. J Lab Physicians. 2011;3(1):25-7. 19. Deotale V, Mendiratta DK, Raut U, Narang P. Inducible clindamycin resistance in Staphylococcus aureus isolated from clinical samples. Indian J Med Microbiol. 2010;28(2):124-6. 20. Upadhya A, Biradar S. The prevalence of inducible clindamycin resistance in Staphylococcus aureus in a tertiary care hospital in north-east Karnataka, India. Health Sciences: An International Journal. 2011;1(3):21-4. 21. Ciraj AM, Vinod P, Sreejith G, Rajani K. Inducible clindamycin resistance among clinical isolates of Staphylococci. Indian J Pathol Microbiol. 2009;52(1):49-51. 22. Gupta V, Datta P, Rani H, Chander J. Inducible clindamycin resistance in Staphylococcus aureus: a study from North India. J Postgrad Med. 2009;55(3):176-9.

23. Ajantha GS, Kulkarni RD, Shetty J, Shubhada C, Jain P. Phenotypic detection of inducible clindamycin resistance among Staphylococcus aureus isolates by using the lower 10. Ruebner R, Keren R, Coffin S, Chu J, Horn D, Zaoutis TE. limit of recommended inter-disk distance. Indian J Pathol Complications of central venous catheters used for the Microbiol. 2008;51(3):376-8. ■■■■ 9. Kasten MJ. Clindamycin, metronidazole, and chloramphenicol. Mayo Clin Proc. 1999;74(8):825-33.

IJCP Sutra: "Consume less salt as a high intake can raise blood pressure."

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

A Simple Inexpensive Surface Applicator for High Dose Rate Intraluminal Brachytherapy of Anal Cancer MEENA J SHAH*, RAKESH K VYAS†

Abstract We attempted this study to evaluate the feasibility and safety of high dose rate intraluminal brachytherapy (HDR-ILBT) in patients with anal cancer using a surface applicator designed by us and also to determine whether HDR-ILBT has an advantage in terms of achieving higher response rates and sphincter preservation. This paper reports our preliminary clinical experience with 10 patients of carcinoma anal canal treated using this surface applicator. The results achieved were largely comparable to the treatment delivered with conventionally used interstitial implant. This application does not require anesthesia of any form and is well-tolerated. This experience suggests that ILBT using a surface applicator appears to be a satisfactory, definitive treatment in selected patients with low volume superficial tumors and as a boost to external beam radiation therapy in the management of anal cancers.

Keywords: Anal cancer, intraluminal brachytherapy, radiotherapy

he challenge of treating anal cancer is to preserve the anal sphincter function while giving high doses to the tumor and sparing the organ at risk. Radiotherapy combined with chemotherapy has an important role in the treatment of anal cancer patients. Not only external beam radiotherapy (EBRT) is an established method for primary treatment of anal cancer, brachytherapy is also an approved method. For anal cancers, high dose rate (HDR) brachytherapy can be used as a boost after EBRT1 or as definitive treatment in selected cases. Both interstitial and intraluminal techniques have been used. The combination of EBRT and brachytherapy allows the clinician to deliver higher doses to the tumor and to reduce dose to the normal tissue. Improvements in local control and reductions in toxicity therefore become possible. Usually interstitial brachytherapy is preferred but implantation has to be done under anesthesia and a constant level of analgesia is to be maintained for comfortable treatment. Patients are required to be hospitalized for 6-7 days. Main limitation

*Associate Professor Government Medical College and New Civil Hospital, Surat, Gujarat †Incharge Director Gujarat Cancer and Research Institute, Ahmedabad, Gujarat Address for correspondence

Dr Meena J Shah 206, Tulsishyam Apartment, Opp. Ratnadeep Society Behind Police Tenament, Bhatar-Althan Road, Surat - 395 017, Gujarat E-mail: drmeena.maheshwari@gmail.com

of intraluminal technique is the tolerance of normal anal mucosa, which receives a much higher dose than the tumor extensions into the wall. In this study, we report our preliminary experience of HDR-ILBT (intraluminal brachytherapy) in anal cancers using surface applicator designed by us. It is a simple and inexpensive applicator. This afterloading surface applicator allows a wide range of adjustments of dose distribution. Material and Methods We initiated a clinical study at the Radiotherapy Department of our institute for anal cancers by using surface mould applicator designed by us. Total 10 eligible patients of anal carcinoma referred to our department were treated with this technique. Patients were selected when they met the following eligibility criteria: (1) histologically proven anal/anorectal squamous cell carcinoma; (2) distal margin of tumor located within 10 cm of the anal verge on endoscopy; (3) maximum longitudinal length not more than 5 cm; (4) thickness of tumor not more than 10 mm; (5) not more than half of the circumference of involvement; (6) Eastern Cooperative Oncology Group performance status 0-2; and (7) normal hematological parameters. Six patients received a course of chemotherapy prior to radiotherapy. The chemotherapy course was given for 5 days with injection mitomycin on Day 1 and injection 5-fluorouracil daily from Day 1-5. External radiotherapy was started on Day 7. A

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

mid-pelvic dose of 3000 cGy was delivered in 15 fractions in 3 weeks through parallel opposed portals. Four out of 6 patients showed partial response to the treatment (more than 50% regression in size of the lesion), while 2 patients achieved complete response (no palpable lesion). Patients were called for brachytherapy treatment after rest for 2 weeks. Dose by brachytherapy was 300 cGy prescribed at 0.5-1 cm from the surface, twice a day for 3 days. Total 6 fractions of 300 cGy were delivered equivalent to 2500 cGy by LDR brachytherapy. Interval between 2 fractions was 6 hours. The second course of chemotherapy was repeated after completion of radiotherapy (EBRT and brachytherapy). Two patients with early T2 (primary tumor not more than 3 cm in size) were treated with radiotherapy alone (external radiotherapy followed by brachytherapy). Two patients having superficial T1 lesions received brachytherapy. The prescribed dose was 300 cGy twice a day for 6 days (equivalent to 50 Gy by LDR brachytherapy) in patients treated with brachytherapy alone.

Applicator The applicator was fabricated from clear cast acrylic cylindrical rod of 10 cm length and 2.5 cm in diameter. Its central portion was drilled and metallic rod was fixed in it by a screw mechanism to act as a handle. Five grooves were drilled on the surface of the applicator along its length in such a manner that the distance between each parallel groove was 1 cm. The grooves were wide enough to accommodate steel needles of 6F diameter. The needles were provided for interstitial treatment on Microselectron HDR Brachytherapy Unit by Nucletron Inc., Holland. The needles could be inserted only through the lower end; the upper ends of the grooves were blind. Needles, once put in the groove, would not come out unless pulled from the lower side. Schematic diagram of surface applicator is shown in Figure 1. Lateral view 100 mm 6 mm

Acrylic cylinder

Steel needles

Holding rod

Cross-sectional view Grooves 2 mm x 5 Nos.

Figure 1. Schematic diagram of the surface applicator.

Treatment Technique The patients were treated in lithotomy position with legs kept on side rests. A per rectal examination was carried out. To allow exact localization of the boost target area following chemoradiotherapy, a very accurate clinical description with a drawing was also necessary. The exact sites of the lesion (anterior, posterior or lateral) and the length to be treated were ascertained. Each needle was pushed inside the grooves up to the blind end and was secured in position by a locking mechanism. The treatment length as marked on the applicator surface and this mark would be at the level of anal orifice. The applicator was wrapped in a condom before insertion. The wrapped surface of the applicator was well-lubricated with anesthetic gel to have a smooth passage in the anal canal. It was inserted after proper dilatation of the anal canal by finger using anesthetic gel. Before fixing the applicator, position of the grooves was checked so that they would lie exactly opposite the lesion. The handle was clamped to the selectron treatment table. X-rays were taken in anterior-posterior and lateral positions for planning. The target volume was marked on the skiagrams and treatment planning was carried out on the Plato treatment planning system. The plan was verified by the radiation oncologist. The needles then were connected to respective channels of the Microselectron HDR. Positioning of the applicator was again checked by two persons before starting treatment and the treatment was delivered. Results The brachytherapy treatment was well-tolerated. Patients were instructed to stay on low residue diet during treatment. We did not face any problem in frequent insertions of the applicator. Patients were called for follow-up after 2 weeks to see the possible acute reactions. Subsequently, they were called for monthly follow-up. Median duration of the follow-up was 6 months. Mucositis developed 1-2 weeks after brachytherapy, was maximal after 3-4 weeks and healed within 5-8 weeks. Local ointments and oral analgesics were given. However, Grade 3 mucositis and bleeding per rectum were seen in only in 2/10 (20%) patients and were well-managed. In other patients, application of local anesthetic jelly and regular purgative dose at bedtime revealed no subjective complaints (rectal discomfort, tenesmus or urgency). Primary disease was under control in all these patients till the last follow-up.

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Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Discussion HDR intraluminal (intracavitary) brachytherapy is a well-known treatment modality for gynecologic, esophageal, pulmonary, biliary tract and nasopharyngeal malignancies.2-6 Acrylic surface applicators have been constructed for use in carcinoma of vagina.7,8 Interstitial, intraluminal or intraoperative HDR brachytherapy may be used in the treatment of anal and rectal cancers. For anal cancers, HDR brachytherapy can be used as a boost after EBRT1 or as definitive treatment in selected cases. Interstitial implant is still the preferred treatment for brachytherapy in anal cancers because of better dose distribution in and around the tumor. Overall, authors using interstitial brachytherapy as a routine boost technique report local control rates between 80% and 90% of cases, with severe necrosis rate requiring colostomy not exceeding 5%. HDR-ILBT, due to its advantage of rapid fall-off of radiation dose, allows the delivery of a high tumor dose, while sparing normal structures such as normal anorectal mucosa and small bowel. Additionally, HDR-ILBT may reduce overall radiation treatment time and the waiting period for radiation, especially in busy radiation centers. Papillon et al9 have given endocavitary radiotherapy in the case of cancer of the rectum and anorectum using 50 kV contact therapy units. The published results were very encouraging with complete clinical response observed in majority of the cases. Similar results were reported by Schild et al.10 HDR-ILBT can be part of a preoperative approach for resectable or locally advanced rectal cancers11-13 or for unresectable, inoperable and recurrent disease. For palliative relief, recurrent or inoperable rectal cancers, HDR-ILBT has been used worldwide.14-16 We investigated the construction and use of an acrylic multichannel cylindrical surface applicator with a central rod and with several channels placed along its periphery. An important aspect of designing this applicator for radiation treatment was the ability to minimize dose to the noninvolved parts of the anal wall and to avoid interstitial implant. The treatment was well-tolerated. We achieved almost similar high dose to primary tumor by using the surface applicator as in interstitial implant and observed 100% regression of the primary tumor in all cases treated by the combined approach or radiotherapy alone. Because of the fragility of the anal canal mucosa, it seems appropriate to deliver fractions of 3 Gy or less, spaced at least 6 hours apart. Though no definite clinical results are available about

the brachytherapy by surface applicators, we found it very satisfactory in early lesions, which are superficial or exophytic and that respond well to chemotherapy and radiotherapy. The applicator made by us is very simple and inexpensive. There is no need to subject the patient to anesthesia and for parenteral administration of analgesics, which are required in all the patients undergoing pelvic interstitial brachytherapy. Treatment can be delivered as an outpatient. Conclusion Definitive combined radiochemotherapy is the current standard for function preservation treatment of anal cancer. If the tumor is eligible for brachytherapy, optimal brachytherapy involves interstitial brachytherapy. Though our experience with HDRILBT using surface applicator is not sufficient to allow us to give any recommendations, selected patients with low volume superficial tumors, may be treated with brachytherapy that involves an intraluminal approach. It is convenient, has satisfactory response rates and can be safely used as a tool to boost the gross tumor volume during chemoradiation. One can treat any specific area of the anal canal without irradiation of the whole lumen with this simple and inexpensive surface applicator. References 1. Oehler-Jänne C, Seifert B, Lütolf UM, Studer G, Glanzmann C, Ciernik IF. Clinical outcome after treatment with a brachytherapy boost versus external beam boost for anal carcinoma. Brachytherapy. 2007;6(3):218-26. 2. Small W Jr, Du Bois A, Bhatnagar S, Reed N, Pignata S, Potter R, et al; Gynecologic Cancer Intergroup (GCIG). Practice patterns of radiotherapy in endometrial cancer among member groups of the gynecologic cancer intergroup. Int J Gynecol Cancer. 2009;19(3):395-9. 3. Frobe A, Jones G, Jaksić B, Bokulić T, Budanec M, Iva M, et al. Intraluminal brachytherapy in the management of squamous carcinoma of the esophagus. Dis Esophagus. 2009;22(6):513-8. 4. Fuwa N, Kodaira T, Tachibana H, Nakamura T, Tomita N, Daimon T. Long-term observation of 64 patients with roentgenographically occult lung cancer treated with external irradiation and intraluminal irradiation using low-dose-rate iridium. Jpn J Clin Oncol. 2008;38(9):581-8. 5. Deodato F, Clemente G, Mattiucci GC, Macchia G, Costamagna G, Giuliante F, et al. Chemoradiation and brachytherapy in biliary tract carcinoma: long-term results. Int J Radiat Oncol Biol Phys. 2006;64(2):483-8. 6. Syed AM, Puthawala AA, Damore SJ, Cherlow JM, Austin PA, Sposto R, et al. Brachytherapy for primary and recurrent nasopharyngeal carcinoma: 20 years’ experience

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019 at Long Beach Memorial. Int J Radiat Oncol Biol Phys. 2000;47(5):1311-21. 7. Amdur RJ, Piontek R, Hadley VE, Conine FE, Sullivan S, Flaherty P. A simple, inexpensive applicator for irradiation of localized areas of the vagina with intracavitary brachytherapy. Int J Radiat Oncol Biol Phys. 1997;37(4):965-9. 8. Peracchia G, Salti C. A simple method of preparing custom molds for intracavitary treatment of gynecological cancer. Int J Radiat Oncol Biol Phys. 1982;8(1):141-3. 9. Papillon J, Berard P. Endocavitary irradiation in the conservative treatment of adenocarcinoma of the low rectum. World J Surg. 1992;16(3):451-7.

12. Vuong T, Belliveau PJ, Michel RP, Moftah BA, Parent J, Trudel JL, et al. Conformal preoperative endorectal brachytherapy treatment for locally advanced rectal cancer: early results of a phase I/II study. Dis Colon Rectum. 2002;45(11):1486-93; discussion 1493-5. 13. Vuong T, Devic S, Podgorsak E. High dose rate endorectal brachytherapy as a neoadjuvant treatment for patients with resectable rectal cancer. Clin Oncol (R Coll Radiol). 2007;19(9):701-5. 14. Tam TY, Mukherjee S, Farrell T, Morgan D, Sur R. Endoscopic brachytherapy for obstructive colorectal cancer. Brachytherapy. 2009;8(3):313-7.

10. Schild SE, Martenson JA, Gunderson LL. Endocavitary radiotherapy of rectal cancer. Int J Radiat Oncol Biol Phys. 1996;34(3):677-82.

15. Begum N, Asghar AH, Shahida N, Khan SM, Khan A. High dose rate intraluminal brachytherapy in combination with external beam radiotherapy for palliative treatment of cancer rectum. J Coll Physicians Surg Pak. 2003;13:633-6.

11. Kamikonya N. Fundamental and clinical studies of preoperative radiotherapy with high-dose rate intraluminal brachytherapy. Nihon Igaku Hoshasen Gakkai Zasshi. 1991;51(8):950-61.

16. Hoskin PJ, de Canha SM, Bownes P, Bryant L, Glynne Jones R. High dose rate afterloading intraluminal brachytherapy for advanced inoperable rectal carcinoma. Radiother Oncol. 2004;73(2):195-8.

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Around 6,00,000 Afghan Children Face Death Through Malnutrition without Emergency Funds: UNICEF In Afghanistan, children suffering from the most serious form of malnutrition may die, unless $7 million in funding is found within weeks, UNICEF said. Speaking in Geneva, UN Children’s Fund spokesperson Christophe Boulierac, likened the humanitarian situation in the war-torn country to “one of the worst disasters on earth.” He warned that increased violence and last year’s severe drought have left hundreds of thousands of underfives, critically vulnerable across the country. (UN)

Barriers to Vaccination Remain, Even in Areas with Measles Outbreaks A small series of mothers who self-identified within ultra-Orthodox Jewish communities in New York City and Rockland County continue to refuse vaccination for their children during a measles outbreak for a host of reasons, researchers found. Reasons ranging from scepticism about vaccines to cultural factors influenced these mothers’ decisions not to vaccinate, to delay vaccinations or have a longer break between vaccines, argued Charles H Hennekens, MD, DrPH, of Florida Atlantic University in Boca Raton, and colleagues, writing in a commentary in the American Journal of Medicine.

FDA Approves Innovative Gene Therapy to Treat Pediatric Patients with Spinal Muscular Atrophy The US FDA has approved onasemnogene abeparvovec-xioi, the first gene therapy approved to treat children less than 2 years of age with spinal muscular atrophy (SMA), the most severe form of SMA and a leading genetic cause of infant mortality. (FDA)

IJCP Sutra: "Tobacco and alcohol are not safe during pregnancy and must be avoided.”

Clinical Study

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Wooden Sticks as Object of Ocular Injury: Anti-infective Profile MEHUL SHAH*, SHREYA SHAH*, PRAMOD UPADHYAY*

Abstract Objective: To compare the incidence of infection and damage done by wooden sticks with that caused by other objects and to evaluate objects causing ocular injury. Methods: Setting: Tertiary care hospital in a rural part of Central Western India. This was a prospective observational cohort study designed in 2002. All open globe injuries in either eye that were diagnosed and managed between January 2003 and December 2009 were enrolled in our study. The patients were grouped according to injuries caused by sticks or by other objects. Data were collected using the International Society of Ocular Trauma (ISOT) initial and follow-up forms, and analyzed. Outcome measures: Final visual acuity and infections. Results: The study comprised 687 cases, including 496 open globe cases. Wooden sticks were one of the most common objects causing eye injury in the rural setting. Eye injuries caused by wooden sticks were not associated with infection, and the final visual outcome in stick-injured eyes was significantly better than that following injuries caused by other objects (p = 0.002). Conclusion: Although sticks cause a high percentage of eye injuries, the incidence of infection in stick-injured eyes is low, and the final visual outcome is good.

Keywords: BETTS, traumatic cataract, object causing injury, wooden stick, open globe injury, post-trauma endophthalmitis

rauma is a cause of monocular blindness in the developed world, although few studies have addressed trauma in developing world.1 The etiology of ocular injury in rural areas is likely to differ from that in urban areas, and is worthy of investigation.2-4 Any strategy for prevention requires knowledge of the cause of injury, which may enable more appropriate targeting of resources toward preventing such injuries. Both eye trauma victims and society bear a large, potentially preventable burden.3 Open globe injury is associated with a breach in the wall of the eyeball, which may be associated with entry of organisms into the globe. Vegetative injury is known to cause infection, particularly fungal, hampering final visual outcome.1-20 Objectives ÂÂ

Study the types of objects causing eye injury.

ÂÂ

Study infection associated with objects causing eye injury.

*Drashti Netralaya, Dahod, Gujarat Address for correspondence

Dr Mehul Shah Drashti Netralaya Near GIDC, Chakalia Road, Dahod - 389 151, Gujarat Email: omtrust@rdiffmail.com

ÂÂ

Compare incidence of infection and eye damage caused by wooden sticks versus other objects.

Patients and Methods We obtained approval from the hospital administrators and research committee to conduct this study, and received the participants’ written consent. This was a prospective observational cohort study designed in 2002. All traumatic cataracts in either eye that were diagnosed and managed between January 2003 and December 2009 were enrolled in our study, and patients consenting to participate and not having other serious body injuries were included. For each patient enrolled in our study, we obtained a detailed history, including details of the injury and information on eye treatment and surgery performed to manage past ocular trauma. Data for both the initial and follow-up reports were collected using the online Birmingham Eye Trauma Terminology System (BETTS) format of the International Society of Ocular Trauma (ISOT). Details of the surgery were also collected using a specified pre-tested online form. The cases of traumatic cataract were grouped as open or closed globe injuries. All open globe injury cases were included in the study. Open globe injuries were further categorized into those with lacerations and those that had ruptured. Lacerations of the eyeball were

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Other demographic details collected included entry of the patient, residence, activity at the time of injury, object causing injury and previous examinations and treatments. After enrollment, all patients were examined using a standard method. Visual acuity was checked using Snellenâ&#x20AC;&#x2122;s chart, and the anterior segment was examined using a slit lamp. Based on lenticular opacity, the cataracts were classified into total, membranous, white soft and rosette types. When an ophthalmologist did not observe clear lens matter between the capsule and the nucleus, the cataract was defined as a total cataract. When the capsule and organized matter were fused and formed a membrane of varying density, it was defined as a membranous cataract. When loose cortical material was found in the anterior chamber together with a ruptured lens capsule, the cataract was defined as a white soft cataract. A lens with a rosette pattern of opacity was classified as a rosette type cataract. For a lens that was partially opaque, the posterior segment examination was performed with an indirect ophthalmoscope and a +20 D lens. When the optical medium was not clear, a B-scan was performed to evaluate the posterior segment. The surgical technique was selected according to morphology and the condition of tissues other than the lens. Phacoemulsification was used to operate on cataracts with hard, large nuclei. With a lens that had either a white soft or rosette type cataract, uni- or bimanual aspiration was used. Membranectomy and anterior vitrectomy, either via an anterior or pars plana route, were performed when the cataract was membranous. In all patients undergoing corneal wound repair, the traumatic cataract was managed in a second procedure. In children younger than 2 years, both lensectomy and vitrectomy via a pars plana route were performed, and the same surgical procedures were used to manage the traumatic cataract. Lens implantation as part of the primary procedure was avoided in all children younger than 2 years. All patients with injuries and without infection were treated with topical and systemic corticosteroids and cycloplegics. The duration of medical treatment depended on the degree of inflammation in the anterior and posterior segments of the operated eye. The operated patients were re-examined after 24 hours, 3 days and 1, 2 and 6 weeks to enable refractive correction. Follow-up was scheduled for the

third day, weekly for 6 weeks, monthly for 3 months and every 3 months for 1 year. At every follow-up examination, visual acuity was tested with Snellenâ&#x20AC;&#x2122;s chart. The anterior segment was examined with a slit lamp; the posterior segment was examined with an indirect ophthalmoscope. Eyes with vision better than 20/60 at the glasses appointment (6 weeks) were defined as having a satisfactory grade of vision. During the examination, data were entered online using a specified pre-tested format designed by the ISOT (initial and follow-up forms), which was exported to a Microsoft Excel spreadsheet. The data were periodically audited to ensure completion. We used the Statistical Package for Social Sciences (SPSS) 17 to analyze the data. The univariate parametric method was used to calculate frequency, percentage, proportion and 95% confidence interval (CI). We used binominal regression analysis to determine the predictors of postoperative satisfactory vision (>20/60). The dependent variable was vision >20/60 noted at the 6-week follow-up after cataract surgery. The independent variables were age, gender, residence, time interval between injury and cataract surgery, primary posterior capsulectomy and vitrectomy procedure and type of ocular injury. Results Our cohort consisted of 687 patients with traumatic cataracts, including 496 (72.2%) eyes with open-globe ocular injuries and 191 (27.8%) eyes with closed-globe injuries (Fig. 1). The patients included 492 (71.6%) males and 195 (28.4%) females. The mean patient age was 27.1 Âą 18.54 (range, 1-80) years. According to crosstabulation and statistical tests, none of the analyzed demographic factors showed a significant relationship with the final visual acuity; these factors included gender (p = 0.340), patient entry (p = 0.4) and socioeconomic status (79% were from a lower socioeconomic class and residence; 95% were from a rural area). The object

Percentage (%)

subcategorized into eyes with perforating injuries, penetrating injuries or injuries involving an intraocular foreign body. Sticks included tree branches, firewood and thorns, but did not include human-fashioned or treated material.

100 90 80 70 60 50 40 30 20 10 0

72.2

27.8

Open-globe injuries

Closed-globe injuries

Figure 1. Distribution of patients with traumatic cataract according to type of injury.

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

causing the injury (p = 0.3) and the activity at the time of the injury (p = 0.3) were also not significantly associated with satisfactory final visual acuity. We classified the 687 injuries according to BETTS. Sticks were the most common injury-causing objects, accounting for 55.9% of the eye injuries in our study (Tables 1 and 2). The activities being performed at the time of injury (Table 3) included breaking sticks while collecting wood for cooking, building fences, riding on the tops of vehicles, Table 1. Objects Causing Eye Injury Object

playing with sharp objects and laboring without eye protection. Working at home was also a common activity at the time of injury. No injury was caused by an assault. The final visual outcome in cases of injury with a wooden stick was significantly different from the outcomes following injuries caused by other objects (Table 4). The overall incidence of infection was 0.4%. Injury with a wooden stick had a zero incidence of infection, but this was not significantly different from the infection incidence associated with injuries caused by other objects (Table 5). The final visual outcome was significantly affected by infection (Table 6).

Frequency

Percentage (%)

Ball

0.9

Cattle horn

2.33

Table 4. Vision Outcome Comparison between Injuries Caused by Wooden Sticks versus Other Objects

Finger

1.0

Firework

1.5

Vision outcome

Glass

0.7

Iron wire

6.7

Other

8.4

Sharp object

1.2

Stone

13.5

Unknown

Wooden stick Total

Wooden sticks

Other

Total

Uncooperative

<1/60

171

1/60 to 3/60

20/200 to 20/120

20/80 to 20/60

145

7.9

20/40 to 20/20

144

223

384

55.9

Total

379

297

676

687

100

Table 2. Frequency of Injuries Caused by Wooden Sticks versus Other Objects Object

Frequency

Percentage (%)

Wooden sticks

384

55.9

Other

303

44.1

Total

687

100

Table 3. Activity at the Time of Eye Injury Activity

Number

Percentage (%)

Fall

1.6

Fighting

0.6

Firecrackers

0.7

Housework

187

27.2

Employment

137

19.9

Other

114

16.6

Walking

Playing

χ2 test, p = 0.002.

Table 5. Infection of Injuries Caused by Wooden Sticks versus Other Objects Infection

Wooden sticks

Other

Total

Absent

384

300

684

Present

384

303

687

Total χ2

test, p = 0.08.

Table 6. Visual Outcome According to the Absence or Presence of Infection Vision outcome

Infection

Total

Absent

Present

Uncooperative

<1/60

168

171

1/60 to 3/60

2.0

20/200 to 20/120

183

26.6

20/80 to 20/60

146

Traveling on top of a vehicle

4.2

20/40 to 20/20

223

Vehicular accident

0.4

Total

684

687

100

Total

χ2

test, p = 0.02.

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Discussion

Conclusion

We studied objects of eye injury and classified the injuries based on the BETTS criteria. This study focused on a rural tribal population in which wooden sticks and thorns are common objects of eye injury.

Although sticks cause a high percentage of eye injuries, the incidence of infection in stick-injured eyes is minimal and the final visual outcome is good. This study was conducted in a specific geographical area, and thus the results may not be generalizable.

A strength of this study is its prospective design and large number of cases. Wooden sticks were the most common object of injury in our study (55.9%) (Tables 1 and 2), as in a study from rural Tanzania reported by Abraham.2 However, sticks are not common injury-causing objects according to the US ocular trauma registry.21 We saw 687 cases of eye injury and 496 of these were open globe, as defined by the BETT classification.22 Many studies have reported that an object causing an open globe injury also causes infection.1-20,23,24 In the present study, the total incidence of infection was 0.4%, which is much lower than the incidence of endophthalmitis reported by Viestenz et al (2-17%) or by Cebulla (4-8%). The final visual outcome following an open globe injury caused by a stick was significantly better than that following injuries caused by other objects (p = 0.002). The key observation made in this study warrants further study to know how society, at large, can be benefited from the search of antimicrobials from higher plants seen in this area. It has been widely observed that the local tribes, which constituted 89% of the patients in the study are known to use various ingredients of the plants arising from stem bark, leaves and roots. The search for antimicrobial agents has mainly been concentrated on lower plants, fungi and bacteria as sources.25,26 The presence of saponins, tannins, alkaloids and steroids in the plants is an indication that the plants are of pharmacological importance.27-30 Much less research has been conducted on antimicrobials from higher plants. Since the advent of antibiotics, in the 1950s, the use of plant derivatives as antimicrobials has been virtually nonexistent. The interest in using plant extracts for treatment of microbial infections has increased in the late 1990s as conventional antibiotics become ineffective. Investigations on plants used in traditional medicine for skin afflictions might provide new tropical antiseptics urgently needed. To reduce the incidence of eye injuries caused by sticks, we suggest that the authorities provide ready-made fences and alternative cooking fuels, regulate travel rules and counsel parents to take care of their children.

References 1. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Katz J. The epidemiology of ocular trauma in rural Nepal. Br J Ophthalmol. 2004;88(4):456-60. 2. Abraham DI, Vitale SI, West SI, Isseme I. Epidemiology of eye injuries in rural Tanzania. Ophthalmic Epidemiol. 1999;6(2):85-94. 3. Alfaro DV 3rd, Jablon EP, Rodriguez Fontal M, Villalba SJ, Morris RE, Grossman M, et al. Fishing-related ocular trauma. Am J Ophthalmol. 2005;139(3):488-92. 4. Shah M, Shah S, Khandekar R. Ocular injuries and visual status before and after their management in the tribal areas of Western India: a historical cohort study. Graefes Arch Clin Exp Ophthalmol. 2008;246(2):191-7. 5. Al-Mezaine HS, Osman EA, Kangave D, Abu El-Asrar AM. Risk factors for culture-positive endophthalmitis after repair of open globe injuries. Eur J Ophthalmol. 2010;20(1):201-8. 6. Wade PD, Khan SS, Khan MD. Endophthalmitis: magnitude, treatment and visual outcome in northwest frontier province of Pakistan. Ann Afr Med. 2009;8(1): 19-24. 7. Yang CS, Lu CK, Lee FL, Hsu WM, Lee YF, Lee SM. Treatment and outcome of traumatic endophthalmitis in open globe injury with retained intraocular foreign body. Ophthalmologica. 2010;224(2):79-85. 8. Zhang Y, Zhang MN, Jiang CH, Yao Y, Zhang K. Endophthalmitis following open globe injury. Br J Ophthalmol. 2010;94(1):111-4. 9. Cebulla CM, Flynn HW Jr. Endophthalmitis after open globe injuries. Am J Ophthalmol. 2009;147(4):567-8. 10. Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML. Low rate of endophthalmitis in a large series of open globe injuries. Am J Ophthalmol. 2009;147(4):601-608.e2. 11. Viestenz A, Schrader W, Behrens-Baumann W. Traumatic Endophthalmitis Prevention Trial (TEPT). Klin Monbl Augenheilkd. 2008;225(11):941-6. 12. Wykoff CC, Flynn HW Jr, Miller D, Scott IU, Alfonso EC. Exogenous fungal endophthalmitis: microbiology and clinical outcomes. Ophthalmology. 2008;115(9):1501-7, 1507.e1-2. 13. Gupta A, Srinivasan R, Gulnar D, Sankar K, Mahalakshmi T. Risk factors for post-traumatic endophthalmitis in patients with positive intraocular cultures. Eur J Ophthalmol. 2007;17(4):642-7.

IJCP Sutra: "Include lot of fruits, vegetables, pulses and curd in your diet."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

14. Al-Omran AM, Abboud EB, Abu El-Asrar AM. Microbiologic spectrum and visual outcome of posttraumatic endophthalmitis. Retina. 2007;27(2):236-42.

penetrating eye injuries reported to the National Eye Trauma System Registry, 1985-91. Public Health Rep. 1993;108(5):625-32.

15. Chhabra S, Kunimoto DY, Kazi L, Regillo CD, Ho AC, Belmont J, et al. Endophthalmitis after open globe injury: microbiologic spectrum and susceptibilities of isolates. Am J Ophthalmol. 2006;142(5):852-4.

22. Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-10.

16. Gupta A, Srinivasan R, Kaliaperumal S, Saha I. Posttraumatic fungal endophthalmitis - a prospective study. Eye (Lond). 2008;22(1):13-7. 17. Essex RW, Yi Q, Charles PG, Allen PJ. Post-traumatic endophthalmitis. Ophthalmology. 2004;111(11):2015-22. 18. Narang S, Gupta V, Simalandhi P, Gupta A, Raj S, Dogra MR. Paediatric open globe injuries. Visual outcome and risk factors for endophthalmitis. Indian J Ophthalmol. 2004;52(1):29-34. 19. Lieb DF, Scott IU, Flynn HW Jr, Miller D, Feuer WJ. Open globe injuries with positive intraocular cultures: factors influencing final visual acuity outcomes. Ophthalmology. 2003;110(8):1560-6.

23. Junejo SA, Ahmed M, Alam M. Endophthalmitis in paediatric penetrating ocular injuries in Hyderabad. J Pak Med Assoc. 2010;60(7):532-5. 24. Duch-Samper AM, Chaqués-Alepuz V, Menezo JL, Hurtado-Sarrió M. Endophthalmitis following open-globe injuries. Curr Opin Ophthalmol. 1998;9(3):59-65. 25. Ahmad I, Mehmood Z, Mohammad F. Screening of some Indian medicinal plants for their antimicrobial properties. J Ethnopharmacol. 1998;62(2):183-93. 26. Abad MJ, Ausuategui M, Bermejor P. Active antifungal substances from natural sources. ARKIVOC. 2007;(vii):11645. 27. Grayer RJ, Harborne JB. A survey of antifungal compounds from plants, 1982-1993. Phytochemistry. 1994;37(1):19-42.

20. Sabaci G, Bayer A, Mutlu FM, Karagül S, Yildirim E. Endophthalmitis after deadly-weapon-related open-globe injuries: risk factors, value of prophylactic antibiotics, and visual outcomes. Am J Ophthalmol. 2002;133(1):62-9.

28. Hostettmann K, Marston A. Saponins. Cambridge University Press, Cambridge; 1995. pp. 19-23.

21. Parver LM, Dannenberg AL, Blacklow B, Fowler CJ, Brechner RJ, Tielsch JM. Characteristics and causes of

30. Scalbert A. Antimicrobial properties Phytochemistry. 1991;30(12):3875-83.

29. Keay RWJ, Onochie CFA, Stanfield DP. In: Nigeria Trees. Volume 1, 1964. pp. 91-3. of

tannins.

■■■■

Half of US States Now Report Measles Cases With Maine reporting its first measles case, half of the United States has been hit with the highly contagious infection, according to the Maine Center for Disease Control and Prevention. The case was reported in a vaccinated school-aged child who had no serious complications and has recovered completely from the infection. As of May 17, 880 confirmed cases were reported in the United States by the US Centers for Disease Control and Prevention. (Medscape)

Genetic Testing may Help Identify Best Antidepressant Pharmacogenomic testing may help clinicians choose the most effective antidepressant for their patients with major depressive disorder (MDD) with greater precision. A study that examined the utility of such testing found that remission, response and relief from depressive symptoms were greater among patients whose care was guided by such testing, compared to patients who received treatment as usual (TAU), which did not include genetic guidance. The findings were presented at the American Society of Clinical Psychopharmacology (ASCP) 2019 annual meeting.

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

A Study to Evaluate Safety and Efficacy of Postpartum Intrauterine Contraceptive Device Insertion MAMTA RANI*, PARNEET KAUR†, KHUSHPREET KAUR‡, GURDIP KAUR#, SATINDER PAL KAUR¥

Abstract Introduction: The postpartum period presents a critical window of opportunity to provide family planning counseling and methods to women who may not otherwise receive family planning services. Postpartum intrauterine contraceptive device (PPIUCD) insertion is one such method. Objective: To determine safety and efficacy of PPIUCD insertion in normal vaginal delivery and during cesarean section. Methods: This study was conducted in Dept. of Obstetrics and Gynecology, Government Medical College and Rajindra Hospital, Patiala from January 2012 to September 2013. The subjects were divided into two groups, Group I in which Copper-T 380 A insertion was done within 10 minutes of delivery of placenta and Group II in which insertion was done during cesarean section using PPIUCD forceps. Follow-up was done at 6 weeks, 3 months and 6 months. Observations: Continuation rate was 89.79% in Group I and 96% in Group II at the end of 6-month follow-up period. Among both the groups, continuation rate was 92.9%. Expulsion rate was higher in Group I (4.08%) as compared to Group II, in which no expulsion occurred. Removal rate was 6.12% in Group I and 4% in Group II. None of the clients reported with perforation, infection or failure in our study. Conclusion: PPIUCD insertion is a safe, convenient, cost-effective, reversible and long-term birth spacing method. It can be used as an alternative to permanent sterilization. It should be a part of every maternal/newborn/ reproductive health package.

Keywords: Copper-T 380 A, PPIUCD, post-placental, intracesarean

ndia contributes to about 20% of births worldwide. Approximately 61% of births in India occur at intervals that are shorter than recommended birth-to-birth interval of approximately 36 months. Women in an unplanned pregnancy account for a significant number of inpatients in maternity hospitals. Studies estimate that prevention of unplanned and unwanted pregnancies could help avert 20-35% of maternal deaths and as many as 20% of child deaths. Postpartum Period The postpartum period presents a critical window of opportunity to provide family planning counseling and methods to women who may not otherwise receive

*Junior Resident †Professor ‡Professor and HOD #Associate Professor ¥Medical Officer Dept. of Obstetrics and Gynecology Government Medical College and Rajindra Hospital, Patiala, Punjab Address for correspondence

Dr Parneet Kaur House No. 52, Phulkian Enclave, Patiala - 147 001, Punjab E-mail: parneetkd@yahoo.co.in

family planning services. Family planning methods can be used immediately following childbirth and will help prevent subsequent mistimed or unwanted pregnancies, especially since women’s fertility can return within weeks of delivery. The time during pregnancy and immediately after delivery may be the only time for physician to connect with women who are poorly motivated to obtain routine health care, best described as crises-oriented. The World Health Organization’s guidelines on postpartum and newborn care include a provision for family planning counseling as a core component of postpartum care. Thus, postpartum period is potentially an ideal time to begin contraception as women are more strongly motivated to do so at this time, which also has the advantage of being convenient for both patients and health care providers. The following family planning methods can be used in postpartum period: ÂÂ

Postpartum intrauterine (PPIUCD) insertion

ÂÂ

Lactational amenorrhea

ÂÂ

Progestin only pills

ÂÂ

Combined estrogen progestin pill

IJCP Sutra: "It is a good idea to avoid complex carbohydrates right before bedtime."

contraceptive

device

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

ÂÂ

Barrier methods like diaphragm/cervical cap

condoms/spermicides,

ÂÂ

Sterilization

ÂÂ

Emergency contraception in the form of pills or intrauterine contraceptive device (IUCD).

Taking advantage of the immediate postpartum period for counseling on family planning and IUCD insertion, overcomes multiple barriers to service provision. The increased institutional deliveries are the opportunity to provide a woman with easy access to immediate PPIUCD services. Various type of PPIUCD insertions are: ÂÂ

Postplacental: Within 10 minutes after delivery of placenta

ÂÂ

Intracesarean: During cesarean section, immediately after delivery of placenta and before closure of uterine incision

ÂÂ

Immediate postpartum: Within 48 hours after delivery.

PPIUCD offers several benefits which are as follows: ÂÂ

It is convenient, saves time and additional visit

ÂÂ

Safe, because it is certain that she is not pregnant at the time of insertion

ÂÂ

Women and family are highly motivated for a reliable birth spacing method

ÂÂ

Has no risk of uterine perforation because of thick uterine wall

ÂÂ

Reduced perception of initial side effects

ÂÂ

Reduced chance of heavy bleeding especially among lactational amenorrhea method (LAM) users

ÂÂ

It has no effect on amount or quality of breast milk

ÂÂ

The woman has an effective method contraception before discharge from hospital.

for

The main disadvantage of IUCD contraception is rate of expulsion and side effects, such as pain and bleeding, which may necessitate its early removal.

ÂÂ

Group II: Intracesarean - Copper-T 380 A was inserted immediately after delivery of placenta and before closure of uterine incision.

In all the clients, insertion was done using PPIUCD forceps. All the clients were interviewed in accordance with enclosed proforma. The counseling was done during antenatal period or early stages of labor or while preparing for scheduled cesarean section for PPIUCD insertion. Informed written consent was taken from all patients.

Inclusion Criteria ÂÂ All the women whether undergoing vaginal delivery or cesarean section. ÂÂ Those who don’t have any contraindications for IUCD insertion. Exclusion Criteria ÂÂ Chorioamnionitis. ÂÂ Membranes ruptured for >18 hours prior to delivery. ÂÂ Unresolved PPH. Regular follow-ups were carried out at: 6 weeks, 3 months and 6 months interval. Results The age of the study subjects ranged from 19 to 40 years. Mean age in Group I was 24.8 years and 24.9 years in Group II. Forty-four percent of the subjects in Group I and 54% in Group II were primiparas (Table 1). Only 13% subjects in both groups had history of previous contraception use. Very few subjects in study groups had history of previous IUCD use i.e., only 4% (Table 2). The most common complaint (Table 3) by subjects in study groups was request for removal. Table 1. Demographic Profile Characteristics

Group I

Group II

Mean age (years)

24.8

24.9

Methods

Primiparas

44%

54%

The present study was conducted in the Dept. of Obstetrics and Gynecology, Government Medical College and Rajindra Hospital, Patiala. One hundred women undergoing vaginal or cesarean delivery were included in the study. The cases were divided into two groups of 50 each.

Multiparas

56%

46%

ÂÂ

Group I: Post-placental - Copper-T 380 A was inserted within 10 minutes of expulsion of placenta following vaginal delivery.

Table 2. Previous Contraceptive Use Contraceptive history

Group I

Group II

Total

Previous contraception (any method)

9 (18%)

4 (8%)

13 (13%)

Previous IUCD use

3 (6%)

1 (2%)

4 (4%)

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Table 3. Side Effects/Complaints of Clients at Follow-up Visits Side effect/ Complaint

Group I Group II Post-placental Intracesarean (n = 49) (n = 50)

Table 4. Causes of Removal Total (n = 99)

Total (n = 99)

1 (2.04%)

1 (2%)

2 (2.02%)

Bleeding

1 (2.04%)

1 (1.01%)

6 (6.06%)

Personal reasons

1 (2.04%)

1 (2%)

2 (2.02%)

3 (6%)

7 (7.07%)

Total

3 (6.12%)

2 (4%)

5 (5.05%)

2 (4%)

2 (2.02%)

5 (10.20%)

3 (6%)

8 (8.08%)

8 (16.3%)

7 (14%)

15 (15.15%)

Bleeding

3 (6.12%)

3 (6%)

Pain

4 (8.16%)

Missing strings

(Lost in follow-up -1 in Group I).

Table 5. Outcome of PPIUCD Outcome

Group I Post-placental (n = 49)

Group II Intracesarean (n = 50)

Total (n = 99)

Expulsion

2 (4.08%)

2 (2.02%)

Removal

3 (6.12%)

2 (4%)

5 (5.05%)

Failure (pregnancy)

Infection

44 (89.79%)

48 (96%)

92 (92.92%)

(Lost in follow-up -1 in Group I).

In Group I, 8 (16.3%) and in Group II, 7 (14%) requested for IUCD removal. All these clients were reassured and counseled regarding benefits of PPIUCD. Complaint of pain was more in Group I i.e., 4 (8.16%) and in Group II, pain was experienced by 3 (6%) subjects. All these were counseled and were managed conservatively with mefenamic acid. Still one client in each group got the IUCD removed (Table 4). Side effect in the form of disturbed bleeding pattern was almost same in both groups’ i.e., 3 subjects in each group. These subjects were given medication in form of tranexamic acid orally. But still in Group I, one client got IUCD removed. Complaint of missing strings was reported by 2 (4%) subjects in Group II. These subjects came with this complaint because they got their Copper-T checked from local practitioner who told them Copper-T was not in place and got worried. Ultrasound was done to confirm Copper-T, which showed Copper-T in situ and they were reassured. In Group I, 5 (10.20%) and in Group II, 3 (6%) presented with complaint of irritation by threads of the device. Threads were trimmed and counseling was done in these patients and also all their myths and misconceptions regarding Copper-T were allayed. Two clients (one in each study group) insisted and got it removed because of personal reasons (one due to irritation by thread and another due to follow-up problem). During examination, missing strings were mostly noticed in Group II, which occurred in 30% subjects. Only 4.08% clients in Group I had missing strings. In both the groups, ultrasound examination was performed in all clients with missing strings and Copper-T in situ was confirmed in all of them. We concluded that threads take time to descend in intracesarean PPIUCD cases.

Group I Group II Post-placental Intracesarean (n = 49) (n = 50)

Pain

Request for removal

Any other (threads irritation)

Causes of removal

Continuation

Only 2 (2.02%) clients had expulsion in study groups. Both expulsions occurred in study Group I. In Group I, 4.08% patients had expulsion, 6.12% got removed and rest (89.79%) were continuing the PPIUCD, whereas in Group II, none of patients had expulsion and 4% got Copper-T removed and 96% continued with use of PPIUCD at the end of study period. Continuation rate was 92.92% among all the subjects and majority of them were satisfied with their choice of contraceptive method. None of clients had failure, infection or perforation with the use of PPIUCD (Table 5). Discussion In developing countries and in particular in the rural or semi-urban areas, women with limited resources have difficulty in reaching to a family planning clinic or a Mother-Child Health-Family Planning Centre after child birth. This emphasizes the need and importance of providing family planning services in the postpartum period. India started repositioning postpartum family planning in February 2009. If we accept that pregnancy spacing of at least 24 months is recommended, that there is large unmet need for postpartum family planning, that there have been advances in understanding of IUCD

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

and that there is new focus on skilled attendance at birth, giving us unique opportunity to provide women with postpartum family planning then; PPIUCD is a potential answer to all these issues. The present study was planned to evaluate the safety and efficacy of PPIUCD insertion. Our study showed follow-up of 100% at 6 weeks. In our study, lost in follow-up rate was 1%. The results of this study showed that expulsion rates in Group I were 4.08%, which is in accordance with study of Gupta et al and total expulsion rate was 2.02%, which was comparable to Khatun, Lopez‐Farfan et al and Kittur et al. No expulsion occurred in intracesarean Group II, which is comparable to study of Letti Müller et al. This lower expulsion rate during cesarean insertion as compared to vaginal insertion may be due to direct placement of PPIUCD at the fundus during cesarean section. This wide variation in the expulsion rates in different studies could be due to the difference in the technique of insertion (hand or ring forceps or PPIUCD forceps), use of USG guidance for immediate insertion following vaginal delivery and skill and experience of practitioner. In Group I, complications/side effects rate in form of pain, bleeding and expulsion occurred in 9 (18.36%) and in Group II, 6 (12%) clients had complications/side effects. Complications/side effects in terms of pain, bleeding and expulsion which occurred in our study is in comparison with Celen et al and Gupta et al. No case of perforation, failure was reported in the present study. None of the subject in our study had infection. Gupta et al showed continuation rate of 87.33% which is in accordance with our study subjects of post-placental Group I over 6 months interval. Higher continuation rates (96%) were obtained for Group II in our study, which is comparable to Gupta et al with continuation rate 92.66% and Lopez‐ Farfan et al with 90% continuation rate. Conclusion PPIUCD insertion is a safe, convenient, cost-effective, reversible and long-term birth spacing method. It is an alternative to permanent sterilization, being longterm reversible method with comparable failure rate. It should be part of a maternal/newborn/reproductive health package. This method may be particularly beneficial in our setting, where women do not come routinely for postnatal contraception counseling and usage. Ideally, the counseling for PPIUCD should be done during routine antenatal visits, so that myths and misconceptions regarding IUCD can be allayed during

further visits and also clients can make clear decision regarding use of Copper-T in immediate postpartum period. SUGGESTED READING 1. Census 2011. Provisional Population Totals: Office of the Registrar General and Census Commissioner, India, Ministry of Home Affairs, 2011. Available at: www. censusindia.gov. 2. The ACQUIRE Project. The postpartum intrauterine device: A training course for service providers. Participant Handbook. New York: Engender Health, Postpartum IUCD Overview. 2008; (Module 2, 10): 5-64. Available at: https:// www.engenderhealth.org/files/pubs/family-planning/ PPIUD_Participant-Handbook.pdf. 3. Darnel L, Jones MD, David R, Helbert MD. Postpartum contraception. Clin Med. 1975;82:20-2. 4. Xu JX, Reusché C, Burdan A. Immediate postplacental insertion of the intrauterine device: a review of Chinese and the world’s experiences. Adv Contracept. 1994;10(1):71-82. 5. Postpartum IUCD Reference Manual. Postpartum Family Planning. Family Planning Division, Ministry of Health and Family Welfare, Government of India. 2010;1:1-4. Available at: http://www.jhpiego.org/files/PPIUCDReference%20 ManualFeb2011.pdf. 6. Çelen Ş, Sucak A, Yıldız Y, Danışman N. Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section. Contraception. 2011;84(3):240-3. 7. Akkuzu G, Vural G, Eroglu K, Dilbaz B, Taskin L, Akin A. Reasons for continuation or discontinuation of IUD in postplacental/early postpartum periods and postpuerperal/ interval periods: one-year follow-up. Turkiye Klinikleri J Med Sci. 2009;29(2):353-60. 8. Gupta A, Varma A, Chauhan J. Evaluation of PPIUCD versus interval IUCD (380A) insertion in a teaching hospital of Western UP. Int J Reprod Contracept Obstet Gynecol. 2013;2(2):204-8. 9. Khatun HA. Post-partum IUCD - A new method in post-partum contraception. Int J Gynaecol Obstet. 2009;107(2):620. 10. Lopez‐Farfan JA, MacIel‐Martínez M, Velez‐Machorro IJ, Vazquez‐Estrada L. Application of Mirenaan during caesarean section (CS). Euro J Contracep Reprod Health Care. 2010;15 Suppl 1:165‐6. 11. Kittur S, Kabadi YM. Enhancing contraceptive usage by post-placental intrauterine contraceptive devices (PPIUCD) insertion with evaluation of safety, efficacy, and expulsion. Int J Reprod Contracept Obstet Gynecol. 2012;1(1):26-32. 12. Letti Müller AL, Lopes Ramos JG, Martins-Costa SH, Palma Dias RS, Valério EG, Hammes LS, et al. Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot study. Contraception. 2005;72(3):192-5.

IJCP Sutra: "Avoid tanning beds: Tanning beds emit UV rays and can increase your risk of skin cancer."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Stroke in Hanging: Ischemic or Thrombotic? KA VIVEK*, N VIJAYAKUMAR†, R UMARANI‡

Abstract Hanging is among the most common methods of committing suicide in India, as reported in recent data published by National Crime Records Bureau. Neurological injury in such cases occurs due to compression of the neck. We present the case of a 52-year-old male who presented to the emergency with an alleged history of attempted suicide by hanging with nylon thread. Patient was started on supportive therapy, and 24 hours following admission, he became stable with normal blood pressure without any antihypertensive medications. However, on Day 3 of admission, he developed weakness of left upper limb and lower limb and deviation of angle of mouth to the left side. Repeat CT imaging of brain showed two hypodense foci in right caudate nucleus, head of adjacent internal capsule and a focus in right lentiform nucleus and posterior limb of internal capsule. MRI of brain, including MRA, showed an acute infarct with restricted diffusion in right lentiform nucleus, caudate nucleus, with filling defect in proximal M1 segment of right middle cerebral artery (MCA) suggestive of thrombus and attenuated signal was also noted in distal branches of right MCA. This case highlights the neurological complication following suicidal hanging and a structured approach to it.

Keywords: Suicidal hanging, neuroimaging, CT, MRI, stroke, hypoxia, thrombosis

uicidal hanging is among the most common methods of committing suicide in India according to recent data published by National Crime Records Bureau, where neurological injury occurs due to compression of the neck. The neck is the target organ for hanging. Easy accessibility, rounded contours, minimum bony shields, the small diameter and unsafe location of the airway, vital blood vessels and spinal cord make it susceptible to life-threatening injuries by hanging, which has been practiced as a popular method of committing suicide since ancient times. The jugular veins are the first structures to get compressed (force of 2 kg) followed by the carotid arteries (5 kg), causing cerebral edema and hypoxic brain damage, respectively. Compression of the airways needs greater force (15 kg), which can lead to severe hypoxia and death. Neurological outcomes in hanging vary from death, permanent hypoxic brain damage to complete recovery.

*Final Year Post Graduate †Lecturer ‡Professor Dept. of General Medicine, Rajah Muthiah Medical College and Hospital, Annamalai University, Chidambaram, Tamil Nadu Address for correspondence Dr KA Vivek Final Year Post Graduate Dept. of General Medicine, Rajah Muthiah Medical College and Hospital, Annamalai University, Chidambaram, Tamil Nadu E-mail: vivekasokan@gmail.com

In the reviewed literature, the neuroimaging findings in hanging have consistently been described as bilateral hemorrhagic and/or ischemic lesions in the thalamus, cerebellum and other areas of the basal nuclei. Unilateral lesions seem to be a very rare event and to the best of our knowledge, very few cases have been reported. We report a case of suicidal hanging where the patient survived an initial brain insult, but later developed a neurological deficit in the form of hemiplegia due to an infarct in the right lentiform nucleus, caudate nucleus and corona radiata. Patient recovered with supportive treatment. This case highlights the neurological complication following suicidal hanging and a structured approach to it. Case Report A 52-year-old male presented to the emergency with an alleged history of attempted suicide by hanging with nylon thread. After few seconds of suspension, he fell down, and was rushed to the hospital. There was no history of seizure, bleeding from nostrils, eyes and mouth. There were no pre-existing comorbid conditions. At the time of admission, patient was conscious and oriented. The pulse rate was 110/min, blood pressure was 170/100 mmHg, respiratory rate was 18/min and oxygen saturation by pulse oximeter was 98%. Local examination revealed one circumferential shallow

IJCP Sutra: "Become familiar with your skin so you’ll notice changes. Examine your skin regularly for new skin growths or changes in existing moles, freckles, bumps and birthmarks."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

abraded ligature mark over anterior aspect of the neck. There was no cyanosis or subconjunctival hemorrhages. Nasal mucosa, post pharyngeal wall and bilateral tympanic membrane were not congested. Neurological examination was normal except for bilateral extensor Babinski response. Fundus was normal. Both pupils were mid-dilated and responding to light. All biochemical investigations and baseline computed tomography (CT) imaging of brain was normal, and there were no fractures of the cervical spine. Patient was started on supportive therapy, and 24 hours following admission, patient became stable with normal blood pressure without any antihypertensive medications. On Day 3 of admission, patient developed weakness of left upper limb and lower limb and deviation of angle of mouth to the left side. Neurological examination revealed hemiparesis of left upper limb and lower limb with a power of 3/5. Tone was increased, reflexes were diminished on both left upper limb and lower limb. Extensor plantar was present on the left side and right side plantar was not elicitable; left upper motor neuron (UMN) type of facial nerve palsy was also present. Urgent repeat CT imaging of brain (Fig. 1a) showed two hypodense foci in right caudate nucleus, head of adjacent internal capsule and a focus in right lentiform nucleus and posterior limb of internal capsule. Magnetic resonance imaging (MRI) of brain (Fig. 1b), including magnetic resonance angiography (MRA), showed an acute infarct with restricted diffusion in right lentiform nucleus, caudate nucleus, with filling defect in proximal M1 segment of right middle cerebral artery (MCA) suggestive of thrombus and attenuated signal was also noted in distal branches of right MCA. Magnetic resonance venography (MRV) had no evidence of venous thrombosis. Cardiac evaluation including echocardiogram was found to be normal. Patient was treated with fluid restriction, mannitol, intravenous antibiotics, low molecular weight heparin, physiotherapy and other supportive measures. Patient gradually improved and was discharged on Day 9, with advice to continue physiotherapy. Discussion The factors that contribute to death after suicidal hanging include pulmonary complications and neurological complications. Pulmonary complications include pulmonary edema and bronchopneumonia, secondary to aspiration. The edema may be due to a centrally mediated sympathetic discharge or due to negative intrathoracic pressure, which is generated as the person

Figure 1 a and b. CT imaging of brain showing two hypodense foci in right caudate nucleus, head of adjacent internal capsule and a focus in right lentiform nucleus and posterior limb of internal capsule (a). MRI showing acute infarct with restricted diffusion in right lentiform nucleus and caudate nucleus (b).

attempts to inspire through an obstructed airway. Neurological complications include transient hemiparesis, spinal cord syndromes, focal cerebral deficits, cerebral edema, various nerve palsies and larger infarctions. Other complications like hyperthermia, subarachnoid hemorrhage, pneumoperitoneum, ruptured esophagus may also occur. Some factors such as systolic blood pressure <90, Glasgow coma scale score ≤8, anoxic brain injury on CT scan and injury severity score >15 have been found to be significantly associated with mortality in hanging. In suicidal hanging, there is slower development of cerebral hypoxia and ischemia, with both the events being strongly dependent on the materials, location and the method of suicide attempt. This cerebral hypoxia and ischemia can be attributed to the mechanical compression and obstruction of the airway and vasculature of the neck. Further, airway can be compromised by the upward displacement of the tongue and epiglottis, jugular vein occlusion by mild neck closure and vertebral artery occlusion by spinal injury. These combined factors can easily lead to acute cerebral hypoxia. In rare instances, direct injury to the spinal cord and brainstem can also occur. The most sensitive areas of hypoxic and ischemic damage are the cerebral cortex, border zones between arterial territories, Ammon’s horn, Purkinje cells, particularly the basal ganglia. In the early stages, ischemic neuronal

IJCP Sutra: "Eat smaller meals, but more often."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

changes are demonstrated by cytotoxic edema (swelling of neurons, glia and endothelial cells) and failure of the sodium ion exchange pump. Sodium accumulates within the cell and water follows this movement to maintain the osmotic equilibrium. The venous hypertension and stasis of blood flow caused by the acute bilateral compression of the internal jugular veins result in hydrostatic transudation of intravascular contents and subsequently rapid occurrence of hypoxia and infarction. Bilateral involvement is the common finding in hypoxic ischemic injury in suicidal hanging. However, unilateral involvement of brain in the form of hemiplegia due to thrombotic stroke can occur rarely. Traumatic thrombosis of internal carotid artery is reported as being caused by one of the four mechanisms: ÂÂ

Injury to intrapetrous or cavernous part of the carotid artery during the basal skull fracture

ÂÂ

Injury to point of emergence of carotid artery from the cavernous sinus as a result of strain

ÂÂ

A direct blow to the neck or trauma to peritonsillar area by a foreign object carried in the month

ÂÂ

Stretching of the carotid artery by hyperextension and lateral flexion of neck.

The pathophysiology of thrombosis is due to adherence of platelets to the endothelium with subsequent aggregation, which releases thromboplastin leading to initiation of coagulation cascade. The neuroimaging in hypoxic ischemic brain injury is often symmetrical, diffuse, low-density lesions found in the watershed areas of the brain. However, in thrombotic injury, the CT and MRI findings are consistent with the vascular territory of the vessels involved. MRA and MRV may show filling defects with attenuated signals. Conclusion The mechanism of injury, pathophysiology, clinical features and neuroimaging are distinct and different

in both cerebral hypoxic ischemic injury and traumatic thrombotic injury to the brain in patients with suicidal hanging. Detailed neurological examination daily to look for subtle changes in clinical features in the patient, repeated neuroimaging studies including MRA and MRV, would help in early diagnosis of thrombotic episodes in suicidal hanging and for early medical management, and if required, surgical management. Suggested reading 1. Garaci FG, Bazzocchi G, Velari L, Gaudiello F, Goldstein AL, Manenti G, et al. Cryptogenic stroke in hanging. A case report. Neuroradiol J. 2009;22(4):386-90. 2. Kumar S, Verma AK, Bhattacharya S, Rathore S. Trends in rates and methods of suicide in India. Egypt J Foren Sci. 2013;3(3):75-80. 3. Kodikara S. Uneventful recovery from suicidal hanging: a case report. Med Sci Law. 2006;46(1):89-91. 4. Salim A, Martin M, Sangthong B, Brown C, Rhee P, Demetriades D. Near-hanging injuries: a 10-year experience. Injury. 2006;37(5):435-9. 5. Matsuyama T, Okuchi K, Seki T, Higuchi T, Ito S, Makita D, et al. Magnetic resonance images in hanging. Resuscitation. 2006;69(2):343-5. 6. Kalita J, Mishra VN, Misra UK, Gupta RK. Clinicoradiological observation in three patients with suicidal hanging. J Neurol Sci. 2002;198(1-2):21-4. 7. Nemoto EM. Pathogenesis of cerebral ischemia-anoxia. Crit Care Med. 1978;6(4):203-14. 8. Kjos BO, Brant-Zawadzki M, Young RG. Early CT findings of global central nervous system hypoperfusion. AJR Am J Roentgenol. 1983;141(6):1227-32. 9. Narayanaswamy R, Sharma RK, Thakur M, Kansra U. Stroke secondary to attempted strangulation. Arch Med Health Sci. 2014;2(1):71-3. 10. Nakajo M, Onohara S, Shinmura K, Nakajo M, Amitani H, Munamoto T, et al. Computed tomography and magnetic resonance imaging findings of brain damage by hanging. J Comput Assist Tomogr. 2003;27(6):896-900.

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World Health Assembly Establishes World Chagas Day The World Health Assembly Member States have agreed to establish World Chagas Day, to be celebrated each year on April 14. Chagas, a neglected tropical disease, currently affects 6-7 million people, mostly in Latin America. The year 2020 has been declared as the “Year of the Nurse and the Midwife.” (WHO)

IJCP Sutra: "Eat in a slow, relaxed manner."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Lingual Thyroid: A Case Report PONNATHPUR LAKSHMI*, MEENA L†

Abstract Lingual thyroid is a rare developmental anomaly caused due to the aberrant embryogenesis during descent of the thyroid gland from the foramen cecum to its pre-laryngeal site. Foreign body sensation in throat, dysphagia, dysphonia, pain and bleeding are the common presenting symptoms of this condition. Treatment includes the use of exogenous thyroid hormone to correct the hypothyroidism and to induce the shrinkage of the gland. Other treatment options include surgery and radiotherapy when symptoms of obstruction, bleeding and malignant transformation are present. Presented here is the case of a 39-year-old male presenting with foreign body sensation in throat of one week’s duration. The patient was diagnosed with lingual thyroid. Treatment with 50 µg/day of L-thyroxine was advised and surgery was deferred as the patient was asymptomatic.

Keywords: Lingual thyroid, ectopic thyroid, technetium-99m thyroid scan, L-thyroxine

ingual thyroid is a rare developmental anomaly caused due to the aberrant embryogenesis during descent of the thyroid gland to the neck. The first case of lingual thyroid was reported in 1869 by Hickman. Most frequent ectopic location (about 90%) of the thyroid gland is in the base of the tongue. Other sites include sublingual, thyroglossal and laryngotracheal, mediastinal and esophageal. Prevalence rate ranges from 1 in 1,00,000 to 1 in 3,00,000 population; 0.3% of cases will present in hypothyroid state. Diagnosis is mainly by clinical suspicion and confirmation by imaging.

Case Report

smooth surfaced, extending from dorsal surface of base of tongue to lingual surface of epiglottis was noted. On palpation, the swelling was hard in consistency without any pain or discomfort. No bleeding points were seen. Ear, nose and neck examination was normal. Provisional diagnosis of lingual thyroid was made based on its location and appearance. The patient was advised for following investigations: ÂÂ

Thyroid function test results showed the following parameters: zz Triiodothyronine (T3) - 1.22 ng/mL, thyroxine (T4) - 6.24 ng/mL and thyroid-stimulating hormone (TSH) - 14.29 mIU/mL

A 39-year-old male presented with foreign body sensation in throat of one week’s duration. There was no history of dysphagia, nocturnal dyspnea and sleep apnea/dysphonia. There were no signs of thyroid dysfunction. On intraoral examination, a globular lesion popped up near the mid-line of base of tongue on gagging (Fig. 1). On videolaryngoscopy examination, a globular swelling measuring about 2.5 cm in diameter,

*Senior Consultant Sagar Hospital and Skin Cosmetic & ENT Care Centre (SCENT), Bengaluru, Karnataka †Junior Consultant Skin Cosmetic & ENT Care Centre (SCENT), Bengaluru, Karnataka Address for correspondence Dr Ponnathpur Lakshmi 742, “Bhagyashree”, 18th Main, 37th F Cross, 4th T Block, Jayanagar, Bengaluru - 560 041, Karnataka E-mail: ponnathpurlakshmi@gmail.com

Figure 1. Intraoral examination.

IJCP Sutra: "Remain upright after meals."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

zz T3 and T4 were measured by competitive electrochemiluminescent immunoassay zz TSH by sandwich electrochemiluminescent immunoassay. ÂÂ

Ultrasonography of neck showed absent thyroid gland in thyroid fossa. Heterogeneous echo pattern solid lesion in the base of the tongue on the right side suggested lingual thyroid.

ÂÂ

Radionuclide thyroid scan and uptake study using 3 mCi of technetium-99m pertechnetate was done, which revealed abnormal radiotracer concentration in the base of tongue consistent with ectopic thyroid tissue. Thyroid gland was not visualized in its normal position. Thus, it indicated that this lingual thyroid is the only functioning thyroid gland.

The patient was advised 50 µg/day of L-thyroxine and surgery was deferred as the patient was asymptomatic. Discussion Lingual thyroid is the presence of ectopic thyroid tissue anywhere between circumvallate papillae of the tongue to epiglottis along the primitive thyroglossal duct. This is due to the embryonic failure of descent of normal thyroid tissue from foramen cecum area of base of tongue to the lower part of the neck in front of the thyroid cartilage. It has been hypothesized that the cause for the arrest in descent of thyroid anlage is due to the maternal antibodies against thyroid antigen. The incidence of lingual thyroid is reported as 1 in 1,00,000. It is seven times higher in females when compared to males. About 33-62% of all patients have hypothyroidism with elevated levels of TSH. Foreign body sensation in throat, dysphagia, dysphonia, pain and bleeding are the common presenting symptoms of this condition. Investigation for lingual thyroid includes serum thyroid profile, radionuclide technetium-99m and iodine-131 thyroid scans. Other investigations include computed tomography (CT) and magnetic resonance imaging (MRI) of the neck with contrast, which helps in planning treatment. In our case, same radionuclide technetium-99m scan was done and abnormal radiotracer concentration in the base of the tongue was noted, consistent with ectopic thyroid tissue. Thyroid gland was not visualized in its normal position.

The treatment options that are available for lingual thyroid include surgery, radioiodine ablation and chemotherapy. The choice of treatment depends on symptoms such as dysphagia, sleep apnea, bleeding from the lesion, location and extent of the lesion. Treatment of an asymptomatic patient in euthyroid state is regular follow-up. In hypothyroid patients, L-thyroxine is supplemented for suppressing the TSH levels as well as to reduce the size of the lesion. Indications for surgery include severe obstructive symptoms and complications such as bleeding, cystic degeneration or malignancy. Surgical excision may be considered after confirmation of adequate thyroid tissue in the neck by radioisotope scan. Surgical excision can be done either transorally or externally through a transhyoidal pharyngotomy. In patients lacking thyroid tissue in the neck, the lingual thyroid can be excised and implanted in the muscles of the neck. In the present case, the patient was kept on hormone replacement therapy with L-thyroxine and was followed-up regularly every 3 months. Surgical excision was not considered in the present case as it was the only functioning thyroid gland. However, surgical excision can be considered in future, if malignant transformation occurs. Conclusion When a mass is observed in the base of tongue, ectopic lingual thyroid must be kept in mind for differential diagnosis. The diagnosis can be confirmed using ultrasonography, radionuclide thyroid scan, CT and MRI scans. Treatment option is based on symptomatology. Suggested reading 1. Léger J, Marinovic D, Garel C, Bonaïti-Pellié C, Polak M, Czernichow P. Thyroid developmental anomalies in first degree relatives of children with congenital hypothyroidism. J Clin Endocrinol Metab. 2002;87(2):575-80. 2. Hickman W. Congenital tumor of the base of the tongue, pressing down the epiglottis on the larynx and causing death by suffocation sixteen hours after birth. Trans Pathol Soc Lond. 1869;20:160-1. 3. Abdallah-Matta MP, Dubarry PH, Pessey JJ, Caron P. Lingual thyroid and hyperthyroidism: a new case and review of the literature. J Endocrinol Invest. 2002;25(3):264-7. 4. Noyek AM, Friedberg J. Thyroglossal duct and ectopic thyroid disorders. Otolaryngol Clin North Am. 1981;14(1):187-201.

IJCP Sutra: "Avoid late night eating (last meal 3 hours before sleep)."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

5. Batsakis JG, El-Naggar AK, Luna MA. Thyroid gland ectopias. Ann Otol Rhinol Laryngol. 1996;105(12):996-1000. 6. van der Gaag RD, Drexhage HA, Dussault JH. Role of maternal immunoglobulins blocking TSH-induced thyroid growth in sporadic forms of congenital hypothyroidism. Lancet. 1985;1(8423):246-50.

9. Kansal P, Sakati N, Rifai A, Woodhouse N. Lingual thyroid. Diagnosis and treatment. Arch Intern Med. 1987;147(11):2046-8. 10. Toso A, Colombani F, Averono G, Aluffi P, Pia F. Lingual thyroid causing dysphagia and dyspnoea. Case reports and review of the literature. Acta Otorhinolaryngol Ital. 2009;29(4):213-7.

7. Williams JD, Sclafani AP, Slupchinskij O, Douge C. Evaluation and management of the lingual thyroid gland. Ann Otol Rhinol Laryngol. 1996;105(4):312-6.

11. Jones P. Autotransplantation in lingual ectopia of the thyroid gland. Review of the literature and report on a successful case. Arch Dis Child. 1961;36:164-70.

8. Aktolun C, Demir H, Berk F, Metin Kir K. Diagnosis of complete ectopic lingual thyroid with Tc-99m pertechnetate scintigraphy. Clin Nucl Med. 2001; 26(11):933-5.

12. Hari CK, Kumar M, Abo-Khatwa MM, Adams-Williams J, Zeitoun H. Follicular variant of papillary carcinoma arising from lingual thyroid. Ear Nose Throat J. 2009;88(6):E7.

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FDA Permits Marketing of First Diagnostic Test to Aid in Detecting Prosthetic Joint Infections The US FDA permitted marketing of a Lateral Flow Test Kit as an aid for the detection of periprosthetic joint infection (infection around a joint replacement) in the synovial fluid of patients being evaluated for revision surgery. Prior to the authorization, there were no FDA-authorized diagnostic tests specifically designed to help health care professionals determine whether the inflammation around a prosthetic joint was due to an infection or another cause, said Tim Stenzel, MD, PhD, Director of the Office of In Vitro Diagnostics and Radiological Health in the FDA’s Center for Devices and Radiological Health. (FDA)

Weight-training may Help Reduce Hot Flashes Postmenopausal women can fight off hot flashes and night sweats through weight-training, suggested a new clinical trial published in the journal Maturitas. “Resistance training is already recommended for all women always, but now we can see it may be effective also for hot flashes around menopause,” said Dr Emilia Berin of Linkoping University in Sweden, who led the study.

Midlife Type 2 Diabetes Tied to Cerebrovascular Disease Type 2 diabetes was tied to a higher risk for cerebrovascular disease (CBD) later in life, according to a twin study. In a cohort of over 33,000 individual twins, midlife type 2 diabetes was associated with 29% higher odds of cerebral infarction later in life compared with people without diabetes (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.03-1.61), reported Rongrong Yang, PhD candidate, Tianjin Medical University in China, and colleagues. Having type 2 diabetes in midlife was also tied to over two fold higher odds of experiencing cerebral artery occlusion (OR 2.03, 95% CI 1.20-3.44), the group reported in Diabetologia.

German Court Sentences Serial-killing Nurse to Life A former nurse was convicted of killing 85 of his patients and sentenced to life imprisonment for the worst killing spree in Germany’s post-war history, multiple local media outlets reported. Niels Hoegel, who injected his patients with lethal drugs and then played the hero by appearing to struggle to revive them, had already been convicted and sentenced for two murders in 2015. Prosecutors last year brought further charges over the dozens of other murders of which he was accused. (Reuters)

IJCP Sutra: "Don’t exercise immediately after meals."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Ptosis in Poisoning: An Interesting Partnership S SARAVANA MOORTHY*, N VIJAYAKUMAR†, R UMARANI‡

Abstract This article describes a patient who presented with bilateral ptosis following overdose of chloroquine tablet followed by complete recovery after 36 hours of ingestion. Ptosis is quite common in the field of toxicology and is caused by many drugs and toxins. The exact mechanism is unknown in many cases. However, the neuromuscular junction is the culprit. The temporal relationship of ptosis to the conception of poison is contributory in many cases and points to the cause, especially in cases of unknown poisoning and multiple drug overdose.

Keywords: Ptosis, poisoning, drug overdose

hloroquine is a 4-aminoquinoline compound effective against the asexual forms of all types of drug sensitive malaria. Because of its cheaper cost and oral availability, chloroquine is the most commonly prescribed drug for malaria. Chloroquine is also used in the treatment of autoimmune diseases, lepra reaction and extraintestinal amebiasis. The neuroophthalmological adverse effects of chloroquine include neuromyopathy, myasthenia like syndrome, retinopathy and psychiatric manifestations. In this article, we present a neurological adverse effect of high-dose chloroquine. Other common side effects include gastrointestinal upset, hypoglycemia, corneal deposits and retinal toxicity. Chloroquine is a rapidly acting erythrocytic schizonticide against all species of plasmodia. It is actively concentrated by sensitive intraerythrocytic plasmodia; higher concentration is found in infected red blood cells (RBCs).

Case Report A 21-year-old male presented to our casualty with drooping of eyelids, double vision and blurring of vision following ingestion of 6 tablets of double strength (500 mg) chloroquine (total dose = 3 g). Patient mistakenly took this drug, which was prescribed for his brother for fever. There was no vomiting, breathing difficulty, difficulty in swallowing, weakness of limbs, diarrhea and neck pain. On examination, patient was conscious and oriented with stable vitals. Central nervous system (CNS) examination revealed bilateral partial ptosis with normal extraocular movements and sluggish pupillary reaction (Fig. 1).

Oral absorption of chloroquine is excellent; around 50% is bound to plasma and has high affinity for melanin and nuclear chromatin.

*Final Year Post Graduate †Lecturer ‡Professor Dept. of General Medicine Rajah Muthiah Medical College and Hospital, Annamalai University, Chidambaram Tamil Nadu Address for correspondence Dr S Saravana Moorthy Final Year Post Graduate Dept. of General Medicine Rajah Muthiah Medical College and Hospital, Annamalai University Chidambaram, Tamil Nadu

Figure 1. Patient at presentation.

IJCP Sutra: "Limit foods high in cholesterol such as liver and other organ meats, egg yolks and full-fat dairy products, like whole milk."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Axon of motor junction

Presynaptic terminal Synaptic vesicles

Neuromuscular junction Sarcolemma

Synaptic cleft

Muscle fiber Capillary

Mitochondrion Myofibrils

Postsynaptic membrane

Figure 3. The neuromuscular junction.

Figure 2. Patient after recovery.

Light reflex was normal and visual acuity was 6/6 on both eyes. Fundus examination was normal. Other neurological examinations like muscle tone, power, reflexes, cerebellar functions, sensory and autonomic systems were normal and there was no fatigability of ptosis. Ice pack test was done, which showed no improvement of ptosis. Other cranial nerves were normal. He was managed with stomach wash, IV fluids and IV proton pump inhibitor. Patient had full recovery after 36 hours of admission (Fig. 2). As patient had full recovery, neuroimaging and Tensilon test which were previously planned were not done. Discussion Usually neuro-ophthalmic side effects of chloroquine occur 24 hours after ingestion. It is due to transient neuromuscular blockade. In our patient, the symptoms developed within 6 hours of ingestion, which may be because of faster absorption as the patient was empty stomach since morning on the day of ingestion. This article highlights the fact that though chloroquine is safe in antimalarial doses, it can cause serious neuroophthalmic side effects at higher doses. Drugs can directly affect neuromuscular transmission through several modes of action (Fig. 3): ÂÂ

At the presynaptic site, they can reduce acetylcholine release by exerting a local anesthetic like effect on the nerve terminal

ÂÂ

By interference with presynaptic calcium fluxes

ÂÂ

By exerting a hemicholinium like effect on the postsynaptic membrane

ÂÂ

They can have curare like effects and potentiate depolarizing and non-depolarizing muscle relaxants

ÂÂ

In addition, some drugs have direct effect on the muscle membrane.

Chloroquine has multiple pharmacological effects. Chloroquine has antimuscarinic effects and anticoagulant properties and effect on lysosomal function, through elevation of intralysosomal pH. In this way, the turnover of several cellular constituents is altered. With important biological consequences, the mechanisms of antigen processing and T-cell recognition by macrophages is interfered with, which together with the inhibitory effect of chloroquine on the secretion of interleukin-1 by monocytes, explains the effect of chloroquine on the immune system. The effect of chloroquine on lysosomal function also results in changes in properties, turnover and binding kinetics of membrane proteins such as the insulin receptor. The relevance of these lysosomotropic actions of chloroquine with its effect on the neuromuscular junction is unclear, as chloroquine-induced changes in the turnover of neuromuscular proteins, e.g., the acetylcholine receptor protein, remains to be studied. Ptosis, drooping or falling of one or both upper eyelid with eyes in primary gaze, may be unilateral or bilateral. The levator muscle and aponeurosis is the major elevator of upper eyelid. The Muller muscle, a sympathetically innervated smooth muscle, originates from the undersurface of the levator superioris. Causes of ptosis include myogenic,

IJCP Sutra: "Stay away from carbonated beverages."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

neurogenic, aponeurotic, mechanical, drug-induced and pseudoptosis. In toxicology, botulinum toxin and drug overdosages with morphine, oxycodone, heroin, pregabalin, steroids, steroid eye drops, reserpine, chlorpromazine, gentamicin, streptomycin, kanamycin, colistin, D-penicillamine, chloroquine, phenytoin and lithium, ptosis is known to occur infrequently. The pathogenesis of drug-induced ptosis in toxicology is not well-understood. However, an increase in serum antibodies to acetylcholine receptors has been documented. Conclusion This article highlights a rare presentation of overdosage due to commonly used drugs. Chloroquine-induced ptosis is a very rare presentation, occurs usually 24-48 hours after drug overdosage with no other neurological abnormalities and is completely reversible with symptomatic treatment. Being aware of this rare presentation of chloroquine toxicity will avoid extensive, costly and invasive investigative procedures.

Suggested reading 1. Argov Z, Yaari Y. The action of chlorpromazine at an isolated cholinergic synapse. Brain Res. 1979;164:227-36. 2. Habara Y, Williams JA, Hootman SR. Antimuscarinic effects of chloroquine in rat pancreatic acini. Biochem Biophys Res Commun. 1986;137(2):664-9. 3. Ohkuma S, Poole B. Fluorescence probe measurement of the intralysosomal pH in living cells and the perturbation of pH by various agents. Proc Natl Acad Sci U S A. 1978;75(7):3327-31. 4. Iwamoto Y, Roach E, Bailey A, Williams JA, Goldfine ID. The effect of chloroquine on the binding, intracellular distribution, and action of insulin on isolated mouse pancreatic acini. Diabetes. 1983;32(12):1102-9. 5. Sorimachi K, Okayasu T, Yasumura Y. Increase in insulin binding affinity by chloroquine in cultured rat hepatoma cells. Endocr Res. 1987;13(1):49-60. 6. Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27(3):193-204. 7. Katz LJ, Lesser RL, Merikangas JR, Silverman JP. Ocular myasthenia gravis after D-penicillamine administration. Br J Ophthalmol. 1989;73(12):1015-8.

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New Global Strategy on Health, Environment and Climate Change World Health Assembly Member States agreed a new global strategy on health, environment and climate change: the transformation needed to improve lives and well-being sustainably through healthy environments. The strategy provides a vision and way forward on how the world and its health community need to respond to environmental health risks and challenges until 2030. They also agreed a plan of action on climate change and health in Small Island Developing States. The plan has four strategic lines of action: empowerment (supporting health leadership in Small Island Developing States); evidence (building the business case for investment); implementation (preparedness for climate risks, adaptation and health-promoting mitigation policies) and resources (facilitating access to climate and health finance). (WHO)

New Obesity Care Algorithm Addresses CVD, Diabetes and Cancer The Obesity Medicine Association (OMA) has released its yearly updated algorithm to help clinicians care for adults with obesity. As a newly added component this year, the algorithm “explores exactly how obesity causes the most common conditions evaluated and treated by clinicians, including cardiovascular disease (CVD), (type 2 diabetes), high BP, dyslipidemia, fatty liver and cancer, and [it] outlines what both patients and clinicians can do to combat this...disease”, noted Harold Bays, the medical director of the Louisville Metabolic and Atherosclerosis Research Center (L-MARC) in Kentucky. (Medscape) More Than 1 Million New Curable Sexually Transmitted Infections Every Day Every day, there are more than 1 million new cases of curable sexually transmitted infections (STIs) among people aged 15-49 years, according to data released by the World Health Organization (WHO). This amounts to more than 376 million new cases annually of four infections - chlamydia, gonorrhea, trichomoniasis and syphilis. Published online by the Bulletin of the WHO, the research shows that among men and women aged 15-49 years, there were 127 million new cases of chlamydia in 2016, 87 million of gonorrhea, 6.3 million of syphilis and 156 million of trichomoniasis. “We’re seeing a concerning lack of progress in stopping the spread of sexually transmitted infections worldwide,” said Dr Peter Salama, Executive Director for Universal Health Coverage and the Life-Course at WHO. (WHO)

IJCP Sutra: "If you have acid reflux, find the foods that trigger your symptoms and avoid them (fatty foods, spicy foods, tomatoes, garlic, milk, coffee, tea, cola, peppermint and chocolate)."

Every citizen of India should have the right to accessible, affordable, quality and safe heart care irrespective of his/her economical background

Sameer Malik Heart Care Foundation Fund An Initiative of Heart Care Foundation of India

E-219, Greater Kailash, Part I, New Delhi - 110048 E-mail: heartcarefoundationfund@gmail.com Helpline Number: +91 - 9958771177

“No one should die of heart disease just because he/she cannot afford it” About Sameer Malik Heart Care Foundation Fund

Who is Eligible?

“Sameer Malik Heart Care Foundation Fund” it is an initiative of the Heart Care Foundation of India created with an objective to cater to the heart care needs of people.

Objectives Assist heart patients belonging to economically weaker sections of the society in getting affordable and quality treatment. Raise awareness about the fundamental right of individuals to medical treatment irrespective of their religion or economical background. Sensitize the central and state government about the need for a National Cardiovascular Disease Control Program. Encourage and involve key stakeholders such as other NGOs, private institutions and individual to help reduce the number of deaths due to heart disease in the country. To promote heart care research in India.

All heart patients who need pacemakers, valve replacement, bypass surgery, surgery for congenital heart diseases, etc. are eligible to apply for assistance from the Fund. The Application form can be downloaded from the website of the Fund. http://heartcarefoundationfund.heartcarefoundation. org and submitted in the HCFI Fund office.

Important Notes The patient must be a citizen of India with valid Voter ID Card/ Aadhaar Card/Driving License. The patient must be needy and underprivileged, to be assessed by Fund Committee. The HCFI Fund reserves the right to accept/reject any application for financial assistance without assigning any reasons thereof. The review of applications may take 4-6 weeks. All applications are judged on merit by a Medical Advisory Board who meet every Tuesday and decide on the acceptance/rejection of applications. The HCFI Fund is not responsible for failure of treatment/death of patient during or after the treatment has been rendered to the patient at designated hospitals.

To promote and train hands-only CPR.

Activities of the Fund Financial Assistance

The HCFI Fund reserves the right to advise/direct the beneficiary to the designated hospital for the treatment.

Financial assistance is given to eligible non emergent heart patients. Apart from its own resources, the fund raises money through donations, aid from individuals, organizations, professional bodies, associations and other philanthropic organizations, etc.

The financial assistance granted will be given directly to the treating hospital/medical center.

After the sanction of grant, the fund members facilitate the patient in getting his/her heart intervention done at state of art heart hospitals in Delhi NCR like Medanta – The Medicity, National Heart Institute, All India Institute of Medical Sciences (AIIMS), RML Hospital, GB Pant Hospital, Jaipur Golden Hospital, etc. The money is transferred directly to the concerned hospital where surgery is to be done.

Drug Subsidy

The HCFI Fund has the right to print/publish/webcast/web post details of the patient including photos, and other details. (Under taking needs to be given to the HCFI Fund to publish the medical details so that more people can be benefitted). The HCFI Fund does not provide assistance for any emergent heart interventions.

Check List of Documents to be Submitted with Application Form Passport size photo of the patient and the family A copy of medical records Identity proof with proof of residence Income proof (preferably given by SDM)

The HCFI Fund has tied up with Helpline Pharmacy in Delhi to facilitate

BPL Card (If Card holder)

patients with medicines at highly discounted rates (up to 50%) post surgery.

Details of financial assistance taken/applied from other sources (Prime Minister’s Relief Fund, National Illness Assistance Fund Ministry of Health Govt of India, Rotary Relief Fund, Delhi Arogya Kosh, Delhi Arogya Nidhi), etc., if anyone.

The HCFI Fund has also tied up for providing up to 50% discount on imaging (CT, MR, CT angiography, etc.)

Free Diagnostic Facility

Free Education and Employment Facility

The Fund has installed the latest State-of-the-Art 3 D Color Doppler EPIQ 7C Philips at E – 219, Greater Kailash, Part 1, New Delhi.

HCFI has tied up with a leading educational institution and an export house in Delhi NCR to adopt and to provide free education and employment opportunities to needy heart patients post surgery. Girls and women will be preferred.

This machine is used to screen children and adult patients for any heart disease.

Laboratory Subsidy HCFI has also tied up with leading laboratories in Delhi to give up to 50% discounts on all pathological lab tests.

About Heart Care Foundation of India

Help Us to Save Lives The Foundation seeks support, donations and contributions from individuals, organizations and establishments both private and governmental in its endeavor to reduce the number of deaths due to heart disease in the country. All donations made towards the Heart Care Foundation Fund are exempted from tax under Section 80 G of the IT Act (1961) within India. The Fund is also eligible for overseas donations under FCRA Registration (Reg. No 231650979). The objectives and activities of the trust are charitable within the meaning of 2 (15) of the IT Act 1961.

Heart Care Foundation of India was founded in 1986 as a National Charitable Trust with the basic objective of creating awareness about all aspects of health for people from all walks of life incorporating all pathies using low-cost infotainment modules under one roof. HCFI is the only NGO in the country on whose community-based health awareness events, the Government of India has released two commemorative national stamps (Rs 1 in 1991 on Run For The Heart and Rs 6.50 in 1993 on Heart Care Festival- First Perfect Health Mela). In February 2012, Government of Rajasthan also released one Cancellation stamp for organizing the first mega health camp at Ajmer.

Objectives Preventive Health Care Education Perfect Health Mela Providing Financial Support for Heart Care Interventions Reversal of Sudden Cardiac Death Through CPR-10 Training Workshops Research in Heart Care

Donate Now... Heart Care Foundation Blood Donation Camps The Heart Care Foundation organizes regular blood donation camps. The blood collected is used for patients undergoing heart surgeries in various institutions across Delhi.

Committee Members

Chief Patron

President

Raghu Kataria

Dr KK Aggarwal

Entrepreneur

Padma Shri, Dr BC Roy National & DST National Science Communication Awardee

Governing Council Members Sumi Malik Vivek Kumar Karna Chopra Dr Veena Aggarwal Veena Jaju Naina Aggarwal Nilesh Aggarwal H M Bangur

Advisors Mukul Rohtagi Ashok Chakradhar

Executive Council Members Deep Malik Geeta Anand Dr Uday Kakroo Harish Malik Aarti Upadhyay Raj Kumar Daga Shalin Kataria Anisha Kataria Vishnu Sureka

This Fund is dedicated to the memory of Sameer Malik who was an unfortunate victim of sudden cardiac death at a young age.

Rishab Soni

HCFI has associated with Shree Cement Ltd. for newspaper and outdoor publicity campaign HCFI also provides Free ambulance services for adopted heart patients HCFI has also tied up with Manav Ashray to provide free/highly subsidized accommodation to heart patients & their families visiting Delhi for treatment.

http://heartcarefoundationfund.heartcarefoundation.org

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Amniotic Fluid Embolism During Labor ANJANI DIXIT*, MONICA VOHRA PANDIT†

Abstract Amniotic fluid embolism (AFE) is a catastrophic condition with high maternal and perinatal mortality. We present a case of a 35-year-old, gravida 2 para 1 in labor who had acute episode of AFE. Prompt management was started, but baby died immediately and mother died on Day 4 post-resuscitation. This case highlights that AFE continues to be one of the most feared upon clinical scenarios. Prompt clinical diagnosis and treatment are key to the survival and management is largely supportive. But, there is no universally agreed upon clinical criteria for the diagnosis. As a result, there are serious problems in case reporting.

Keywords: Amniotic fluid embolism, cardiopulmonary resuscitation, pregnancy, maternal mortality

mniotic fluid embolism (AFE) is a catastrophic condition that occurs when amniotic fluid and fetal tissue enters maternal circulation. It is an unpredictable, unpreventable condition that needs prompt diagnosis so that treatment can be quickly instituted.

Incidence varies from region to region, due to absence of universally accepted diagnostic criteria, but most studies give incidence varying from 1.9 to 6.1 cases per 1,00,000 deliveries.1 World Health Organization (WHO) defines maternal death as death of a woman during pregnancy or within 42 days after termination of pregnancy due to causes related to pregnancy or aggravated by it.2 AFE is one among the top five leading causes of direct obstetric deaths in developed countries like UK.3 Caserelated maternal mortality varies from 13.5% to 44% and perinatal mortality ranges between 7% and 38%.4 Here we report a case of AFE in a 35-year-old gravida 2 para 1 in labor. Fetus died in utero after cardiovascular collapse and mother died on Day 4 post-resuscitation. Case Report A 35-year-old, unbooked, gravida 2 para 1 at 38.2 weeks of gestation, was admitted in labor room with complaint

*Senior †Head

Resident

Dept. of Obstetrics and Gynecology Dr Hedgewar Arogya Sansthan, Delhi Address for correspondence Dr Anjani Dixit 143A, First Floor, Shahpur Jat, New Delhi - 110 049 E-mail: doc.anjani@gmail.com

of labor pains for 3 hours. She was diagnosed as a case of pre-eclampsia without severe features 2 weeks back and her blood pressure (BP) was controlled on 100 mg labetalol 12 hourly dosage. At the time of presentation, she was alert, conscious and afebrile with stable vitals. Her BP recorded in right arm in sitting position was 128/76 mmHg. Abdominal examination showed term size uterus with cephalic presentation with moderate contractions. Vaginal examination revealed cervical dilation of 4 cm, 50% effacement and the fetal head at -3 station with bag of membrane forming. Admission non-stress test was reactive. Urine albumin dipstick test showed 1 plus (30-100 mg/dL) result. After 15 minutes of admission, bag of membranes ruptured spontaneously and liquor was meconium-stained. Patient was put on continuous fetal heart rate monitoring and labor was augmented with oxytocin drip. Fifteen minutes later, she complained of severe respiratory distress. Her peripheral capillary oxygen saturation began to fall, as shown on pulse oximeter with bilateral wheezes all over her chest. Within a minute, she collapsed with no recordable pulse and BP. Immediate cardiopulmonary resuscitation (CPR) was started. Endotracheal intubation was immediately performed, and the patient was mechanically ventilated. Return of spontaneous circulation (ROSC) was established after 20 minutes. The electrocardiogram showed ventricular tachycardia. She was immediately transferred to intensive care unit (ICU). Laboratory values revealed mild coagulopathy. On cardiotocography, fetal heart was not localized after patient collapsed. Supportive measures, including fluid resuscitation, inotropic support and plasma, were administered. By this time, cervical os was fully dilated

IJCP Sutra: "Chew sugarless gum after a meal, which promotes salivation and neutralizes acid."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

and cervix was fully effaced with vertex at +2 station. She had forceps assisted vaginal delivery and a stillborn male baby weighing 2.8 kg was delivered. Her BP rose to 160/110 mmHg after delivery and she was started on Pritchard regimen of magnesium sulfate. She did not regain consciousness and expired 4 days later. Autopsy was not performed. Discussion Amniotic fluid embolism (AFE) was first described in 1926 by Meyer. Later, Steiner and Luschbaugh published a case series of 8 women in 1941, where they detailed AFE.5 The main risk factors of AFE are maternal age 35 years and above, placenta previa, placental abruption, multiple pregnancy, cesarean delivery, uterine hyperstimulation, uterine rupture, induction of labor, meconium-stained liquor, eclampsia, pre-eclampsia and use of uterine stimulants. Our patient was 35 years old, diagnosed case of pre-eclampsia, with meconiumstained liquor and labor was augmented with oxytocin drip, making her a high-risk case for AFE. Tsunemi et al5 attempted to classify AFE, according to its presentation, into three subtypes: ÂÂ

Classical subtype with early respiratory distress and hypoxia

ÂÂ

Anaphylactoid subtype with dysfunction and arrhythmias

ÂÂ

Disseminated intravascular subtype with coagulopathy.

early

coagulation

cardiac (DIC)

They found considerable overlap of features. As per the presentation of patient, ours was classical type, which has highest mortality as per Tsunemi et al.5 The earlier belief that presence of fetal cells in the pulmonary vessels is evidence of AFE is no longer valid as fetal cells can be detected in 21-100% of pregnant women without AFE.4 The diagnosis of AFE is mainly clinical and that of exclusion. There is no universally agreed upon clinical criteria for the diagnosis. As a result, there are serious problems in case reporting. Kobayashi et al compared the diagnostic criteria of AFE case reporting used in USA, UK and Japan, and found that Japan criteria had only medium agreement with UK and USA criteria. There is low agreement between USA and UK criteria. Such disagreement has serious implications for research and treatment.6 Management of AFE is mainly supportive, with aggressive resuscitation at the time of collapse, which can largely affect fetal and maternal outcome.

Thus, a final diagnosis is not required to manage these patients. Supportive management based on the pathophysiological changes should be started as soon as signs and symptoms arise and should not wait for laboratory tests. These patients are ideally managed in an intensive care setting by a multidisciplinary team. With the improvement in health care settings, mortality has declined but not the long-term sequelae, like neurological impairment. Our case highlights that in such an unpredictable clinical scenario, high index of suspicion is of utmost importance. Keeping the risk factors in mind, one must be prepared for any eventuality including this dreaded complication - AFE. Conclusion Patient’s profile is as important as the clinical presentation of AFE because patient profile will enable the treating obstetrician to categorize the patient as high risk and be more vigilant. This can be made possible by more and more reporting of such cases as well as development of separate national registry for AFE in developing countries like India, so that uniform diagnostic criteria can be established, along with identification of risk factors, along the lines of which prognosis and effective management can be established. References 1. Knight M, Berg C, Brocklehurst P, Kramer M, Lewis G, Oats J, et al. Amniotic fluid embolism incidence, risk factors and outcomes: a review and recommendations. BMC Pregnancy Childbirth. 2012;12:7. 2. World Health Organization. Maternal mortality ratio (per 100,000 live births). Mar 11, 2014. Available at: https://www. who.int/healthinfo/statistics/indmaternalmortality/en/. 3. Harper A, Wilson R; On behalf of the MBRRACE-UK AFE chapter writing group. Caring for women with amniotic fluid embolism (Chap 5). In: Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.). Saving Lives, Improving Mothers’ Care-Lessons Learned to Inform Future Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-12. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2014. pp. 57-63. 4. Rath WH, Hoferr S, Sinicina I. Amniotic fluid embolism: an interdisciplinary challenge: epidemiology, diagnosis and treatment. Dtsch Arztebl Int. 2014;111(8):126-32. 5. Tsunemi T, Oi H, Sado T, Naruse K, Noguchi T, Kabayashi H. An overview of amniotic fluid embolism: Past, present and future directions. Open Womens Health J. 2012;6:24-9. 6. Kobayashi H, Akasaka J, Naruse K, Sado T, Tsunemi T, Niiro E, et al. Comparison of the different definition criteria for the diagnosis of amniotic fluid embolism. J Clin Diagn Res. 2017;11(7):QC18-21.

IJCP Sutra: "Check your drugs that can relax the lower esophageal sphincter or cause acid reflux or inflammation of the esophagus."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Amebiasis Mimics Malignancy in the Transverse Colon and Transpires in Liver Abscess BV NAGABHUSHANA RAO*, BVS RAMAN†, SAILESH MODI‡, M UMAMAHESWARA RAO#

Abstract Amebiasis is a problem of developing countries with inadequate sanitation. It may affect visitors from affluent nations if they stick around long enough. Presentation can be intestinal or extraintestinal. Amebiasis may present as pain abdomen, fever and weight loss without increased bowel movements. Ameboma, a rare complication of intestinal amebiasis may mimic malignancy or inflammatory bowel disease. We present a case of ameboma of transverse colon, an unusual site, which may increase suspicion of malignancy. Our patient developed liver abscess during illness, giving clues to the diagnosis. Metronidazole or tinidazole is the drug of choice; liver abscess may require drainage if it is large and where there is impending rupture, if it is located in the left lobe or there is delayed response to medical management. It is prudent to check for complete resolution of ameboma, not to leave behind a malignant lesion.

Keywords: Ameboma, transverse colon, mimics, malignancy, hepatic abscess

mebiasis is caused by Entamoeba histolytica, a protozoan. Clinical manifestation can be either intestinal or extraintestinal. Over 50 million people are affected annually with a mortality of 1,00,000 people a year.1 Hepatic abscess is the most common extraintestinal problem; other organs that are affected less frequently are the lungs, heart and the brain. It is a disease of economically disadvantaged communities; in developed countries, it is commonly seen in immigrants or travelers. Very rarely colonic infection may localize to form a mass of granulation tissue, an ameboma which may mimic colonic carcinoma in clinical presentation. Metronidazole or tinidazole is the drug of choice for intestinal and extraintestinal amebiasis; paromomycin or diloxanide furoate need to be used in patients carrying intestinal cysts.

*Dept. of Medicine †Dept. of Surgery ‡Dept. of Neurology #Dept. of Radiology Queens NRI Hospital, Visakhapatnam, Andhra Pradesh Address for correspondence

Dr BV Nagabhushana Rao Dept. of Medicine Queens NRI Hospital, Visakhapatnam - 530 013, Andhra Pradesh E-mail: bhavanavnrao@gmail.com

Case Report A 73-year-old gentleman was admitted to the hospital with symptoms of abdominal pain of 20 days duration. He was a diabetic, on glimepiride 2 mg and metformin long-acting 500 mg daily. His blood sugar was not under control and glycosylated hemoglobin (HbA1c) at the time of admission was 9%. He is a frequent traveler and preferred to eat vegetable salads as he was a pure vegan. The pain was in periumbilical region and in right iliac fossa. Pain was not related to food or radiating to other areas. The patient was not nauseated and there were no loose motions or vomitings. He lost 6 kg weight in spite of normal appetite. There was no history of mucus or blood in the feces. The patient began to have fever 5 days prior to hospitalization, which was treated by family physician with intravenous ceftriaxone without much response. He underwent ultrasound examination of the abdomen, which revealed bowel wall thickening of ileocecal junction, which was suspicious of tuberculosis or inflammatory bowel disease. Contrast-enhanced computed tomography (CECT) of the abdomen was performed for further evaluation of the intestinal lesions. It was found on computed tomography (CT) to be a focal eccentric mural thickening of cecum and transverse colon (Fig. 1). He underwent colonoscopy. The gastroenterologist felt that patient might be having tuberculosis or malignancy in

IJCP Sutra: "Lose weight if you need to."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Figure 1. CECT of the abdomen, showing focal eccentric mural thickening of transverse colon.

Figure 3. CT scan of chest demonstrated 55 × 50 × 39 abscess in the left lobe of liver.

ameba were demonstrated in the aspirate. He was given tinidazole 2 g a day intravenously for 5 days and orally for another 10 days. His fever subsided in 3 days and intestinal lesions resolved in a month’s time on colonoscopy and CT scan. Discussion

Figure 2. Ulcerated nodular lesions in the transverse colon with skipped lesions by colonoscopic examination.

the view of ulcerated nodular lesions in ileocecal valve and transverse colon with skipped lesions (Fig. 2). Multiple biopsies were taken and sent for histopathological examination. At that stage he was referred to our hospital. Histopathologist reported it to be focal active colitis with super added ulcers and acute inflammation. On CD3 IHC and CD20 IHC, they found it positive in a few lymphocytes. This indicated that it may be inflammatory bowel disease. As the patient was persistently pyrexial, we did CT chest to find out any evidence of pulmonary tuberculosis or mediastinal lymphadenopathy. To our surprise, we found that he had a 55 × 50 × 39 abscess in the left lobe of liver (Fig. 3). Under CT guidance 100 mL anchovy sauce-colored pus was aspirated and on saline mounting, multiple

Intestinal and extraintestinal complications of amebiasis are more common in adult males and travelers within the community. Amebic hepatic abscess is more common in a diabetic.2 Ameba establishes hepatic infection through the portal circulation. Our patient was a poorly controlled diabetic and a frequent traveler too, exposing himself to amebic infection and its complications. Factors that predispose one to severe infections include genetic susceptibility, age, immune status, pregnancy, corticosteroid treatment, malignancy, malnutrition and alcoholism. Amebiasis commonly presents with dysentery, but may only present with abdominal pain and weight loss as in our patient. Rarely, colonic infection may localize to form a mass of granulation tissue, an ameboma mimicking a colonic malignancy.3 It has been reported that sometimes, it may present as acute intestinal obstruction or intussusception. Our patient presented with pain abdomen, fever and weight loss. His ultrasound and CT scan abdomen displayed thickenings of cecum and transverse colon. On colonoscopy, nodular ulcerated skip lesions were found which were suspected to be malignant. Histopathological examination of a biopsy specimen taken at colonoscopy suggested that it might be inflammatory bowel disease. At times, it may be difficult to differentiate amebic colitis from inflammatory

IJCP Sutra: "Avoid hurry, worry and curry."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

bowel disease clinically, endoscopically and histopathologically.4 In such situations, administration of steroids can be detrimental if the patient has an amebiasis instead of inflammatory bowel disease. We should be extravigilant when managing ulcerative intestinal lesions in endemic areas of amebiasis. As we were searching for any other cause of fever in this individual, we found an abscess in the liver which was not seen in the previous ultrasound and abdominal CT scan. Anchovy sauce-colored pus was aspirated pointing towards amebic abscess rather than pyemic abscess. We could also demonstrate amebic trophozoites confirming the diagnosis which is often difficult to do. Colonic mass in the form of ameboma and liver abscess have been reported in the literature, confounding with colonic malignancy and hepatic metastasis leading to surgical procedures like colonic resection.5 But there are not many reports of transverse colonic ameboma with liver abscess. Liver abscess may rupture into pleura, pericardium, lungs or peritoneum. Unless large in size or located in the left lobe of liver, it can be managed with medical treatment without recourse to aspiration. In our patient, we demonstrated clearance of pathological lesions endoscopically. Complete resolution of ameboma should be observed by colonoscopic examination, otherwise we may miss a concomitant malignant lesion.

Conclusions Ameboma, a rare intestinal manifestation of amebic infection, may present with pain abdomen alone without a history of dysentery and mimic malignancy or inflammatory bowel disease. Vigilance should be maintained as a liver abscess may develop during the course of illness rather at inception.

Acknowledgment We thank Dr Ramakoteswara Rao, Pathologist, Chaitanya Medical Centre for his expertise.

References 1. Bercu TE, Petri WA, Behm JW. Amebic colitis: new insights into pathogenesis and treatment. Curr Gastroenterol Rep. 2007;9(5):429-33. 2. Jha AK, Das A, Chowdhury F, Biswas MR, Prasad SK, Chattopadhyay S. Clinicopathological study and management of liver abscess in a tertiary care center. J Nat Sci Biol Med. 2015;6(1):71-5. 3. Misra SP, Misra V, Dwivedi M. Ileocecal masses in patients with amebic liver abscess: etiology and management. World J Gastroenterol. 2006;12(12):1933-6. 4. Tucker PC, Webster PD, Kilpatrick ZM. Amebic colitis mistaken for inflammatory bowel disease. Arch Intern Med. 1975;135(5):681-5. 5. Moorchung N, Singh V, Srinivas V, Jaiswal SS, Singh G. Caecal amebic colitis mimicking obstructing right sided colonic carcinoma with liver metastases: a rare case. J Cancer Res Ther. 2014;10(2):440-2.

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Stroke Treatment ÂÂ

IV alteplase (recombinant tissue-type plasminogen activator or tPA) improves functional outcome from ischemic stroke; benefits outweigh the risks for patients who receive treatment within 4.5 hours of onset of symptoms (or within 4.5 hours of when the patient was last seen normal in cases if the time of onset of symptoms is not known).

ÂÂ

Treatment must be given as soon as possible, rather than near the end of the time window.

ÂÂ

A successful thrombolytic treatment of acute ischemic stroke requires early treatment. But suitable candidates are chosen based on a neurologic evaluation and a neuroimaging study.

ÂÂ

Start IV alteplase in eligible patients with acute ischemic stroke within 3 hours of clearly defined symptom onset.

ÂÂ

For patients who cannot be treated in less than 3 hours, start IV alteplase therapy within 3 to 4.5 hours of clearly defined symptom onset.

ÂÂ

For patients who are ineligible for intravenous thrombolysis with angiographically demonstrated acute basilar artery occlusion and associated stroke symptoms but no signs of major infarction on a baseline CT or MRI scan, go for intra-arterial thrombolytic therapy with alteplase at centers with appropriate expertise (within 6 hours).

IJCP Sutra: "Screen for diabetes and prediabetes (fasting sugar, A1c, 2-hour OGTT) in patients aged 65 years and older without known diabetes."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Complete Hydatidiform Mole Coexisting with a Live Fetus in Twin Pregnancy AVISHEK BHADRA*, PALLAB KUMAR MISTRI†, BANDANA BISWAS‡, SHILPA KUMARI#, SUDIP MUKHERJEE¥

Abstract Twin pregnancy with one complete hydatidiform mole (CHM) and coexisting live fetus is a very rare condition. It is an obstetric problem, which may put the mother at risk of harmful complications of molar pregnancy. It is associated with advanced maternal age and associated treatment for artificial reproductive techniques. The risk of persistent trophoblastic disease in live fetus with coexisting CHM in twin pregnancy is 19-50%. We present a case of a 33-year-old female in whom a CHM was coexisting with a live fetus in twin pregnancy. As the conservative management of such pregnancy was difficult due to risk of persistent trophoblastic disease and as she had completed her family, the couple opted for termination of the ongoing pregnancy.

Keywords: Complete hydatidiform mole, twin pregnancy

win pregnancy with one complete hydatidiform mole (CHM) and coexisting live fetus is a very rare condition. It is an obstetric problem which may put mother into harmful complications of molar pregnancy. Most common causes for termination of pregnancy are antepartum hemorrhage, thyrotoxicosis, pre-eclampsia and risk of persistent gestational trophoblastic diseases. Incidence of such type of pregnancy is one in 20,000 to 1 in 1,00,000 cases. The incidence is associated with advanced maternal age and associated treatment for artificial reproductive techniques. In our case report, we are reporting a case where it was associated with advanced maternal age only.

Case Report A 33-year-old female, gravida 4, para 3, with living issue 4 with a history of twin pregnancy in her 2nd pregnancy, presented to Gynecology and Obstetrics

*Assistant Professor †Associate Professor ‡Professor #Junior Resident ¥RMO cum Clinical Tutor Dept. of Obstetrics and Gynecology, Medical College, Kolkata, West Bengal Address for correspondence Prof (Dr) Bandana Biswas 69, Chandi Ghosh Road, Regent Park, Kolkata - 700 040, West Bengal E-mail: bandana.biswas2010@gmail.com

outdoor of a tertiary care teaching hospital in eastern India referred from a District Hospital, with a complaint of 4 months amenorrhea and occasional spotting for the last 2-3 months. She had a transabdominal ultrasound done from outside revealing a live pregnancy of 22 weeks gestation with a placenta in the posterior wall and upper segment of the uterus, along with a heterogeneous space-occupying lesion (SOL) with small cystic component, seen in lower part of anterior wall of the uterus, which was suggestive of a partial molar or pseudomolar pregnancy. On examination, patient had pulse rate - 80/min, blood pressure (BP) - 110/80 mmHg, negative urine dipstick for protein, mild palor and no feature suggestive of thyrotoxicosis. Per abdomen, the uterine height was 32 weeks, not corresponding to the period of amenorrhea. She perceived fetal movements and fetal heart sound was audible with stethoscope. Patient was advised admission and counseled regarding her pregnancy and its probable outcome. After admission, she underwent another ultrasound scan at the Radiology Department and one serum betahuman chorionic gonadotropin (β-hCG) quantification. Ultrasound done the next day revealed a live fetus of 22 weeks and 1 day with fundoposterior placenta in one sac and one 9.4 × 6.4 cm heterogeneous multicystic SOL adhered to anterior wall of uterine cavity close to internal os, in another sac (Fig. 1). β-hCG done on the same day was 2.5 lac IU/dL, which was quite high, suggesting molar pregnancy. She experienced

IJCP Sutra: "Periodically screen older patients with diabetes for undiagnosed cognitive impairment."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Figure 1. A well-defined gestational sac with fetus and separate molar tissue near internal os at 22 weeks of gestation.

Figure 2. A normal looking premature baby with umbilical cord attached to a normal looking placenta and molar tissue separately.

two episodes of vaginal bleeding after admission. All routine laboratory investigations were done; reports including liver function test (LFT), renal function test (RFT), blood sugar were within normal limits except Hb%, which was 8.08 g/dL.

uterus showed features of invasion. Karyotyping of both placenta and molar tissue was 46, XX. Patient was discharged from hospital on Day 6 and asked to come for follow-up. During her follow-up period, β-hCG showed pattern of plateau for which she was prescribed single agent chemotherapy (methotrexate). After first cycle of chemotherapy, there was marked fall in the β-hCG level and the value reached 78 IU/dL. She is still under follow-up for any necessary subsequent chemotherapy and until β-hCG becomes <5 IU/dL.

Three days later, another ultrasound scan was performed with color Doppler, which showed a fetus and placenta in upper part enclosed within a sac, separate from a heterogeneous SOL having vascularity in it, located at lower part of the uterus. A diagnosis of twin pregnancy with single fetus and coexisting molar pregnancy was confirmed. Patient was kept under strict observation and counseling was done. As the conservative management of such pregnancy was difficult due to risk of persistent trophoblastic disease and as she had completed her family, the couple opted for termination of the ongoing pregnancy. She was planned for termination by hysterotomy in the operation theater with 2 units of blood component in hand. On the day of operation, a fetus of 1,200 g was delivered along with normal looking placenta in one sac and a complete molar tissue in another sac (Fig. 2). During separation of molar tissue, it was found to be an invasive mole and there was severe hemorrhage. Decision of hysterectomy was taken and total hysterectomy was done. Baby was sent to Sick Neonatal Care Unit (SNCU) and placenta, uterus and molar tissue were sent for histopathology and karyotyping. Postoperatively, there was remarkable decrease in β-hCG level; it was 51,990 IU/dL on the 3rd postoperative day. Histopathological report confirmed the mass as CHM; placenta was normal and

Discussion Twin pregnancy with a CHM and a single normal fetus is an extremely rare condition. So far, there have only been about 200 cases of twin pregnancy with CHM fully documented in literature; only 56 cases resulted in a live birth. There are two different pathologic entities, partial and CHM, with different mechanisms of origin based on cytogenetic analysis. Partial moles arise from dispermic fertilization of a haploid normal oocyte and produce a triploid set of chromosomes. A CHM contains a diploid set of 46 chromosomes, all of paternal origin and no traces of fetal parts can be identified. There has always been dilemma about continuation or termination of pregnancy. The risk of persistent trophoblastic disease is more in CHM. The risk of persistent trophoblastic disease in live fetus with coexisting CHM in twin pregnancy is 19-50%. The true incidence of this rare entity is difficult to establish, and some suggest that the modern increased incidence of iatrogenic multiple gestations will cause a higher incidence of CHM with

IJCP Sutra: "If mild cognitive impairment is present, simplify medication regime and glycemic targets to improve compliance."

Case Report

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

fetus. In cases of partial hydatidiform mole, as the fetus is triploid, it is an indication for termination of pregnancy, while in case of CHM with live fetus continuation of pregnancy is frequently associated with severe maternal complications. It is important to differentiate between CHM with partial mole when fetus coexists because it has been reported that CHM has higher tendency of invasive mole and choriocarcinoma when compared with partial mole. Ultrasonography has made possible diagnosis of a hydatidiform mole and coexistent fetus. With regard to our case, there was extremely high concentration of β-hCG, which confirmed the ultrasonographic diagnosis of molar pregnancy and possibility of later developing trophoblastic disease. SUGGESTED READING 1. Matsui H, Sekiya S, Hando T, Wake N, Tomoda Y. Hydatidiform mole coexistent with a twin live fetus: a national collaborative study in Japan. Hum Reprod. 2000;15(3):608-11. 2. Steller MA, Genest DR, Bernstein MR, Lage JM, Goldstein DP, Berkowitz RS. Natural history of twin pregnancy with

complete hydatidiform mole and coexisting fetus. Obstet Gynecol. 1994;83(1):35-42. 3. Cunningham ME, Walls WJ, Burke MF. Grey-scale ultrasonography in the diagnosis of hydatidiform mole with a coexistent fetus. Br J Obstet Gynaecol. 1977;84(1): 73-5. 4. Dolapcioglu K, Gungoren A, Hakverdi S, Hakverdi AU, Egilmez E. Twin pregnancy with a complete hydatidiform mole and co-existent live fetus: two case reports and review of the literature. Arch Gynecol Obstet. 2009;279(3):431-6. 5. Moini A, Riazi K. Molar pregnancy with a coexisting fetus progressing to a viable infant. Int J Gynaecol Obstet. 2003;82(1):63-4. 6. Sebire NJ, Foskett M, Paradinas FJ, Fisher RA, Francis RJ, Short D, et al. Outcome of twin pregnancies with complete hydatidiform mole and healthy co-twin. Lancet. 2002;359(9324):2165-6. 7. Callen PW. Ultrasound evaluation of gestational trophoblastic disease. In: Callen PW (Ed.). Ultrasonography of Obstetrics and Gynaecology. 2nd Edition, Philadelphia, PA: WB Saunders; 1988. p. 416. 8. Montes-de-Oca-Valero F, Macara L, Shaker A. Twin pregnancy with a complete hydatidiform mole and coexisting fetus following in-vitro fertilization: case report. Hum Reprod. 1999;14(11):2905-7.

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WMA Signs up to Promoting Universal Health Coverage The World Medical Association (WMA) has committed the world’s 12 million physicians to promoting the benefits of universal health coverage (UHC) across the globe. In a special ceremony in Geneva, WMA President Dr Leonid Eidelman officially signed the UHC2030 Global Compact for a safer, fairer and healthier world by 2030. The ceremony came on the second day of the World Health Assembly. Dr Eidelman said that universal health coverage was key to reaching the World Health Organization’s ‘triple billion’ targets - 1 billion more people benefitting from UHC, 1 billion more people better protected from health emergencies and 1 billion more people enjoying better health and well-being. “The WMA embraces the concept wholeheartedly, and we are keen to see quality primary care provided by multidisciplinary teams at the core of strong and comprehensive health care systems. In our view, UHC is the biggest step forward ever made by WHO, and we are firmly part of the movement.” “In parts of the world where health systems are close to UHC, we can show that this is for the benefit of everybody - for our patients, our colleagues and the communities we serve. UHC is an ideal platform, not only for providing curative care, but also for providing prevention, rehabilitation and palliative care.” Dr Eidelman said that investing in UHC was not only a strong humanitarian move, it was also a sound economic development to create viable and value-adding services for communities. UHC2030, run by the WHO and the World Bank, involves building and expanding equitable, resilient and sustainable health systems, funded primarily by public finance, and based on primary health care… (WMA)

IJCP Sutra: "Lifestyle modification is the first-line treatment of hyperglycemia in ambulatory patients with diabetes."

Medicolegal

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Professional Indemnity Insurance for Medical Professionals KK aggarwal*, IRA Gupta†

octors in India, since Vedic time, have been equated to God. No other profession, whether it is priest, lawyers, judges or politicians, occupies the same status as that of the medical doctors. Medical profession is the noblest profession.

Meaning of the term “Indemnity”

However, doctors are also human beings and “to err is human”. Medical error or injury has been known since the time of Hippocrates as principle of nonmaleficence, derived from the doctrine of “primum non-cere”, which means “first do no harm” and its natural corollary, beneficence or “do good”, which means doing the right thing for the patient.

Indemnity means a legal obligation to cover the liability of another. “To indemnify” does not merely mean to reimburse in respect of money paid but to save from loss in respect of the liability against which indemnity has been given.

With the modern advancement in medical profession, the doctor-patient relationship has also changed from “paternalism”, where doctors were “parent figures” taking medical decisions on behalf of their patients to the current “patient-centric” where the patient is an “equal partner”. Thus, the type of patients has also changed from ignorant to enlightened. With the advent of Consumer Protection Act, 1986 and various judgments by the Hon’ble Apex Court of the country and other courts and commissions, patients have started questioning the doctors and their treatment. Numerous cases are being filed against the doctors, hospitals, medical staff, etc., under consumer law, criminal law, civil law, etc. Compensation in lakhs and crores of money is being awarded in favor of the patient or his/her relative, which is to be paid by the doctor from his own pocket. With increasing litigations against the doctors in the country, it has become very important and vital for the doctors to obtain insurance cover against all such litigations and compensation to be paid, if any. Accordingly, in the year 1991, the Professional Indemnity Insurance was introduced for the doctors and hospitals in the country.

*Group Editor-in-Chief, IJCP Group †Advocate and Legal Advisor, HCFI

The term “indemnity” means “to compensate” or reimburse. The principle of indemnity is strictly followed in liability insurances.

“To indemnify” means to make good a loss suffered by a person in consequence of the act or default of another. Indemnity is a contract, express or implied, “to keep a person who has entered, or is about to enter, into a contract of liability indemnified against the liability independently of the question whether a third party makes default or not.” Professional Indemnity Insurance Professional indemnity insurances are designed to provide the insured person protection against the financial consequences of legal liability. This policy is meant for professionals to cover liability falling on them as a result of errors and omissions committed by them whilst rendering professional service. If the insured is legally liable to pay damages or compensation to others, the policy will indemnify him subject to the terms and conditions and limitations of the contract. Indemnity is also available in respect of legal costs awarded against the insured as well as legal costs and expenses incurred by the insured with the written consent of the insurers in the defense or settlement of claims. Importance of Professional Indemnity Insurance in Medical Profession The medical professional is expected to bring a reasonable degree of skill and knowledge and must exercise a reasonable degree of care.

IJCP Sutra: "Assess nutritional status to detect and manage malnutrition."

Medicolegal

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

The medical professionals are entitled to get protection so long as they perform their duties with reasonable skill and competence and in the interest of the patients. The interest and welfare of the patients have to be paramount for the medical professionals. The Hon’ble Apex Court in the matter titled as “Kusum Sharma & Others versus Batra Hospital & Medical Research Centre, 2010 (3) SCC 480 has held that “94. On scrutiny of the leading cases of medical negligence both in our country and other countries specially United Kingdom, some basic principles emerge in dealing with the cases of medical negligence. While deciding whether the medical professional is guilty of medical negligence following well known principles must be kept in view:

i. Negligence is the breach of a duty exercised by omission to do something which a reasonable man, guided by those considerations which ordinarily regulate the conduct of human affairs, would do, or doing something which a prudent and reasonable man would not do. ii. Negligence is an essential ingredient of the offence. The negligence to be established by the prosecution must be culpable or gross and not the negligence merely based upon an error of judgment….”

death of any patient caused by or alleged to have been caused by error, omission or negligence in professional service rendered or which should have been rendered by the insured or the assistants or the team of people employed by the insured.

Policy Period Period commencing from the effective date and hour as mentioned in the policy and terminating at the midnight on the expiry date as mentioned in the policy.

Period of Insurance Period of insurance means period commencing from the retroactive date and terminating on the expiry date as mentioned in the policy.

Commission of Act The Act (medical negligence by doctor or hospital) has to be committed during the period of insurance commencing from retroactive date.

Retroactive Date Retroactive date is the date when the risk is just incepted under “claims made” policy and thereafter renewed without any break in the period of insurance.

Gross negligence is intentional failure to perform a manifest duty in reckless disregard of the consequences. Ordinary negligence is based on the fact that one ought to have known results of his acts, while gross negligence rests on the assumption that one knew results of his acts, but was recklessly or wantonly indifferent to the results.

Limit of Indemnity

If there is gross medical mistake, then the doctor will be liable for the negligene committed by him. In such case, doctor would be liable to pay huge compensation to the patient or his/her relatives.

Defence Cost

To protect oneself from such huge compensation to be paid, if any, it is important and vital to obtain professional indemnity insurance. Salient Features of Professional Indemnity Insurance

Irrespective of the number of persons or entities named in the insurance policy or added by endorsement, the total liability of the insurance company for damages inclusive of defense costs shall not exceed the limit of indemnity as mentioned in the policy.

The insurance company pays all costs, fees and expenses incurred with their prior consent in the investigation, defense or settlement of any claim made against the doctor or hospital and the costs of representation at any inquest, inquiry or other proceedings in respect of matters which have a direct nexus to any claim made or which might be made against the insured. Such costs, fees and expenses are called defence cost.

Claims Series Clauses Indemnity The professional indemnity insurance is meant for professionals to cover liability falling on them as a result of errors and omissions committed by them whilst rendering professional service. The indemnity applies only to the claim arising out of bodily injury and/or

Where series of losses and/or bodily injuries and/or deaths are attributable directly or indirectly to the same cause or error or commission relating to discharge of professional services all such losses and/or bodily injuries and/or deaths claims shall be added together and all such losses and/or bodily injuries and/or deaths

IJCP Sutra: "Keep target BP 140/90 mmHg in patients with diabetes to reduce risk of heart disease, stroke and progressive chronic kidney disease (CKD)."

Medicolegal

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

shall be treated as one claim and such claim shall be deemed to have been made when the first claim was made in writing.

zz Genetic injuries caused by X-ray treatment or diagnosis with radioactive substances zz Professional services rendered by the insured prior to retroactive date

Registration ÂÂ

Doctor: The doctor should be duly registered with his/her respective medical council.

ÂÂ

Hospital/Medical establishment: The Hospital/ Medical establishment should be registered with competent authority as per local law and rules. In territories where there is no registration facility, then following minimum norms have to be complied with for considering the indemnity insurance policy: zz At least 10 in-patient facility zz Fully equipped operation theater of its own zz Fully qualified nursing staff in its employment round the clock, unless indicated to the contrary and additional premium paid zz Fully qualified doctor/doctors should be in charge round the clock zz The insured shall comply with registration formalities as and when official regulations or laws are enforced.

Short Period Policy Short period policies are not permitted. However, in case of cancellation of the policy by the insured, short period scale rates as provided for will be applicable.

Compromise/Settlement In normal course, all claims for compensation have to be legally established in court of law. However, insurers can arrive at compromise or settlement if prima facie liability exists under the policy.

zz War and warlike perils zz Nuclear fuel/ionizing contamination.

Premium Rate of Insurance Separate rates of insurance are applicable to doctors, medical establishments, medical professionals, etc. Group discounts are available with the insurance companies for a group of doctors. Additional premium is applicable in case doctors want to cover qualified staff working with them. Whenever multiple specializations are involved, then the rate of insurance shall be of the specialization which attracts higher rate of insurance.

List of Eligible Medical Establishments ÂÂ

Laboratories and diagnostic centers

ÂÂ

Hospitals

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Mental homes

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Nursing/convalescent homes

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Homes for physically disabled

ÂÂ

Clinics

ÂÂ

Dispensing pharmacies

ÂÂ

Veterinary hospitals and/or clinics and the like.

Benefits of professional indemnity insurance ÂÂ

It is beneficial not only to the doctors or hospital but also to the patients and their dependents because the insurance company takes care of the compensation.

ÂÂ

Retroactive benefit: This means that the insured will be covered for any professional act or omission occurring during the period of insurance.

ÂÂ

It would take care of the amount of damages against third party.

ÂÂ

Scheme will also compensate on the principle of “no fault liability“ to give some relief in the case of death or permanent disablement of the patient.

ÂÂ

The company will also pay the defense costs, which have a direct relevance to the claim.

Jurisdiction Jurisdiction applicable will be of Indian courts only.

Exclusions ÂÂ

Liability assumed under the agreement

ÂÂ

Cosmetic surgery (cosmesis)

ÂÂ

Liability arising out of: zz Deliberate, willful or intentional compliance of statutory provisions

non-

zz Loss of goodwill, libel, slander, false arrest, defamation, etc. zz Fines, penalties, punitive or exemplary damages

radiation/radioactive

IJCP Sutra: "Use angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) as the first-line therapy in patients with diabetes and hypertension."

Medicolegal

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Limitations of professional indemnity insurance The only limitation that this policy has is that the amount of compensation is restricted by the limit of indemnity as mentioned in the policy. Conclusion Professional indemnity insurance is a tool, which not only meets the claim of compensation awarded against doctor/hospital but also gives a sense of mental security that even if some negligence is proved, the insurance company will take care of it. Professional indemnity insurance covers all sums, which the insured professional becomes legally liable to pay as damages to third party in respect of any error and/or omission on his/her part committed whilst rendering professional service. The insurance companies not only pay the compensation to other party but also arrange for the

legal help from advocates because they sometimes join hand with other party for monetary gains with an excuse that it’s the insurance not the doctor who is to pay the compensation. However, one must never forget that the security is only monetary. The person’s reputation and goodwill is not insured. So, all doctors should use their reasonable standard of care while treating and operating on their patients. SUGGESTED READING 1. Singh J, Bhushan V. Medical Negligence & Compensation. 2nd Edition, New Delhi: Bharat Publications; 2004. 2. Professional indemnity insurance vis-a-vis Medical professionals by Sweta Agarwal * & Swapnil S. Agarwal, J Indian Acad Forensic Med. 31(1). 3. Kusum Sharma & Others versus Batra Hospital & Medical Research Centre, 2010 (3) SCC 480. 4. Legal dictionary.

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Rules in Chest Pain ÂÂ

Rule of 30 sec: Chest pain, burning, discomfort, heaviness in the center of the chest lasting for more than 30 sec and not localized to a point unless proved otherwise is a heart pain. The ‘rule of pinpointing’ finger can be added to this rule i.e., any chest pain, which can be pinpointed by a finger is not a heart pain.

ÂÂ

Rule of 5: If you suspect a heart attack, do not wait for more than 5 min and get to a hospital right away.

ÂÂ

Rule of 3: Reach hospital within 3 hours in heart attack to receive clot-dissolving angioplasty or clotdissolving drugs.

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Rule of 300: Chew a tablet of water-soluble 300 mg aspirin and take 300 mg clopidogrel tablets at the onset of cardiac chest pain (heart attack) to reduce mortality.

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Rule of 10: Door-to-ECG time is the time within which an ECG should be done in the emergency room. It should be less than 10 min.

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Rule of 30: Door-to-needle time in acute heart attack is the time before which the clot-dissolving drug should be given after a patient reaches the hospital. In ST elevation heart attack (STEMI), the door-to-needle time should be less than 30 min.

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Rule of 40: First-onset acidity or first-onset asthma after the age of 40, rule out heart attack or heart asthma.

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Rule of 90: Door-to-balloon time is the ideal time for primary percutaneous coronary intervention (PCI) in acute heart attack by an experienced operator and should be less than 90 min.

IJCP Sutra: "An annual lipid profile and statins are recommended in patients with diabetes to reduce absolute cardiovascular disease events and all-cause mortality."

Medical Voice for Policy change

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Medtalks with Dr KK Aggarwal Maharashtra FDA Asks DCGI to Include Balloon Catheters and Guiding Catheters Under NLEM The Maharashtra Food and Drug Administration (FDA) has reportedly urged the Drug Controller General of India (DCGI) and the National Pharmaceutical Pricing Authority (NPPA) to include balloon catheters and guiding catheters under National List of Essential Medicines (NLEM) as was done for coronary stents. Balloon catheter and guiding catheters are accessories used during the stenting procedure to ease the pathway for flow of blood, as per a report in pharmabitz. Capping the price of stents has obviously ended with increasing the prices of accessories to cover the margins. Earlier NPPA had also noted that “it had been found that after the price control of cardiac stents, several hospitals have increased the various procedure charges in order to compensate for their losses.” NPPA has also found some specific complaints that several hospitals have increased the prices of balloons and the cardiac catheters which have not been included in NLEM, 2015.

Each of these four elements must be proved to have been present, based on a preponderance of the evidence, for malpractice to be found. The principles of psychopharmacology and the information in the package insert for a drug often play a central role in deciding whether dereliction and direct cause for damages were or were not applicable in a particular case.

Doctors’ Unusual Prescription: Go and Ride Bicycles A new program in Wales will allow family doctors to offer patients an unusual prescription for better health: bicycles. The pilot program, the first such initiative in Britain, according to the health board that is leading it, reflects an effort by medical professionals around the world to give patients alternatives to drugs, in order to avoid side effects and improve cost efficiency.

In some cases, the cost of balloons and catheters has been charged at a much higher level than the cost of stent itself.

Patients at two medical centers in Cardiff, the Welsh capital, will be offered 6-month subscriptions to a bikerental service that allows them to make unlimited free rides of up to 30 minutes at a time, and officials hope to expand the program.

Standard practice followed in hospitals is that consumables like guide wire and balloon are not covered by the cost of the stent. So, they are billed separately. During an angioplasty procedure, a number of different peripherals are used like guiding catheters, balloons, inflators and stents.

“For the first phase of the pilot, we want to make sure the scheme works as intended and is easy to use for patients and their health professionals, so we’ll be seeking feedback from participants,” Dr Tom Porter of the Cardiff and Vale University Health Board, said in a statement. (ET Health - NYT News Service)

As of today, only 23 categories of medical devices are regulated which cover around 400 medical devices amongst the 5,000 odd unregulated medical devices in the country. The move is right. If you cap device, it is expected you also cap prices for all the accessories required for that procedure. You cannot eat dosa without sambar. You can not subsidize dosa but charge more for the sambar. It is the end result of the stent procedure, which matters and not the cost of stent alone.

US ‘Emerging Adults’ with Type 1 Diabetes Face DKA Danger In contrast to youth with type 1 diabetes in Canada, those in the United States are vulnerable to lapses in care at the time of transition from adolescence to adulthood, placing them at risk for the serious complication of diabetic ketoacidosis (DKA) and other adverse outcomes, new research suggests.

The Four Ds of Medical Malpractice

Indeed, the study found that as teens became young adults in the United States, hospitalization rates for DKA soared by 90%, compared with a 23% rise for the same age group in Canada.

Duty, dereliction (negligence or deviation from the standard of care), damages and direct cause.

“The US health care system is failing far too many patients, including those with diabetes,” said lead

IJCP Sutra: "If you can walk more than 500 meters in six minutes you do not have significant blockages or if you can walk 2 km or climb two flight of stairs you do not have significant blockages."

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Medical Voice for Policy change

author Adam Gaffney, MD, a pulmonary and critical care physician at the Cambridge Health Alliance and Harvard Medical School, Massachusetts, in a press release by the US Physicians for a National Health Program (PNHP). Gaffney and colleagues published their findings online in the Journal of General Internal Medicine… (Medscape)

The primary end point was infection resulting in system extraction or revision, long-term antibiotic therapy with infection recurrence or death, within 12 months after the CIED implantation procedure. The secondary end point for safety was procedurerelated or system-related complications within 12 months.

Woman Fighting to Stay in UK for Treatment

A total of 6,983 patients underwent randomization: 3,495 to the envelope group and 3,488 to the control group. The primary end point occurred in 25 patients in the envelope group and 42 patients in the control group. The safety end point occurred in 201 patients in the envelope group and 236 patients in the control group. The mean (±SD) duration of follow-up was 20.7 ± 8.5 months. Major CIED-related infections through the entire follow-up period occurred in 32 patients in the envelope group and 51 patients in the control group.

An Indian woman suffering from a rare disease, which left her in a coma after a major surgery, is fighting to stay in the UK and avoid being deported to India. Bhavani Espathi, who came to Britain as a student, suffers from Crohn’s Disease, a digestive tract disorder, for which she requires a specific immunosuppressant that she says is currently unavailable in India. “The only thing keeping me somewhat ‘healthy’ besides constant medical attention are immunosuppressants such as Ustekinumab, which is currently unavailable in India, the country that the British Home Office believes is a place I should return for ‘palliative care’ instead of living in the UK,” says the 31-year-old, who has launched an online campaign to seek support for her case. The UK Home Office recently issued a letter stating that her application for leave to remain in the UK had been refused and that she was liable to be forcibly removed. The letter arrived as she lay in a coma after a major operation and her fiance, Martin Mangler, appealed against the decision while she was still unconscious. Medical letters from her doctors stated that her life would be at risk if she were to travel... (New Indian Express-PTI)

Antibacterial Envelope to Prevent Cardiac Implantable Device Infection NEJM Abstract: Infections after placement of cardiac implantable electronic devices (CIEDs) are associated with substantial morbidity and mortality. There is limited evidence on prophylactic strategies, other than the use of preoperative antibiotics, to prevent such infections. A NEJM Published, Medtronic Supported Study conducted a randomized, controlled clinical trial to assess the safety and efficacy of an absorbable, antibiotic-eluting envelope in reducing the incidence of infection associated with CIED implantations. Patients who were undergoing a CIED pocket revision, generator replacement or system upgrade or an initial implantation of a cardiac resynchronization therapy defibrillator were randomly assigned, in a 1:1 ratio, to receive the envelope or not.

The study concluded that adjunctive use of an antibacterial envelope resulted in a significantly lower incidence of major CIED infections than standard-ofcare infection-prevention strategies alone, without a higher incidence of complications. (N Engl J Med. 2019; 380:1895-905)

Increasing Age and Respiratory Symptoms were Indicators of Infectivity of Nipah Virus Nipah virus is a highly virulent zoonotic pathogen that can be transmitted between humans. A Bangladesh NIH funded study used data from all Nipah virus cases identified during outbreak investigations from April 2001 through April 2014 to investigate case-patient characteristics associated with onward transmission and factors associated with the risk of infection among patient contacts. Of 248 Nipah virus cases identified, 82 were caused by person-to-person transmission, corresponding to a reproduction number (i.e., the average number of secondary cases per case patient) of 0.33. The predicted reproduction number increased with the case patient’s age and was highest among patients 45 years of age or older who had difficulty breathing. Case patients who did not have difficulty breathing infected 0.05 times as many contacts as other case patients did. Serologic testing of 1,863 asymptomatic contacts revealed no infections. Spouses of case patients were more often infected (8 of 56 [14%]) than other close family members (7 of 547 [1.3%]) or other contacts (18 of 1996 [0.9%]).

IJCP Sutra: "Never ignore unexplained weakness, tiredness, first onset chest burning or first onset breathlessness after the age of 40."

Medical Voice for Policy change The risk of infection increased with increased duration of exposure of the contacts and with exposure to body fluids. The study concluded that increasing age and respiratory symptoms were indicators of infectivity of Nipah virus. Interventions to control person-to-person transmission should aim to reduce exposure to body fluids. (N Engl J Med. 2019;380:1804-14)

Antibiotics in Outer Space Antibiotics should be used with caution in outer space since they may quickly fuel drug resistance in bacteria, researchers report in mBio. The researchers found Escherichia coli bacteria treated with antibiotics in a simulated microgravity environment rapidly developed resistance to antibiotics. The bacteria were still resistant to the drugs over time even when they were no longer exposed to an antibiotic. This finding is especially concerning for astronauts, who may have suppressed immune systems due to microgravity, sleep deprivation, isolation or microbial contamination.

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

more likely to have remission of both type 2 diabetes and high blood pressure, compared to adults who had the same procedure. Results are from an NIH-funded study comparing outcomes in the two groups 5 years after surgery. Researchers evaluated 161 teens and 396 adults who underwent this surgery at clinical centers participating in Teen-LABS (Teen-Longitudinal Assessment of Bariatric Surgery) and its adult counterpart, LABS. Teens in the study were under 19 years old at the time of surgery, and adults in the study reported having obesity by age 18. Teen-LABS clinical centers had specialized experience in the surgical evaluation and management of young people with severe obesity, and both studies were funded primarily by NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The results were published in The New England Journal of Medicine. Key findings of the research include: ÂÂ

Overall weight loss percentage was not different between the groups. Teens lost 26% of their bodyweight and adults lost 29% at 5 years after surgery.

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Type 2 diabetes declined in both groups, but teens with type 2 diabetes before surgery were 27% more likely than adults to have controlled blood glucose (blood sugar) without the use of diabetes medications.

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Researchers at Washington University in St. Louis examined whether triclosan could protect bacteria from antibiotics designed to kill bacterial cells. They monitored bacterial cells’ survival after exposure to antibiotics.

No teens in the group needed diabetes medications after surgery, compared to 88% of teens before surgery. Seventy-nine percent of adults used diabetes medications before surgery, and 26% used diabetes medications 5 years later.

ÂÂ

Triclosan increased the number of surviving bacterial cells substantially as per Petra Levin, PhD, a professor of biology at Washington University.

Before surgery, 57% of teens and 68% of adults used blood pressure medications. Five years after surgery, 11% of teens and 33% of adults used blood pressure medications.

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Among those with high blood pressure before surgery, teens were 51% more likely than adults to no longer have high blood pressure or take blood pressure medication.

Consumer Products that Contain Triclosan are Fueling Antibiotic Resistance The use of consumer products that contain the chemical triclosan is fueling antibiotic resistance, according to a study in Antimicrobial Agents and Chemotherapy. Triclosan is the active ingredient in many products marketed to have antibacterial properties, such as toothpaste, mouthwash and cosmetics.

Normally, one in a million cells survive antibiotics, and a functioning immune system can control them. But triclosan was shifting the number of cells. Instead of only one in a million bacteria surviving, one in 10 organisms survived after 20 hours.

Early Weight-loss Surgery may Improve Diabetes, Blood Pressure Outcomes NIH-funded study: Despite similar weight loss, teens who had gastric bypass surgery were significantly

People with Calcium Stones should not Cut Back Dietary Calcium It may be surprising, but results of a randomized clinical trial show that people with calcium kidney stones should not cut back on dietary calcium. In fact, they should consume the recommended daily allowance of calcium (1,000 mg/day for women younger than 50 years old

IJCP Sutra: "If any member of your family male had heart disease before 55 or female before 65, it amounts to strong family history."

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and men younger than 70, and 1,200 mg/day for women over 50 and men over 70). Why? Calcium binds to oxalate in the intestine and prevents its absorption through the gut, so there is less in the urine to form stones. Ideally, calcium should come from food. Foods high in oxalates (nuts, spinach, potatoes, tea and chocolate) can increase the amount of oxalate in the urine. Consume these in moderation. Potassium citrate is another medication that can bind to calcium and help keep calcium oxalate and calcium phosphate in the urine from forming into stones.

Hypertension During Pregnancy can be Detrimental to Mother and Baby: HCFI Awareness must be raised on preventive measures during and after pregnancy National studies show that prevalence of hypertension among the Indian urban middle-class men and women is 32% and 30%, respectively. Factors such as family history, age, gender, diabetes mellitus, kidney disease, obesity, alcohol consumption, smoking, physical inactivity, and stress increase the risk. Despite this, not many people are aware of the condition or do not take preventive measures at an early stage. Research indicates that women with high blood pressure, especially during pregnancy, are at a twofold risk of heart failure post-delivery. The need of the hour is to monitor women before discharge and after giving birth, through the postpartum period. Hypertension during pregnancy can be detrimental to both the mother and the baby. Women with high blood pressure can develop resistance in their blood vessels. This hampers the flow of blood throughout the body including the placenta and uterus leading to problems with fetal growth. It can also cause premature detachment of the placenta from the uterus, disruption in the flow of oxygen to the placenta leading to delayed fetal growth, or in worst cases, even stillbirth. If not closely monitored before, during and after childbirth, it may become a major cause of heart problems including heart failure in such women. Some other fatal repercussions of high blood pressure include preterm birth, seizures or even death of the mother and the baby. Heart failure, or peripartum cardiomyopathy, can occur up to 5 months after giving birth. Some symptoms of this condition include tiredness, shortness of breath, swollen ankles, swollen neck veins and feeling of missed heartbeats or palpitations.

It is imperative for women diagnosed with hypertension to remain hospitalized for some time. Although the damage caused by peripartum cardiomyopathy to the heart is irreversible, it can still function with the help of some medications and treatment. In severe cases, a heart transplant may be recommended. Women must take steps to bring blood pressure under control from the time they wish to conceive, through certain lifestyle changes. Drugs such as b-blockers can help reduce blood pressure. Diuretics are another class of drugs that help lower blood pressure by removing excess water and salt from the body. Some other treatment options include coronary artery bypass surgery and implantable cardioverter defibrillators. Some tips to control and prevent high blood pressure from HCFI ÂÂ

Monitor your blood pressure before, during and after pregnancy.

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Consume less salt as high intake can raise blood pressure.

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Be physically active even during pregnancy. Sedentary women are likely to gain more weight than required, which can increase the risk of hypertension.

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Make sure you are not taking medication that can raise blood pressure levels. If you already have high blood pressure, talk to your doctor about the steps that need to be followed.

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Get regular prenatal checkups.

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Tobacco and alcohol are not safe during pregnancy and must be avoided.

CDC Recommendations for Screening and Testing Health Care Personnel for Tuberculosis A systematic review of evidence published after release of the 2005 CDC guidelines for preventing Mycobacterium tuberculosis transmission in health care settings found that a low percentage of health care workers have a positive tuberculosis test at baseline and upon serial testing. The CDC published its conclusions in the May 17 Morbidity and Mortality Weekly Report. Health care workers should be considered to be at increased risk for tuberculosis if they answer “yes” to any of the following statements: residence for a month or more in a country with a high tuberculosis rate; current or planned immunosuppression, including HIV, receipt of an organ transplant, treatment with a tumor necrosis factor-a antagonist, chronic steroids or

IJCP Sutra: "Don't use tobacco or alcohol: Use of alcohol or tobacco during pregnancy increases the risk of having a baby with a birth defect."

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Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

other immunosuppressive medication; or close contact with someone who has had infectious tuberculosis since the last test.

This is known as left ventricular outflow tract (LVOT) obstruction, a common and the most life-threatening complication of TMVR.

Recommendations for testing US health care personnel have been updated to include:

To increase the availability of TMVR for this subset of patients, Khan and colleagues at NHLBI and Emory University developed a procedure that makes an intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction, dubbed LAMPOON.

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Tuberculosis screening with an individual risk assessment and symptom evaluation at baseline (preplacement)

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Tuberculosis testing with a tuberculin skin test for people without documented prior latent tuberculosis

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No routine serial tuberculosis testing at any interval after baseline in the absence of a known exposure or ongoing transmission

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Encouragement of treatment for all health care personnel with untreated latent tuberculosis, unless treatment is contraindicated

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Annual symptom screening for health personnel with untreated latent tuberculosis

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Annual tuberculosis education of all health care personnel.

care

Novel Technique Reduces Obstruction Risk in Heart Valve Replacement Researchers at the National, Heart, Lung and Blood Institute (NHLBI), part of the National Institutes of Health, have developed a novel technique that prevents the obstruction of blood flow, a common fatal complication of transcatheter mitral valve replacement (TMVR). The new method, called LAMPOON, may increase treatment options for high-risk patients previously ineligible for heart valve procedures. The Journal of the American College of Cardiology published the findings online on May 20. TMVR is used to treat mitral valve stenosis, a narrowing of the valve that restricts blood flow into the main pumping chamber of the heart. It also treats regurgitation, which occurs when the valve leaks and causes blood to flow back through the valve. Untreated, these conditions can cause pulmonary hypertension, heart enlargement, atrial fibrillation, blood clots and heart failure. For elderly or frail patients, TMVR offers a less invasive alternative to open heart surgery. During TMVR, doctors replace the mitral valve by delivering an artificial valve through a catheter, through blood vessels and into the heart. But in more than 50% of patients, the heart’s anatomy gets in the way. The heart leaflet is pushed back and blocks blood flow.

In the LAMPOON procedure, the operator inserts two catheters through the patient’s groin, and then through the blood vessels until it reaches the heart. The doctor then uses an electrified wire the size of a sewing thread woven through the catheter to split open the leaflet. At that point, the patient is ready to undergo TMVR. Surgeons cut out the leaflets when they replace valves. They can do it, because they have cut open the chest and the heart and can clearly see the problem. LAMPOON is designed for patients who need a new mitral valve, but can’t, or may not want to undergo open heart surgery. Between June 2017 and June 2018, the LAMPOON study enrolled 30 patients, median age 76, considered at high risk for surgical valve replacement and at prohibitive risk of LVOT obstruction during TMVR. All patients survived the procedure and 93% reached the 30-day survival mark, which compares favorably to a 38% reported with other methods. The primary outcome of the study, which combined a successful LAMPOON, followed by a successful TMVR without reintervention, was achieved in 73% of the patients.

Beer before Wine and you’ll Feel Fine: Is it True? Assumption: If you start with wine and then drink beer, the carbonation in beer makes you more easily or quickly absorb alcohol from the wine. In theory, this leads to greater inebriation and a worse hangover. Study: Researchers enrolled 90 adults between the ages of 19 and 40, randomly assigning them to one of three groups: ÂÂ

Group 1 drank beer until their breath alcohol level was at least 0.05%, then drank wine until it was at least 0.11%. That’s well over the limit of what can get you charged with drunk driving in the US.

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Group II drank wine until their breath alcohol level was at least 0.05%, then drank beer until it was at least 0.11%

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Group III was allowed to drink either only wine or only beer until their breath alcohol level was at least 0.11%

IJCP Sutra: "Avoid late-night meals. Having a meal or snack within 3 hours of lying down to sleep can worsen reflux, causing heartburn. Leave enough time for the stomach to clear out."

Medical Voice for Policy change

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After a week or so, the experiment was repeated. This time, though, members of Groups I and II swapped, so that the order of the wine or beer they drank was reversed from the initial assignment. For Group III, wine drinkers were provided only beer and vice versa. The groups were similar with respect to gender, body size, drinking habits and frequency of hangovers. Hangover symptoms were assessed after each drinking session. Results: There was no correlation between hangover symptoms and whether subjects drank only wine, only beer, or switched between them in either order. The best predictors of a bad hangover were how drunk the subjects felt or whether they vomited after drinking. Alcohol is absorbed rather well and rather quickly, regardless of its source. Regardless of your drinks of choice or the order in which you drink them, what matters most is drinking responsibly, never driving under the influence, and knowing when to quit. (Harvard Newsletter; Am J Clin Nutr. 2019;109(2):345-2.)

A Woman Lost Her Spleen During an Operation Intended to Remove a Kidney at a Hong Kong Private Hospital A 57-year-old woman underwent surgery performed by a visiting urologist at St Paul’s Hospital in Causeway Bay on March 25 to remove a tumorous kidney, according to the Dept. of Health and the hospital. But pathological tests after the surgery showed the organ removed was her spleen, a hospital spokesman said. The doctor, the patient and the department were alerted immediately. The patient was discharged on April 16. Doctor’s admission rights and privileges for the establishment had been suspended. A hospital investigation showed that the preoperative check had met the standard. Comments How can it happen? ÂÂ

Wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant but is found lower in the abdomen or in the pelvic region because of the laxity of the peritoneal attachments. Many patients with wandering spleen are asymptomatic, hence the condition can be discovered only by abdominal examination or at a hospital emergency department if a patient is admitted because of severe abdominal pain, vomiting or obstipation.

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Accessory spleen is a variation of spleen development. The most common location of an accessory spleen is at the splenic hilum. Wandering accessory spleens may mimic tumors, such as pancreatic tumor, adnexal tumor, abdominal tumor, retroperitoneal tumor, adrenal tumor or testicular tumor, according to its location. Accessory spleens are usually smaller than 3 cm but up to 6 cm have been reported. These wandering accessory spleens are indicated for surgery when there are symptoms, such as pain, rupture, infarction or vascular torsion.

Always Obey the Patient’s Wish A Montana hospital has been ordered to pay more than $400,000 (2.8 crore) in damages to the estate of a man after jurors found the hospital, on two consecutive days, violated the man’s wishes not to be resuscitated, reports FOX 28 news. The jury found St. Peter’s Health in Helena and Dr Virginia Lee Harrison negligent for violating Rodney Knoepfle’s patient rights. Jurors awarded $209,000 in damages for medical costs and $200,000 for mental and physical pain and suffering. Knoepfle filed the lawsuit after medical teams performed cardiopulmonary resuscitation (CPR) on him on March 21, 2016, and, despite confirming his do-not-resuscitate order, the next day used ventilation and adrenaline after he became unresponsive with a very low heart rate. His wishes not to be resuscitated were included in his patient chart, had been expressed verbally to his doctors and he wore a blue wristband indicating he did not wish to be resuscitated or intubated. After the second resuscitation, Harrison wrote in Knoepfle’s chart that he and his wife “DO NOT WANT INTUBATION or CPR again” but would want treatment up to that point. Knoepfle had a pacemaker implanted and was released to a nursing home on April 1, 2016. He died in March 2018 at age 69.

Is it a blunder? Yes: If it was not a case of wandering spleen. In which case, it will be error of judgment.

Avoidable Mistakes ÂÂ

Treating the wrong patient.

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Surgical souvenirs: Surgical staff miscounts (or

IJCP Sutra: "Identify and avoid foods associated with heartburn. Common foods are fatty foods, spicy foods, tomatoes, garlic, milk, coffee, tea, cola, peppermint and chocolate."

Medical Voice for Policy change

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

fails to count) equipment used inside a patient during an operation. ÂÂ

Lost patients: Patients with dementia are sometimes prone to wandering.

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Fake doctors: Con artists pretend to be doctors.

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The ER waiting game: Emergency rooms get backed up when overcrowded hospitals do not have enough beds.

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Air bubbles in blood: The hole in a patient’s chest is not sealed airtight after a chest tube is removed.

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Operating on the wrong body part.

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Infection infestation: Doctors and nurses do not wash their hands.

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Lookalike tubes: A chest tube and a feeding tube can look a lot alike.

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Waking up during surgery: An under-dose of anesthesia.

the use of portable oxygen concentrators; trains usually allow concentrators and sometimes allow oxygen tanks on board with limitations. ÂÂ

If you choose to bring some of your medications along in a multi-compartment pillbox, secure the box with a rubber band. Because if the box opens, the pills may spill and you may not be able to identify which pill is which.

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It’s safer—and in many states and countries, required—to leave each prescription medication in its original labeled container. The label should show who prescribed the drug and when, as well as the drug name, dose and your name.

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Pack your medication in a clear plastic bag and keep it in a carry-on so it’s always with you.

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Use extra caution when packing injectable medications and other drugs that must be kept cold.

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Liquid or gel medications are allowed on airplanes in excess of the standard 3.4-ounce liquid limits. But you must inform security that you have medical liquids, and you may be asked to open the containers.

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For travel in some countries, prescription labels are not enough to authenticate your medications. Check the government websites of countries to which you are traveling. It may be necessary to bring a copy of your prescriptions as well as a letter from your physician (on letterhead) explaining what the medications are and why you need them. This is especially important for controlled substances, such as prescription pain medications.

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If you’re traveling to another country, consider having the letter translated into the language of your destination.

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Bring a master list. Keep a separate list of your medications and doses in case you lose anything.

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Include the name, address, fax number and phone number of a pharmacy where the medication can be called in. (Harvard Newsletter)

Traveling Abroad with Medicines ÂÂ

Research your destination.

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Remember that medication laws vary.

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Some medications such as pseudoephedrine and opioids used in the US are illegal in other countries or require government authorization prior to your arrival.

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Some countries limit the amount of medication you can bring with you to a 30-day supply or less.

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The Centers for Disease Control and Prevention (CDC) advises calling the embassy of the country you’re going to visit to ask if your medication is permitted there.

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Bringing oxygen on a trip is tricky. The rules vary by the type of oxygen products you use (such as a tank or a portable oxygen concentrator) and by your means of transportation (airplane, train, bus, or ship). For example, not all airlines allow

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IJCP Sutra: "Keep lower BP, LDL ‘bad’ cholesterol levels, resting heart rate, fasting sugar and abdominal girth levels <80."

Conference Proceedings

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

INDIA LIVE 2019 March 01, 2019 | Renaissance Mumbai Convention Centre Hotel, Powai, Mumbai

Does Diabetes Mellitus Affect Clinical Outcomes in Patients with DES? Dr Ashwin Mehta, Mumbai Diabetes mellitus (DM) is known to predict angiographic restenosis and ischemia-driven target lesion revascularization (TLR) and target vessel revascularization (TVR) after PCI with bare-metal stents (BMS). Use of DES significantly reduces restenosis rates in patients with and those without DM, compared with BMS. Lesions in patients with DM are known to be longer and diffuse than in patients without DM. DM thus seems to be a risk factor for restenosis given the propensity for more complex lesions in this condition. A study assessed if baseline lesion complexity affects DES outcomes according to diabetic status. DM was shown to be a risk factor for repeat revascularization only in those patients with complex lesions. Patients with DM and noncomplex lesions had similar rates of 1-year freedom from repeat revascularization as patients without DM. Tuxedo India study, headed by Dr U Kaul, interventional cardiologist from Batra Hospital, New Delhi has noted that Xience (EES) was superior to Taxus (PES) with regard to several end points, including target-vessel failure, myocardial infarction and stent thrombosis, in diabetes patients. The benefits of Xience (EES) vs. Taxus (PES) in the diabetic population seen at 1 year were maintained at 2 years. Resting Full Cycle Ratio (RFR) - Wireless Nonhyperemic Index of Coronary Stenosis Dr G Sengottuvelu, Chennai Fractional flow reserve (FFR) measurement under hyperemic conditions has been the gold standard for invasively determining the physiologic significance of coronary artery disease. Recently, two large-scale randomized controlled trials using a nonhyperemic resting measurement for physiological assessment of moderate coronary stenoses, the instantaneous wavefree ratio (iFR), reported noninferiority for major adverse cardiovascular events (MACE) comparing iFR

to FFR at 1-year follow-up. These studies demonstrated a statistically significant reduction in patient discomfort and in cost by avoiding adenosine. However, iFR has a number of inherent limitations including sensitive automated landmarking of components of the pressure waveform and the assumption that maximal flow and minimal resistance during resting conditions occur during a precise period within diastole, which previous evidence contests. The VALIDATE-RFR aimed to validate a novel hyperemia-free resting measure of pressure at the point of absolute lowest resting diastolic pressure (Pd) to aortic pressure (Pa) ratio (Pd/Pa) during the cardiac cycle, the resting full-cycle ratio (RFR). The RFR represents the maximal relative pressure difference in the cardiac cycle completely independent of the ECG and irrespective of systole or diastole, thus being an unbiased physiological assessment of coronary artery stenosis. RFR was shown to be diagnostically equivalent to iFR but unbiased in its ability to detect the lowest Pd/Pa during the full cardiac cycle, thus unmasking physiologically significant coronary stenoses that can be missed by assessment focused on specific segments of the cardiac cycle. TAKE HOME MESSAGE: The RFR may be used as an alternative to Pd/Pa and iFR as a nonhyperemic index to assess coronary artery stenosis severity. Unlike iFR, RFR is not limited by sensitive landmarking of components of the pressure waveform or specific to the wave-free period and thus may have greater clinical utility as a result of its versatility. Nonetheless, RFR is diagnostically equivalent to iFR, justifying its extension to all guidelines and clinical recommendations for iFR. What is the Significance of OCT in Saphenous Vein Grafts? Dr Viveka Kumar, New Delhi Saphenous vein graft (SVG) occlusion following surgery continues to be a significant limitation of CABG. Optical coherence tomography (OCT) has the potential to identify the features of atherosclerosis, including circumferential fibrous neointima, thin-cap fibroatheroma (TCFA) and adherent thrombus. It can

IJCP Sutra: "Use low-dose aspirin (75-162 mg/day) for secondary prevention of CVD after careful evaluation of bleeding risk and collaborative decision-making with the patient, family and other caregivers."

Conference Proceedings provide significant insights into the causes of vein graft failure. OCT of culprit lesions of old SVGs in patients with ACS can show fibrofatty composition, relatively thin fibrous cap, plaque rupture and thrombus. The VEST study revealed that OCT is useful for characterizing luminal features of SVGs that are not clearly seen using IVUS. OCT could also identify differences in SVGs with and without external stent support. A recent Indian case report suggested the safety and feasibility of LMWD-40-based OCT-guided zero contrast PCI in in-stent restenosis of SVG in a CKD patient. Another recent study compared the morphology of SVG in stenotic vs. nonstenotic lesions using OCT imaging in 29 patients hospitalized within the OCTOPUS registry. Stenotic lesions were characterized by higher incidence of TCFA, thrombus, lipid-rich plaque (LRP) and plaque within the SVG valve as compared to nonstenotic lesions. OCT provides good reproducibility for the measurements of parameters relevant for the development of atherosclerosis in vein grafts. What are the Uses of OCT? Dr Tejas Patel, Ahmedabad Intravascular optical coherence tomography (OCT) can add value to angiography as a diagnostic as well as an intervention tool for PCI guidance. In diagnostic terms, it is important to separate two very distinct populations: Stable coronary artery disease (CAD) and acute coronary syndromes (ACS). For both populations, the key questions include the following - Is intervention required? If so, which vessel/lesion? With regard to procedure planning, intravascular OCT can help with planning every coronary intervention procedure. When it comes to lesion preparation, we need to ascertain if there is a need for atherectomy, if there is a need for thrombectomy, if predilatation is chosen over direct stenting, how aggressive should the procedure be, etc. In terms of stent selection, what length and diameter are appropriate, is there a need for multiple stents or a single stent, if a need exists for overlapping stents, where is the best location, etc., need to be determined. Other potentially significant findings revealed by intravascular OCT after stent implantation are stent malapposition, edge dissections and tissue prolapse. The higher resolution and contrast between lumen and vessel wall obtained with intravascular OCT allow for

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

a more detailed lumen segmentation compared with IVUS, which is marked in irregular calcified plaque segments. Reference vessel lumen analyses as well as perfect circular phantom models show excellent agreement between intravascular OCT and IVUS, with lower interobserver variability obtained with intravascular OCT. OCT has unique features that favor its utilization in the setting of ACS. Intravascular OCT has 100% sensitivity (vs. 33% sensitivity of IVUS) in detecting intraluminal thrombus when compared with coronary angiography. OCT is suitable for the detection of non-CAD-related ACS causes like spontaneous coronary artery dissection. OCT-derived information could defer unnecessary stenting. Calcium is the most important predictor of suboptimal stent expansion. OCT has high tissue penetration on calcium thus allowing for the assessment of calcium thickness. In terms of stent selection, the very fast pullback acquisition obtained with intravascular OCT makes the method a precise one for length measurements. The high-resolution nature of intravascular OCT unravels stent malapposition frequently. Real World Experience with DES Dr Mathew Samuel, Chennai Drug-eluting stents have been in use since 2002 and have clear advantages of reducing the risk of target vessel revascularization and a reduction in restenosis rate from 40% to less than 10%. These stents have potential role in reducing major cardiovascular outcomes, especially target vessel revascularization (TVR), compared with bare-metal stents. A study reported on the clinical findings and 8-year follow-up parameters of all patients that underwent PCI with a drug-eluting stent from January 2002 to April 2007 at a single center. Total mortality was 8.7% and nonfatal infarctions were noted in 4.3% of the cases. Target vessel revascularization occurred in 12.4% of the cases, and target lesion revascularization occurred in 8%. The rate of stent thrombosis was 2.1%. No new episodes of stent thrombosis after the fifth year of follow-up were noted. Comparative subanalysis showed no outcome differences between the different types of stents used. These findings indicated that DES are safe and effective at very long-term follow-up and patients in the â&#x20AC;&#x153;real worldâ&#x20AC;? may benefit from these stents with excellent, long-term results. Results of 13 years of the DESIRE (Drug-eluting Stents in the Real World) registry revealed that the use of DES was associated with very long-term safety and

IJCP Sutra: "If you have diabetes, get an annual eye examination (by an ophthalmologist) to detect retinal disease; annual screening to detect CKD with eGFR and urine albumin-to-creatinine ratio."

Conference Proceedings

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

effectiveness with acceptable low rates of adverse clinical events, including stent thrombosis.

Imaging is Always Necessary During Coronary Interventions!!

In a recent study in Indian unselected real world patients with coronary artery disease, MACE at the end of 12-month was 4.4%, consisting of 6 (1.8%) cases of cardiac death, 3 (0.9%) cases of MI, 5 (1.5%) cases of TLR and 1 (0.3%) case of TVR. There were 3 (0.9%) cases of ST at the end of 12 months. The cumulative event freesurvival rate was found to be 95.6%. In this multicenter registry on real world population with coronary artery disease, everolimus-eluting stents demonstrated low event rate at up to 12-month follow-up.

Dr G Sengottuvelu, Chennai

The RESET trial has also shown that in patients undergoing PCI for mostly stable angina, EES is noninferior to SES for TLR at 12 months. This was maintained at 7 years of follow-up. The primary endpoint of TLR at 12 months was found to be similar between EES and SES (4.3% vs. 5.0%). Target vessel revascularization (TVR) rates were also similar (6.9% vs. 6.9%). Other endpoints including all-cause mortality (1.9% vs. 2.5%, p = 0.23), MI (3% vs. 3.5%, p = 0.42), and definite/probable stent thrombosis (0.32% vs. 0.38%, p = 0.77) were also similar. In the subset of patients undergoing angiographic followup, in-segment late loss at 8 months was similar (0.06 mm vs. 0.02 mm). Stent thrombosis rates at 7 years were shown to be extremely low with both stents (approximately 1%). Concepts of CABG that an Interventional Cardiologist Must Know Dr OP Yadava, New Delhi ÂÂ

Stable and low-risk CAD is over treated while complex and high-risk CAD is under treated, indeed a dichotomy.

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Early post-CABG ischemia may occur in 2-4% of patients with sinister outcomes and meriting aggressive interventional treatment.

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Multiple arterial grafts are superior to single IMA plus saphenous vein. However, barely 5-10% patients get more than one arterial graft.

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Minimally invasive CABG is safe and feasible, but hard outcomes in terms of mortality benefit have not been proven.

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Off Pump vs. Pump CABG debate continues with Asian countries favoring Off Pump CABG. It is probably the surgeon and not the technique, which is in contention.

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Angiogram has luminogram.

limitations

and

only

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Intracoronary imaging (IVUS and OCT) gives a complete picture of the vessel including plaque morphology, disease burden, vessel size, landing zone identification and appropriate device selection. Post-PCI imaging is extremely useful to optimize results and to identify complications not seen by routine angiography.

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A recent large meta-analysis of imaging vs. only angiography, which included 31 studies with 17,882 patients has shown significant reduction in all-cause death, MI, TLR and stent thrombosis with IVUS guidance. PCI guidance using either IVUS or OCT was associated with a significant reduction of MACE.

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Although it is not mandatory to use imaging in all cases, every operator should have exposure to one of the imaging modality - IVUS or OCT - even if either imaging modality is not available in their cath lab. Even when imaging is not used, exposure to imaging helps the operator to make better angiography-only based decisions. IVUS trained eyes select larger diameter stents even when IVUS is not used.

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Ideally if imaging is available, it is important to strongly consider imaging in all complex PCI subsets, which has been shown to have huge benefits on long-term outcome.

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The operator should ideally consider imaging in all cases. But it may not be feasible considering the socioeconomic status and hence it may be prudent to have a very low threshold for imaging in all cases when in slightest doubt.

Precision PCI of Left Main Bifurcation with Adjunct Imaging Modalities Like FFR-OCT Dr Sridhar Kasturi, Hyderabad The angiographic evaluation of left main (LM) disease can present challenges and requires additional intravascular imaging in order to make the correct decision regarding revascularization. The angle of the ostium often presents challenges for the accurate angiographic evaluation of disease. FFR evaluation of the LM depends not only on the lesion characteristics but also on the territory supplied by the vessel. FFR is very reliable in the presence of isolated LM disease. It seems to be accepted that an FFR in the

IJCP Sutra: "Minimize use of sedative drugs or drugs that promote orthostatic hypotension and/or hypoglycemia in patients with diabetes and advanced chronic sensorimotor distal polyneuropathy; refer to physiotherapy to reduce risk of fractures and fracture-related complications."

Conference Proceedings LM <0.8 or an MLA <5.9-6.5 mm2 is the threshold for revascularization. FFR is a potential tool for assessing the hemodynamic significance of an LM stenosis. A poor correlation has been noted between quantitative coronary angiography and FFR, which points to the shortcomings of relying on angiography alone in evaluating LM lesions. Angiographically intermediate LM lesions with an FFR of ≥0.80 can have revascularization deferred with favorable long-term outcomes. OCT provides precision information very quickly and helps in the treatment of cardiovascular disease, including LMCA disease. OCT can help assess atherosclerotic plaque and visualize thrombus. It can also assist in evaluation of the lumen area with accurate automated measurements. During PCI, it can help in stent placement and may be used to assess stent apposition and tissue coverage and assist in the identification and quantification of stent coverage. OCT is indicated for the assessment of lesions and for guidance of stent sizing and implantation. OCT can help assess the thickness of calcium plaques which may affect the lesion preparation strategy. Dissections resulting from predilatation are also detected by OCT that can be taken into account when assessing the required stent length. There is a benefit to integrating FFR and OCT technologies for the evaluation of disease and PCI optimization. They enable physicians to identify, diagnose and treat CAD while improving outcomes. FFR provides an accurate assessment of the functional significance of a lesion in varied clinical scenarios, such as single lesions, diffuse disease, left main, ostial disease, side branches. OCT further helps in the assessment and treatment of disease through high resolution lesion evaluation, both pre- and postintervention. Practical Guide to FFR Dr A Sreenivas Kumar, Hyderabad ÂÂ

Standardized approach to FFR: Indication, prepare your device, position the wire, induce hyperemia, measure gradient, store the tracing, interpret the tracing ...Be consistent.

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FFR would be higher with microvascular disease than it would be without microvascular disease. But, it still indicates exactly to what degree maximum blood flow can be improved by stenting an epicardial coronary stenosis!

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The hyperemic pull-back recording is the best practical way to guide where exactly the stent(s) should be placed and to evaluate the result.

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

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FFR pitfalls: Height of the fluid-filled transducer, equalization, hyperemia, drift, guiding catheter, side holes, whipping, position of the cursor, accordion effect.

Left Main Interventions – PCI or CABG? Dr PC Rath, Hyderabad Patients with obstructive left main coronary artery disease (LMCAD) have often been treated with coronary artery bypass grafting (CABG). The EXCEL trial has; however, shown that percutaneous coronary intervention (PCI) with everolimus-eluting stent is a suitable and less invasive option in patients with a SYNTAX score <32. There was a major difference between PCI and CABG in terms of 30-day incidence of procedural myocardial infarction (MI). A systematic review and meta-analysis suggested that in patients with significant LMCA stenosis and predominantly low to intermediate CAD complexity, both PCI and CABG may be reasonable approaches to revascularization. Patient preference should be taken into consideration regarding the risks of periprocedural complications of surgery and long-term repeat revascularization after PCI. Patients with low surgical risk may benefit from CABG; however, if a patient is not a good candidate for surgery or wishes to avoid the morbidity associated with CABG, PCI appears to be a reasonable option. The EXCEL trial randomly assigned 1905 patients with left main CAD of low or intermediate anatomical complexity (SYNTAX score of 32 or lower) to either PCI (with a goal of complete revascularization) with everolimus-eluting stents or CABG. The primary end point, a composite of death from any cause, stroke, or MI at 3 years, occurred at a similar rate in both groups (15.4% vs. 14.7%; hazard ratio 1, 95% CI 0.79-1.26). There were no significant between-group differences in the 3-year rates of the components of the primary endpoint. The secondary endpoint of death, stroke, or MI at 30 days occurred less often in patients in the PCI group (4.9% vs. 7.9%) due mainly to a lower rate of MI. The secondary endpoint of death, stroke, MI, or ischemia-driven revascularization at 3 years occurred more often with PCI (23.1% vs. 19.1%). What is the Role of OCT in Stent Thrombosis? Dr Rony Mathew, Cochin OCT is an imaging technique with high resolution and plays a key role in diagnosis and management of

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stent thrombosis (ST). It must be noted that all stent thrombosis are not equal. It is important to identify the specific cause of stent thrombosis. The cause may vary depending on the time course - subacute, late and very late. Identification of specific causes of stent thrombosis can help make the strategy specific to the cause and can prevent recurrent stent thrombosis. Intravascular OCT may provide insights into mechanistic processes leading to ST. The PRESTIGE Consortium (Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort) subjected patients presenting with ST to OCT imaging of the culprit vessel with frequency domain OCT. In patients with ST, uncovered and malapposed struts were observed with the incidence of both decreasing with longer time intervals between stent implantation and presentation. The most frequent dominant observation varied according to time intervals from index stenting: uncovered struts and underexpansion in acute/subacute ST and neoatherosclerosis and uncovered struts in late/very late ST.

(revascularization vs. medical therapy alone [deferral]) for this group.

How is the Use of OCT Beneficial for the Patient?

A study presented at EuroPCR 2018 revealed that among 104 patients randomly assigned in the singlecenter, unblinded, prospective Gray Zone FractionalFlow Reserve (GZ-FFR) trial to PCI or optimal medical therapy (OMT), patients assigned to receive PCI had less frequent angina and larger improvements in quality-oflife (QoL) measures at 2 months compared with patients assigned to OMT.

Dr Sanjeeb Roy, Jaipur OCT is an imaging technique that yields significant benefits when it comes to the assessment of coronary artery disease and stent implantation as well as followup. The technique helps assess stent placement, vessel injury and proper deployment of stent. It can yield realtime information beyond that obtained by angiography alone, and helps the physician in the decision-making process. By enhancing clinical outcomes, it can improve the patient’s well-being. Every case is different and thus every patient has different clinical requirements. OCT can help tailor the treatment strategy on basis of individualistic requirements. OCT guidance can help prevent incomplete/unnecessary procedures/surgeries and the associated risks, thus benefiting the patient directly. It provides the patients with economic benefits. Overall, the use of OCT has been shown to improve patient outcomes in the short- and long-term, reduce number of stents and is cost-effective. Clinical Decision-Making for the Hemodynamic Gray Zone Dr Takashi Akasaka, Japan Fractional flow reserve (FFR) value between 0.75 and 0.80 is considered the ‘gray zone.’ There is a scarcity of outcomes data relative to treatment strategy

A study published in J Invasive Cardiol followed 238 patients (64.3 ± 8.6 years; 97% male; 45% diabetic) with gray-zone FFR for the primary endpoint of major adverse cardiovascular event (MACE), defined as a composite of death, myocardial infarction (MI), and target-vessel revascularization. Deferred patients were found to have a higher prevalence of smoking and chronic kidney disease compared with the PCI group. Patients who underwent PCI had significantly lower MACE compared with the deferred patients (16% vs 40%; log rank P<.01). The composite of death or MI was significantly lower in the PCI group (9% vs. 27%; P<.01). Multivariate Cox proportional hazards regression analysis revealed that PCI was associated with lower MACE (hazard ratio, 0.5; 95% confidence interval, 0.27-0.95; P=.03). Revascularization for patients with gray-zone FFR was thus shown to be associated with a significantly reduced risk of MACE compared with medical therapy alone.

OCT in Complex PCI Dr Giulio Guagliumi, Italy ÂÂ

Imaging guidance has more clinical evidence in complex lesion/patient cohorts. It is not imaging per se but its correct interpretation, measurements and consequent action that makes a difference.

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Imaging is not FFR, does not give a black and white answer and we are still trying to find a practical algorithm to apply.

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Each Cath lab should develop expertise with at least one of these two technologies and a busy lab should know how to implement both imaging methods in more straightforward lesions.

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OCT in contrast to IVUS can often assess calcium thickness.

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Patients with LM lesions should be considered for imaging-guided intervention by IVUS or OCT (in nonostial LM lesions), due to particular challenges in angiographic evaluation and procedural

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complexity and because of the clinical sequelae of a suboptimal result in this context. ÂÂ

OCT for guidance of PCI is more user-friendly as the interpretation is simpler and automatic analyses are available immediately.

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Patients at high risk of developing contrast-induced AKI can benefit from IVUS-guided PCI due to potential for lower volume of contrast.

Acute Thrombotic Closure Dr Ajay Kumar Mahajan, Mumbai ÂÂ

Carefully watch for catheter-induced dissection as well as dissection at proximal and distal stent edge. Ensure adequate stent expansion and apposition.

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Consider adjuvant pharmacotherapy like GPIIb/IIa and thrombus aspiration and intracoronary thrombolytic, in case of high thrombotic burden.

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Ensure adequate pre-treatment with dual antiplatelet. Ensure adequate heparinization.

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Operator should note time at which heparin is given.

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Monitor ACT meticulously; repeat heparin, if subtherapeutic ACT.

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Frequent back bleeding from catheters; ensure that the dye syringe is free of blood. Check and recheck hardware; avoid reuse of hardware.

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Cath lab should always have drugs like GPIIb/IIa inhibitors, thrombolytics.

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Suspect in situ catheter thrombus if unexplained pressure damping or failure to back bleed.

Coronary Perforation: Management Dr VK Shah, Mumbai ÂÂ

All Cath labs must be equipped with more than 1 covered stents.

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All Cath labs must be equipped with Embolization Kits.

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All Cath labs must Pericardiocentesis Tray.

equipped

with

Drug Eluting Stents in ACS Dr Brian Pinto, Mumbai Percutaneous coronary intervention is often used for acute coronary syndrome (ACS). DES have been reported to result in fewer serious adverse events compared with BMS without increasing the risk of

all-cause mortality or major cardiovascular events in ACS. A Cochrane review noted that the absolute risk of death was 6.97% in the DES group compared with 7.74% in the BMS group based on the risk ratio (RR) of 0.90 (95% confidence interval (CI) 0.78 to 1.03, 11,250 participants, 21 trials/22 comparisons). The absolute risk of a major cardiovascular event was 6.36% in the DES group compared with 6.63% in the BMS group based on the RR of 0.96 (95% CI 0.83 to 1.11, 10,939 participants, 19 trials/20 comparisons). Meta-analyses at maximum follow-up showed evidence of a benefit when comparing DES with BMS on the risk of a serious adverse event. The absolute risk of a serious adverse event was 18.04% in the DES group compared with 23.01% in the BMS group based on the RR of 0.80 (95% CI 0.74 to 0.86, 11,724 participants, 22 trials/23 comparisons), and Trial Sequential Analysis confirmed this result. A recent observational study revealed significantly smaller thrombus burden with DES than with BMS at 1-month follow-up in STEMI cases. Second-generation DES are associated with a lower rate of acute and subacute stent thrombosis compared with BMS in the setting of ST-segment elevation myocardial infarction (STEMI). The EXAMINATION (clinical Evaluation of the Xience-V stent in Acute Myocardial INfArcTION) trial also demonstrated a lower rate of definite stent thrombosis with an everolimus-eluting stent (EES) compared with the bare-metal stent (BMS). Safety and Efficacy of Sirolimus-coated Balloon in Coronary In-Stent Restenosis: Insights from NANOLUTE Registry Dr Keyur Parikh, Ahmedabad NANOLUTE: A post market registry on SCB demonstrated that MagicTouch SCB is associated with reduced revascularization rates in patients with coronary in-stent restenosis (ISR) up to 3-year of followup. In patients with recurrent ISR, implantation of new DES would result in a vessel with multiple metal layers (“onion skin” phenomena). These “frequent flyer” patients seem to be at high risk for additional recurrences. SCB might emerge as the treatment strategy in this setting. Ad hoc, powered studies are an indispensable tool for assessing the preliminary results in the Western world population.

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News and Views Healthy Lifestyle Helps Reduce the Risk of Dementia – WHO Guidelines People can reduce their risk of dementia by getting regular exercise, not smoking, avoiding harmful use of alcohol, controlling their weight, eating a healthy diet, and maintaining healthy blood pressure (BP), cholesterol and blood sugar levels, suggest new guidelines issued by the World Health Organization (WHO). WHO Director-General, Dr Tedros Adhanom Ghebreyesus, said, “In the next 30 years, the number of people with dementia is expected to triple. We need to do everything we can to reduce our risk of dementia. The scientific evidence gathered for these Guidelines confirm what we have suspected for some time that what is good for our heart, is also good for our brain.” (WHO)

Heart Deaths up for First Time in 5 Decades in UK Deaths from heart and circulatory diseases among people under 75 are on the rise for the first time in 50 years, suggest UK figures. The British Heart Foundation (BHF) says increasing rates of diabetes and obesity are responsible in part. In 2017, there were 42,384 deaths in under-75s from heart and circulatory conditions, up from 41,042 in 2014. The charity says that the historic pace of progress in reducing these deaths has slowed to a near standstill. According to the charity’s report, more than 14 million adults have high BP but nearly 5 million do not know it because they have not yet been diagnosed. Around 15 million, or one in every four, adults in the UK is obese. Over the last 5 years, the UK has seen an 18% increase in people diagnosed with diabetes. Simon Gillespie, chief executive at the BHF, said, “In the UK we’ve made phenomenal progress in reducing the number of people who die of a heart attack or stroke. But we’re seeing more people die each year from heart and circulatory diseases in the UK before they reach their 75th or even 65th, birthday. We are deeply concerned by this reversal.” (BBC)

Global Platform for Disaster Risk Reduction The Global Platform for Disaster Risk Reduction is a biennial multi-stakeholder forum established by the UN

General Assembly to review progress, share knowledge and discuss the latest developments and trends in reducing disaster risk. The Global Platform for Disaster Risk Reduction is a critical component of the monitoring and implementation process of the Sendai Framework for Disaster Risk Reduction (2015-2030). The sixth session of the Global Platform for Disaster Risk Reduction (GP2019) took place in Geneva, Switzerland from 13 to 17 May, 2019, and was convened and organized by the UN Office for Disaster Risk Reduction (UNDRR) and hosted by the Government of Switzerland. It represented the next important opportunity for the international community to boost the implementation of the Sendai Framework related goals of the 2030 Agenda, as well as commitments of the Paris Climate Agreement. The theme of the sixth session was “Ensuring the Resilience Dividend: Towards Sustainable and Inclusive Societies.” In the words of Mami Mizutori, Special Representative of the UN Secretary-General for Disaster Risk Reduction, “If it’s not risk-informed, it’s not sustainable and if it’s not sustainable it has a human cost.” (UN)

Antibiotics after Assisted Vaginal Delivery Reduce Infections A blinded, randomized, placebo-controlled trial, published online in The Lancet, suggests that prophylactic antibiotic administration within 6 hours of assisted vaginal delivery can considerably reduce infection rates in the 6-week post-delivery period. Marian Knight, MBChB, DPhil, FFPH, FRCPE, from the University of Oxford, United Kingdom, and colleagues, state, “From our results, a high proportion of women—almost one in five—experience an infective complication and this can be reduced by almost half.” Investigators noted that only 11% (180/1619) of women in the antibiotic group developed an infection compared with 19% (306/1606) in the placebo group (risk ratio [RR] 0.58; 95% confidence interval [CI], 0.49-0.69). Additionally, significantly less women in the antibiotic group reported perineal pain, need for perineal care or wound breakdown in comparison with women in the placebo group.

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Around the globe Gaps in Diabetes Prevention Advice, Activities Diabetes prevention measures are under-utilized in the United States, suggest new data published online in JAMA Network Open. Both the US Preventive Services Task Force and American Diabetes Association recommend screening and lifestyle counseling to achieve weight loss and reduce diabetes risk in high-risk adults. Yet, the research found major gaps in provision of advice and referrals for diabetes prevention for adults at increased risk for type 2 diabetes, and low levels of patient engagement in diabetes risk-reduction activities or programs.

CDC Creates Interactive Training for Diagnosis, Management of Rocky Mountain Spotted Fever The Centers for Disease Control and Prevention (CDC) has created a first-of-its-kind education module to help clinicians recognize and diagnose Rocky Mountain spotted fever (RMSF), a sometimes serious and fatal disease spread by the bite of an infected tick. “Rocky Mountain spotted fever can be deadly if not treated early – yet cases often go unrecognized because the signs and symptoms are similar to those of many other diseases,” said CDC Director Robert R Redfield, MD. “With tickborne diseases on the rise in the US, this training will better equip health care providers to identify, diagnose and treat this potentially fatal disease.” The module includes scenarios based on real cases to help health care providers recognize the early signs of RMSF and differentiate it from similar diseases. Continuing education credit is available for physicians, nurse practitioners, physician assistants, veterinarians, nurses, epidemiologists, public health professionals, educators and health communicators… (CDC)

CDC Updates Guidelines for Cancer Cluster Investigations CDC is seeking public comment on updating federal guidelines used by public health agencies to assess and respond to potential cancer clusters in communities. The request for comment was posted on May 15, 2019 in the Federal Register and will be available for public comment through July 15, 2019. The current guidelines, Investigating Suspected Cancer Clusters and Responding to Community Concerns: Guidelines from CDC and the Council of State and Territorial Epidemiologists, were published in the Morbidity and Mortality Weekly Report (MMWR) in September 2013.

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Since the publication of the 2013 guidelines, there have been technical and scientific advances that may help public health agencies in responding to potential cancer clusters. CDC is working with the Agency for Toxic Substances and Disease Registry (ATSDR) to develop updated guidelines to ensure that public health agencies and stakeholders have access to current scientific tools and approaches… (CDC)

Countries must take Greater Action to reduce Low Birth Weights, warns UN-backed report Many countries need to invest more and take greater action to reduce the number of babies born with low birth weight which puts their health at risk, urges a United Nations-backed report released recently. Around 1 in 7 babies globally weighed <5.5 pounds, or 2.5 kg at birth, suggest latest data from 2015. The Lancet Global Health research paper, developed by experts from the WHO, UN Children’s Fund (UNICEF) and the London School of Hygiene and Tropical Medicine, revealed that over 20 million babies that year were born with a low birth weight, and that 80% of the world’s 2.5 million low weight newborns die every year, as they are either pre-term and/or small for gestational age. “We have seen very little change over 15 years”, said lead author Hannah Blencowe, from the London School of Hygiene and Tropical Medicine in the United Kingdom. “Despite clear commitments, our estimates indicate that National Governments are doing too little to reduce low birth weight”… (UN)

Benzodiazepines in Early Pregnancy Increase Miscarriage Risk Use of benzodiazepines in early pregnancy is associated with increased risk of spontaneous abortion, revealed a nested case-control study published in JAMA Psychiatry. Women who started using benzodiazepines in pregnancy were at an increased risk for miscarriage from the 6th through 19th gestational week compared to women not exposed to benzodiazepines (adjusted odds ratio [OR] 1.85, 95% CI 1.61-2.12), after controlling for pre-pregnancy maternal mood and anxiety disorders.

New AHA/ACC/AACVPR Statement on Home-based Cardiac Rehabilitation For patients who need cardiac rehabilitation (CR) but find it difficult to go to a clinic that offers it, home-based, medically supervised CR may be an alternative, suggests a joint scientific statement from the American Heart

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Association (AHA), American College of Cardiology (ACC) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).

Around the globe Pool chemical injuries lead to over 4,000 ED Visits each year: CDC

The scientific statement on home-based CR was published in Circulation, the Journal of the American College of Cardiology and in the Journal of Cardiopulmonary Rehabilitation and Prevention.

Pool chemical injuries led to 4,535 US emergency department (ED) visits annually during 2008-2017, revealed a report published in CDC’s Morbidity and Mortality Weekly Report. Pool chemicals kill germs in the water but can harm people if mishandled.

Home-based CR “may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program,” concludes the writing group.

While injuries from pool chemicals are preventable, the number of serious injuries from these chemicals has not shown much change over the last 15 years. The thousands of ED visits highlight the need to raise awareness about safe handling of pool chemicals.

New Tool to predict Childhood Asthma Jocelyn Biagini Myers and colleagues have developed the Pediatric Asthma Risk Score (PARS), a free online tool to assess the risk for asthma in young children. “Asthma-prediction tools to date have, by and large, been binary,” said Myers, PhD, from the Cincinnati Children’s Hospital Medical Center. “We wanted a simple, noninvasive tool that was a little more quantitative for families, researchers, and clinicians,” she said. Results from a comparison of the standard Asthma Predicative Index (API) and PARS were published in advance of their presentation at the American Thoracic Society 2019 International Conference in Dallas (J Allergy Clin Immunol. 2019;143:180310.e2). (Medscape)

Smarter Research and Development to Tackle Global Health Priorities WHO’s new Science Division launched an online resource to guide the development of new health products for which there are limited markets or incentives for research and development. An essential tool for realizing universal health coverage, the Health Product Profile Directory, is aimed at promoting research and development for products to combat neglected diseases and threats to global health, including antimicrobial resistance and diseases with pandemic potential. The Health Product Profile Directory is a free-to-use online resource created and developed by TDR, the Special Program for Research and Training in Tropical Diseases, on behalf of WHO as a global public good. There is a searchable database of profiles for health products needed to tackle critical health issues in global health, including those prioritized by WHO. The WHO Chief Scientist has invited global health R&D community to contribute to the Directory. (WHO)

CDC examined data on ED visits due to pool chemical injuries during 2015-2017 and found the top diagnosis as poisoning due to breathing in chemical fumes, vapors or gases, for instance, while opening chlorine containers. It was noted that more than one-third of these preventable injuries were in children or teens (36%). Nearly 56% of pool chemical injuries occurred at a home. (CDC)

In 4 Years, Severest form of TB Strikes 55 in Pune A total of 55 cases of the extensively drug-resistant tuberculosis (XDR-TB) - the world’s most untreatable form of TB - have been detected within the municipal limits of Pune in a little over 4 years, between January 2015 and March 2019, revealed the latest report of the Pune Municipal Corporation’s health department. The highest number of XDR-TB cases were recorded in the city in 2018 when 25 patients were diagnosed with the condition. In 2017, 12 patients were diagnosed with XDR-TB, while 8 and 7 cases were reported in 2016 and 2015, respectively. Health officials had diagnosed the first patient with XDR-TB in Pune in 2013, the report said … (ET Health)

Zilucoplan may decrease Symptoms of Generalized Myasthenia Gravis The novel peptide inhibitor zilucoplan is safe and effective in treating patients with generalized myasthenia gravis (gMG), suggests new research. A randomized, double-blind phase 2 trial of 44 patients with gMG revealed that those who received zilucoplan 0.3 mg/kg daily for 12 weeks showed a significant 6-point improvement from baseline in Quantitative Myasthenia Gravis (QMG) scores, the primary endpoint, and significantly improved scores on the MG Activities of Daily Living (MG-ADL) scale. Long-term data from the open-label extension phase of the study were also presented at the American

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Academy of Neurology (AAN) 2019 Annual Meeting and showed significantly sustained responses at 24 weeks for subjects receiving the study drug at 0.3 mg/kg daily.

WHO Mobile Medical Clinics Reach Displaced People in Iraq More than 8,000 internally displaced Iraqis living in camps and villages in Kalar and Kifri districts in Garmian, south-east of the Sulaymaniyah governorate, now have access to basic primary health services provided by WHO-supported mobile medical teams. Following the closure of a primary health care facility in Tazade and Qoratu and internally displaced persons (IDP) camps earlier this year, thousands of men, women and children were left with no access to medical care. Together with the Directorate of Health and Civil Development Organization, a local nongovernmental organization, WHO established two mobile medical teams, each comprising a medical doctor, a nurse and a pharmacy assistant. WHO also provided three ambulances to facilitate referrals of emergency patients. The mobile clinics serve IDPs in camps in Tazade and Qoratu, and IDPs and host communities in Kalar and Kifri districts. Many of these areas are located more than an hour away from Kalar Hospital, the closest available secondary health facility. (WHO)

FDA Approves First Anticoagulant for Pediatric Patients to Treat Potentially Life-threatening Blood Clots The US Food and Drug Administration (FDA) approved dalteparin sodium injection for subcutaneous use to reduce the recurrence of symptomatic venous thromboembolism (VTE) in pediatric patients ≥1 month of age. VTE can include deep vein thrombosis (blood clot in the deep veins of the leg) and pulmonary embolism (blood clot in the lungs), which can lead to death. (FDA)

Bowel Cancer Rates Rising among Young Adults More young people below 50 years of age are being diagnosed with bowel cancer, report two studies in European and high-income countries. Although total numbers of cases in young people remain low, the studies underscore a sharp rise in rates in 20-29 years old. While researchers are not clear why this is happening, obesity and poor diet could be the factors. Experts urged doctors not to ignore symptoms in young people.

In most of Europe, bowel cancer screening programs start at the age of 50 because cases of the disease are much higher among the older age group. However, recent research suggests rates are now rising more steeply among under-50s, and there have been calls for screening to start at 45 instead, in the US particularly. (BBC)

New App Boosts Kids’ Asthma Management An app called e-AT (for e-Asthma Tracker) helps physicians and families manage children’s asthma, reducing severe attacks and keeping kids out of the hospital, suggests a prospective cohort study. The app “has potential to broadly improve pediatric ambulatory asthma care,” write Flory L Nkoy, MD, MS, MPH, of the Dept. of Pediatrics at the University of Utah in Salt Lake City, and colleagues in a paper published online in Pediatrics. The app has varied features to improve asthma management over time, including real-time graphing of results, alerts for children and parents, automatic notification of primary care providers when asthma control starts to worsen, and real-time recommendations for action with a color-coded system based on level of urgency.

Reduced-Fat, Balanced Diet may Cut Death Risk from Breast Cancer Long-term adherence to a reduced-fat diet that includes a robust daily intake of fruits, vegetables and grains reduces the relative risk for death from breast cancer in postmenopausal women, suggest investigators from the landmark Women’s Health Initiative (WHI) study. Lead investigator Rowan Chlebowski, MD, PhD, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, said, “A dietary change can favorably influence a woman’s risk of dying from breast cancer.” This is the first study that provides “randomized controlled trial evidence” that a dietary intervention can reduce the risk of dying from breast cancer, Chlebowski said during a press cast preceding the presentation of the study at the meeting of the American Society of Clinical Oncology (ASCO) in Chicago.

Promoting “a Healthy Sustainable Future”, UN Health Agency Engages Young and Young at Heart to “Walk the Talk” Celebrating the importance of fitness, recently in Geneva, the United Nations health agency kicked off its second “Walk the Talk: The Health for All Challenge.”

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The WHO gathered people of all ages and abilities for a free walk/run event ranging from 3 to 8 kilometres. Health advocates and the general public joined Assembly delegates and the UN family in recognizing the value of healthy lifestyles and the importance of all people having access to the health services. “Today is not only about sport”, said WHO DirectorGeneral Tedros Adhanom Ghebreyesus. “It is about promoting health for all”. Special guest Margaret Kenyatta, First Lady of Kenya, said that “physical activity has always been the lifelong secret to healthy lives and longevity for the people and communities around the world.” According to WHO, the Walk movement promotes “physical activity as part of a healthy sustainable future.” (UN)

Too Many Children in Mental Health Hospitals, Says Report Too many children in England are being admitted to mental health hospitals unnecessarily, suggests a report. Research for the Children’s Commissioner for England found that children were often unable to get appropriate support at school and in the community. This was contributing to children ending up in institutions, sometimes for months or years, the report found. Children with learning disabilities or autism were being particularly let down by the system, it stated. Children’s Commissioner Anne Longfield’s report states that successive governments have tried to tackle the problem, but the number of children in mental health hospitals remains unacceptably high. Research shows a clear need to focus on children’s journeys before they are admitted into inpatient care, but often this does not happen. (BBC)

FDA Warns Against Use of Unauthorized Devices for Diabetes Management The US FDA is warning patients and health care professionals of risks associated with the use of unapproved or unauthorized devices for diabetes management, including continuous glucose monitoring systems, insulin pumps and automated insulin dosing systems. In the safety communication issued May 17, the agency noted that the use of unapproved or unauthorized devices could result in inaccurate blood glucose measurements or unsafe insulin dosing, which can lead to injury requiring medical intervention or even death. (FDA)

Cardiac Drug Sales up by Double Digits Across India Higher incidence of cardiovascular diseases (CVDs) has pushed up sales of cardiac medicines across the country. Cardiovascular drug sales have been clocking double digit growth every quarter in fiscal 2018-19 with the growth rate peaking at 14.8% in January to March period. The double-digit growth has continued in 2019-20. The sales of cardiovascular medicines in April increased by 13.2% to Rs. 1,492 crore, suggest data compiled by AIOCD AWACS, a market research wing of All India Organization of Chemists and Druggists (AIOCD). The overall sales stood at Rs. 16,523 crore in fiscal 2018-19. Experts believe that the consistent increase in the sales of cardiac medicines is a clear reflection of rising incidence of CVDs. (ET Healthworld)

High Juice Consumption could Increase Mortality Risk Several studies have shown that sugar-sweetened beverages (SSBs), such as soda and iced tea, have a deleterious effect on human health. Findings from a large cohort study suggest that 100% fruit juices should also be added to that list. In a survey of more than 13,000 adults aged 45 years or older from across the United States, each additional daily 12-ounce serving of fruit juice, independent of other SSBs, was found to be associated with a 24% increase in the risk for all-cause mortality, Lindsay J Collin, MPH, and co-authors wrote in an article published online in JAMA Network Open. Each additional serving of any sugary beverage was associated with an 11% increase in all-cause mortality risk.

Shorter Combo Treatment OK in Stage III CRC While a shorter duration of adjuvant chemotherapy does not appear to increase the risk of death in stage III colon cancer patients on combination regimens, those receiving monotherapy should have the entire 6 months of treatment, suggested the authors of a new metaanalysis published in JAMA Network Open. The meta-analysis of 22 studies involving 43,671 patients with stages II or III disease included two randomized trials and 20 observational studies. The authors noted that the findings support those from the International Duration Evaluation of Adjuvant Therapy (IDEA) collaboration, a prospective pooled analysis of six randomized trials that has prompted the adoption of shorter duration of adjuvant chemotherapy for certain patients with stage III colon cancer.

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Around the globe World Governments Urged to Condemn Doctors’ Sentences The World Medical Association (WMA) has called on all governments to condemn the recent prison sentences against leaders of the Turkish Medical Association. The WMA demanded that the Turkish Government annuls the convictions and prison sentences that were handed down to the Turkish physicians for issuing a press release claiming that “War is a Public Health Problem.” This follows the joint open letter to EU leaders from the Standing Committee of European Doctors and the WMA urging them to add their voices to the protests. WMA Secretary General, Dr Otmar Kloiber, said it was an ‘outrage’ that 11 former members of the Turkish Medical Association’s Central Council had been sent to prison for up to 39 months for claiming that war is a public health concern. Their statement is directly in line with ethical WMA policy and with the Hippocratic Oath requiring doctors to dedicate their lives to the service of humanity. To claim that this is “propagandizing for terrorist organisations” makes a mockery of the principle of freedom of speech. “We urge all world leaders to join us in denouncing the shameful treatment of these doctors. Justice demands their immediate release.” (WMA)

Ebola Threat Still “Very High” in DRC, Warns WHO Chief The risk of Ebola spreading in the Democratic Republic of the Congo (DRC) remains “very high”, said the chief of the WHO, Tedros Adhanom Ghebreyesus. The warning came after a recent spike in the number of infections due to the virus in the unstable north-eastern part of the country. Since January, there have been several attacks on health facilities in North Kivu, and on April 19, 42-yearold Dr Richard Valery from Cameroon was killed in Butembo. Dr Tedros told the World Health Assembly in Geneva what Dr Valery’s colleagues told him, when he visited them in DRC, “They told me, and I quote, ‘We’re here to save lives. We will not be intimidated by violence. We will finish the job.’…Unless we unite to end this outbreak, we run the very real risk that it will become more widespread, more expensive and more aggressive…Ebola does not take sides, it’s the enemy of everybody.”

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

To date, WHO has vaccinated nearly 12,000 people against Ebola, which Tedros said was more than 97% effective, and four experimental treatments have been given to 800 patients. (UN)

WHO Announces Four New Goodwill Ambassadors for Promoting Global Health WHO announced the appointment of four new goodwill ambassadors from the fields of sports, politics and community mobilization to promote healthier lives, stronger health workforces and improved mental health globally. The new ambassadors include Alisson Becker, goalkeeper of the Brazilian national and Liverpool football teams, and Dr Natália Loewe Becker, medical doctor and health advocate from Brazil, as WHO Goodwill Ambassadors for Health Promotion; Cynthia Germanotta, President of Born This Way Foundation, which was co-founded with her daughter Lady Gaga, as WHO Goodwill Ambassador for Mental Health and Ellen Johnson Sirleaf, former President of Liberia, as WHO Goodwill Ambassador for Health Workforce. The announcements were made by WHO DirectorGeneral Dr Tedros Adhanom Ghebreyesus in his speech to open the 72nd World Health Assembly in Geneva. (WHO)

Belgian Doctors Recommend Against Vegan Diet for kids Belgium’s Royal Academy of Medicine recommended that children, teens, pregnant women and nursing mothers do not follow a vegan diet. An estimated 3% of Belgian children follow this type of vegetarianism that excludes meat, eggs, dairy products and all other animal-derived ingredients, according to the academy’s statement. The academy stated that the eating plan is “restrictive”, creates “unavoidable” nutritional deficiencies and, if not properly monitored, could lead to deficiencies and stunted development. The Royal Academy of Medicine functions as an advisory agency for Belgium’s government institutions. Dr Georges Casimir, a pediatrician at Queen Fabiola Children’s Hospital and Head of the Commission appointed by the academy to study the issue of veganism, discouraged the diet for children and pregnant women due to the possibility of irreversible harms. A potential health issue caused by vegan diet is a lack of sufficient proteins and essential fatty acids for the developing brain. (CNN)

IJCP Sutra: "The contagious period for measles is estimated to be from 5 days before the appearance of rash to 4 days afterward."

Around the globe

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Liposuction Rise Linked to Gym Wear Trend An increasing number of women are seeking liposuction, possibly to get a body that looks good in trendy gym clothing, suggested a leading cosmetic surgeon. Rajiv Grover, from the British Association of Aesthetic Plastic Surgeons, says latest UK data suggest that procedures have gone up 12% in a year, from 2,039 in 2017 to 2,286 in 2018. He warned that there was no quick fix to fighting flab. Surgery has risks as well as benefits and should be a ‘last resort’, he said.

0.34-0.70, p < 0.0001), reported Tracey Simon, MD, of Massachusetts General Hospital. Researchers also revealed that the magnitude of risk reduction was similar between participants who exercised vigorously (HR 0.46, 95% CI 0.30-0.69, p = 0.0001), defined as ≥6 metabolic equivalent tasks (METs) per week, and moderately, defined as 3-6 METs/ week (HR 0.57, 95% CI 0.40-0.79, p = 0.0003). Individuals who walked a minimum of 4 hours/week had >40% reduced risk compared to sedentary adults, which is particularly notable as >85% of those involved in the study reported walking as their primary form of exercise.

According to the statistics, more than 28,000 plastic surgery procedures took place in 2018, a small increase of 0.1% from 2017. Women underwent 92% of all cosmetic procedures recorded. As in 2017, the three most popular procedures for women were breast augmentation, breast reduction and blepharoplasty (eyelid surgery). The biggest increases for women were for liposuction, which rose 12%, and facelifts, which rose 9%.

Fight Vaccine Hesitancy as “Contagious Disease”

Grover, who runs the audit, said: “The rise comes at a time where a fashion trend for women is athleisure clothing, showing what kind of physique you have rather than covering up.” Athleisure includes figurehugging clothing, such as leggings and bra tops, suitable for exercise and everyday wear. (BBC)

WHO Chief, Tedros Adhanom Ghebreyesus, joined experts and health ministers from several countries at an event on “promoting vaccine confidence”, amid rising concerns that resistance to immunization is allowing preventable diseases to flourish.

FDA Approves Midazolam Nasal Spray for Seizure Clusters The US FDA has approved midazolam nasal spray for the acute treatment of intermittent, stereotypic episodes of frequent seizure activity (seizure clusters, acute repetitive seizures) that are distinct from a patient’s usual seizure pattern in epilepsy patients aged 12 or above. Midazolam nasal spray is the first and only FDAapproved nasal option for treating seizure clusters. It is packaged as a single-use treatment that can be carried with a patient and administered by persons who are not health care professionals. (Medscape)

Even Moderate Exercise may Reduce Risk for Liver-related Death Engaging in mild physical activity may lower the risk of liver-related mortality, revealed researchers at the annual Digestive Disease Week. Across two 26-year prospective studies, patients with the highest quintile of physical activity had a 51% lower risk of dying from liver disease compared with sedentary adults after adjusting for age, body mass index (BMI), diabetes and hypertension, among other factors (hazard ratio [HR] 0.49, 95% CI

Faced with a global resurgence of measles, health experts called for countries to step up the fight against vaccine resistance, warning that the movement was spreading like a contagious disease.

“No country can afford to be complacent about immunization,” Tedros told the meeting in Geneva, where the WHO hosted its main annual gathering. “Vaccines are some of the most thoroughly tested medical products we have. Vaccines are safe, effective, and lifesaving,” US Health and Human Services Secretary, Alex Azar said. He slammed “social media conspiracy groups (that) confuse well-meaning parents so they hesitate to get the recommended vaccinations.” “This misinformation has real impacts,” he said. According to WHO, vaccines save nearly 3 million lives annually. “Vaccines do not cause autism. Vaccines actually cause adults,” said Katherine O’Brien, who heads WHO’s Immunization Department. (ET Healthworld)

Heart Scan may Pick up signs of Sudden Death Risk Scientists state that a new scan technique could identify people at risk of collapsing and dying suddenly from a hidden heart condition. Normally, in people with hypertrophic cardiomyopathy (HCM), signs of structural changes in the heart can only be identified after death. However, University of Oxford researchers used microscopic imaging to spot the same patterns

IJCP Sutra: "Every child needs to get the MR vaccine at 9 months and then again at 18 months."

Around the globe

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

in living patients. The research team focused on detecting those at risk of sudden death, by looking for abnormal fiber patterns in the heart which could lead to potentially deadly heart rhythms. A small device can then be implanted in their heart, to kick-start it into beating again when an abnormal heart rhythm is detected. Dr Rina Ariga, study author and cardiologist at University of Oxford, said: “We’re hopeful that this new scan will improve the way we identify high-risk patients, so that they can receive an implantable cardioverterdefibrillator early to prevent sudden death.” The study, published in the Journal of the American College of Cardiology, scanned 50 patients with HCM and 30 healthy volunteers and found “disarray” in living patients with the heart condition that had previously only been found in patients after sudden cardiac death. (BBC)

CBD Effective in Treating Heroin Addiction, says Study Cannabidiol, the non-psychoactive ingredient in hemp and marijuana, could treat opioid addiction, suggests a new study. Given to patients with heroin addiction, cannabidiol, or CBD, reduced their cravings for the illicit drug as well as their levels of anxiety. “The intense craving is what drives the drug use,” said Yasmin Hurd, the lead researcher on the study and director of the Addiction Institute of Mount Sinai. “If we can have the medications that can dampen that [craving], that can greatly reduce the chance of relapse and overdose risk.” The study published in the American Journal of Psychiatry, looked at 42 adults who had a recent history of heroin use and were not using methadone or buprenorphine. The participants were divided into three groups: one group received 800 mg of CBD, another 400 mg of CBD and another a placebo. All the participants were dosed once-daily for 3 consecutive days and followed over the next 2 weeks. A week after the last administration of CBD, those who had been given CBD had a two- to three-fold reduction in cravings relative to the placebo group. (CNN)

Mediterranean diet may keep Late-life Depression at Bay New research, presented at the American Psychiatric Association (APA) 2019 annual meeting, has suggested that adherence to a Mediterranean diet may guard against late-life depression. Investigators from Hellenic Open University in Patras, Greece, found that for older individuals who adhered to a Mediterranean diet, the odds of developing depression were significantly decreased.

Nintedanib Slows FVC Decline in Systemic Sclerosis-related ILD The tyrosine kinase inhibitor nintedanib appeared to slow the progression of systemic sclerosis-associated interstitial lung disease (ILD), reported the phase III SENSCIS trial. In the primary endpoint analysis, the adjusted annual rate of decrease in forced vital capacity (FVC) was 52.4 mL among patients assigned to nintedanib compared with 93.3 mL for patients on placebo (p = 0.04), reported Oliver Distler, MD, of the University Hospital Zurich in Switzerland. The 41.0 mL per-year difference (95% CI 2.9-79.0) between the two groups translated to a 44% reduction in the slope of lung function decline for these patients with interstitial lung disease, said Distler. The study was published in the New England Journal of Medicine.

Preserving Biodiversity Vital to Reverse Tide of Climate Change: UN The food people eat around the world is becoming “alarmingly homogenous”, suggest UN data, even though access to a wide variety of nutritious food has never been greater. That’s one of the warning signs discussed as the world marked the International Day for Biological Diversity on 22 May 2019, which this year highlighted the impact of environmental neglect on food security and public health. The day themed “Our Biodiversity, Our Food, Our Health” aimed to leverage knowledge and spread awareness of how much all life depends on biodiversity. (UN)

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IJCP Sutra: "The Nipah virus is a highly pathogenic paramyxovirus"

Spiritual Update

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Dharma, Artha, Kama and Moksha of Medical Profession KK aggarwal

he eras of Rama and Krishna represent two different perceptions of life. While Rama taught us the message of truthfulness, Krishna taught us when not to speak the truth and also when speaking a lie is justified. The medical profession today cannot survive on the principles of Rama. According to principles of Krishna, a truth which if spoken may cause harm to someone and if not spoken does not cause any harm, may not be spoken. Similarly, a lie, which without harming the community may help a particular person or situation, may be spoken. In medical profession, doctors come across situations every day where speaking the truth may be harmful to the patient. Quite often, false hopes are given and patients of terminal cancer are not told about their exact nature of illness and the prognosis. There is no way a doctor is going to tell the patient that you are going to die in the next 24 hours even if it is medically true. Dharma, artha, kama and moksha are the four basic purposes of life for which we are born. The basic purpose of life is to fulfil our desires in such a way that we end up with inner happiness. Fulfilment of desires should be done by following the principles of righteous or ethical earning. Charges in most hospitals are different depending upon the categories chosen by the patient. A single room patient invariably has to pay more than a patient admitted in the concessional three-bed room or general ward. Even the charges of the treatment, operation theater, investigations and consultations may be

different depending upon the categories. Taking more money from the rich and helping the poor - this relates more to Krishna’s principle than Rama’s. Placebo therapy is a well-established therapy in medical science, which means treating the patient without giving the actual drug. The information that the drug does not contain any ingredient is withheld from the patient in this type of therapy. As per the literature, 35% of the illnesses and symptoms may resolve using a placebo and is based on the principle that the very feeling that a medicine is being given stimulates the inner body pharmacy and produces healing substances and chemicals. Nocebo effect, on the other hand, means that if the patient is told that your illness is not going to be cured even if medicines are given, they may not act as the patient’s body produces negative chemicals, which neutralize the effect of medicines that otherwise are effective. Indian doctors are known for their social medicine, which involves proper assessment of patients’ and their families’ financial status before deciding the treatment. There is no point giving options to a family to spend 10-15 lakhs of rupees for getting an implantable cardioverter-defibrillator (ICD) device implanted in the heart, which may increase life span only by 1 or 2 years or improve quality-of-life for a few years to a family that cannot afford this amount of money and may have to sell their house or spend all the money saved for the marriage of their daughters. But now, with the Consumer Protection Act applicable to the medical profession, not informing the family may amount to negligence. Disclaimer: The views expressed in this write up are entirely my own.

Group Editor-in-Chief, IJCP Group

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IJCP Sutra: “Two consecutive negative sputum samples for AFB at the end of full treatment means TB is cured.“

INSPIRATIONAL Story

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

Trust Your Relationship When you see a couple fight or having an argument, what is the first thing that comes in your mind? Probably you think that you will never allow arguments to set in your relationship (especially when you get married), or will never think to start one, but arguments seem to come naturally. You argue about the brand of coffee, or what to eat at lunch, who will do the dishes, etc. Sometimes, more than that, but regardless of your reasons for the argument (or fight), patching up a troubled relationship and having a solution is very important. Second to God, our partners are a believer’s most valuable asset. Companions provide a listening ear for our troubles, support for our dreams, and a safety net when we fall. They give us love, even when we are unlovable. They are and must be our friends. Inevitably, though, sometimes we go through troubled periods and a solution should be sought through the following steps: 1. Address the situation. Acknowledge to your partner that something is amiss and needs to be fixed.

2. Determine the problem. Together, discuss where the relationship veered off course and what wrongs may have been spoken or committed. Be honest and let your honesty be in its proper place. Remember, you are talking to your partner, another half of yourself. 3. Apologize. As believers, we accept responsibility for our actions and seek forgiveness. 4. Refuse to blame. In addition, we must avoid defending ourselves. There could be a temptation to argue over who did what; however, the goal is not proving who is right but saving the relationship. 5. Begin repairs. Ask, “What can I do to rebuild our closeness?” The key here is to do willingly whatever is requested. 6. Commit to rebuilding. Immediately start investing your time, energy and love in restoring the relationship. In order to have the blessing of a good relationship, with a partner who accepts and loves us, we must be willing to pay the high price of patching things up. Walking away might seem easier, but in the long run, we would lose a valuable treasure.

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Thousands of Cancer Diagnoses Linked to a Poor Diet Diet may have more impact on your cancer risk than you might think, suggests a new study. An estimated 80,110 new cancer cases among adults 20 and older in the United States in 2015 were attributable simply to eating a poor diet, reported the study, published in the JNCI Cancer Spectrum. Low whole-grain consumption was associated with the largest cancer burden in the US, followed by low dairy intake, high processed-meat intake, low vegetable and fruit intake, high red-meat intake and high intake of SSBs. (CNN)

FDA Approves Calcipotriene for Plaque Psoriasis in Adolescents The US FDA has approved calcipotriene foam, 0.005% for the treatment of plaque psoriasis of the scalp and body in adolescents aged 12 years or older. Calcipotriene is a synthetic vitamin D analog that regulates skin cell production and growth and has a similar receptor binding affinity as natural vitamin D. (Medscape)

FDA Advisory Panel Recommends Approval of TB Alliance’s Tuberculosis Treatment Independent experts of an FDA advisory panel voted in favor of the not-for-profit TB Alliance’s treatment for drug resistant tuberculosis, as a part of a three-drug combination regimen. The panel voted 14-4 when asked to assess the treatment, pretomanid, in combination with Johnson & Johnson’s bedaquiline and linezolid for multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). (ET Healthworld)

IJCP Sutra: “Observe cereal fast 80 days in a year.“

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lighter reading

Indian Journal of Clinical Practice, Vol. 30, No. 1, June 2019

HUMOR

Lighter Side of Medicine Three Professionals

What are you doing?

A Mechanical, Electrical and Computer Engineer were riding together to an Engineering Seminar; the car began jerking and shuttering.

A woman went shopping. At the cash counter she opened her purse to pay. The cashier noticed a TV remote in her purse.

The mechanical engineer, said, “I think the car has a faulty carburettor.”

He couldn’t control his curiosity and asked, “Do you always carry your TV remote with you?”

The electrical engineer said, “No, I think the problem lies with the alternator.”

She replied, “No, not always, but my husband refused to accompany me for shopping today.

The computer engineer brightened up and said, “I know, let’s stop the car, all get out of the car and get back in again!”

The story continues...

Can I help you

Shocked at this act, she asks the shopkeeper, “What are you doing?”

There was this man driving along in his car when he suddenly got a flat tire. When he pulled over he was at the fence of a mental hospital. When he got out of the car, one of the patients came to the fence and asked “Can I help you?” And the man said “No, I need to figure out how to make it home with only 2 lugs on this wheel.” The patient asked again “Are you sure you do not need any help?” And the man said “No.” The man tried to figure it out when all of a sudden the patient said “If I were you I would take one lug off the other 3 wheels and put them on that wheel and you should be able to get home.” The man asked “How did you think of that?” The patient replied “I am in here because I’m crazy not because I’m stupid.”

The shopkeeper laughs and takes back all the items that lady had purchased.

He said, “Your husband has blocked your credit card.” Who discovered America? Teacher: George, go to the map and find North America. George: Here it is! Teacher: Correct. Now, class, who discovered America? Class: George!

Dr. Good and Dr. Bad Situation:

A 63-year-old obese female with type 2 diabetes from the past 10 years was recently diagnosed with chronic kidney disease.

Organic vegetables A wife goes to the local market to buy some organic vegetables for her husband. She came back rather upset.

It is not commonly associated with diabetes

It is a common complication of diabetes

Have they been sprayed with any poisonous chemicals? And he said, ‘No, ma’am. You’ll have to do that yourself’.”

When her husband asked her what was wrong, she said, “I don’t think I like that produce guy. I went and looked around for organic vegetables and I couldn’t find any. So I asked him, ‘Where the organic vegetables were?’ He didn’t know what I was talking about so I said, ‘These vegetables are for my husband. Lesson: Despite improvement in management strategies

for type 2 diabetes, its complications including vision loss, neuropathy, renal problems, cardiovascular disease and amputation are still reported worldwide.

IJCP Sutra: “Do not smoke or be ready to shell out Rs. 80,000/- for treatment.“

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Indian Journal of Clinical Practice is published by the IJCP Group. A multispecialty journal, it provides clinicians with evidence-based updated information about a diverse range of common medical topics, including those frequently encountered by the Indian physician to make informed clinical decisions. The journal has been published regularly every month since it was first launched in June 1990 as a monthly medical journal. It now has a circulation of more than 3 lakh doctors. IJCP is a peer-reviewed journal that publishes original research, reviews, case reports, expert viewpoints, clinical practice changing guidelines, Medilaw, Medifinance, Lighter side of medicine and latest news and updates in medicine. The journal is available online (http://ebook.ijcpgroup.com/ Indian-Journal-of-Clinical-Practice-January-2018.aspx) and also in print. IJCP can now also be accessed on a mobile phone via App on Play Store (android phones) and App Store (iphone). Sign up after you download the IJCP App and browse through the journal. IJCP is indexed with Indian Citation Index (ICI), IndMed (http://indmed.nic.in/) and is also listed with MedIND (http://medind.nic.in/), the online database of Indian biomedical journals. The journal is recognized by the University Grants Commission (20737/15554). The Medical Council of India (MCI) approves journals recognized by UGC and ICI. Our content is often quoted by newspapers. The journal ISSN number is 0971-0876 and the RNI number is 50798/1990. If you have any Views, Breaking news/article/research or a rare and interesting case report that you would like to share with more than 3 lakh doctors send us your article for publication in IJCP at editorial@ijcp.com. Dr KK Aggarwal Padma Shri Awardee Group Editor-in-Chief, IJCP Group

IJCP Sutra: “Do not drink alcohol; if you do, do not consume more than 80 mL daily for men (50% for women) or 80 grams/week. Ten grams of alcohol is present in 30 mL or 1 oz of 80 proof liquor.“

Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Indian Journal of Clinical Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter –

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IJCP Sutra: “If you are a heart patient, consider 80 mg aspirin and 80 mg atorvastatin a day.“

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

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111.

Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat. – All photomicrographs should indicate the magnification of the print. – Special features should be indicated by arrows or letters which contrast with the background. – The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen. – Color illustrations will be accepted if they make a contribution to the understanding of the article. –

Do not use clips/staples on photographs and artwork.

–

Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”.

Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________ 2. Total number of pages ________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________

Books

5. Special requests _____________________________

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

6. Suggestions for reviewers (name and postal address)

Articles in Books

2.____________ 2.________________

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

3.____________ 3.________________

4.____________ 4.________________

Tables –

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends – These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text. –

The legend must include enough information to permit interpretation of the figure without reference to the text.

Indian 1.____________Foreign 1.________________

7. All authors’ signatures________________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Online Submission Also e-Issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Indian Journal of Clinical Practice E-219, Greater Kailash Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com

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