January 2017 by ejima

Volume 115 u Number 01 u Kolkata u January 2017

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Dr K K Aggarwal

Dr R N Tandon

Dr Dilip Kumar Dutta

Dr Kakali Sen

National President IMA

Honorary Secretary General, IMA

Honorary Editor, JIMA

Honorary Secretary, JIMA

Volume 115 u Number 01 u Kolkata u January 2017

CONTENTS Editorial : u Why mother’s die? — Dilip Kumar Dutta ............................................................................5 Original Articles : u Cell mediated immune response in children suffering from tuberculosis — Gaytri Koley, K C Koley ................................................................................................................7

u Early neonatal morbidities in late preterm newborns in a tertiary care teaching

hospital of Uttarakhand —Jain Anand, Jain Suchitra, Upadhyay Amar N..........................................10

u Prevalence and association of metabolic syndrome with C-reactive protein in

people attending a tertiary care hospital of North Bengal — Debjani Laha, Ranjan Pal, Anupam Gupta, P P Pal, G Ghoshal, D S Mondal.......................................................13 u Status of cold chain monitoring in primary health centres of Bangalore urban — north — Jyothi Jadhav, Selvi Thangaraj, Thilak S A, Ranganath T S............................................................17

Observational Studies : u A study on knowledge, attitude and practices (KAP) regarding usage of Hydrogen Peroxide among Orthopaedic surgeons in Hyderabad, AP — K L Jagadishwar Rao, Kantilal G Jain, Subash B ..........................................................................21 u Profile of road traffic accidents from semi-urban area of Bihar — A Kumar, R R Jha ..........................26 u Knowledge of cardio-pulmonary resuscitation in medical undergraduates — Meenakshi Girish, Nilofer Mujawar, Prachi Marlecha, Rohinie Dhokane ....................................28

Case Reports : u Epidural anaesthesia for fixation of intertrochanteric fracture in a 108-year old elderly patient — Leena Goel, Pabitra Ghoshal, Rina Cordeiro, Sambhram Shenoy .........................31

u Placenta accreta — a multidisciplinary team approach — Nellepalli Sanjeeva Reddy,

Vembu Radha, Marianallur Ganesan Dhanalakshmi, Jayalakshmi D................................................33

u Tuberculosis of spleen : a rare case report — Ajithkumar C S..............................................................35 Pictorial CME : u Lichen Amyloidosis— Sonthalia Sidharth, Arora Rahul, Sharma Sonal ...........................................37 V Comments / Feedback 2

Editorial

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

JOURNAL OF THE INDIAN MEDICAL ASSOCIATION Founder Hony Editor Founder Hony Business Manager Ex-officio Members

: : :

Kolkata Hony Editor Hony Secretary Hony Associate Editors

: : :

Assistant Secretary

OFFICE BEARERS OF IMA (HQs)

National President Dr K K Aggarwal Honorary Secretary General Dr R N Tandon

IMA CGP (Chennai) Dean of Studies Dr V C Shanmuganandan (Karnataka) Honorary Secretary Dr R Gunasekaran (Tamil Nadu)

IMA AMS (Hyderabad) Chairman Dr Joseph Mani (Kerala) Honorary Secretary National President-Elect (2017-2018) Dr Ravi S Wankhedkar (Maharashtra) Dr Sadanand Rao Vulese (Telangana)

Immediate Past National President Dr S S Agarwal (Rajasthan)

National Vice-Presidents Dr Roy Abhram Kallivayalil (Kerala) Dr K Prakasam (Tamil Nadu) Dr Mahendra Choudhary (Gujarat) Dr Parmanand Prasad Pal (Bihar)

IMA AKN Sinha Institute (Patna) Director Dr Sarbari Dutta (Bengal) Honorary Executive Secretary Dr Raman Kumar Verma (Bihar)

Honorary Finance Secretary Dr V K Monga (Delhi)

JIMA (Calcutta) Honorary Editor Dr Dilip Kumar Dutta (Bengal) Honorary Secretary Dr Kakali Sen (Bengal)

Honorary Joint Secretaries Dr Vinod Khetarpal (Delhi) Dr Anil Goyal (Delhi) Dr Ashwini Kumar Dalmiya (Delhi) Dr Santosh Kumar Mandal (Bengal) Dr B B Gupta (Delhi) Honorary Assistant Secretaries Dr Dinesh Sahai (Delhi) Dr Amrit Pal Singh (Delhi) Honorary Joint Finance Secretaries Dr Manjul Mehta (Delhi) Dr Santanu Sen (Bengal)

Your Health (Calcutta) Honorary Editor Dr Ashok Kumar Chatterjee (Bengal) Honorary Secretary Dr Meenakshi Gangopadhyay (Bengal) IMA N.S.S.S. (Ahmedabad) Chairman Dr Kirti M Patel (Gujarat) Honorary Secretary Dr Yogendra S Modi (Gujarat)

Why mother’s die?

Sir Nilratan Sircar Dr Aghore Nath Ghosh Dr Santosh Kumar Mandal Hony. Joint Secretary, IMA (Hqs),Kolkata Dr Santanu Sen Hony Jt Finance Secretary, IMA (Hqs), Dr Dilip Kumar Dutta Dr Kakali Sen Dr Amitabha Bhattacharya Dr Dipanjan Bandyopadhyay Dr Gopal Das

IMA N.P.P.Scheme (Thiruvananthapuram) Chairman Dr Krishna M Parate (Maharashtra) Honorary Secretary Dr Jayakrishnan A V (Kerala) Apka Swasthya (Varanasi) Honorary Editor Dr Vivek Kumar (Uttar Pradesh) Honorary Secretary Dr Sanjay Kumar Rai (Uttar Pradesh) IMA Hospital Board of India Chairman Dr R V Asokan (Kerala) Honorary Secretary Dr Jayesh M Lele (Maharashtra) IMA National Health Scheme Chairman Dr Ashok SAdhao (Maharashtra) Honorary Secretary Dr Alex Franklin (Kerala) IMA National Pension Scheme Chairman Dr Sudipto Roy (Bengal) Honorary Secretary Dr K V Devadas (Kerala)

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

HAPPY NEW YEAR 2017

Dr Dilip Kumar Dutta MD, PhD, FRCOG (Hon), FICOG, FIAMS, FICMCH, MAMS, DACOG (USA), DPS (Germany) Published 36 Books Honorary Editor, JIMA

My Wholehearted thanks to all IMA fraternity for electing me as Editor of JIMA 2017. I am cent percent confident to do justice to my post. I will not only focused on evidence based excellent articles but also try to make this journal one of the best in the world (Pubmed index with good impact factor). First issue of JIMA will be focused on Maternal Death. Why mother’s die? It is a very important issue to all concerned. Whether it is due to for delays- to seek treatment, or to reach Hospital or to start treatment by doctors or lack of transportation due to bad road condition.

Women are dying during their long journey of 280 days during pregnancy period without antenatal check up, investigation & treatment. Every minute of everyday a woman dies as a result of pregnancy or child birth somewhere in the world may be due to –(a) Teenage pregnancy, physically not fit to deliver the baby leading to obstructed labor, sepsis, eclampsia and anemia, etc. (b) Due to want of blood or drug. (c) Elderly women from low socioeconomic resources going for illegal abortion. Such tragic picture still exists in many states of India excluding Kerala, Mizoram and in other two or three states. Maternal death reviews are not done in many states till date. No CME was held on MMR in many places. Government (State & Central) in good faith started National Rural Health Mission (NRHM) by spending a lot of fund but no positive result to prevent MMR so far. MDG (Goal 5)-Mother: cut back by three quarters the number of women who die when they are having babies has failed to fulfill its goal. SDG is now started to implement his own vision. The Sustainable Development Goals (SDGs), officially known as transforming our world: the 2030 Agenda for Sustainable Development is a set of seventeen inspirational “Global Goals” with 169 targets between them. I strongly recommended Following below mentioned preventive measures which can be can be implemented to prevent maternal death as priority basis (1) 1st priority - Prevention of teenage pregnancy (5A) BY (a) Aware– not to marry before 20years,(b) Avoid pregnancy before 20 years if married early by contraception, (c) Awake – if she come with pregnancyadequate to prevent maternal complications, (d) Audit- if she dies during pregnancy, (e) Assurance–for education, employment and health care after delivery. (2) 2nd priority - Cent percent antenatal checkup and institutional delivery. (3) 3rd priority - adoption of family planning by contraception/PPIUCD etc. (4) 4th priority - Govt. should invite doctors who are working in the rural India rather than doctor working in urban area (less experience to tackle the maternal death) for any meeting in relation to the maternal death. (5) Facility based maternal Death Review Format would be filled up The Medical officer (MO) who had treated the mother and was in duty at the time of maternal Death.

Disclaimer The information and opinions presented in the Journal reflect the views of the authors and not of the Journal or its Editorial Board or the Publisher. Publication does not constitute endorsement by the journal. JIMA assumes no responsibility for the authenticity or reliability of any product, equipment, gadget or any claim by medical establishments/institutions/manufacturers or any training programme in the form of advertisements appearing in JIMA and also does not endorse or give any guarantee to such products or training programme or promote any such thing or claims made so after. — Hony Editor 5

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Review Article Cell mediated immune response in children suffering from tuberculosis Gaytri Koley1, K C Koley2 Tuberculosis is a serious problem in children. The objective of the study was to study the cell mediated immune response in childhood tuberculosis and its' role in prognosis if any. This was a cohort study, undertaken among 40 children visiting outpatient department and aged between 2 to 5 years who were diagnosed as tuberculosis in a tertiary care hospital setting in Delhi. Mantoux test which was used as diagnostic criteria was also taken as a marker of intact cell mediated immune (CMI). Mantoux positivity irrespective of size was the first in-vivo indicator of CMI. Cytokines released from lymphocyte were assessed in-vitro. Peripheral venous blood samples were taken and mononuclear cells were harvested. lymphocyte suspensions were prepared and lymphocyte proliferation was done in vitro after BCG stimulation. The cytokines released from these were assayed as per the genzime protocol provided with the kit. Since CMI is protective in tuberculosis clinical correlation and outcome of patients at the end of 6 months was done to see the correlation between the 2 tests done as an indicator of CMI and the clinical profile of the patient and to see if these tests could be used to prognosticate the case. The study revealed that children with only pulmonary tuberculosis that is a restricted disease showed a higher incidence of Mantoux positivity, as compared to children with disseminated disease. They also responded by showing a Th1 pattern of cytokine release. These children also responded well to therapy and had excellent cure rates. This shows that Mantoux test besides being a good diagnostic test along with cytokine response can be used to predict a better prognosis in pulmonary tuberculosis in preschool going children. [J Indian Med Assoc 2017; 115: 7-9]

Key words : Pulmonary tuberculosis, disseminated, mantoux test, cytokines, Th1, Th2, IFN-Îł (interferon gamma), IL-2, IL-4.

uberculosis (TB) is a serious problem in children. Globally about 2 billion people are infected with Mycobacterium tuberculosis, 8 to 10 million of them develop active disease and 2 million die from TB every year1. The ease with which the pathological process spreads and difficulties with disease confinement are the most characteristic features of tuberculosis in children. These are mainly due to immaturity of both respiratory and immune systems. Protective immunity in tuberculosis is T cell mediated2 and this study was done to see a correlation between T cell response in the form of Mantoux test, cytokine secretion, the clinical severity and the outcome of the disease. Mantoux test is an established test in diagnosing childhood tuberculosis but its exact role in prognosticating a case has not been established1.

MATERIAL AND METHOD

This study was conducted at Army Hospital, New Delhi. Forty children aged 2-5 years diagnosed as pulmonary tuberculosis/ extra pulmonary tuberculosis/ disseminated tuberculosis visiting the paediatric outpatient department over 1 year comprised the material for this study. In the absence of a gold standard for diagnosis of tuberculosis in children, the study children were diagnosed based in criteria for diagnosis of tuberculosis as per Seth V and in accordance with other studies and subsequently they also satisfied the latest IAP guidelines as per the consensus statement on childhood tuberculosis . These were based on (i) essential criteria of symptoms, mainly low grade fever, weight loss, and persistent cough of more than 2 weeks (ii) an important criteria of a positive chest skiagram /other site scanning (iii) presence of acidfast bacilli (AFB) in gastric aspirate/ sputum / any other tissue fluid (iv) contact with an adult TB index case (v) presence of some other supportive criteria. A thorough clinical examination was done to find the extent of the 3

MD (Ped), Associate Professor, Department of Pediatrics, PIMS Medical College Hospital, Jalandhar 144006 2 MD (Med), Senior Adviser, Department of Medicine, Military Hospital, Jalandhar Cantt 144005 6

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017 | 9

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

disease and any associated pathology. is 88%. In group B only 3 out of 9 are Mantoux positive The test children were divided into 2 groups group A (n whereas 6 are Mantoux negative. This shows that in severe = 31) consisted of children with only pulmonary disseminated disease only 33% are Mantoux positive. tuberculosis and group B (n = 9) were children with extra A significant pattern of cytokine secretion from these pulmonary as well as disseminated tuberculosis. Four of these had TB meningitis and 5 were cases of disseminated lymphocytes was seen. As seen in (Table 2), a majority (26 TB. All the children were in category 1 as per IAP out of 40 cases) showed increased levels of IFN –γ (mean guidelines . These children were treated with standard level 34 ng/ml) and IL-2 (mean level 26 ng/ml). This is a antituberculosis therapy (ATT) (EHRZ for 2 months Th1 response in children . Five cases showed a Th2 followed by HR for 4 months). Their clinical profile was response with predominantly IL-4 secretion (mean level monitored throughout the duration of treatment and 20 ng/ml) . A third group comprising 9 out of 40 patients compared to their laboratory profile. Cure was declared responded to BCG stimulation by producing all three when the children after 6 months of treatment were totally , IL-2 and IL-4. Such a response is symptom free and had gained their weight, regained their cytokines IFN-γ appetite, the skiagrams / CT scans had resolved and there described as Th0 or a mixed response and has been seen in was resolution of all symptoms pertaining to the disease. other studies . To study the immune profile, two tests were done, (i) Clinical correlation of the cytokine response with the Mantoux test which is an indicator of delayed hypersensitivity, a type of CMI and ii) the cell mediated clinical profile shows that of 26/40 cases responding with immune response in-vitro in the form of cytokines Th1 pattern of cytokines all had only pulmonary secreted by lymphocyte from the harvested mononuclear involvement. The next group of 5 cases which responded cells. These tests were done before starting treatment. The by producing mainly IL-4 (Th2) were all cases of CMI was compared to the clinical profile the outcome of disseminated disease. Finally the third group of 9 children, the disease at the end of 6 months. which responded by producing all the 3 cytokines namely Mantoux test was done on the volar aspect of left IFN- ?, IL-2 and IL-4 (Th0) had 4 children of disseminated forearm using PPD of 2TU strength. The result was read tuberculosis and 5 children of pulmonary tuberculosis. between 48 hours to 72 hrs and interpreted as positive or negative. Induration more than 10 mm was taken as Table 1 — Showing Correlation between Incident of Mantoux positive. This cut-off size was in accordance with various Positivity and type of Disease other studies . Ten ml of heparinised blood was collected and Group No of mantoux test No of mantoux test Total No positive cases negative test of cases mononuclear cells were separated using ficoll hypaque gradient centrifugation technique. Lymphocyte cell Group A 28 03 31 (Pulmonary disease) suspensions were prepared. BCG was used to stimulate the Group B 03 06 09 suspension. All the samples were cultured for 3 days at (Extrapulmonary/ 37°C. Cytokines, IFN - γ , IL-2 and IL-4 were assayed as disseminated disease) Total 11 29 40 per genzime protocol provided with the kit. The difference between the groups with continuous variables was statistically tested using Table 2 — Showing Clinical Correlation between Cytokines Response and the Clinical Student’s t test. Phenotypic distributions Profile between the study groups were compared using the Chi-square test. Type of disease Group Th1 Th2 Th0 Cured Not Death Lost after 6 cured to Two tailed P values <0.05 were months after 6 follow considered statistically significant. months up Informed consent of parents was taken. The study was approved by the Pulmonary Mantoux positive A 26 02 28 0 0 0 institute ethics committee. 5

7,8

5,6

OBSERVATIONS

Table 1 shows that 28 children in group A are Mantoux positive and only 3 are Mantoux negative. This shows that in restricted pulmonary disease Mantoux positivity in this study

Pulmonary Mantoux negative Extra pulmonary/ disseminated Mantoux positive Extra pulmonary/ disseminated Mantoux negative

B 8

DISCUSSION The study of cellular immune response of T cells in patients with tuberculosis is important for the understanding of the protective and pathological mechanisms in tuberculosis. A clinical correlation of severity and outcome of the disease with CMI response helps us to understand the significance of CMI in TB as also predicts the outcome of the disease on the basis of these tests. This study was done to see the correlation of Mantoux test with (i) the type of disease (ii) the cytokine secretion by these patients as another indicator of T cell response (iii) the outcome of the disease in children aged 2 to 5 years which is a very vulnerable population. Mantoux test is a widely used diagnostic test in children for diagnosing tuberculosis. The basis of this test is a delayed hypersensitivity reaction which is a cell mediated immune response. Here Mantoux test was used as an indicator of an intact CMI. The cytokine profile was another test to see the in-vitro response in the study group and its correlation to the clinical pattern of the disease and the ultimate response in terms of cure in these children. About 88% of group A patients were Mantoux positive showing that in children with a limited disease, delayed hypersensitivity reaction and CMI were unimpaired. Other various studies have also cited 70% to 91% Mantoux positivity in non-immunocompromised TB patients4. A significant pattern of cytokine secretion from these lymphocytes was seen. In 84% of group A patients that is patients with only pulmonary involvement, the cytokine assayed were IFN-γ and IL-2 .This Th1 response has been shown to be the protective immune response and is ultimately responsible for cure9,10. Five cases which showed a Th2 response with predominantly IL-4 secretion were all cases from group B with disseminated TB and comprised 55% of that group9,10. A third group of 9 out of 40 patients responded to BCG stimulation by producing all three cytokines IFN-γ , IL-2 and IL-4. Such a response is described as Th0 or a mixed response and has been seen in other studies7,8 .This response was seen in16% of group A and 45% of Group B. Correlating the clinical severity with the Mantoux test and cytokine release reveals a very significant pattern. In group A that is patients with only pulmonary disease Mantoux positivity is 88%, Th1 pattern of cytokine release is seen in 84% and clinical cure is seen in 100% signifying a very strong correlation between limited disease, intact CMI with a Th1 pattern of cytokine release and outcome of the disease9,10. In group B Mantoux positivity is 33%, Th2 pattern is seen in 55% cases, Th0 in 45% cases and clinical cure is seen in 50% cases. The above results are in agreement with various other studies which showed that protective

immunity in tuberculosis is Th1 mediated and Th2 response is associated with increased inflammatory response and tissue destruction . This again shows that disseminated /advanced disease is associated with an impaired CMI . On further clinical correlation it is seen that in group B 33% patints show a good CMI and these same patients achieve cure after 6 months. This very significant finding tells us that though CMI is impaired in a large majority in severe tuberculosis, it is associated with clinical cure and a good outcome can be predicted when it is intact. Hence though an impaired T cell response is seen in severe disease and is generally associated with poorer outcomes but 50% of these children do achieve cure and these are the children who still have a fairly large amount of IFN-γ secretion along with IL-4 secretion. Based on this study, prognosis of a case can be predicted. Children showing aTh1 response and Mantoux positivity have a better prognosis . 10,11

12,13

10,11

REFERENCES 1 World Health Organisation — Tuberculosis Facts. Geneva: WHO, 2006. 2 Banaszkiewicz A, Feleszko W — Immune mechanisms in children with tuberculosis. Pol Merkur Lekarski 2003; 15: 203-7. 3 Seth V — Tuberculosis in Children : diagnosis and treatment. In: Seth V, Puri RK, Sachdev HPS, editors. Indian Pediatrics. New Delhi: 1991: 8-52. 4 Rigouts L — Clinical practice: diagnosis of childhood tuberculosis. Eur J Pediatr 2009; 168: 1285-90. 5 Amdekar YK, Singh V, Kabra SK — Consensus statement on childhood tuberculosis. Indian Pediatr 2010; 47: 41-55. 6 Alseda M, Godoy P — Tuberculin reaction size in tuberculosis patient contacts. Arch Bronchoneumol 2007; 43: 161-4. 7 Kruisbeek AM, Shevach EM — Proliferative assays for T cells. In: Cougan JE, Kruisbeek AM, Marguiles DH, Shevach EM, Strober W editors. Current Protocols in Immunology. Vol 3. 12th ed. New York: John Wiley and Sons, 1992: 1-13. 8 Orme IM, Anderson P, Boom WH — T cell response to mycobacterium tuberculosis. Inf disease 1993; 167: 148197. 9 AE, Ciftic F, Bilgic S — Peripheral immune response in pulmonary tuberculosis. Scan J Immunol 2009. 10 Rook G A — Th2 cytokines in susceptibility to tuberculosis. Curr Mol Med 2007; 7: 327-37. 11 Al-Attiyah RJ, Mustafa AS — Mycobacterial antigen-induced T helper type 1 (Th1) and Th2 reactivity of peripheral blood mononuclear cells from diabetic and non-diabetic tuberculosis patients and Mycobacterium bovis bacilli calmette-guérin (BCG)-vaccinated healthy subjects. Clin Exp Immunol 2009; 158: 64-73. 12 Leite AL, Carvalho I, Tavares E — Tuberculosis disease : statistics of a paediatric department in the 21st century. Rev Port Pneumol 2009; 15: 771-82. 13 Tsuyuguchi I — Immunology of tuberculosis and cytokines. Kekkaku 1995; 70: 335-46.

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Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Original Article Early neonatal morbidities in late preterm newborns in a tertiary care teaching hospital of Uttarakhand 1

Jain Anand , Jain Suchitra , Upadhyay Amar N

To compare early neonatal morbidity (within first 7 days of life) in late preterm infants with term infants. A Prospective non-interventional study. All live inborn late preterm infants (34 0/7 to 36 6/7 weeks) and term infants (37 0/7 to 41 6/7 weeks). Any of the predefined medical conditions listed in the study, resulting in post- delivery inpatient hospital observation, admission, or readmission in first 7 days of life. 522 late preterm infants and 5906 term infants were included in the study (228 of total 6656 being excluded because of unsure/unreliable date of L.M.P./other causes). Number of babies having at least one of the predefined neonatal conditions was 320 (61.3%) of late preterm and 1778 (30.1%) of term nfants. (Late preterm infants were at significantly higher risk for overall morbidity due to any cause (P<0.001), respiratory morbidity (P<0.001), any ventilatory support (P=0.001), jaundice (P<0.001), hypoglycemia (P<0.001), and probable sepsis (P<0.001). The incidence of morbidities increased from 27% at 40 weeks to 37%, 45%, 58%, 61% and 73% at 38, 37, 36, 35 and 34 weeks, respectively (P<0.001). Late preterm infants are as acompared with term infants at high risk for respiratory morbidity, need of ventilation (non invasive or invasive), jaundice, hypoglycemia, sepsis, and probable sepsis. All gestations except 39 weeks were at significantly higher risk for morbidity as compared to 40 weeks. [J Indian Med Assoc 2017; 115: 10-2 & 16]

Key words : India, late preterm infants, early neonatal morbidity, outcome.

environment, compared with term infants. Although late preterm infants are the largest subgroup of preterm infants, there has been little research on this group until recently. This is mainly because of labeling them as ‘‘near-term’’, thus being looked upon as ‘‘almost mature,’’ with little need to be concerned. Recent research has revealed a contrary trend . While serious morbidities are rare, the late preterm group has 2 to 3 fold increased rates for mild to moderate morbidities, such as hypothermia, hypoglycemia, and respiratory distress, poor feeding, jaundice, infection, and readmission. As the late preterm subgroup accounts for nearly 10-20% of all births, even a modest increase in any morbidity will have a huge impact on the overall health care resources. The absolute number of late preterm infants being admitted to NICUs has been increasing worldwide. Few studies have been conducted to assess the neonatal morbidity and mortality in late preterm infants . All Studies were from developed countries and were retrospective in nature. A recent study is the only study from India (AndhraPradesh) and the only prospective study. Our study is the only study from Uttarakhand and the 2nd in it’s being a prospective study.

aving pregnancy, that too wanted, is most pleasur-able event in the life of a lady. But the long drawn period of 40 weeks, fear of ultimate labor pains coupled with perhaps uncertain outcome isn’t so pleasurable always. Attempts on the part of women and attendants have been there to reduce this suffering, by insisting on having elective CS and byepassing the process of normal vaginal delivery. Of late, especially in affluent societies there has been a stress on cutting the period of 40 weeks to 34-36 weeks, by having elective CS at about 34 weeks, and it is, at times not easy for obstetrician to refuse. The rationale behind this is, as the baby is almost free (??) of risks of prematurity why to bear the agony & the risk of continuing pregnancy for additional 4-6 weeks or so? Besides the question that, is it truly a healthy trend , the larger matter is, that is it really risk free ? The late preterm infants (34- 0/7 through 36- 6/7 weeks of gestation) are physiologically less mature and have limited compensatory responses to the extra-uterine

1-9

1-8

Department of Pediatrics, VCSGGMS&RI, Government Medical College, Srinagar Garhwal, Uttarakhand 246174 1 MD (Paediatrics), Associate Professor 2 MS (Obst & Gynaecol), Gynaecologist 3 MD (Paediatrics), Assistant Professor

MATERIAL AND METHOD

This prospective non-interventional study was con 10

OBSERVATIONS ducted at VCSGGMS& RI & Government Medical College & Attached Hemwati Nandan Bahuguna Base There were 7492 deliveries in hospital during the study Hospital Srinagar Garhwal (Uttarakhand). All live inborn period, of whom 836 were stillbirths and 228 were late preterm infants (34 0/7 to 36 6/7 weeks) and term excluded from study due to unreliable/uncertain date of infants (37 0/7 to 41 6/7 weeks), born between July 2008 to LMP/major congenital anomalies/gestation >41- 6/7 June 2011 were eligible for enrollment in the study. weeks. Thus the study constituted of total 6428 neonates. Infants in whom mother was not fully certain of exact date Of these 522 (8.12%) were late preterm and 5906 of LMP/dates given appeared unreliable & those with (91.88%) were term births. All included infants were major congenital anomalies were excluded. Gestational followed for 7 days of life for outcomes. On comparing the age was assessed by maternal last menstrual period and by two groups, there was appreciable difference in mean ultrasound scan whenever required. gestation, mean birth weight, appropriateness of weight A performa mentioning infant’s particulars, risk for gestational age and the mode of delivery (Table 1). factors, and neonatal morbidity was developed for the 320 (61.3%) of late preterm and 1778 (30.1%) of term study. It was pre-tested on 20infants and modified. Any of infants had at least one of the neonatal morbidities the following predefined medical condition resulting in requiring inpatient hospital observation, admission or post delivery inpatient hospital observation, admission or readmission during the first 7 days of life. On comparing readmission in first 7 days of life: (i) Post Resuscitation the neonatal morbidity, late preterm infants were at highly care: Requirement of post-resuscitation care as per NRP significant increased risk for overall morbidity due to 2005 guidelines. (ii) Hypoglycemia: Blood glucose of less causes viz respiratory morbidity, jaundice requiring than 40 mg/dL. Blood sugars were monitored frequently PTT/ET, hypoglycemia, probable sepsis, and confirmed in all late preterm, IUGR (intrauterine growth restriction), sepsis; and at significantly increased risk of requiring IDM (Infant of diabetic mother) and LGA (Large for ventilatory support (Table 2). gestation, birth weight >2SD) infants. Random blood DISCUSSION sugar estimation was also done in all symptomatic infants In the present study, 61.3% of late preterm and 30.1% as per the clinician’s discretion. (iii) Jaundice: only babies of term infants had at least one neonatal morbidity requiring phototherapy/exchange transfusion (PTT/ET) requiring inpatient hospital observation, admission or as per hour specific total serum biluribin (TSB) nomogram (AAP chart) were included. Criteria for 35 weeks were used for infants with 34 weeks gestation. (iv) Respiratory distress: Presence of at least 2 of the Table 1 — Baseline variables of the study population following criteria: Respiratory rate >60/min, Late preterm Term Total/Overall Subcostal/intercostal recessions, Expiratory Variable (n = 522) (n = 5906) (n=6428) grunt/groaning, and requiring oxygen therapy. (v) Sepsis: Probable sepsis: Positive septic screen Gestation (wks) mean 35.42wks. 38.82wks. 38.54wks (two of the five parameters namely, TLC Birth weight (Kg) mean 2.25Kg 2.89Kg 2.84Kg 252 (48.28%) 2836 (48.02%) 3088 (48.04%) <5000/mm or >15000/mm , band to total Female sex (%) polymorph ratio of >0.2, absolute neutrophil count Appropriateness of weight for Gestation : less than 1800/mm3 or >7200/mm , C reactive AGA (%) 410 (78.54%) 4879 (82.61%) 5289 (82.23%) protein >0.5mg/dL, platelets <1 lakh/mm ); or SGA (%) 106 (20.31%) 826 (13.98%) 932 (14.50%) LGA (%) 006 (1.15%) 201 (3.40%) 207 (3.22%) Proven sepsis: Isolation of pathogens from Blood or CSF or Urine. (vi) Readmission: Any Mode of delivery Cessarean (%) 228 (43.68%) 1373 (23.25%) 1601(24.91%) readmission after post-delivery discharge from Vaginal (%) 294 (56.32%) 4533 (76.75%) 4827(75.09%) hospital. All infants enrolled in study were followed daily till first 7 days of life for any morbidity by clinical evaluation and reviewing hospital Table 2 — Comparison of morbidity in late preterm and term infants records. Infants who were discharged before 7 days were called for mandatory follow up Variable Late Preterm Term Overall P value evaluation in the outpatient clinic on 5th or n=522 n=5906 (%) n=6428 Betw. (2) (3) (4) (2)&(3) 7th day of life. Infants who did not come for (1) follow up were called on telephone and status Any morbidity 320 (61.3) 1778 (30.1) 2098 (32.6%) <0.001 of the baby was enquired. Statistical analysis Jaundice requiring PTT/ET 248 (47.5) 868 (14.7) 1116 (17.4%) <0.001 was done and P-value calculated by using Respiratory morbidity 85 (16.4) 331 (5.6) 416 (6.5%) <0.001 66 (12.6) 283 (4.8) 349 (5.4) <0.001 chi-square Method with the help of Hypoglycemia 37 (7.1) 151 (2.6) 188 (2.9%) <0.001 t e s t w w w . o p u s 1 2 . o r g / C h i - Probable sepsis Confirmed sepsis 8 (1.5) 23 (0.4) 31 (0.5%) <0.001 Square_Calculator.html Ventilatory support required 21 (4.0) 124 (2.1) 145 (2.3%) 0.004 3

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

readmission during the first 7 days of life. Neonatal study. Rates in our study (61.3% & 30.1% respectively) jaundice requiring phototherapy (47.5%) followed by also, are more close to this only prospective study . respiratory morbidity (16.4%) and hypoglycemia (12.6%) In our study, the incidence of morbidity increased from were the frequently identified morbidities in late preterm 27% at 39-40 weeks to 73% at 34 weeks showing an infants while neonatal jaundice requiring PTT (14.7%) inverse relationship with gestational age. There was an 8% was the most frequently identified morbidity in term increase from 38 weeks to 37 weeks, 11% increase from 37 infants. Of late preterm (43.68%) babies were born by weeks to 36 weeks and 17% from 36 weeks to 34 weeks. cessarean delivery, corresponding rate being (23.25%) in The differences were highly significant statistically with term group. Compared with term infants, late preterm rise of every single week up to 39 , except for 34 to 35, & infants were at 2.04 times higher risk for overall morbidity 35 to 36 weeks rise, as depicted in Table 4. With 40 weeks due to any cause, 2.93 times higher risk for respiratory as reference standard, all gestations except 39 weeks were morbidity, 1.9 times higher risk for ventilation, 3.23 times at significantly higher risk for morbidity. Similar findings higher risk for jaundice, and 2.62 times and 2.73 times were also reported in the study from Hyderabad in 2010. higher risk for hypoglycemia and probable sepsis, Similarly the study in 2008 also concluded that clinically respectively (Table 3). significant respiratory morbidities are least common at 39Similar to our findings, in a retrospective study1 40 weeks. The mortality and morbidity having a strong 77.8% near term infants compared with 45.3% of term Gestational Age related trend with the lowest incidences infants had at least one clinical problem and nearly all found between 38 and 40 weeks of gestation were also clinical outcomes differed significantly between nearreported by a study in 2009. term and full-term neonate viz hypoglycemia, respiratory Our study is among earliest prospective studies to problem, and jaundice. They found that during the initial obtain actual data on late preterm births and associated birth hospitalization, late preterm infants were 4 times neonatal morbidities from India and the first only from the more likely than term infants to have at least one medical state. Among the neonatal units, often there is as a wide condition diagnosed and 3.5 times more likely to have two or more conditions diagnosed. In another study it was variation in antenatal use of steroids, asepsis protocols and found that compared with full-term infants, late preterm management of jaundice/ respiratory distress and hence delivery was independently associated with an increased the results of this study may be more applicable to similar risk of neonatal morbidity, including Table 3 â&#x20AC;&#x201D; Comparison of morbidity in late preterm and term ,as per their gestational ages respiratory distress syndrome, sepsis, Variable 34wks 35wks 36wks 37wks 38wks 39wks 40wks 41wks intraventricular Any morbidity 83/114 110/180 127/228 192/428 293/798 564/208 574/2112 155/488 hemorrhage, (32.7%) (72.8%) (61.1%) (55.7%) (44.9%) (36.7%) (27.1%) (27.2%) (31.8%) hypoglycemia, and Jaun 67/114 86/180 95/228 91/428 146/798 277/20 279/2112 75/488 jaundice requiring (17.4) (58.8%) (47.8%) (41.7%) (21.3%) (18.3%) (13.3%) (13.2%) (15.4%) PTT. Another study Resp. morbidity 17/114 23/180 26/228 36/428 55/798 104/2080 107/2112 29/488 (6.2%) (14.9%) (12.8%) (11.4%) ( 8.4%) (6.9%) ( 5.0%) (5.1%) ( 5.9%) in 2006 reported that Probable sepsis 10/114 13/180 14/228 16/428 25/798 51/2080 50/2112 9/488 late preterm infants (2.9%) (8.8%) (7.2%) (6.1%) (3.7%) (3.1%) (2.5%) (2.4%) (1.9%) were 1.5 times more Confirm sepsis 2/114 3/180 3/228 3/428 4/798 8/2080 7/2112 1/488 likely to require (0.5%) ( 1.8%) ( 1.7%) (1.3%) (0.7%) (0.5%) (0.4%) (0.3%) (0.2%) Vent. support 6/114 7/180 8/228 14/428 21/798 39/2080 40/2112 10/488 hospital-related care (2.3%) (5.3%) (3.9%) (3.5%) (3.3%) (2.6%) (1.9%) (1.9%) (2.0%) and 1.8 times more likely to be readmitted than term infants. In yet another study , Table 4 â&#x20AC;&#x201D; Differences in the incidence of morbidity (all) as per gestational age & corresponding p values newborn morbidity was 7 times more likely in late 34 weeks 35 weks 36 weeks 37 weeks 38 weeks 39 weeks 40 weeks 41 weeks preterm compared with term 0.039 0.002 <0.001 <0.001 <0.001 <0.001 <0.001 infants (22% versus 3%). A 34weeks 0.039 0.271 <0.001 <0.001 <0.001 <0.001 <0.001 recent prospective study 35weeks 36weeks 0.002 0.271 0.008 <0.001 <0.001 <0.001 <0.001 f r o m H y d e r a b a d i n 37weeks <0.001 <0.001 0.008 0.005 <0.001 <0.001 <0.001 2010(being only study done 38weeks <0.001 <0.001 <0.001 0.005 <0.001 <0.001 0.070 in India), found a much 39weeks <0.001 <0.001 <0.001 <0.001 <0.001 0.964 0.039 <0.001 <0.001 <0.001 <0.001 0.964 0.042 higher risk of neonatal 40weeks <0.001 <0.001 <0.001 <0.001 0.070 0.039 0.042 morbidity viz 70.8% in late 41weeks <0.001 39+40wks <0.001 <0.001 <0.001 <0.001 <0.001 0 .03 pre terms compared to 29.1% in term babies. They (Continued on page 16) attributed it to be due to more precise follow-up being a hospital based prospective

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Original Article

Prevalence and association of metabolic syndrome with C-reactive protein in people attending a tertiary care hospital of North Bengal 1

Debjani Laha , Ranjan Pal , Anupam Gupta , P P Pal , G Ghoshal , D S Mondal

Metabolic syndrome (MS) is a constellation of several cardiovascular risk factors. It is often found to be associated with elevated C-Reactive Protein level. Compared to other established cardiovascular risk factors, CRP adds more predictive information about the possible future cardiovascular complications. The present study was carried out to enquire about the association of C-reactive protein with Metabolic Syndrome ,in persons of age group of 20-50 years and residing in the sub-himalayan region of West Bengal, using NCEP- ATP III criteria to identify MS and qualitative estimation of C-reactive protein. Sixty three subjects were chosen for the study from patients attending the general Medicine OPD in North Bengal Medical College for minor ailments. 46.1% of study population was found to be affected with MS. Amongst the MS positive personnel 65.5% were also positive with CRP (p value <0.05 (0.002). The result suggests that a significant fraction of persons with MS are at risk to develop cardiovascular complications as evidenced by presence of high levels of CRP in these subjects. [J Indian Med Assoc 2017; 115: 13-6]

Key words : Metabolic syndrome, c-reactive protein.

etabolic syndrome is defined as presence of insulin resistance in combination with at least 3 of the following conditions: Hyperglycemia, Hypertension, Dyslipidaemia & Central obesity1. People with MS are twice as likely to die from coronary heart disease and three times as likely to have a heart attack or stroke compared with the People without the syndrome2. Diagnosis & management of Metabolic Syndrome is of paramount importance not only to prevent type II DM but also to abort the future vascular complications of the MS3. The National Cholesterol Education Program- Third Adult Treatment Panel III (NCEP-ATP III) has set guidelines for clinically identifying the subjects with Metabolic Syndrome & defined them as new secondary targets for Cardiovascular risk reduction therapy. Data have revealed that the plasma concentration of inflammatory mediators, such as TNF-Alfa,

Interleukin-6, CRP, Fibrinogen,& Plasminogen activator inhibitor-1 are increased in insulin resistant states of obesity & type-II diabetes mellitus4,5. Also an increase in inflammatory mediators have been shown to predict the future development of obesity & type-II diabetes4,5. Variation of plasma level of CRP can prospectively predict the risk of Myocardial Infarction. CRP level also correlates positively with the outcome of acute coronary syndrome. A control trial was conducted by Tahir Ahmed Munir et al where CRP levels increased in patients with ACS as compared to controls, and in patients of STEMI and NSTEMI as compared to UA6. The use of CRP and other novel inflammatory markers may significantly add to our ability to correctly identify patients presenting with Acute Coronary Syndrome who are at high risk for future cardiovascular events7. HSCRP has the potential to play an important role as an adjunct for global risk assessment in the primary prevention of cardiovascular disease8.

Department of Physiology, North Bengal Medical College, Thiknikata, West Bengal 734012 1 MBBS, MD, Assistant Professor 2 MBBS, DGO, RMO cum Clinical Tutor, Department of Obst & Gynae 3 MBBS, Assistant Professor, Department of Pharmacology 4 MBBS, MD (Community Medicine) Assistant Professor, Department of Community Medicine 5 MBBS, Medical Officer, Emergency Department 6 MBBS, Assistant Professor, Department of Physiology

In a study among those with the metabolic syndrome at study entry, age-adjusted incidence rates of future cardiovascular events were 3.4 and 5.9 per 1000 personyears of exposure for those with baseline CRP levels less than or greater than 3.0 mg/L, respectively. Additive effects for CRP were also observed for those with 4 or 5 13

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characteristics of the metabolic syndrome. The use of different definitions of the metabolic syndrome had minimal impact on these findings. These prospective data suggest that measurement of CRP adds clinically important prognostic information to the metabolic syndrome . India is projected to have the largest number of individuals suffering from atherosclerotic cardiovascular diseases by the year 2020, but the number of data on Asian Indians is limited. Available data suggests that the prevalence of MS in Indian general population is about 40% which is much higher than the 25% prevalence quoted for the western population . Indians are also found to have higher visceral obesity & waist circumference compared to their body weight . There is scarcity of data on the association of C-Reactive protein and Metabolic syndrome in the eastern part of India particularly in the Sub Himalayan Bengal.The present study aims to throw light on this. 9

MATERIALS AND METHODS

The study had been conducted in General Medical Out Patient Department of North Bengal Medical College & Hospital, Darjeeling amongst the patient presenting with minor ailments other than the following preexisting diseases like; (a) patients with previous episodes of cardiovascular accidents, proven diabetes mellitus, CRF, hyper-urecimia (b) people who had other CRP related diseases, like , recent trauma, surgery, neoplasia , rheumatoid arthritis, SLE, thyroid related disorders and (c) all pregnant & nursing mothers. The prior necessary departmental permission and ethical committee approval were taken accordingly along with informed consent from each subjects. Data collected twice weekly at every alternate individual of 20-50 years age group attending here and fulfilling the selection criteria over a period of 6 months. Total 63 study subject of either sex were ultimately included and one year duration was taken to conduct this cross-sectional study for necessary lab. investigation, analysis and manuscript preparation. Tools & Technique : A pretested, predesigned semi structured questionnaire was used for data collection. The Modified NCEP-ATP III criteria was used to define Metabolic Syndrome as shown below. Fasting blood samples were drawn from the subjects on the following morning for Blood Glucose, Triglyceride estimation and HDL Cholesterol. Blood pressure was recorded as per averages of three occasions of measurement by same investigator. To measure waste circumference , measurement was taken by the help of measuring tape absolutely in the horizontal plane both antero-posterior and laterally. The value recorded at the mean of the height of expiration and inspiration nearest to 0.5 cm. For female subjects a female attendant’s presence was considered.

National Cholesterol Education Program – Adult Treatment Panel III (NCEP-ATP III) Any three of five: Abdominal obesity (waist circumference >102 cm (men) or 88 cm (women) Plasma triglycerides > 150 mg/dl HDL-cholesterol < 40 mg/dl (men) or < 50 mg/dl (women) Blood pressure > 130/85 mmHg Blood glucose > 110 mg/dl Plasma C-reactive rotein (CRP) Estimation : As acute phase protein CRP found in level up to 5 microgram /dl in normal individuals, This test is based on immunologic reaction between CRP as an antigen , latex particles have been coated with monospecific anti- human CRP & sensitized to detect levels greater than 6 microgram/ ml CRP. It is a qualitative test . Observation Conclusion Coarse agglutination Strongly positive Finer agglutination Weakly positive Smooth suspension without any noticeable change Negative • Positive & Negative control are used simultaneously. Data was analyzed using SPSS (ver 14, Chicago Inc) after entering into MS Excell data sheet (Microsoft Corporation, USA). Descriptive statistics along with nonparametric test were applied where necessary at 95% confidence interval considering P value 0.05 as level of significance.

Results : Table 1 — Relation between Metabolic Syndrome & C-Reactive Protien Metabolic Syndrome Present CRP Absent Positive Negative

19 (65.5%) 10 (34,5%)

09 (26.5%) 25 ( 73.5%)

Total 28 (44.4%) 35 (55.6%)

Pearson Chi- Square test value is 9.664, df =1, p value =< 0.05 (0.002 ), so there is an obvious significance lies between Metabolic Syndrome and CReactive protein.

DISCUSSION

Table 2 — Distribution of study population (according to the NCEP- ATPIII

Criteria) who either have MS or not (n=63) Humans have become victim of their own evolutionary success, having high caloric diet Parameters Metabolic Total no Mean Std Significance with lacking exercise. As a consequence Syndrome of study Deviation population obesity, type II diabetes mellitus have reached epidemic proportion. Today the biggest killers Age Yes 29 40.21 7.817 T test= 0.181 No 34 39.82 8.851 P value>0.05(0.857) in the world are not the infectious diseases but Yes 29 29.72 3.401 T test= 2.496 it is the chronic afflictions such as BMI No 34 27.06 2.725 P value<0.05(0.005) cardiovascular diseases, obesity & diabetes. WC in inches Yes 29 36.55 4.214 T test= 1.933 No 34 34.44 4.405 P value>0.05(0.06) Evolving role of inflammation in obesity & TAG in mg/dL Yes 29 151.41 14.498 T test= 0.396 MS provide a common path physiological No 34 134.71 19.140 P value<0.05(0.00) 29 112.55 20.523 T test= 5.299 link between these diseases. Atherosclerosis is Bl Glucose in mg/dL Yes No 34 88.94 14.730 P value<0.05(0.00) a low grade inflammatory disorder leading to HDL in mg/dL Yes 29 43.48 7.297 T test= 1.562 No 34 40.38 7.828 P value>0.05(0.121) expression of many inflammatory markers of plasma, CRP is one of them. Shows that out of 63 subjects studied, 29 subjects were detected to be suffering Prevalence of MS in the Asian Indian from Metabolic population ranges from 20-55%. This wide syndrome (46.03%) while 34 subjects (53.97%) were MS negative. Syndrome (46.03%) while 34 subjects (53.97%) were MS negative. variation is due to the considerable heterogeneity of population. Some authors tried to estimate the prevalence of MS in Table 3a — Sex wise distribution of CRP different countries, like Third National Health and Nutrition examination Survey by Ford ES et al estimated Sex CRP Total Test of Yes No Significance 27.3%in USA, Ramchandran et al in 2004 found that 41.1% prevalence in India. Male 13 (44.8) 16 (55.2) 29 (100.0) Pearson Present study revealed 46.1% prevalence (Table 2)in Female 15(44.1) 19 (55.9) 34 (100.0) chi square 0.003, Total 28 (44.4) 35 ( 55.6) 63 (100.0) df 1, P> 0.05 patients attending general Medicine OPD of North Bengal Medical College. Majority of the MS positive patients belong to the age group of the 46-50 years. There was a significant relation between MS & CRP as seen in Table 1, Table 3b — Relation of Obesity Grade and CRP 65.5% CRP positive people also having Metabolic Syndrome, p value <0.05 (0.002). Obesity CRP Total Test of Grade yes no Significance There were no significant variation (Pearson chi square 0.003, df 1, P>0.05) of Metabolic syndrome 2 3 (30.0) 7 (70.0) 10 (100.0) Linear-by-Linear 3 12 (41.4) 17 (58.6) 29 (100.0) Association 1.912, prevalence with CRP positivity in this study (44.1% male 4 10 (52.6) 9 (47.4) 19 (100.0) & 44.8% female )as shown in Table 3a. 5 3 (60.0) 2 (40.0) 5 (100.0) From obesity grade 2-5 (there is no people belongs to Total 28 (44.4) 35 (55.6) 63 (100.0) grade I obesity in the study) there was increase of the CRP level but statistically it is insignificant (Linear-by-Linear Association 1.912, df 1, P>0.05). Performance of the qualitative estimation of the CRP lation lies between MS & CRP. Further investigation is was done in the study, but quantitative estimation might needed quantitative estimation of CRP to evaluate the help to categorize the subjects who were at immediate progression of MS. risk, as CRP value not only tell us about the progression of REFERENCES the disease but also tell about the prognosis of the disease. 1 AH – Astanga Hrdaya. Profhy, KR Srikantha Murthy , So this was a limitation of the study. The study was small Krisnadas Academy, Varanasi. second edition, 1994. one involving only 63 people . further study involving 2 Cameron AJ, Shaw JE, Zimmet PZ — The Metabolic much larger population will be needed along with the Syndrome; prevalence in worldwide populations. Endocrinol quantitative estimation of CRP. Metab Clin North Am 2004; 33: 351-75. This can be concluded from that from the study, the 3 Sehnert H, Kuhlsmann H — Hypertonie and Diabetes prevalence of metabolic syndrome is quite high in patients Mellitus. Dtsch Med J 1968; 19: 567-71. attending in General Medicine OPD. A significant corre 4 Insulin resistance and metabolic syndrome –a challenge of a 11,12

Original Article

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new millennium .Hasner H, German diabetic research institute at the Heinrich. Heine-University, Dusseldorf, Germany. Publication type review :- PMID. 11965519. Hanefield M, Leonhardt W, Das Metabolische Syndromje, DT, Gesundh –wesen in 1981; 36: 545-51. Munir TA, Afzal MN, Ahmed R — C-reactive protein and acute coronary syndrome: correlation with traditional risk factors, diagnostic cardiac biomarkers, and ejection fraction. RMJ 2009; 34: 154-9. Gavin J Blake, M Ridker — C-reactive protein and other inflammatory risk markers in acute coronary syndromes. J Am Coll Cardiol 2003; 41: 37-42 Paul M Ridker — High-Sensitivity C-Reactive Protein Potential Adjunct for Global Risk Assessment in the Primary

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Prevention of Cardiovascular Disease. Circulation 2001; 103: 1813-8. C-Reactive Protein, the Metabolic Syndrome, and Risk of Incident Cardiovascular Events An 8-Year Follow-Up of 14 719 Initially Healthy American Women Paul M Ridker, MD; Julie E. Buring, ScD; Nancy R. Cook, ScD; Nader Rifai. Hanefield M — Untersue hungen uber Wechselbeziehungen zwischen lipidstoffwechsel und Hasson GK — atherosclerosis, & coronary artery diseases. N Engl J Med 2005; 252: 1685-95. Fernández-Real JM1, Ricart W — Insulin resistance and chronic cardiovascular inflammatory syndrome. Endocr Rev 2003; 24: 278-301.

(Contined from page 12)

settings and may not be generalizable. Another limitation of our study is that we neither asessed morbidity beyond 7 days, nor long term outcomes. Results show that so presumed ‘almost mature’ (late preterms) infants have more than 2 times higher risk for overall morbidity due to any cause relative to term infants.The concluding message is that elective caesserian/induced labor at 34 or 35 weeks, hoping an almost mature baby is not true. 1 2

REFERENCES Wang ML, Dorer DJ, Fleming MP, Catlin EA — Clinical outcomes of near-term infants. Pediatrics 2004; 114: 372-6. Raju TN, Higgins RD, Stark AR, Leveno KJ — Optimizing care and outcome for late-preterm (near-term) gestations and for late-preterm infants: a summary of the workshop sponsored by the National Institutes of Health and Human Development. Pediatrics 2006; 118: 1207-14. Tomashek KM, Shapiro-Mendoza CK, Weiss J, Kotelchuck M, Barfield W, Evans S, et al — Early discharge among late preterm and term newborns and risk of neonatal mortality. Semin Perinatol 2006; 30: 61-8 Young PC, Glasgow TS, Xi Li, Guest-Warnick G, Stoddard GJ — Mortality of late-preterm (near-term) newborns in Utah. Pediatrics 2007; 119: 659-65. Mc Intire DD, Leveno KJ — Neonatal mortality and morbidity rates in late preterm births compared with births at term.

Obstet Gynecol 2008; 111: 35-41. 6 Shapiro-Mendoza CK, Tomashek KM, Kotelchuck M, Barfield W, Weiss J, Nannini A, et al — Effect of latepreterm birth and maternal medical conditions on newborn morbidity risk. Pediatrics 2008; 121: 223-32. 7 Khashu M, Narayanan M, Bhargava S, Osiovich H — Perinatal outcomes associated with preterm birth at 33 to 36 weeks’ gestation: a population-based cohort study. Pediatrics 2009; 123: 109-13. 8 Melamed N, Klinger G, Tenenbaum-Gavish K, Herscovici T, Linder N, Hod M, et al — Short term neonatal outcome in low risk, spontaneous, singleton, late preterm deliveries. Obstet Gynecol 2009; 114: 253-60. 9 Jaiswal Ashish, Murki Srinivas, Gaddam Pramod, Reddy Anupama — Early Neonatal Morbidities in Late Preterm Infants. Indian Pediatrics 2011; 48: 607-11. 10 Yoder BA, Gordon MC, Barth WH — Late-preterm birth: Does the changing obstetric paradigm alter the epidemiology of respiratory complications? Obstet Gynecol 2008; 111: 814-22. 11 Luca RD, Boulvain M, Irion O, Berner M, Pfister RE — Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery. Pediatrics 2009; 123: 1064-71.

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Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Status of cold chain monitoring in primary health centres of Bangalore urban — north 1

Jyothi Jadhav , Selvi Thangaraj , Thilak S A , Ranganath T S

Child immunisation is among the most cost-effective ways of preventing premature child deaths. The potency of vaccines, crucial for vaccine efficacy, is dependent on effective management of the cold chain at all levels of vaccine handling. India’s immunization program is one of the largest in the world. However, full immunization coverage still stands at 61% only. Since there were gaps in immunization coverage and a situation of high morbidity and mortality among under five children, India decided to declare the year 2012-13 as a year of “Intensification of Routine Immunization” for effective vaccine management. This is a cross sectional study in which 30 Primary Health Centres that were allotted, 27 were studied on immunization days (Thursday). Mentors were trained and data was collected using observational checklist. Among the 27 Primary Health Centre’s studied, 1 centre didn’t have Ice line refrigerator or Deep freezer, 13 centres didn’t have deep freezer. In 22 centres, Cold Chain equipments were attached to stabilizer, 7 centres placed equipments as per standard norms, 3 centres had not maintained temperature charts, 3 centres didn’t have thermometers. Ten centres showed discrepancy in recorded temperature. Vaccines at the session site were in zipper pouch in vaccine carrier at 23 centres. There are a lot of weaknesses and gaps in cold chain maintenance, thus arising the doubt of potency/efficacy and safety of vaccines administered. To improve the situation constant monitoring and supervision, periodic training of personnel is necessary. [J Indian Med Assoc 2017; 115: 17-20]

Key words : Cold chain equipments, immunization, supervised monitoring, vaccines.

mmunization is one of the most cost effective health investments and proven tool for controlling and eliminating life-threatening infectious diseases (known as vaccine preventable diseases). Globally it is estimated to avert over between 2-3 million deaths each year . India’s immunization program is one of the largest in the world in terms of quantity of vaccines used, beneficiaries, number of vaccine sessions organized, the geographical spread and diversity of area. Regrettably, however, full immunization coverage in the country continues to be sub-optimal, standing at a mere 60% at the national level . There are many states where full immunization coverage is less than 50%. On the other hand there are states having coverage above the national level yet the coverage there is either stagnant or is declining. Government of India is annually spending more than 1500 crores on universal immunization program and pulse polio . Gaps in the immunization coverage result in low return on this investment, besides a situation

where morbidity and mortality among children continues to be unacceptably high. In view of the above, it has been decided to declare the financial year 2012-13 as the year of ‘Intensification of Routine Immunization’ in which all efforts shall be made to improve full immunization cover throughout the country. This declaration is in consonance with the resolution of all countries in South-East Asian region to declare 2012 as the year of “Intensification of Routine Immunization”4. One of the major activities proposed during 2012-13 as the year of “Intensification of Routine Immunization” is the effective vaccine management exercise in all priority states to assess and strengthen cold chain and vaccine management4. The cold chain is a system of storing and transporting vaccines at recommended temperatures from the point of manufacture to the point of use. The key elements of the cold chain are : (1) Personnel-to manage vaccine storage and distribution. (2) Equipment- to store and transport vaccines and to monitor temperature. (3) Procedure- to ensure that vaccines are stored and transported at appropriate temperatures5.

Department of Community Medicine, Bangalore Medical College & Research Institute, Bangalore 560002 1 MD, PGDHHM, Associate Professor 2 MD, Professor 3 MBBS, MD, Postgraduate student 4 MD, Professor & Head 17

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Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Reconstituted BCG, measles, JE vaccines are the most sensitive to heat and light. Also there is risk of contamination with staphylococcus aureus leading to Toxic Shock Syndrome. And therefore they should be used within 4 hours of reconstitution. Hepatitis B and all T series vaccines lose their potency if frozen. Deep freezers (DF) maintain a cabinet temperature between -15 to -25 C. Ice lined refrigerator( ILR) maintain a cabinet temperature between +2 C to +8 C and are used to store all Universal Immunization Programme (UIP) vaccines at the Primary Health Centre level (PHC). ILRs can keep vaccines safe with as little as 8 hours continuous electricity supply in a 24 hour period . At PHC level, deep freezers are used only for preparation of ice packs and are not to be used for storing UIP vaccines. In India, UIP was introduced since 1985 with objective of immunization of pregnant women with two doses of tetanus toxoid and immunization of children in their first year of life against six vaccine preventable diseases . Achieving this objective depends on quality of vaccines used. To preserve its potency and safety, cold chain has to be maintained at all levels. Those involved in this to be skilled and equipped regarding condition of storage and transportation as well as temperature monitoring. In Karnataka, there has been a decline in full immunization coverage between National family health survey (NFHS) - 2 (60%) and NFHS- 3 (55%) . Reasons for poor coverage were said to be poor monitoring and lack of feedback on reported data in monthly meetings at various levels by routine immunization managers, poor usage of the standard tools to track, document and report immunized children by health workers at PHC/Subcentre level. There is a disarray of documentation with poor quality coverage of data, lack of effective and supportive supervision of the program, failure to assess output of the program. Realizing the need for additional supporting monitoring of the program, State institute of health and Family welfare (SIHFW) in collaboration with UNICEF has developed a model by involving medical colleges for this activity. Two mentors were selected from medical colleges and were trained. Each mentor will do field visits on selected Thursdays (thrice a month) to supervise and monitor various components of routine immunization activities viz the adherence to micro planning for conducting immunization session, quality of practices, session monitoring, quality of reports, hands on training to service providers, identification of training needs, availability of equipments and supplies, maintenance of cold chain equipments and supplies, knowledge and attitude towards immunization among primary care givers, etc. Thus, here we have presented the status of cold chain monitoring which was one of the components of supportive supervision. o

MATERIALS AND METHODS

It was a cross sectional study to assess the cold chain maintenance of vaccines. This study was part of program to support district health authorities by monitoring and providing supportive supervision for the immunization related activities. Bangalore district was one of the selected districts in terms of densest urban district. A list of 30 PHCs were given by SIHFW, out of which 27 centers were studied. PHCs were visited on Thursdays (immunization day). The mentors were trained and data was collected using observational checklist to ascertain cold chain maintenance of vaccines and by related documents. Data collected were on availability of Cold Chain Equipments (CCE) and its placements, twice daily monitoring of temperature recordings and its variation on the day of the visit, presence of functional thermometer, record of power failures and periodic defrosting, periodic check of temperature Log books by facility in charge. Information on storage conditions of vaccine and diluents, its correct placement in ILR, correct placement of ice packs in DFs, presence of any food items or any other nonrecommended items found in CCE and at the session site, presence of vaccines in zipper bag in the vaccine carrier and written time on reconstituted BCG, measles vaccine was recorded. Collected data were coded and entered in excel sheet and analyzed using trial version of SPSS 20.

Fig 1 — Placement and functioning of ILR’s and DF’s

Fig 2 — Monitoring of temperature log books

Fig 3 — Maintenance of ILR’s

Fig 4 — Functioning of Deep Freezers

RESULTS

Twenty seven PHCs were included in the study. One PHC (3.7%) out of 27 did not have ILR or DF, 13 PHC‘s (48.1%) out of 27 did not have DF. CCEs were attached to electric outputs through voltage stabilizer in 22 PHC’S (81.5%) (Fig 1). Placing of ILRs and DF 10cm away from the wall or adjoining structures were in 7 PHCs (25.9%) (Fig 1). The CCEs were kept away from direct sunlight in all the centers. Temperature chart with 2 entries was maintained in 23 centers (85.2%) (Fig 2). Three of the centers did not have functional thermometer (Fig 1) where the temperature was recorded from display. On the day of the visit, discrepancy in ILR temperature was noted among 10 (37%) PHC’S (Fig 2) where the temperature was less than +2 deg c in 4 centers and more than +8 deg c in 6 centers and with one centre having power fluctuation from two days. Food articles were not present in any of the PHCs. Ice formation of more than 5mm in CCEs were found in 11 centers (40.7%) (Fig 1) and water logged ILR in one centre, suggestive of lack of regular defrosting. Heat sensitive vaccines were correctly stored. Freeze sensitive vaccines were not correctly stored in 9 PHCs where they were placed at the bottom of the ILR. The power failure was present for more than 24 hours in 1 center. Uninterrupted Power Supply backup was present in 3 of the centers. Actions taken during these power failures were

not documented in 19 centres (63%) (Fig 2). In 9 centres (33.3%) ice packs in DFs were not placed in criss-cross manner (Fig 3). At the session site there was no shortage of any of the vaccines or the diluents. All the vaccines were found in the usable condition with respect to vaccine vial monitor (VVM). The vaccines at the session site were in the zipper pouch in vaccine carrier in 85.2% (23) (Table 1). In 15 centers (55.6%), time of reconstitution was written on reconstituted BCG and measles vials (Table 1). Flaws noticed during the monitoring of immunization session were brought to the notice of the medical officer. Methods of correcting the same were discussed. The importance of ensuring that these methods were put into practice on a regular basis was emphasized to the health worker. Table 1 — Observation of placement of vaccines in vaccine carrier and time of reconstitution Yes

DISCUSSION

The purpose of the study was to provide supportive supervision and monitoring of routine immunization. It is a process of helping staff to continuously improve their knowledge and skills, thus improving work performance. It is a two way communication and builds team approach that facilitates problem solving. One of the PHC was conducting immunization sessions without CCEs where they had to get the vaccines from mother PHC. Transporting of vaccines before and after immunization session increases the risk of vaccine to lose its potency thus increasing its wastage. It was good to note that power source was permanent (UPS backup) in 11% which can be extended to other centers. Non functional thermometer (11.53%), lack of temperature monitoring charts (11.1%) and documentation of irregular power supply is one of the critical elements in maintaining the potency of vaccines. The degree of implementation of cold chain with respect to presence of ILR was 96.3% and DF was 51.9%.The study by S Sachdeva and U Dutta showed the presence of ILR as 6.25%. Our study showed an insufficient supervision of 59.3% whereas it was 25.9% in a study by Jerome Ateudjieu et al . It was noted that lack of temperature maintenance and monitoring was 11.1% in 8

Vaccine vials in zipper bag of vaccine carrier Time of reconstitution written on BCG, Measles vials

23 (85.2)

04(14.8)

15 (55.6)

12 (44.4)

Observational Study

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

our study. However, S.Sachdeva , U Dutta, and a study by Jerome Ateudjieu et al observed 71.87% and 40.7% respectively. Freeze sensitive vaccines (T series and hep.B) were not correctly stored in 9(33.3%) PHCs where they were placed at the bottom of the ILR. The consequences of not keeping the vaccines at the right temperature (either heat or cold) can be disastrous. Once vaccine potency is lost, it cannot be regained. This leads to wastage of expensive vaccines. Moreover, children and women who receive such a vaccine are not protected. All vaccines are damaged by temperatures more than +8 C, whether they are exposed to a lot of heat in a short time or a small amount of heat over a long period (frequent opening of lid of ILR). Various loopholes in the system have been noted from this study as a risk factor for vaccine potency. The project experiences were used for further strengthening the immunization programme. Some intervention like constant supervision, training of professionals in charge, availability of cold chain tools and its maintenance in case of breakdown can reduce the gaps. Furthermore, strategies like installment of UPS, annual maintenance contract, developing thermostable vaccines could improve the vaccine potency. o

CONCLUSION

There are a lot of weakness and gaps in cold chain maintenance in the country, thus arising the doubt of potency/efficacy and safety of vaccines administered. This in turn increases the cases of vaccine preventable diseases and adverse events following immunization. To improve this situation, we recommend: • Constant supervision of CC equipments and periodic check by supervisors. • Identify and address factors leading to failure of CC monitoring. • Periodic training of personnel in CC monitoring and strengthening their skills. • Assistance to make repair when necessary. • Routine maintenance of CCEs.

ACKNOWLEDGMENTS

The author acknowledges the support and cooperation of SIHFW, Directotare of Health and Family welfare services, DME. The authors are indebted to Dr Santhosh Shirol for his enormous support.

REFERENCES 1 WHO | Immunization coverage. World Health Organization; [cited 2014 Jan 24]; Available from: http://www.who.int/mediacentre/factsheets/fs378/en/ 2 National Family Health Survey [Internet]. [cited 2014 Jan 28]. Available from: http://www.rchiips.org/nfhs/nfhs2.shtml 3 Handbook for Vaccine & Cold Chain Handlers [Internet]. [cited 2014 Jan 24]. Available from: http://www.unicef.org/ india/Cold_chain_book_Final_(Corrected19-04-10).pdf 4 Strategic framework for Intensification of routine Immunisation in India [Internet]. [cited 2014 Jan 24]. Available from: http://210.212.20.93:8082/ jrhms/FileUploaded By User/7. India_IRI_Strategic Framwork_2012_FINAL.pdf 5 Immunization handbook for medical officers. Dept of health and family welfare, MoHFW, Govt. of India. 2009. 39-72. 6 Park K — Park’s Text book Preventive & Social Medicine. 21st ed 2011: Jabalpur; M/s Babsaridas Bhanot. 404. 7 National Family Health Survey (NFHS-3) [Internet]. [cited 2014 Jan 28]. Available from: http://www.rchiips.org/ nfhs/NFHS-3 Data/ Karnataka_report.pdf 8 Sachdeva S, Datta U. Status of vaccine cold chain maintenance in Delhi, India. Indian J Med Microbiol [serial online] 2010 [cited 2014 Jan 28];28:184-5. Available from: http://www.ijmm.org/text.asp?2010/28/2/184/62507 9 Ateudjieu J, Kenfack B, Nkontchou BW, Demanou M. Program on immunization and cold chain monitoring: the status in eight health districts in Cameroon. BMC Res. Notes [Internet]. 2013 Jan [cited 2014 Jan 24];6:101. Available from:http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid= 3630054&tool=pmcentrez& rendertype=abstract

We request you to send Quality Article addressed to : Hony. Editor, Journal of IMA (JIMA), 53, Sir Nilratan Sarkar Sarani (Creek Row), Kolkata 700014 Dr. Dilip Kumar Dutta Hony. Editor, JIMA

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Dr. Kakali Sen Hony. Secretary, JIMA

A study on knowledge, attitude and practices (KAP) regarding usage of Hydrogen Peroxide among Orthopaedic surgeons in Hyderabad, AP 1

K L Jagadishwar Rao , Kantilal G Jain , Subash B

Hydrogen peroxide is familiar to most of the Orthopaedic surgeons as an over the counter preparation that is easily available at any supermarket as well as pharmacy. Hydrogen peroxide is regarded as a safe antibacterial and oxidising agent by US FDA. Hydrogen peroxide is used therapeutically in a variety of different ways. Most of the surgeons use H O routinely without fully knowing the facts, some are reluctant to use fearing complications and some refuse to disclose its usage. In such scenario, we thought it is worthwhile doing such a study. 2

[J Indian Med Assoc 2017; 115: 21-5]

Key words : Hydrogen peroxide, questionnaire, orthopaedic surgeons.

Methods:

Introduction :

It is a descriptive, cross sectional and observational study. The participants are about 100 Orthopaedic surgeons in tertiary care hospitals in and around Hyderabad, Andhra Pradesh. It includes teaching, non teaching and corporate hospitals. The tool of data collection is a close ended, self administered, pre tested questionnaire.

The usage of Hydrogen Peroxide looks a little anachronistic in the present scenario, wherein a lot of costly antimicrobial solutions are available. As an aficionado of Hydrogen Peroxide since 30 years, we have embarked on doing such a study on its usage, which is a cheap and easily available solution. Our interest is to highlight the usage of Hydrogen Peroxide in Orthopaedic practice furnishing little known facts. Most of the surgeons are unaware of many facts pertaining to its usage as an adjunct to surgical debridement and intra operative use. Dealing with such subject in detail will certainly clear the myths and encourage its use benefiting many more patients. Our intention is to disseminate the information regarding the usage of Hydrogen Peroxide to the Orthopaedic fraternity, considering our experience of using this since 30 years. Hydrogen Peroxide was prepared first by a chemist Thenard. Commercial name of Hydrogen Peroxide is Perhydril . Hydrogen Peroxide in high concentration is used in agriculture, chemical, food and textile industries as oxidizer, disinfectant and bleaching agent. Properties of Hydrogen Peroxide : It is colorless, odorless but not tasteless . It is an unstable compound made up of two atoms of Oxygen and Hydrogen each. Anhydrous Hydrogen Peroxide is a syrupy liquid; which has a bluish tinge in thick layers. It is regarded as weak acid. Its boiling point is 152 C and melting point is 0.4 C. On heating it decomposes liberating oxygen. It is a very powerful oxidizing; reducing and bleaching agent thus effectively kills bacteria, virus and fungi. It is

Results & Conclusions : The results are analyzed after collecting the response to the questionnaire. The data analyzed depicted by the pie diagrams. Our study revealed that the level of knowledge pertaining to questions 1,2,5,6 ranged from 62 to78%, obviously showing a majority.The level of practice pertaining to questions 3,7,8,10 was about 63% and the attitude levels pertaining to questions 4 and 9 was meager as regard to usage in medical conditions. 94% of the surgeons did not come across any untoward reactions. 6% had encountered complications like embolic phenomenon, wound dehiscence, surgical emphysema in puncture wounds and anaphylaxis. The attitude to use Hydrogen Peroxide was found to be more in senior faculty members and senior Orthopaedic surgeons contrary to young and recent surgeons.

Department of Orthopaedics, SVS Medical College, Mahabubnagar, AP 509002 1 MS, Professor 2 DNB, Consultant Orthopaedic Surgeon, Sai Vani Super Speciality Hospital, Hyderabad, Telangana 500029 3 MS, Consultant Sagar Lal Memorial Hospital, Hyderabad, Telangana 500020

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Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

supplied in plastic bottles in 3-6% strength. It disintegrates in contact with light and rough surfaces, so it used to be supplied in brown glass bottles. Of late it is supplied in opaque plastic bottles. Molecular structure : Hydrogen Peroxide has a nonpolar, non-linear structure. Can be best pictured as oxygen atoms lying on the spine of a book, opened at an angle of 94 and the hydrogen atoms lying along each leaf of the open book. Strength of Hydrogen Peroxide solution : The concentration or the strength of Hydrogen Peroxide is usually expressed in terms of volume. For example 10 volume solution means that one milliliter of this solution will liberate 10 milliliters of oxygen. Strength is also expressed in weight/volume- w/v. 10 volume Hydrogen Peroxide = 3.036% w/v. 100 volume Hydrogen Peroxide = 30.36%w/v. Commercial Hydrogen Peroxide (Perhydril) is supplied as 30% w/v and medical grade Hydrogen Peroxide is supplied as 3%w/v . Mechanism of action : Hydrogen Peroxide is nonallergenic. Hydrogen Peroxide is used for high-level disinfection and sterilization . It provides hydroxyl free radicals and ions that can attack membranes, lipids, DNA and other essential cell components. The effervescence that occurs when it is applied to open wounds is because it reacts with the peroxidase enzymes present in blood. This reaction is exo-thermic in nature. This thermal injury to the vessels releases lipids, resulting in the formation of tissue thrombin, which in turn reduces bleeding or oozing from the wound. It also produces temporary spasm of small vessels which aids in haemostasis . Hydrogen Peroxide does not act on dead tissue which can be readily observed during debridement where the effervescent action is seen only with living tissue. Dead and macerated tissues will not react with Hydrogen Peroxide because catalase is present in living tissues only. The decomposition of Hydrogen Peroxide liberates nascent oxygen, which can kill many pathogens, by damaging cell wall and cell membranes, leading to changes in the membrane permeability. All anaerobic strains of pathogens cannot survive in the presence of Hydrogen Peroxide. No one can doubt its efficacy in treating infections topically . A variety of irrigation fluids have been used including water, wine, milk, urine and vinegar since prehistoric times (biblical story God Samaritan Luke 10:33-34). Irrigation is the key component of the effort to prevent infection by decreasing bacterial load and removing foreign bodies. Copious amounts of irrigation fluids either at higher pressure or otherwise is recommended by many . In vitro studies by Bhandari et al showed macroscopic bone damage. Adili et al showed reduced mechanical strength of the bone in diaphysial fractures, some even showed an increased depth of bacterial o

5,6

penetration into the deep muscles . Thus there is insufficient evidence to make recommendations as regards to irrigation methods. No significant difference with respect to infection and bone healing were found by Anglen et al except for the wound healing problem. Therefore given the available evidence it is not possible to recommend any particular additive to the irrigation fluid in musculo skeletal wounds.The usage of 3% Hydrogen Peroxide intra operatively in almost all orthopedic surgeries has become a routine in our institutions. We use Hydrogen Peroxide in our hospital for conditions like open musculoskeletal wounds and fractures, intra operative use in clean wounds, joint replacement surgery, infected wounds – post op or otherwise, spine surgeries and in bone tumors and cysts. 8

MATERIALS AND METHODS

The pretested questionnaire of 10 questions was prepared going through the scantily available literature and with our experience of using it since 30 years (author 1). This questionnaire was answered by 100 practicing orthopedic surgeons in and around Hyderabad, India. As regards the questions, we have classified them into knowledge based (q no. 1,2,5 & 6), practice based (q no. 3,7,8 & 10) and attitude based (q no. 4 & 9). The data collected was analyzed. Questionnaire in awareness and usage of hydrogen peroxide: (1) You know hydrogen peroxide solution as : (a) Antiseptic, (b) disinfectant, (c) microbicidal, (d) bleaching agent. (2) Percentage of hydrogen peroxide solution commonly used : (a) 3%, (b) 6%, (c) 30%, (d) do not know. (3) Conditions where you have used hydrogen peroxide : (a) Tidy injuries, (b) untidy injuries, (c) infected wounds, (d) diabetic ulcers, (e) others. (4) Any other medical conditions you have tried like : (a) Pulmonary medicine, (b) bio oxidative therapy, (c) dermatology, (d) degenerative joint disease, (e) no idea. (5) Are you aware of mechanism of action of hydrogen peroxide : (a) N a s c e n t o x y g e n l i b e r a t i o n , ( b ) haemostatic, (c) bactericidal, (d) do not know. (6) Is the solution sterile to be used intra operatively in elective cases : (a) Yes, (b) do not know. (7) Among these solutions which one do you prefer for cleaning wounds : (a) Saline, (b) hydrogen peroxide, (c) Betadine, (d) Eusol, (e) spirit. (8) Does it control hemorrhage : (a) Yes, (b) no, (c) not aware. (9) Where did you use the solution: (a) Intra operatively, (b) orally, (c) nasally, (d) topically, (e) replacement surgeries. (10) Any untoward reactions encountered like : (a) Anaphylaxis, (b) surgical emphysema, (c) wound dehiscence, (d) nil, (e) embolic phenomenon.

‘The answers highlighted in red were presumed to be correct and considered for analyzing the response from the surgeons.’

Knowledge based indicators (Q.no’s :- 1,2,5 & 6).

Results : Among the hundred Orthopaedic surgeons evaluated after going through the answers to the questionnaire, the following were observed. The age of the surgeon ranges from 27 years to 81 years. The experience of using H O less than 10years was about 32 % and 68 % had the experience of using H O for more than 10 years. Among these surgeons 61 % were from teaching hospitals and 39 % were non teaching as well as corporate set up. Analysis of knowledge based questions revealed that 83% of the surgeons knew it as antiseptic disinfectant and anti microbicidal and remaining knew it 21% used in diabetic ulcers and other conditions. as bleaching agent, 69% were aware of its percentage of Regarding commonly used solutions for cleaning wounds usage from 3 – 6%, 7% revealed it as 30% and 24% of the 51% used saline, remaining have used H O , Betadine and surgeons are unaware of the percentage of its use which is EUSOL. None have used surgical spirit.81% have used it quiet significant. Seventy one per cent knew its as haemostatic agent and remaining 19% have never used/ mechanism of action as nascent O liberation, remaining aware of it. Ninety four per cent did not come across any were aware of its haemostatic untoward incident which is quiet and bactericidal actions. s ignificant, 5% had embolic Attitude based indicators (Q.no’s :- 4&9) Sixty two per cent were aware phenomenon which was later that it is a sterile solution controlled with the help of which can be used intra anaesthesiologist and revived. One operatively, rest of them were revealed anaphylaxis which proved not aware of its sterility. fatal. Analysis of attitude based The results of the knowledge, questions revealed that attitude and practices are depicted in the seventy six per cent of the following pie diagrams. surgeons had no idea about its Discussion : usage in medical conditions, Going through the responses for the remaining had an idea of its questionnaire and the results, it looks a usage in dermatology, biovast majority of surgeons know about oxidative therapy and the usage as an adjunct to surgical degenerative joint disease. debridement and its usage in intra Fifty three per cent of the operative clean incised wounds. surgeons have used intra Knowledge about the percentage of operatively in elective cases, hydrogen peroxide, mechanism of 14% used topically and action looks to be well understood. remaining 23% used the Only few expressed reservations using solution in replacement it in view of complications like embolic surgeries.Analysis of practice phenomenon, wound dehiscence and based questions revealed that surgical emphysema in punctured 79% of the surgeons used in wounds . The purpose of adding tidy, untidy and infected additives like hydrogen peroxide and wounds remaining 2

9,10,11

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soaked ribbon gauge. In infection like osteomyelitis, diabetic foot, gangrene, post operative infections both superficial and deep hydrogen peroxide is extensively used without concomitant use of topical antibiotics, resulting in good healing. In all the cases of usage of hydrogen Peroxide, it is imperative to wash off the debris and residual hydrogen peroxide with normal saline. Usage of hydrogen peroxide in tumors and cysts based on the facts that it inhibits the giant cells and osteoblast metabolism in vitro, we have been using in all cystic lesions and tumors like giant cell tumor12. After using hydrogen peroxide extensively in all cases, since years, we have not come across the problems of wound dehiscence, wound healing nor did we encounter clinically significant embolic phenomenon nor cardiac arrest13.

Practice based indicators (Q.no’s : 3, 7, 8, 10)

povidone iodine is to kill the pathogens in the wounds and this lessens the pathogen load that must be handled by immune system. Cell and tissue culture studies have shown that antiseptics have a concentration dependant detrimental effect on the viability and function of host cells. Wound healing and efficacy in preventing infection were two problems encountered in evaluation of hydrogen peroxide in animal studies done by Geffery O Anglen (IBID 7). The negative effect in the study was wound dehiscence and little or no influence in controlling infection. In human studies as expressed by Anglen the usage of antiseptics in surgical wounds lowering the rate of infection, is not convincing and little or no information regarding usage of hydrogen peroxide in clean incised musculo skeletal wounds is available. The idea in using hydrogen peroxide intra operatively in clean musculo skeletal wounds is to show, in case of immense oozing, bleeding from inaccessible sites packing with hydrogen peroxide definitely stops the ooze and provides clear operating field. In major joint replacement surgeries, open reduction of diaphysial fractures of long bones the usage of hydrogen peroxide is beneficial and exemplary. The area of surgical field becomes dry, mainly in replacement surgeries where it is desirable for optimal cementing. This is practiced by most of the replacement surgeons who pack the femoral madullary cavity with 3% hydrogen peroxide

Observations : The following were observed during the usage of hydrogen peroxide (1) Less bleeding and oozing in the surgical field14,15. (2) Immediate and temporary hypotension. (3) Temporary changes in pulse rate, blood pressure, no change in oxygen saturation as noted by anesthesiologist. (4) In major joint replacement surgeries medullary cavity becomes bone dry to facilitate easy cementing16. (5) By its effervescent action any small loose bony fragments are brought up in the surgical field to be removed easily. A few case reports of embolism phenomenon while using hydrogen peroxide which were correctible . Absorption of suture material and decrease in tensile strength of the wound are also reported17. Venous gas embolism due to hydrogen peroxide irrigation in neurosurgery as reported18.

Conclusion : Our study concludes that majority of the surgeons had good amount of knowledge about mechanism of action

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and other advantages. Only few had complications like embolic phenomenon which were controlled. Quantitative and qualitative assessment of microscopic tissue damage after the usage was beyond the scope of this article. There were some variations in perception in using H O as regards to its toxicity, anaphylaxis during surgery in comparison with other microbicidal solutions. Difference in perception depended on the experience of the surgeon in using it in various conditions. Our study also shows senior faculty members and senior Orthopaedic surgeons have more knowledge and attitude to use than the young and recent surgeons who are averse to use it. The advantage of using H O in all routine surgeries outweigh the rare complications and disadvantages, which was expressed by a few. Inspite of the extensive knowledge of H O among the surgeons, it is fraught with the danger of complications. Our experience of using it since 30 years shows that it can still be safe, less expensive and useful solution to be used in all Orthopaedic surgeries. Finally H O usage does not increase the risk of fatal and non fatal vascular occlusive events like pulmonary embolism, DVT, air and venous thromboembolism. 2

Recommendations : We strongly recommend the usage of H O in all Orthopaedic surgeries as we have explained in introduction and discussion. During surgery the anesthetist must be informed about the possibility of adverse reactions like embolic phenomenon, anaphylaxis. To be watchful in using in case of puncture wounds. Special care is to be taken in using the solution in punctured wounds to avoid local surgical emphysema and compartment syndrome. It is important to wash off the debris along with the residual Hydrogen Peroxide with normal saline. To the objection that it is not a sterile solution to be used in clean incised wounds as expressed by some, this can be achieved by passing the solution through.Twenty two micron filters to make it devoid of contaminants. There is a need to understand and research about the implications of using H O in clean incised wound, as to reveal the amount of debris liberated and its detrimental effect on host tissue. We intend to extend our further study in detail about the various conditions in which we have used and the conclusions to be derived from it. 2

Acknowledgements : We thank Dr. Surya Prabha MD, Professor of Social and Preventive medicine, Osmania Medical College, Hyderabad, India, for her valuable advice. All the Orthopaedic Surgeons who took part in the study. SVS Medical College, Mahaboobnagar Andhra Pradesh, India. All the family members of the authors.

REFERENCES 1 Textbook of chemistry, Intermediate I yr. Board of Intermediate Education, 2002, Telugu Academy Publications – preparation and properties of H2O2. 2 NCERT, chemistry part 2, class 11 unit 9 , 285-6. 3 http/www.a2c2.com/articles/lifejano2asp!pid=328article text=lifejano2. 4 Hawkin FM, Campbell SE, Goldstein SA et al - H2O2 as topical haemostatic agent – Clinical Orthopaedics and Related Research 1984; 186: 244-8. 5 Altman, Nathaneck – oxygen healing therapies, Rochester VT Healing Arts press. 1995. 6 The many benefits of H O by Dr David G Williams (title – H2O2 Curse or Cure) posted July 17, 2003. http/www.educateyourself.org/cancer/benefits of H2O2 html. 7 Jeffrey O Anglen MD — Wound irrigation in musculoskeletal surgery – Journal of American Academy of Orthopaedic Surgeons, Vol. 9, no.4 July, August 2001. 8 Bhandari M, Schemitsch EH, Adili A — High and low pressure lavage of contaminated fracture tibia – An in vitro study of bacterial adherence and bone damage. Journal Orthopaedics and trauma 1999; 13: 526-33. 9 Shukrimi A, Aminuddin CA, Azril MA — Venous gas embolism following H2O2 irrigation during debridement in osteomyelitis. Medical Journal Malaysia 2006; 61: 88-90 10 D Uday PK, Singh AK — Venous oxygen embolism due to H2O2 irrigation posterior fossa surgery. Department of Anaesthesia, Indira Gandhi Institute of Medical Sciences, Patna, India. Journal of Neurosurgical Anesthesia 2000; 12: 54-6. 11 H O could cause absorbable sutures to come apart – decreased tensile strength. Research from UT Southwestern Medical Centre. Source – UT Southwestern Medical Centre. 12 Nicholson NC, Ramp WK, Kneisl JS — H O inhibits Giant Cell Tumor and osteoblast metabolism in vitro. Department of orthopaedics, Carolina Medical Centre, Charlotte NC 28232-2861 USA. 13 AJ Timperly FRCS Edin, Bracy FRCS Edin. Cardiac arrest following use of H O . Volume 4 Issue 4 Dec 1989 –369-70. 14 Lichtenbaum R, deSouza AA, Jaff JJ — Intramural H O during meningioma resection. Dept neurosurgery NY, University School of Medicine NY. Neurosurgery 2006; 59: (4 supplement 2). 15 Potyodyl, Lottenburg L, Andersa J — Use of H2O2 for achieving dermal haemostasis after burn resection. Journal of Burn Care Research 2006; 27: 99-101. 16 Masomori, Shigemattu, Masaru Kitajama — Effect of H2O2 as artificial joint – The Journal of Arthroplasty 2005; 20: 63946. 17 Lineaweawer W, McMorris S, Saucy D, Howard R — Cellular and bacterial toxicity of commonly used topical antimicrobials. Plastic and Reconstructive Surgery 1985; 75: 394. 18 Hitoshi Morikawa MD, Hiroyuki Mima MD, Hishashi Fujija — oxygen embolism due to H2O2 irrigation during cervical spine surgery – a case report. Canadian Journal Of Anesthesia 1995; 42: 231-3. 2

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Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Observational Study Profile of road traffic accidents from semi-urban area of Bihar A Kumar1, R R Jha2 Road traffic accidents cause 1.25 million deaths throughout world. Majorities of them are young adults aged between 15 to 29 years. In India 1,42,485 people died due to RTA in 2011. The worst suffers are "vulnerable road users" pedestrians, cyclists and motorcyclists. Major risk factors for accidents are drink and drive, not using protective measures, speed, defective maintenance of vehicle, distracted driving etc. A cross-section study with convince sampling method. Combination of interview method and hospital records was used to gain required information. Most of the victims were male of younger age group. Average stay for major injuries was almost twice that of minor injuries. No seasonal variation in accident was noted. Alcohol was strongly associated with severity of injury sustained. Most of the accidents were reported by twowheelers. With development of country more vehicles on road and increases in road congestion thus more probability of road traffic accidents. There is an urgent need of intervention in terms of public awareness about road safety and compliance of strict traffic rules. [J Indian Med Assoc 2017; 115: 26-7 & 30]

Key words : RTA, severity of injury, drink and drive, Bihar.

ny accident resulting due crash originating from, ter-minating into or involving vehicle partially or fully on public road is known as road traffic accidents. Road traffic accidents cause 1.25 million deaths throughout world where, 90% of fatality occurs in low and middle income countries . Majorities of them are young adults aged between 15 to 29 years. As per 2012 data RTA is ninth leading cause of death worldwide, accounting 2.2% of all deaths . RTA is not limited to mortality but 2050 million suffers non-fatal injuries leading to major disabilities. Development in India is accompanied by major development in infrastructures and increase in vehicles. RTA in India is no exception, as by numbers of fatalities due to RTA. According to 2011 data 1, 42,485 people died due RTA . These accidents involved more than 18000 people in age group of 15-24 years. Every year the numbers are increasing steadily. The worst suffers are "vulnerable road users" pedestrians, cyclists and motorcyclists. Unlike developed world in India twowheeler are more in numbers and being unstable, more venerable to accidents. RTA is matter of national concern. Major risk factors for accidents are drink and drive, no use or improper use of protective measures like helmet/seat belts etc, speed, defective maintenance of vehicle,

distracted driving etc. Objec tive of the study was to find the profile of patients of RTA and to find association of risk factors with type of injury sustained. MATERIAL AND METHODS

A cross-section study was done at tertiary center of Rohtas. The hospital is situated 7 km from national highway; hence most of RTA comes to this hospital. The study was done for one year ie, January 2015 to December 2015. The subjects were enrolled using convenience sampling technique. During this period all the RTA cases admitted in the hospital were taken up, with only exclusion criteria being those who were severely sick or not willing to participate. Data was collected using pretested and predesigned questionnaire and further information was collected using hospital records. Questions accessed socio-demographic profile, type of vehicle involved, use of alcohol and severity of injury sustained. The participation was voluntary. Data was analyzed using Microsoft excel software.

OBSERVATION

In this study 98 cases were taken up where 79 (80.6%) were males and 19 females (19.4%). The mean age of participants was 35.3 years, where mean age of males was less than females, which were 33.7 years and 42.1 yrs respectively. Most of patients were from Rohtas district which was 78.5% followed by Aurangabad district 20.5% and rest were from other areas.

Department of Community Medicine, Narayan Medical College and Hospital, Sasaram, Bihar 821305 1 MBBS (MAHE), MD (PSM), Assistant Professor 2 MBBS, MD (Community Medicine), Assistant Professor 26

The average length of stay of patient in hospital was 6.9 days with median stay of 3 days. Among total cases 41(41.8%) cases were admitted with major injury and 57 (58.2%) were of minor injuries. Average stay of patients with major injury was 7.5 days and with minor injury it was 3.6 days. There are various factors which is responsible for RTA. Time and Season Factor — It was found that 70 (71.4%) of the accident occurred during day time and 28 (28.5%) during night. The difference in type of injury sustained depending upon duration of accident (Table 1) was found out to be statically insignificant where, p= 0.746103. The difference in injury depending on weather condition (Table 2) was found to statically insignificant where, p= 0.08052. Alcohol and RTA — Drink and drive is major risk factor of RTA. Use of alcohol by drivers was accessed by smell of breath or other evidence like ineptitude in behavior, was considered for some evidence of alcohol consumption (Table 3) by found that there is a probability of major accident if driver is intoxicated. When chi-square was applied it was found to be statically significant where, p= 0.0045. Type of vehicle and RTA — Majority of RTA was reported by two wheeler (Fig 1) as its unstable ride but accident involving four wheeler reported maximum proportion of major injury (Table 4) followed by heavy vehicles like truck/dumper. When chi square was applied it was found to statically significant where, p = 0.012582. DISCUSSION

RTA is a major NCD problem which claims ninth spot in leading cause of deaths worldwide. In India there is one accident every minute . Majority of victim are of younger 4

Table 1 — Severity of injury depending upon duration of accident

Fig.1: - Types of vehicle involved in RTAs (N=98) Table 4 — Severity of injury depending upon Type of vehicle Type Two Wheeler (59) Four Wheeler (18) Heavy Vehicle (13) Others (8) Total (98)

Major

Minor

17 (28.8.1%) 12 (66.7%) 7 (53.8%) 5 (62.5%) 41 (41.8%)

42 (71.2%) 6 (33.3%) 6 (46.2%) 3 (37.5%) 57 (58.2%)

χ = 10.847 DF = 3 2

age ie, in their productive age group. In this study it was noted that mean age of victim was 35 years where 80% of them were males. Study done by Baruah and Chaliha in 2013-14 at Gauhati, found almost all involved were males with most of the in age group of 20-29 years. Similarly study done by Singh et al found mean age of victim to be 30.91 years with highest number of victim in age group of 20-30years. In this study severity of injury was independent of timing of a day and season of the year. It was found to be statically insignificant. As most of patient of RTA were from NH which is four or six lanes, so the condition of the road may be the reason for this. Moreover the local traffic uses by-lanes for their daily commute, leading to decrease congestion of NH. In 2004-05 Mishra et al found peck numbers during evening and morning hours. This may be due to fact that place of study was done in city as morning and evening hours have higher congestion and hence more number of accidents. Moreover they also noted rise in fatal accidents in month of January. This was attributed to foggy condition of hilly area. In 2008-09 Singh et al found that maximum accidents were noted during winter season. Again it may be due to dense fog during winter in catchment area of SIMS. In 2010-11 Bayan et al found the peak in accidents during night as the study was done in city and it may be due to it to low visibility and peak hours for office commuters. In this study it was found that severity of injury was associated with driver intoxication. This was statically significant. Patil et al found that 29.5% of drivers who meet accident were under influence of alcohol. Similarly 2013-14 Baruah and Chaliha noted that among all fatal 5

Duration of day

Major

Minor

30 11

40 17

Day Night

χ = 0.1048 DF = 1 2

Table 2 — Severity of injury depending upon season

Season Summer Winter Monsoon Total

Major

Minor

Total

22 13 6 41

31 9 17 57

53 (54.08%) 22 (22.44%) 23 (23.46%) 98 (100%)

χ = 5.0385 DF = 2 2

Table 3 — Severity of injury depending upon Driver's intoxication Intoxicated Yes No

Major

Minor

16 25

8 49

χ = 8.0529 DF = 1 2

(Continued on page 30)

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017 |

Observational Study Knowledge of cardio-pulmonary resuscitation in medical undergraduates Meenakshi Girish1, Nilofer Mujawar2, Prachi Marlecha3, Rohinie Dhokane4 The objective of the study was to evaluate the knowledge of Cardio-Pulmonary Resuscitation in medical undergraduates (final year MBBS students & Interns). The study was designed as a cross sectional questionnaire based study, conducted at a private medical institute. Data was analyzed with SPSS version 11.101. Out of 73 participants, only one scored passing percentage of > 85%. More than half of the respondents (68.49%) scored in the range of 10-18 marks. The overall performance of students as well as interns was very poor. Interns were found to be better than students (p < 0.001) in their knowledge of CPR. Conclusion: Knowledge of CPR must be one of the core topics in medical curriculum. Every medical practitioner must compulsorily attend a certified course in CPR for renewal of their license. [J Indian Med Assoc 2017; 115: 28-30]

Key words : Cardiopulmonary resuscitation, knowledge of CPR, medical curriculum.

in emergency situations. This study was conducted to test the knowledge of CPR amongst final MBBS students and Interns. Interns were included because this is the group which is posted directly in rural health centers with only the basic knowledge they acquire during their undergraduate course and in many remote areas of the country, interns may be the sole providers of health care and also the first responders to cardiac arrest. Objective : To evaluate knowledge of CardioPulmonary Resuscitation in medical undergraduates (final year MBBS) & Interns.

mmediate commencement of resuscitation may increase survival rate amongst victims of cardiac arrest and Cardiopulmonary Resuscitation (CPR) is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing. The objective of CPR is to delay tissue death and to extend the brief window of opportunity for a successful resuscitation without permanent brain damage. It may be performed both in and outside of a hospital1. The success of the first golden minute after cardiopulmonary arrest depends entirely on the skill of the personnel attempting rescue. CPR skills based workshops are held regularly by various medical organizations and it is also included as a one hour lecture in the medical curriculum for the final MBBS course. Medical undergraduates usually do not undergo any formal training in CPR, thus when they become interns they have no practical skills for prompt institution of rescue procedures2,3. It is no wonder then that most of our medical students feel helpless when they suddenly come across a situation of a critically ill patient. There are not many studies from India, which assess the expertise of health care professionals who often assume the role of first responders

Material & Methodology : This study was conducted in a private teaching institute. It is a questionnaire based cross sectional study and all the final MBBS students and interns from the same year who consented to participate in the study were included. The final MBBS students had already completed all their lectures at the time the study was conducted. A prevalidated questionnaire on CPR was given to them. The questions included were based on American Heart Association guidelines 2010 for Cardio-Pulmonary Resuscitation. There were 35 multiple choice questions in English with only one correct answer in each. Students were given 30 minutes to complete the task. Each correct answer was awarded 1 mark. There were no negative marking. The test was conducted on the spot without any prior intimation. Students who scored at least 85% were considered successful and declared as having knowledge of Cardio-Pulmonary Resuscitation.

Department of Pediatrics, NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Nagpur 440019 1 MD Associate Professor 2 MD Professor 3 MBBS, Student 4 MD Assistant Professor 28

Study Design : Cross sectional questionnaire based study. Statistical Analysis was done by SPSS version 11.101. Descriptive statistics and Mann Whitney U Test was applied.

Results : There were 73 respondents, 51 (69.86%) undergraduates and 22 (30.13%) interns. A uniformly low scoring performance was observed amongst both interns and students (Table 1). Majority of students (76.5%) and 50% of interns, scored in the range of 10-18 marks (Table 2). While none of the undergraduate students was declared successful, only one out of 22 interns (4.54%) scored more than 85% and was declared successful (Table 3). Though the overall performance was very poor, two-sample Wilcoxon rank-sum (Mann-Whitney) test was applied to compare the knowledge of students and interns. There was a significant difference in knowledge (p value 0.001), with interns scoring significantly better (Table 4).

Discussion : CPR is a life saving skill to be acquired not just by health professionals but also general public because cardiopulmonary arrests are more common in the out of hospital scenario . While the developed countries have devised a successful policy wherein even school children are taught CPR skills, in India even the medical curriculum does not give enough emphasis on acquiring knowledge of CPR at the undergraduate level . Neither the Govt. of India nor Medical Council of India has made it mandatory for interns to attend a certificate course in 4, 5

Table 2 — Distribution of participants based on range of marks Range of marks

No of student (%)

No interns (%)

Total number (%)

0-9 10-18 19-27 28-36 Total

2 (3.92%) 39 (76.47%) 10 (19.60%) 0 51

0 11 (50%) 8 (36.36%) 3 (13.63%) 22

2 (2.73%) 50 (68.49%) 18 (24.65%) 3 (4.10%) -

Table 3 — Distribution of participants based on percentage marks Percentage of marks obtained <54 55-70 71-84 >85

MBBS (final year) (n=51)

Interns (n=22)

43 8 0 0

11 7 3 1

Table 4 — Comparison of performance of students and interns Variables Marks obtained : Mean SD Minimum Maximum Percentage : Mean SD Minimum Maximum Median score Interquartile range First interquartile Second interquartile

Students (n=51)

Interns (n=22)

15.84 3.48 11 24

19.59 5.73 10 30

45.26 9.97 31.42 68.57 15 5 13 18

55.97 16.39 28.57 85.71 19 8 16 23.5

P value 0.001 (MW test) Table 1 — Scorewise distribution of participants Final MBBS students

Interns

No of Marks Marks No of Marks Marks students obtained obtained in students obtained obtained in (out of 35) in percent (%) (out of 35) in percent (%) 1 2 2 1 2 2 4 6 4 10 2 6 2 7 Total 51

24 68.57 23 65.71 22 62.85 21 60 20 57.14 19 54.28 18 51.42 17 48.57 16 45.71 15 42.85 14 40 1 13 37.14 12 34.28 11 31.42 Average Average % marks 15.84 45.26

1 30 85.71 2 28 80 1 27 77.14 2 24 68.57 3 22 62.85 1 21 60 1 20 57.14 1 18 51.42 3 17 48.57 2 16 45.71 15 42.85 1 14 40 1 13 37.14 2 10 28.57 Total 22 Average Average % marks 19.59 55.97

CPR . Our in stitute conducts orientation programme for all interns at the beginning of their internship in which CPR is taught in a one hour session, but this remains an individual policy by institutes not mandated by any governing body. In this background, the results shown in our study is not very surprising. In fact, other studies from India have also shown similar observations . The overall scores in our study were very low and all subsequent analysis is made only to compare the students and the interns. Thus the significant difference observed between the students and interns just shows that the one hour session undergone by the interns prior to participating in this study probably helps, though only in a small way. Such results are really disturbing because CPR is one of the fundamental emergency technique performed in medical practice, and lack of knowledge can have dreadful consequences, especially in remote health care areas where the only tool to deal with emergencies are the skills 7

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

in CPR in the absence of any other life saving equipments or medical facilities . This paper assumes greater significance in the background of a national debate on the issue of compulsory posting of interns in rural areas. This study also serves to send a strong message to policy makers to make acquisition of CPR skills a mandatory step in obtaining a MBBS degree either during the undergraduate course or during internship and an essential criteria for renewal of license for medical professionals especially considering the fact that already there are private organisations in India like the Indian Academy of Pediatrics, the Cardiology society etc. who have the infrastructure and manpower required to conduct such programmes across the whole country. 8

Conclusion : The basic knowledge of cardiopulmonary resuscitation amongst medical students is inadequate. A major revision in the medical curriculum is required to rectify the error. In fact, knowledge of CPR should become a ‘must know’ category of topic in medical curriculum, so that all forms of evaluation must include testing this knowledge. Renewal of license for all medical professionals should also mandate attending a CPR course every few years.

REFERENCES 1 Sasson C, Rogers MA, Dahl J, Kellermann AL — Predictors of survival from out-of hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010; 3: 63-81. 2 Skinner D, Camm A, Miles S — Cardiopulmonary skills of preregistration house officers. BMJ 1985; 290: 1549-50. 3 Casey WF — Cardiopulmonary resuscitation: a survey among junior hospital doctors. J RSoc Med 1984; 77: 921-4. 4 Sankar J, Janakiraman L, Ramesh J, Ranjith S — Impact of PALS on pediatric resuscitation Knowledge, Asian Journal of Critical Care 2007; 3: 18-21. 5 Zaheer H, Haque Z — Awareness about BLS (CPR) among medical students: status and requirements. Journal of Pakistan Medical Association 2009; 59: 57-9. 6 Chandrasekaran S, Kumar S — Awareness of basic life support among medical, dental, nursing students and doctors. Indian J Anaesth 2010; 54: 121-6. 7 Avabratha SK, Bhagyalakshmi K, Puranik G, Shenoy KV, Rai BS — A Study of the Knowledge of Resuscitation among Interns. Al Ameen J Med Sci 2012; 5: 152-6. 8 Zaheer H, Haque Z — Awareness about BLS (CPR) among medical students: status and requirements. JPMA 2009; 59: 57.

(Continued from page 27)

cases of RTA nearly 20% of them had alcohol in their blood. From various studies it is well documented fact that alcohol is one of the major risk factor for RTA. In this study most of the RTA was reported by two wheelers followed by four-wheeler. Four-wheeler and heavy vehicle had bigger impact than two-wheeler, causing most of the major injuries to victims. Patil et al in their study found that highest number of victims were two-wheeler occupants, followed by four-wheelers. Similarly Singh et al found that maximum number of cases and casualty with two-wheelers. 9

CONCLUSION

In India, there is rapid urbanization and modernization. This development also means more number of vehicles and increases in road congestion thus more probability of road traffic accidents. The result from this study clearly indicates alcohol as major preventable factor for RTA. It also points more number of two-wheeler involvement in RTA. If strong political and public commitment supports the implementation of preventive measures like use of protective gears, following of traffic rules, good medical emergency support on highways can prevent lots of morbidity and mortality. REFERENCES 1 Road Traffic Injuries: WHO: May 2016. Available on http://www.who.int/mediacentre/factsheets/fs358/en/ [last accessed on 02/07/16]

2 Factsheet: Top 10 causes of Death: WHO: May 2014. Available on http:// www. who.int/ mediacentre/ factsheets/ fs310/en/ [last accessed on 02/07/16] 3 OGD Platform India: Ministry of Road Transport and Highways, Government of India: Available at https://data.gov.in/catalog/total-number-road-accidentsindia [last accessed on 15/07/16] 4 Road Accidents in India: Issues and Dimensions. Ministry of Road Transport and Highways, Government of India. Available from: http://www.unescap.org/ sites/default/ files/2.12.India_.pdf. 5 Baruah AM, Chaliha R — A study of Incidence of Alcohol Use In Fatal Road Traffic Accidents. J Indian Acad Forensic Med 2015; 37: 12-5. 6 Singh R, Singh HK, Gupta SC, Kumar Y — Pattern, Severity and Circumstances of Injuries Sustained in Road Traffic Accidents: A tertiary Care Hospital-Based Study. IJCM 2014; 39: 30-4. 7 Mishra B, Sinha ND, Sukhla SK, Sinha AK — Epidemiological Study of Road Traffic Accident Cases from Western Nepal. IJCM 2010; 35: 115-9. 8 Bayan P, Bhawalkar JS, Jadhav SL, Banerjee A — Profile of non-fatal injuries due to road traffic accidents from a industrial town in India. IJCIIS 2013; 3: 8-11. 9 Patil SS, Kakade RV, Durgawale PM, Kakade SV — Pattern of Road Traffic Injuries: A study From western Maharastra. IJCM 2008; 33: 56-7.

Case Report

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Epidural anaesthesia for fixation of intertrochanteric fracture in a 108-year old elderly patient 1

Leena Goel , Pabitra Ghoshal , Rina Cordeiro , Sambhram Shenoy

Age itself is an independent morbidity and mortality risk factor for a long list of diseases and injuries and awareness of such additional risk factors may modify our perioperative anaesthetic management in a way that will ultimately improve the postoperative outcome. Here we describe the successful anaesthetic management in a rare case of a 108 year old female with intertrochanteric fracture of right femur by dynamic hip screw fixation. Taking into account her age and compromised cardiac function, epidural anaesthesia was planned as it had several distinct advantages over general anaesthesia in terms of an improved pulmonary and myocardial function, decreased chances of thromboembolic complications, early mobilization and postoperative analgesia through epidural catheter. [J Indian Med Assoc 2017; 115: 31-2 & 34]

Key words : Age factors, epidural anaesthesia, mortality.

lderly patients’ still have the highest postoperative mortality and morbidity rate in the adult surgical population in spite of advancement in knowledge and techniques of geriatric pathophysiology. Preoperative clinical assessment to detect patients at high risk of postoperative events, and specific intra-operative and postoperative anaesthesia management are important to minimize postoperative adverse events in the elderly . Among the steadily increasing population of surgical patients aged 65 years and older, the fastest growing section is of individuals 85 years or older . Physiological reserve is reduced and mortality becomes more common with increasing age. Cardiovascular diseases, renal disease, compromised respiratory function, neurosurgical pathology and metabolic disease are more likely in the elderly. The incidence of diabetes is up to 25% in those aged over 80 years. For improved outcome in elderly patients surgery is recommended between 24 to 36 hours after admission . Epidural Anaesthesia and Analgesia have been demonstrated to improve postoperative outcome and alternate the physiological response to surgery. In particular, significant reduction in perioperative cardiac morbidity (30%), pulmonary infections (40%), pulmonary embolism (50%), ileus (-2 days), acute renal failure (30%) and blood loss (30%) were noted . 1

Fig 1— A 108 year old patient

She also had fever with cough and expectoration since one week, for which she was started on tablet cefexime 200mg twice a day for 5 days. The patient was obese and her BMI was 32.87 kg/m . Her pulse rate was 86/minute regular and blood pressure 138/72 mm of Hg. She was edentulous and her haemoglobin was 9.7gm%. Total and differential counts were normal. Her random blood sugar was 92 mg%. Her renal function tests were deranged. Serial recording of serum creatinine showed a continuous rise up to 2.2 mg/day. Preoperative Arterial Blood Gases (ABG) analysis showed pH – 7.42, pCO of 40.4 mm of Hg, pO of 70.2 mm of Hg and 125.9 mEq/L HCO BE-1.3 mEq/L and SpO 92%. Nephrologists suggested maintaining adequate hydration. Renal ultrasound was normal. Her blood sugar levels and liver function tests were normal. Her ECG had changes suggestive of an old anterioseptal myocardial infarction. Echocardiography revealed a calcified aortic valve, akinesia of whole septum, hypokinesia of anterior wall, concentric left ventricular hypertrophy and LV grade-1 diastolic dysfunction with LV 2

CASE REPORT

A 108 year old female (Fig 1) was scheduled to undergo an internal fixation by dynamic hip screw for intertrochanteric fracture of right femur. Patient was a known case of ischemic heart disease (IHD) since 10 years and was on tablet enalapril 5 mg, atorvastatin 20 mg and aspirin 75mg once a day, tablet betaloc 25 mg and isosorbide mononitrate 20 mg twice a day.

Department of Anaesthesia, Goa Medical College, Goa 403202 1 MD (Anaesthesia), Assistant Professor 2 MD (Anaesthesia), Senior Resident 3 MBBS (PG Student), Junior Resident 31

Case Report

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

ejection fraction 45%. Her chest X-ray showed mild emphysematous changes. Pulmonary functioned test suggested mild restrictive and obstructive changes. The patient was started on enoxaparin 40 mg subcutaneous OD which was continued in the post-operative period. Patient had dementia. Considering her age, medical and surgical conditions, epidural anaesthesia was planned. She was kept nil by mouth 6 hours prior to surgery and was given 5 mg of Alprazyolam the previous night. In OT intravenous access was secured with an 18 G cannula. Monitoring of pulse rate, electrocardiography, oxygen saturation, non-invasive blood pressure, urine output and temperature was started and continued throughout the surgery. She was preloaded with 500 ml of Ringer Lactate Solution. An 18 G Tuohy needle was inserted via a para median approach into L - L interspace using the loss of resistance technique in sitting position. An epidural catheter was inserted via the Tuohy needle and was fixed at 8cm (12 hours after the dose of enoxaparin). Test dose of 3ml 2% lignocaine with 1:200,000 epinephrine was injected. 8ml of 0.5% bupivacaine was given in a titrated manner through catheter and the block was ensured to be up to the sensory level of T8. Oxygen was given by mask at 6L /min. Ephedrine was kept ready intraoperatively. Mean blood pressure of 90-100 mm of Hg was maintained with the help of ephedrine and crystalloids. We avoided colloids in view of her altered renal status. Intraoperating blood loss was 300 ml and her urine output was 100 ml. The patient remained hemodynamically stable throughout the 90 minutes procedure. After surgery the patient was shifted to the Intensive Care Unit (ICU) for monitoring. Postoperative analgesia was given by an epidural infusion of 0.125 % Bupivacaine with Fentanyl 2mcg /ml at 2-4 ml/h. The patient was well postoperatively and she was discharged from the hospital after one week. 2

DISCUSSION

Management of geriatric patients can be challenging to an anaesthesiologist due to limited organ reserve, compromised organ functions and unique disease predispositions. Functional status can be expressed in Metabolic Equivalent of Task (MET) levels. It’s one of the most important predictors of perioperative outcome in elderly surgical patients. Our patient had a MET less than 4, ie, poor functional capacity . Three factors contribute to the increased perioperative risk due to an advanced age. (1) Physiological aging is accompanied by a progressive decline in resting organ function. Consequently, the reserve capacity to compensate for impaired organ function, drug metabolism and added physiological demands is increasingly impaired. (2) Ageing is associated with progressive manifestation of chronic diseases which further limits baseline function and accelerates loss of functional reserve in the affected organ. (3) The increased intake of medications and altered pharmacokinetics and pharmacodynamics . Renal blood flow and kidney mass decrease with age. Muscle bulk decreases with age resulting in reduced creatinine production; hence even a modest rise in serum creatinine may represent a significant renal impairment and should be viewed cautiously. Impairment of sodium handling, concentrating ability and diluting capacity predisposes elderly patients to dehydration and fluid overload. Preoperative fluid replacement must be managed carefully in eld 5

erly patients to prevent development of postoperative pulmonary oedema as a result of age related prolonged extracellular water (ECW) expansion. Compared with 5 days for young patients with sepsis, elderly septic patients require 10 days to excrete over expanded ECW. Renal functions deteriorate with age and hence urine output monitoring and pulmonary artery catheterization are invaluable to guide fluid therapy in elderly patients . Perioperative hypothermia is more frequently pronounced and prolonged in the elderly who have compromised ability to regain normal thermoregulatory control quickly. In the postoperative period for the elderly, mild hypothermia can elevate norepinephrine concentration and increase peripheral vasoconstriction and arterial blood pressure, thereby contributing to cardiovascular ischemia and arrhythmia. It may also increase blood loss during total hip replacement procedures thereby risking wound infection, decreasing drug metabolism and prolonging hospitalization . Adverse perioperative effects on the cardiac, pulmonary, cerebral systems and cognitive functions are major concerns in case of elderly patients . Regional Anaesthesia techniques attenuate the perioperative stress response improving myocardial oxygenation, reducing release of troponin T and effectively controlling unstable refractory angina pectoris . Epidural Anaesthesia has the ability to completely block the sympathetic response to surgery below the umbilicus and to significantly blunt the response to surgery above the umbilicus. Local epidural anaesthetics block the sympathetic response, whereas epidural opioids incompletely block the signal. This is consistent with the fact that opioids only block the nociceptive pathways of sympathetic activation while local anaesthetics inhibit both nociceptive and non-nociceptive routes . Cardiac morbidity is the most common cause of death after major surgical procedures in elderly. Anaesthetic techniques that reduce cardiac morbidity will therefore have potential for improving surgical morbidity and mortality. Since perioperative excessive activation of the cardiac (T -T ) sympathetic nervous system by surgical stress has been demonstrated to increase indices of myocardial oxygen demand, while inducing coronary artery vasoconstriction (decreasing supply), thus resulting in clinical correlates of myocardial ischemia such as ST segment changes, angina and arrhythmias. Thoracic Epidural Anaesthesia (TEA) with local anaesthetics can produce a selective segmental blockade of the cardiac sympathetic innervation (T -T ) . Thoracic Epidural Anaesthesia and Analgesia (TEAA) can reduce incidence of postoperative atelectasis, pneumonia and hypoxemia. TEAA improves measurable pulmonary function by blunting spinal reflex arcs, controlling pain and increasing chest wall compliance. The use of systemic and epidural opioids is associated with a higher incidence of hypoxemic events when compared to epidural analgesia with local anaesthetic alone . Epidural Anaesthesia and Analgesia (EAA) decreases blood loss during total hip arthroplasty thereby preventing intraoperative hypertension in patients with intraoperative ischemia and results in lower incidence of reoperation for inadequate tissue perfusion during vascular surgery . It also attenuates the hypercoagulable perioperative state and decreases thromboembolic complications associated with surgery by blunting the sympathetic response and improving lower extremity blood flow . EAA preserves postoperative immune function by 7

Placenta accreta — a multidisciplinary team approach Nellepalli Sanjeeva Reddy1, Vembu Radha2, Marianallur Ganesan Dhanalakshmi3, 4 Jayalakshmi D

The management of placenta accreta is a night mare. They are at increased risk for uncontrolled haemorrhage. This patient with history of previous caesarean section, type II placenta praevia with accreta, with complications of intra-uterine growth refardation, oligo-amnios was planned for elective classical caesarean section preceeded by prophylactic uterine artery embolisation. This case report was been presented to emphasise a "team based approach" comprising obstetrician, neonatologist, anaesthesiologist, interventional radiologist and transfusion medicine specialist for prevention and life saving strategies to prevent morbidity and mortality. [J Indian Med Assoc 2017; 115: 33-34]

12,

(Contined on page 34)

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Key words : Placenta accreta, uterine artery embolisation, multidisciplinary team approach.

patient with placenta accreta is at increased risk for uncon-trolled haemorrhage. The clinical and surgical management should focus on prevention and treatment of uncontrolled haemorrhage.

1590g,with an APGAR of 8/10 and 9/10. The placenta was extending from the upper to the lower uterine segment (LUS) anteriorly and was partially covering the os. It was highly vascular and manual removal of placenta (MRP) was done. There was profuse bleeding from the placental site and LUS. Hence it was decided to proceed with UAE. Left uterine artery was embolised with graded PVA particles and gel foam and the same was repeated on the right uterine artery. Post embolisation angiogram revealed complete absence of abnormal blush and the vascularity on either side. Patient tolerated the procedure well and the peripheral pulsation was felt. Uterus was closed in layers. Two units of packed cells were transfused intra-operatively in view of blood loss of around 1500ml. She was kept under observation in ICU for 24 hours. Post operative period was uneventful. Sutures were removed on 9th post operative day (POD) and discharged on 10th POD.

CASE REPORT A 29-year-old second gravida with previous caesarean section done for foetal distress 2 / years back was referred at 33weeks, 4days gestational age with the diagnosis of placenta praevia type II anterior, suspected placenta accreta, with intrauterine growth refardation and oligoamnios for tertiary care. She had regular antenatal check up. Placenta praevia with suspected placenta accreta was diagnosed at 33 weeks. Examination — On admission she had no episodes of bleeding per vaginum or pain abdomen. Her vitals were stable, clinically she had evidence of IUGR and reduced liquor, with an estimated foetal weight of 1500g. She was administered two doses of steroid prophylaxis. Investigation — Ultrasound revealed a gestational age of 2829 weeks, cephalic presentation, placenta was anterior, low lying and the edge covering the os with increased retroplacental vascularity with an estimated foetal weight of 1421±213g, AFI – 4.6. Her Hb was 12gm/dl%, renal and liver function tests were normal. Management — In view of the previous cesarean section, presently with type II placenta previa with accreta, severe oligoamnios and IUGR, she was planned for elective classical caesarean section; preceeded by prophylactic uterine artery embolisation (UAE). Earlier the interventional radiologist sited the uterine catheter under fluoroscopic guidance, followed by a classical caesarean section under general anaesthesia in catheter laboratory. Per operatively there was increased vascularity over lower uterine segment and on the bladder. A baby girl was delivered as breech, weighing 1

DISCUSSION

A team based approach is needed for prevention and life saving strategies to stop bleeding . By definition placenta accreta is abnormal placental attachment with absence of both decidua basalis and Nitabuch membrane. In placenta accreta there is superficial attachment of the trophoblastic villi to myometrium. The risk factors include prior uterine surgery, multiparity, advanced maternal age and previous uterine curettage. This patient had a previous caesarean section as the risk factor. The incidence of placenta accreta has climbed from 1: 2,510 in 1980’s to 1: 533 in 2002 and 1: 210 in 2006. That is likely to be related to the rising caesarean section rates in the same period . After a prior caesarean section, a woman is twice as likely to develop placenta accreta . With the advent of ultrasound, placenta accreta can be diagnosed as early as first trimester and so caesarean section can be scheduled before labour, thereby reducing the morbidity and the mortality. In Maternal Foetal Medicine Unit (MFMU) network study, the mean gestational age was 35 years unlike in our patient; where termination of pregnancy was done at 33-34 weeks itself in view of IUGR and severe oligo-amnios. Routine MRI is not required when ultrasound shows evidence of placenta accreta. 1

Department of Obstetrics & Gynaecology, Sri Ramachandra University, Chennai 600116 1 MBBS, MD, DGO, Professor & Head of the Department 2 MBBS, DGO, DNB, MNAMS, FICS, Associate Professor 3 MBBS, MD, DGO, DICOG, DNB, Associate Professor 4 MBBS, MD, Assistant Professor 33

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

The pre-operative preparations included in this patient were: (1) Counseling the patient and her attendants regarding the risks, trauma to surrounding structures, treatment options, consent for hysterectomy in case of uncontrolled haemorrhage and documenting the same in medical records (2) Preparation for massive blood transfusion. (3) Alerting the interventional radiology team and the vascular surgical team. (4) Preparation for step wise devascularisation. In this patient after MRP, it was necessary to proceed with the UAE in view of uncontrolled haemorrhage from placental site and LUS. Even though conservative management is not an option for placenta increta and percreta, it has a role in placenta accreta . The post operative complications like laryngeal and pulmonary oedema, prolonged intra-operative hypotension leading to renal compromise, Sheehan’s syndrome, thromboembolism were not encountered in this patient. This is due to the pre-operative diagnosis and preparations, the prophylactic measures taken and the team approach. Such measures will 5

reduce not only the morbidity and mortality but also would preserve the uterus. REFERENCES

1 Stafford I, Belfort MA, Placenta accrete, increta and percreta: a team based approach starts with prevention. Contemp OB/GYN 2008; 52: 77-82. 2 Silver RM, Landon MB, Rouse DJ — Maternal morbidity associated with multiple caesarean delivery. Obstet Gynecol 2006; 107: 1226-32. 3 Kockerginsky YW, Mankutta D, Rojansky N — Perinatal outcome of pregnancies complicated by placenta accreta. Obstet Gynecol 2004; 104: 527-30. 4 Grobman WA, Gersnoviez R, Landon MD — Pregnancy outcome for women with placenta praevia in relation to the number of prior caesarean delivery. National Institute of Child health and Human Development(NICHD), Maternal Foetal Medicine unit (MFMU) network. Obstet Gynecol 2007; 110: 1249-55. 5 Stafford I, Belfort M — Placenta accre, increta and percreta: life saving strategies to stop the bleeding. Contemp OB/GYN 2008; 53: 48-53.

(Contined from page 32)

attenuating the stress response, reducing the Minimum Alveolar Concentration (MAC) of inhaled anaesthetics and minimizing the use of parenteral opioids, thus helping to maintain a competent immune system . It also allows better pain control with less sedation, and increase post-operative pO , all of which may contribute to improved postoperative cognition . So patients undergoing major operations under EAA benefit from improved venous blood flow, attenuation of the sympathetic response to surgery, anticoagulant properties of local anaesthetics, early mobility and lowering of Mean Arterial Pressure (MAP).These advantages strongly support the use of Epidural Anaesthesia as the anaesthetic technique of choice in the present case. To facilitate early mobilization, improve recuperation and reduce morbidity with decreased hospital stay, Epidural Anaesthesia should be considered as a reliable anaesthetic technique as compared to general anaesthesia for appropriate surgical procedures in the elderly. 17

REFERENCES

1 F Jin, F Chung — Minimizing perioperative adverse events in the elderly. British Journal of Anaesthesia 2001; 87: 60824. 2 Weintraub HD, Kekoler Lj — Demographics of aging. In: Mcleskey CH, ed. Geriatric Anaesthesiology. Williams and Wilkins 1997; 3-12. 3 Jandziol A, Griffiths R — The anaesthetic management of patients with hip fractures. British Journal of Anaesthesia CEPD Reviews 2001; 1: 52-5. 4 Moraca RJ, Sheldon DG, Thirlby RC — The Role of Epidural Anaesthesia and Analgesia in Surgical Practice. Ann Surg 2003; 238: 663-73. 5 Reilly DF, Mcneely MJ, Doerner D — Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intem Med 1999; 159: 2185-92. 6 Priebe HJ — The aged cardiovascular risk patient. British Journal of Anaesthesia 2000; 85: 763-78. 7 Cheng AT, Plank LD, Hill GL — Prolonged overexpansion of extracellular water in elderly patients with sepsis. Arch Surg 1998; 133: 745-51.

8 Frank SM, Higgins MS, Breslow MJ — The catecholamine, cortisol, and hemodynamic responses to mild perioperative hypothermia. A randomized clinical trial. Anesthesiology 1995; 82: 83-93. 9 Pederson T, Eliasen K, Henrikson E — A prospective study of mortality associated with anaesthesia and surgery: Risk indicators of mortality in hospital. Acta Anaesthesiol Scand 1990; 34: 176-82. 10 Glantz L, Drenger B, Gozal Y — Perioperative myocardial ischemia in cataract surgery patients: General versus local anaesthesia. Anesth Analg 2000; 91: 1415-9. 11 Magnusdottir H, Kimo K, Ricksten SE — High thoracic epidural anaesthesia does not inhibit sympathetic nerve activity in the lower extremities. Anaesthesiology 1999; 91: 1299-304. 12 Grass JA — The role of epidural anaesthesia and analgesia in postoperative outcome. Anaesthesiol Clin North America 2000; 18: 407-28. 13 Park WY, Thompson JS, Lee KK — Effect of epidural anaesthesia and analgesia on peri-operative outcome. Ann Surg 2001; 234: 560-71. 14 Wheatley R, Somerville I, Sapsford D — Postoperative hypoxemia: comparison of extradural, I M And patientcontrolled analgesia. Br J Anaesth 1990; 64: 267-75. 15 Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al — Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from an overview of randomised trials. BMJ 2000; 321: 1493. 16 Muravchick S — Anaesthesia for the geriatric patient. In: Barash PG, Cullen RK, Stoelting RK. Ed. Clinical Anaesthesia. 4th ed. Philadelphia, USA: LWW; 2001: 120516. 17 deLeon – Casasola OA, Parker BM, Lema MJ — Epidural analgesia verses intravenous patient-controlled analgesia: differences in the postoperative course of cancer patients. Reg Anesth 1994; 19: 307-15. 18 Salomaki TE, Leppaluoto J, Laitinen JO — Epidural vs. Intravenous Fentanyl for reducing hormonal, metabolic and physiologic responses after thoracotomy. Anesthesiology 1993; 79: 672-9.

Case Report

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Tuberculosis of spleen : a rare case report Ajithkumar C S1 Twenty four years old immunocompetent male patient with fever for 6 weeks duration with left upper abdominal pain. On examination he was febrile with minimal tenderness at left hypochondral area. USS abdomen revealed the splenic abscess. CT abdomen showed multiple hypodense lesions of splenic abscess. Mantoux test was non reactive but ESR was elevated. Laparotomy done revealed the enlarged spleen with attachment to the diaphragm. Histopathology result was of caseating granuloma which was confluent consistent with tuberculosis of spleen. Tuberculous chemotherapy started with 4 drug regime. Patient was also given pneumococcal and influenza vaccination in the post operative period. [J Indian Med Assoc 2017; 115: 35-6 & 37]

Key words : Splenic abscess, tuberculosis, splenectomy.

linically tuberculosis may present as pulmonary or extra pul-monary disease. Extra pulmonary tuberculosis accounts for 15% of tuberculosis. Of all the organs, lung is the predominantly affected organ. Involvement of spleen in tuberculosis occurs in miliary/disseminated form of the disease. However isolated splenic tuberculosis or solitary tuberculosis of spleen is very rare in immunocompetent individuals. When spleen is involved as an isolated organ, patient may have multiple hypoechoic foci less than 2 cm which may be evident on USS and multiple hypodense lesions in CT abdomen. Splenic abscess is a comparatively commoner stage than the solitary or nodular stage when patient seeks medical advice. Isolated splenic tuberculosis abscess is rarely suspected clinically and the diagnosis is made retrospectively.

nonreactive. Sputum AFB was negative. In Chest x ray reading nothing was suggestive of tuberculosis. Ultrasonography of abdomen showed multiple hypoechoic lesion in the spleen with splenomegaly. Liver was normal and no lymphadenopathy or intra abdominal collection were seen. CT abdomen revealed multiple hypodense lesions in the spleen consistent with splenic abscess. Laparotomy was done based on these data. Intraoperatively spleen was found enlarged and found adhered to diaphragm on separation of which pus discharged from spleen. Splenectomy done and was submitted for histopathology examination.Tuberculous splenic abscess was identified by the pathologist and based on this 4 drug antituberculous chemotherapy was started along with other supportive treatments. Patient also received post splenectomy pneumococcal and influenza vaccination

CASE REPORT

Twenty four years old immunocompetent male patient without any previous history of tuberculosis or family history of tuberculosis presented with left hypochondrial pain and fever for previous 6 weeks. There was no previous history of contact with tuberculosis. Fever was of low grade with chills and rigor. There was no associated cough, sputum or dyspnea. Abdominal pain on left hypochondriac area was not associated with vomiting or diarrhoea or malena. Examination revealed a moderately built and ill nourished patient with temperature of 38.2 C . Respiratory system examination was within normal limits. Tenderness on deep palpation on left hypochondral area was there without any mass or hepato splenomegaly. There was no ascites. Bowel sounds were normal. Other systems were with in normal limits. Routine work up showed hemoglobin 14.3 grams per dl, total count 7700 cells per cmm with 66% polymorphs, lymphocytes 26%, eosinophils of 8% and ESR of 30 mm in the first hour. Liver and renal function tests were with in normal limits. Serum calcium and phosphorous were 9.3 mg per dl and 4.8 mg per dl respectively. Mantoux test was

DISCUSSION

Isolated splenic tuberculosis is a very rare manifestation of extra pulmonary tuberculosis in immunocompetent individuals . Here a young HIV negative patient with out prior history of contact with tuberculosis presented with fever and left upper abdominal pain for 6 weeks duration and he had tuberculous splenic abscess. Splenic tuberculosis is a rare form of abdominal tuberculosis. It is usually seen in immunocompromised individuals or as a part of disseminated tuberculosis although it can also be manifested in immunocompetent individuals infrequently . Spleen can be the only site of tuberculous infection (isolated splenic tuberculosis) . Bhansali et al in a series of 300 patients with abdominal tuberculosis did not encounter even a single case of splenic tuberculosis. Tuberculosis has been reported as a rare cause of splenic abscess . On USG, splenic tuberculosis usually presented as multiple small hypoechoic lesions and CECT (Fig 1) may demonstrate hypodense lesions . The reported yield of aspiration cytology from the splenic lesions is variable. Suri et al reported up to 88% sensitivity for fine needle aspiration cytology (FNAC) for diagnosing a tuberculous pathology in the spleen . On histopathologic examination there will be epithelioid granulomas composed of aggregates of epithelioid cells, lymphocytes and Langhans giant cells with variable de 9

4,7,8,9

17,18

3,9,18

MBBS, DNB (Respiratory Diseases), FCCP (USA), Assistant Professor, Department of Pulmonary Medicine, Medical College, Thrissur, Kerala 68059 35

Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

Pictorial CME Journal of the Indian Medical Association, Vol 115, No 1, JANUARY 2017

LICHEN AMYLOIDOSIS

Fig 1 — CT abdomen showing multiple hypoechoic lesions of splenic tuberculosis Fig 3 — Granuloma with central caseation typical of tuberculosis

gree of central caseous necrosis involving both the red and white pulps (Figs 2,3,4). There are 5 types of pathomorphological classifications for splenic TB including miliary TB, nodularTB, tuberculous spleen abscess, calcific TB and mixed type TB.Tuberculosis should be considered as one of the differential diagnosis in patients presenting with FUO and splenomegaly especially in areas where the disease is prevalent . Splenic tuberculosis can even affect immunocompetent individuals . In patients presenting with FUO and splenomegaly, where an exact diagnosis could not be established after all possible and available investigations, splenectomy is strongly recommended for the diagnosis and further treatment. Empirical exposure to antituberculous drugs could be hazardous in these situations as it may mask a definite diagnosis later. At times such patients may not respond to antituberculous drugs and require splenectomy subsequently . 6, 11

CONCLUSION

Tuberculosis should be considered in the differential diagnosis of patients presenting with FUO and splenomegaly. Splenic tuberculosis can present in isolation without extrasplenic involvement, and even in immunocompetent individuals.

Fig 2 — Low power view of caseating granuloma of tuberculous splenic abscess (H&E Stain)

Fig 4 — Granuloma with Langerhan’s giant cell and epithelioid cells

REFERENCES

1 Prathmesh CS, Tamhankar AP, Rege SA — Splenic Tuberculosis and HIV-1 infection. Lancet 2002; 369: 353. 2 Thomson SR, Ghimenton F — Splenic Tuberculosis. Postgrad Med J 1999; 75: 578. 3 Chandra S, Srivastava DN, Gandhi D — Splenic tuberculosis: an unusual sonographic presentation. Int J Clin Pract 1999; 53: 318-9. 4 Adil A, Chikhaoui N, Ousehal A — Splenic Tuberculosis Apropos of 12 cases. Ann Radiol (Paris) 1995; 38: 403-7. 5 Singh B, Ramdial PK, Royeppen E — Isolated splenic tuberculosis. Trop Doct 2005; 35: 48-9. 6 Ho PL, Chim CS, Yuen KY — Isolated Splenic Tuberculosis presenting with pyrexia of unknown origin. Scand J Infect Dis 2000; 32: 700-1. 7 Sato T, Mori M, Inamatsu T — Isolated splenic tuberculosis. Nippon Ronen Igakkai Zasshi 1992; 29: 305-11. 8 Fernandez Miranda C, Perpina C kESSLERp, Torres N, Manion P, Dela Calle A — Hepatosplenic tuberculous abscess in a patient with polyarteritis nodosa. Am J Gastroenterol 1993; 88: 1297-8. 9 Sharma S, Dey AB, Agarwal N, Nagarkar KM, Gujral S — Tuberculosis : a rare cause of splenic abscess. J Assoc Physicians India 1999; 47: 740-1. (Continued on page 37)

A 53-year-old man presented with a 10-year history of itchy brownish skin eruptions over both shins. He gave history of scrubbing his legs with a pumice stone while bathing every day for many years. Cutaneous examination revealed multiple, 2 to 3-mm sized, light to dark brown-colored xerotic and hyperkeratotic papules present discretely and symmetrically over both shins, extending from the knees till dorsa of the feet (Fig 1). Rest of the body was spared. Except for the history of chronic friction and scratching due to the use of pumice stone, there was no history of preceding trauma, or any systemic symptoms. His medical and family histories were insignificant. Clinical possibilities of lichen amyloidosis, hypertrophic lichen planus, and prurigo nodularis were considered. Histopathology from skin biopsy revealed prominent hyperkeratosis, hypergranulosus, epidermal hyperplasia and dermal papillae filled with multiple eosinophilic globular amyloid deposits and sparse, superficial perivascular lymphocytic infiltrate (Fig 2). On Congo red staining, the globules produced apple-green birefringence under polarizing light, confirming them to be amyloid deposits. Laboratory investigations including Fig 1 — Discrete light to complete blood count, plasma dark brown-colored glucose, renal, hepatic, and thyroid hyperkeratotic papules over the shin of left leg function tests and urinalysis were normal. With the final diagnosis of lichen-variant of primary localized cutaneous amyloidosis (with secondary lichenification due to chronic scratching), patient was prescribed an ointment containing halobetasol (super-potent topical steroid) and 3% salicylic acid twice a day (1 month regularly followed by weekend therapy ie, twice a day on weekends with 5-day steroid free period, for 6 months),

Fig 2 — Histopathology revealing prominent hyperkeratosis, hypergranulosus, epidermal hyperplasia and dermal papillae filled with multiple eosinophilic globular deposits of amyloid and sparse superficial perivascular lymphocytic infiltrate (100X, hematoxylin & eosin). Arrow inside the inset (left inferior corner) points towards a prominent amyloid deposit (400X, hematoxylin & eosin)

oral acitretin 50 mg/day (6 months with monitoring of liver enzymes and serum lipids) and oral levocetrizine 5 mg at night for itching. He had marked improvement within 3 months of treatment and remains asymptomatic till one year follow-up. MD, DNB, MNAMS, Consultant Dermatologist & Dermatosurgeon, The Skin Clinic, Gurgaon 122009 MD, Senior Resident, Department of Dermatology & STD, UCMS-GTB Hospital, Delhi 110095 MD, Associate Professor, Department of Pathology, UCMS-GTB Hospital, Delhi 110095 1

Sonthalia Sidharth Arora Rahul Sharma Sonal

(Continued from page 37) 10 Bhansali SK — Abdominal tuberculosis: experiences with 300 cases. Am J Gastroenterol 1977; 67: 324-37. 11 Ho PL, Chim CS, Yuen KY — Isolated splenic tuberculosis presenting with pyrexia of unknown origin. Scand J Infect Dis 2000; 32: 700-1. 12 Wilde CC, Kueh YK — Case report: tuberculous hepatic and splenic abscess. Clin Radiol 1991; 43: 215-6. 13 Nayyar V, Ramakrishna B, Mathew G, Williams RR, Khanduri P — Response to antituberculous chemotherapy after splenectomy. J Intern Med 1993; 233: 81-3. 14 Suri R, Gupta S, Gupta SK, Singh K, Suri S — Ultrasound guided fine needle aspiration cytology in abdominal tuberculosis. Br J Radiol 1998; 71: 723-7.

15 Fooladi AAI, Hosseini MJ, Azizi T — Splenic tuberculosis: a case report. Int J Infect Dis 2009; 13: e273-5. 16 Ozgüroðlu M, Celik AF, Demir G, Aki H, Demirelli F, MandelN, Büyükünal E, Serdengeçti S, Berkarda B — Primary splenic tuberculosis in a patient with nasal angiocentric lymphoma:mimicking metastatic tumor on abdominal CT. J Clin Gastroenterol 1999; 29: 96-8. 17 Porcel-Martin A, Rendon-Unceta P, Bascunana-Quirell A — Focal splenic lesions in patients with AIDS: sonographic findings. Abdom Imaging 1998; 23: 196-200. 18 Jain A, Sharma AK, Kar P, Chaturvedi KU — Isolated splenic tuberculosis. J Assoc Physicians India 1993; 41: 605-6. 37

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