June 2017 by ejima

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JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, VOL 115, NO 6,

JUNE 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 06 u Kolkata u June 2017

CONTENTS Editorial : u Management of poor ovarian reserve — a challenge to gynaecologist

— Dilip Kumar Dutta ............................................................................................................5 Original Article : u Lower segment caesarean section comparison between Bupivacaine 0.5%

heavy 7.5mg with Bupivacaine 0.5% heavy 5mg + Fentanyl 25µg —a clinical study — Bhavna Sriramka, Narayan Sahoo, Sanjukta Panigrahi.....................................................8 Observational Studies : u Injuries during Dahi handi festival — Pradip S Nemade, Apoorva R Patwardhan, Sneha R Kale ...................................................................................................................................11 u Prevalence of obesity and its influencing factors among rural and urban school

children in Prakasam district of Andhra Pradesh, South India — Rama Kumari N, Bhaskara Raju I, Surya Prabha T, Patnaik A N ......................................15 u The 21st century revolution in the management of keratoconus — Ajay K.............................19 u Visit of 2nd professional MBBS students to Museum and Service Laboratories of Microbiology department — Nilotpal Banerjee...........................................23 u Filling and refilling — the melancholy of malaria since independence in India — Amitabha Sarkar, Sandip Ghosh.......................................................................................25 Case Reports : u A case of aorto-arteritis, presenting with recurrent hypertensive encephalopathy-

successively managed with renal angioplasty — Rajeev Bhardwaj, Praveen Bhardwaj........30 u Tuberculosis of calcaneum — a unique presentation — Vinod Kumar B P............................32 u Congenital malaria in a term neonate mimicking sepsis : a case report

— Birendra Nath Roy, Radheshyam Purkait, Tryambak Samanta, Suman Ghosh, Angshumitra Bandyopadhyay, Mridula Chatterjee...............................................................33 u Arterial thrombosis in a case of Mycoplasma Pneumonia with Protein S deficiency — Abhishek Parlikar, Rajashree Ratnaparke, Manjiri Vyawahare........................................35 Wcomments / Feedback 3

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JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, VOL 115, NO 6,

JUNE 2017

JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, VOL 115, NO 6,

Editorial

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

: : :

Hony Editor Hony Secretary Hony Associate Editors

: : :

Assistant Secretary

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), Kolkata Dr Dilip Kumar Dutta Dr Kakali Sen Dr Amitabha Bhattacharya Dr Dipanjan Bandyopadhyay Dr Gopal Das

MD, PhD, FRCOG (Hon), FICOG, FIAMS, FICMCH, MAMS, DACOG (USA), DPS (Germany) Chairman, Indian College of Obstetrics & Gynecology (2015) Dean, Indian Academyt of Obstetrics & Gynecology (IAOG) 2017 Vice Chairman, ISAR Bengal 2015-2017 National Editor of 'Jogi Journal' Director, GICE, Kalyani, Nadia, WB Author of 36 books (Obstetrics and Gynaecology) Honorary Editor, Journal of the Indian Medical Association (JIMA)

Dr Dilip Kumar Dutta

Management of poor ovarian reserve — a challenge to gynaecologist

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)

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)

varian reserve is a term that is used to determine the capacity of the ovary to provide eggs that are capable of fertilization, resulting in a healthy and successful pregnancy. Folliculogenesis, the developmental progression of an ovarian follicle from the primordial to the preovulatory state, is a key reproductive event in the female. The number of primordial follicles, which constitute the ovarian reserve at birth, the rate of replenishment during postnatal life, and the rate at which follicles are recruited dictate the functional ovarian life span of an individual (clinic in RM & ART). When the total number of follicles is less than normal at birth or there is increased rate of atresia before menopause, the ovaries will contain less number of follicles during childbearing age leading to a clinical condition of “poor ovarian reserve”. In addition, even if the follicular stock is normal, but sensitivity of follicular receptors to circulating gonadotropin in deficient, a similar state of low ovarian reserve will be the consequence. Also, suboptimal bioactivity of pituitary gonadotropin (which is found in elderly women) may also be responsible for poor ovarian reserve.

(A) The broad etiological factors of poor ovarian reserve are : (1) Low follicular stock (2) Accelerated atresia of the existing number of follicles. (3) Low follicular response to endogeneous or exogeneous gonadotropins (4) Low bioactive FSH (1) Low Follicular stock : The germ cells (oocytes) originating from hind gut and yolk sac of embryos at 6-7 weeks intrauterine life migrate to genital ridge where they multiply by mitotic division. By 12 weeks the number of germ cells (oocytes) becomes 6-7 million. This process is activated by fetal thymus. Hence hypoplasia or aplasia of the fetal thymus may lead to ovarian insufficiency, At 12 weeks of gestation the number of follicles becomes 6-7 million & remains in resting pool. At an interval of 70-80 days, cohort or follicles is selected from resting pool (primordial follicle) they grow and run for maturity and eventually become atretic. Before gonadotrophins are available, growth & development of follicles depend on a variety of factors locally produced and regulated important ones are – TGF B superfamily of proteins, activins, inhibins, AMH etc. After puberty the cohort of follicles recruited during the last 20 days of 80 days cycle (late luteral phase of previous cycle) few becomes gonadotropin sensitive through the action of GH, IGF-1, androgens and other unknown factors. Deficiency of these sensitizing factors may reduce the number of effective follicles, leading to ovarian insufficiency. (2) Accelerated atresia may be due : (a) Immunological — Autoimmune disease, addition’s disease, IDDM, Hypothyroidism. (b) Infective — Mumps, mycobacterium tuberculosis, cytomegalovirus (c) Metabolic — Galactose-I – phosphate uridyl transferase

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(d) Iatrogenic — Lap, ovarian drilling, oophorectomy, chemotherapy (Alkylating agents and cyclophosphamide). (e) Chromosomal — Turner (45XO), super females (47XXX) (f) Genetic — X fragile syndrome, BPES syndrome (3) Low follicular response to endogenous or exogenous gonadotrophins : Savage syndrome (resistance ovarian syndrome). (4) Low bioactive FSH : Dysfunction is primarily due to receptor defect in the follicular wall or may be because of dificiency of synthesis and release of normal amount of bioactive pituitary gonadotropin.

(B) How we can Diagnose : Two types of markers – (a) Conventional markers – (i) Age > 45 years, (ii) Basal FSH, oestradiol, inhibin level, antral follicle count, (iii) Measurement of ovarian volume, (iv) Clomiphene citrate challenge test (CCCT). (b) Additonal markers – (i) Anti-mullerian hormone, (ii) Basal plasma androgen measurement, (iii) Insulin resistant (IR) assessment.

(C) How to manage : Practically management of poor ovarian responders is difficult. At the moment, no uniform and standard effective agent has been established. In fact a positive impact of different protocols reviewed in literature for the treatment of ‘poor ovarian responders’ is negligible. Principles of Therapeutic approaches : (a)

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Modification of the existing protocol, (b) Pharmacological manipulation of endocrine profile in both follicular and luteal phases of the treatment cycle with innovative protocols, (c) Oocyte donation, (d) Surrogacy. Management of poor responders : (a) Cycle cancellation, (b) Low pregnancy rate, (c) Cost. Poor response may be ovarian or endometrial. Practical points to remember for improvement of results in poor responders : For improvement of result it is crucial to acquire maximum clinical expertise and experience. In addition, the following important points are to be noted: (a) Higher dose of gonadotropin (maximum 300-450 IU). (b) Long GnRH agonist protocol; still preferable with following modifications : (i) Preceding luteal phase progesterone with GnRH agonist (to prevent recruitment of asynchronous follicles), (ii) Mini-dose GnRH agonist, (iii) Stop protocol GnRH agonist. (c) OC pretreatment followed by short agonist or microflare protocol. (d) Failure to respond to long or short GnRH protocol, before cencelation one should try either stop protocol or antagonist protocol or modified natural cycle protocol. (e) Addition of LH is must in final stage of stimulation (D5/D6 onwards). (f) Androgen supplementation or pretreatment with DHEA or addition or rLH in elderly women is theoretically preferably but they require further studies.

____________________________________________________________ Source : Clinics in Reproductive Medicine and ART by Prof B N Chakraborty

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

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JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, VOL 115, NO 6,

JUNE 2017

JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, VOL 115, NO 6,

Original Article Lower segment caesarean section comparison between Bupivacaine 0.5% heavy 7.5mg with Bupivacaine 0.5% heavy 5mg + Fentanyl 25µg — a clinical study 1

Bhavna Sriramka , Narayan Sahoo , Sanjukta Panigrahi

Spinal anaesthesia is the preferred type of anaesthesia in caesarean section by most of the anesthesiologists, be it elective or emergency. The impediments to the effective use of spinal anaesthesia are the unpredictable decreases in the arterial blood pressure and heart rate. These adverse effects of spinal anaesthesia can be curbed by lowering the dosage of local anesthetic and mixing with additive like epinephrine, clonidine, fentanyl, and sufentanil. This study is designed to determine the efficacy of spinal anaesthesia with low dose Bupivacaine with additive Fentanyl. Study were performed on 100 parturients divided into two groups B and BF, who received intrathecal Bupivacaine (0.5% heavy) 7.5 mg and Bupivacaine (0.5% heavy) 5 mg + fentanyl 25 µg respectively. The parameters taken into consideration were level of sensory block, time taken for highest block, hemodynamic stability, visceral pain, nausea / vomiting, shivering and pruritus. Level of sensory block is higher and time taken for highest block is faster in group BF when compared to B. There is a significant change in systolic blood pressure in group B. Incidence of visceral pain and nausea/vomiting is much less in group BF when compared to group B. Pruritus was noted in only two case in group BF and none in group B. Low dose of Bupivacaine (0.5% heavy, 5 mg) + fentanyl 25 µg injected intrathecally act synergistically to reduce the requirement of local anesthetic and provide better hemodynamic stability with lesser side effects. [J Indian Med Assoc 2017; 115: 8-10 & 18]

Key words : Spinal anaesthesia, parturients; bupivacaine, fentanyl, level of block, blood pressure.

elivery of a baby by caesarean section has become increasingly common with rates of rising to 1030% in the past decade alone . Obstetric anesthetists face the unique challenge of proving anesthesia which is safe both for the mother and the unborn baby. There has been a move towards more cesarean section being performed under regional than general anesthesia . Newer techniques of regional anesthesia like combined spinal epidural, continuous spinal anesthesia offer specific advantages yet spinal anesthesia remains the most widely used means for cesarean section . It offers many advantages apart from being simple to perform, economical, highly efficient, yet rapid in onset to be used in the urgent or emergency cesarean section. However, it has limitations likehypotension, a finite duration of anesthesia, and lesser control of block height . An approach has been adapted to minimize these by using very small or titrated doses of local anesthetic . Many a times low dosage local anesthetic for spinal block may not provide acceptable anesthesia . Opioids and local anesthetics administered together intrathecally have a potent synergistic a n a l g e s i c e ff e c t . T h u s w h e n o p i o i d s a r e 1,2

3,4

6,7,8

8,9

6,10

Department of Anesthesia, Ispat General Hospital, Rourkela 769002 1 DA, DNB Resident 2 MD, Senior consultant and head of the department 3 MD, Senior consultant

position during 15-30 minutes and the baseline blood pressure, heart rate, were noted. Subarachnoid injection was performed in the sitting position using a 25gauge Quincke needle positioned midline at the L3-L4 interspace. After aspiration of drop of CSF the drug was injected. After injection the patient was immediately returned to the supine position, in 15-30 degrees head down, with left uterine displacement. The systolic & diastolic BP, HR was recorded every one minute up to the birth of neonate and then every five minutes, thereafter using an automated non-invasive device. Hypotension was defined as a systolic blood pressure of less than 100 mmHg, or a decline of 20% from baseline . Hypotension was treated promptly by increasing left uterine displacement and the rate of fluid administration with IV ephedrine 2.55 mg and repeated if hypotension persisted after 2-3 minutes. Sensory block was tested by pinprick in mid-clavicular line using a 23-gauge hypodermic needle after spinal anaesthesia. Surgical incision was allowed when the block reached T6. Sensory block was assessed at 3 min and every 30 sec after that. Highest level of sensory block was recorded. The time taken for highest level of sensory block was also recorded. Degree of motor block was assessed by using Bromage scale. Intraoperative pain was checked using visual analog score whenever the parturient complained of pain or discomfort. Each time when visual analog score exceeded 3, Inj. Pentazocine 15 mg was injected intravenous as analgesic if the baby delivery had been completed and if the baby had not been delivered then patient was converted to general anesthesia and excluded from study. The systolic & diastolic BP, HR, number of hypotension episodes, number of ephedrine usage, total ephedrine dose for each patient and intraoperative patient complaints like nausea, vomiting, pruritus, itching, shivering was recorded. The condition of the neonates was assessed by Apgar score. Statistical analysis was performed using Chi-square / Fisher Exact test. Results were considered significant at P = <0.05.

coupled with sub therapeutic doses of local anesthetic, it may be possible to achieve successful spinal anesthesia using otherwise inadequate doses of local anesthetic . This study is designed to determine the efficacy of spinal anaesthesia using low dose bupivacaine with additive fentanyl in terms of hemodynamic stability and the level of block achieved. 7

MATERIALS AND METHODS

The study was cleared from the Ethics Committee and written consent was taken from patients who participated in this study. All the patients taken for this study belonged to ASA grade 1 or 2. None of the patients had any contradiction for spinal anesthesia. Complicated pregnancies such as multiple pregnancies, pregnancy induced hypertension and placenta previa were excluded. Also the antenatal patients with acute fetal distress were excluded, keeping the respiratory depressant effect of fentanyl in mind. Prospective single blind study was performed on 100 parturients. They are divided into 2 groups - Group B and Group BF of 50 each. The first group (Group B) received Inj. Bupivacaine 0.5% heavy 7.5 mg intrathecal. The second group (Group BF) received Inj. Bupivacaine 0.5% heavy 5 mg with addition of preservative free fentanyl 25 µg intrathecal. Before block each patient received a rapid infusion of 8ml/kg of lactated ringer's solution, in left lateral

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parturients had bradycardia (<60) intraoperatively. Systolic blood pressure of both the groups showed statistically significant change in systolic blood pressure at 3, 9, 15, 30, 60 and 90. Graph shows that fall in systolic blood pressure was steeper in Group B when compared to Group BF and the rise is faster in Group BF when compared to Group B after 6 minutes (Fig 2). The diastolic blood pressure values were comparable in both groups (Fig 3). 28% in group B received Inj. Ephedrine (4.8mg, p value 0.006) in Group B compared to 10% in Group BF (3mg). 12% (n=6) of the parturients in Group B experienced a pain of VAS Score 4 and none of the parturients in Group BF experienced this score of pain ( p value 0.003). The Apgar score is remained clinically insignificant in the two groups (p value 1.3). Two patients in Group BF complained of pruritus but did not require medication. 12% (n=6) of parturients in Group B complained of nausea/vomiting when compared to 4% in Group BF (Table 2). DISCUSSION

Anaesthesia remains responsible for approximately 5%-12% of all maternal deaths during surgery . General an12

Table 1 — Comparison of demographic profile of the two groups Group B

Group BF

Age in years ±SD 24.21 ± 5.13 23.85 ± 5.34 BMI ±SD 25.2 ± 3..3 24.2 ± 3.0 Time of spinal in min ±SD 5.5 ± 0.5 4.35 ± 0.5 Pulse rate ±SD 98.4 ± 4.2 99.6 ± 3.8 Baseline systolic BP in mm ±SD 128.2 ± 8.4 126.4 ± 10.6 Baseline diastolic BP in mm ±SD 84.4 ± 6.4 82.6 ± 8.4

P Value 0.76 0.37 0.45 0.22 0.32 0.43

OBSERVATIONS

The demographic data in both groups were similar and there were not significant differences. Age, BMI, time from spinal anesthesia to starting surgery, baseline heart rate, systolic blood pressure and diastolic blood pressure were recorded in both groups and results were compared with T-test (Table 1). 72% of Group BF attained the sensory level of aboveT5 (60% at T5 and 12% at T4) and only 48% of Group B attained a sensory level aboveT5 (44% at T5 and 4% at T4, Fig 1). The time taken for highest block in Group B was 5.50 ± 0.5 min and time taken for highest block in Group BF is 4.35 ± 0.5 min (mean ± SD). All the parturients had a motor block of scale 3 and only 2 of parturients of group BF had a motor block of scale 2 (p value 1.0). Pulse rate changed at 30, 4, 60 minutes, however it was clinically insignificant as there was a difference of around 5 beats/min only. None of the

Fig 1 — Level of sensory block

Fig 2 — Comparison of Systolic BP between the two groups

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esthesia is associated with higher mortality rate in comparison to regional anesthesia . However, regional anesthesia is not without risk. Deaths in regional anesthesia are primarily related to excessive high regional blocks and toxicity of local anesthetics . Reduction in doses and improvement in technique to avoid higher block levels and heightened awareness to the toxicity of local anesthetics have contributed to the reduction of complications related with regional anesthesia . Spinal anaesthesia is simpler to perform and presence of CSF provides a more certain end point and higher success rate than epidural anaesthesia . The rapid onset of spinal anaesthesia allows it to be used for most urgent emergency caesarean section. Bupivacaine 0.5% heavy is most commonly used drug for spinal anaesthesia. It was decided to combine it with intrathecal fentanyl to provide adequate depth of anesthesia with lesser doses. Fentanyl is a lipophilic opioid and is preferred for having a rapid onset and short duration of action with lesser incidence of respiratory depressions. The difference in demographic data between two groups weren't significant (Table 1), so the two groups were comparable. In our present study all the patients attained a sensory level of above T6. In group BF majority attained a level of T5 whereas in group B majority attained T6. Highest sensory block is attained faster in Group BF (4.35 minutes compared to 5.48 min. Shende D et al had similar trend in their study though the average time taken in the two groups is 2 minutes more when compared with our study. This variation in average time may be because of higher dose of fentanyl used in our study (25µg) compared with 12

JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, VOL 115, NO 6,

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their study (15µg) and also the average height and weight is lower in our study. All parturients except 2 in BF group had a motor blockade of 3. Jaishri Bogra et al , Pederson et al had found no difference in the pattern of motor blockade. This result may be attributable to the fact that we used a very low dose of Bupivacaine 5 mg with 25µg of fentanyl which none of the studies used. Pulse rate was comparable and statistically insignificant in two groups and none of the patients experienced bradycardia. The incidence was 7% in the study by Jaishri Bogra et al and similarly in Singh et al . We used low dose bupivacaine in both groups and to the fact that severity of hypotension was also less in our study. Seyedhejazi et al had in their series noted 30% of their patient who receives 8mg bupivacaine plus 10mg fentanyl suffered from intraoperative hypotension requiring supplemental epinephrine compared to 70% when only 12mg bupivacaine was used. Bruce Ben-David studied 32 women undergoing cesarean section with spinal anesthesia, and their study showed that a mini dose of 5mg bupivacaine in combination with 20mg fentanyl provides successful spinal anesthesia and cause less hypotension, vasopressor requirement and nausea than 10mg bupivacaine. Similarly Chung and co-workers reported that the incidences of hypotension in patients given 1011mg bupivacaine (Group-I) was significantly higher than in group received 8-9mg bupivacaine (Group-II) but the efficacy of intraoperative analgesia in group I was significantly better than group II.6. Visceral pain is a common problem during spinal anesthesia. In our study, 26 parturients in Group B complained of pain and only 8% in Group BF. Rescue analgesia was used in 12% o patients in Group B but none in BF. Intraoperative analgesia was good in BF when compared to B. It was clear from the study conducted by Penderson et al that by increasing the dose of bupivacaine did not help much in abolishment of visceral pain completely. Jaishri Bogra et al , Choi found in their study that Bupivacaine alone could not completely removed the visceral pain. Bupivacaine fentanyl combination provided better depth of anesthesia. Nausea and vomiting during spinal anesthesia may be related to a postural hypotension and hypoxemia of the vomiting center, excessive rise in blood pressure following administration of a vasopressor is also to produce nausea10. In the present study, 12% in group B complained of nausea and vomiting when compared to 3% in group BF. Two patients experienced pruritus in Group BF, however none required any medication. Randalls et al , Seyedhejazi et al found significant reduction in the incidence of nausea by the addition of fentanyl to bupivacaine Also, the Apgar score of the babies remained same in all the groups.

Complications

Bradycardia Hypotension Nausea/vomiting Pruritis Shivering Coversion to GA

Group B (n=50)

Group BF (n=50)

No.

0 14 6 0 0 0

0.0 28 12 0.0 0.0 0.0

0 5 2 2 0 0

0.0 10 4 4 0.0 0.0

P value

0.002 0.074 1.10 -

Observational Study

Injuries during Dahi handi festival Pradip S Nemade1, Apoorva R Patwardhan2, Sneha R Kale3 Injuries related to the ethnic Hindu festival of Dahi handi have seen a spurring growth in the past few years. To understand this alarming situation better, we decided to study the possible causes of injuries among the participants of human pyramid in the festival. This cross sectional study was conducted for the first time at Seth G S Medical College and KEM Hospital on 124 patients who were part of a human pyramid during the festival. The data was collected on a pre planned case record form and was analyzed by SPSS program. Of the 124 patients, 14 injured were minors. 46 patients among them suffered major injuries while 78 had minor injuries. 39(31.4%) were diagnosed with fractures; out of them 3 had spine fractures. 10 patients had head injury with one fatality among them. 56.1% patients reported in the evening. 58.9% injured participants were part of the pyramid constructed to reach the dahi handi placed 30 feet above the ground. 51.8% participants were part of the middle layers of the pyramid. 83% participants suffered injury during descent after collapse of the pyramid .The main mechanism of injury was due to the fall of a participant from upstream layers upon the participant beneath him. For minimizing injuries, a committee needs to be formed for formulating safety guidelines and precautionary measures during the festival. Emphasis should be given upon restricting the maximum height of dahi handi and safe descent technique. Changing the ladder form of hollow human pyramid to a triplet ladder pattern can also be given a consideration.

Table 2 — Comparison of complications of two groups

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Fig 3 — Comparision of Diastolic BP between the two groups

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CONCLUSION

Low dose of Bupivacaine 0.5% heavy (7.5 mg) injected intrathecally reduces the side effects caused by (Continued on page18)

[J Indian Med Assoc 2017; 115: 11-4]

Key words : Dahi handi, Injury, Indian festivals, Human pyramid.

ahi Handi is a popular aspect of Janmashtami, a Hindu festival marking the birth of Lord Krishna . It is celebrated amidst revelry recalling the little Krishna scrambling upon his friends forming a human pyramid to reach the Dahi handi (Curd Pot). The pot contains a mixture of curd, milk, dry fruits etc. which is hung by means of a rope at a suitable height. Bands of youth take up the challenge of reaching these pots by forming human pyramids. (Fig 1) Prizes are distributed to the participants for breaking the pot. The festival promotes team work and the importance of physical fitness, agility, concentration and psychomotor skills . However in recent times, the event has gathered a political one-upmanship and commercialization . Huge sums are being offered as prize money. The highest amount offered increased from `11 lakhs in 2007 to ` 75 lakhs in 2010 . To make the whole celebration a grand affair, the height of dahi handi is being raised. At a few places, dahi handi is raised to an astronomical height of 50 feet . Large number of mandals (teams) participate in this venture for the lure of money. Around 700 govinda (participant) troops compete each year for prizes for over 4000 dahi handis in Mumbai . 1

Being a mega sport event, this human pyramid formation also carries high risk of injury. Each year many govindas get injured in this adventurous sport and suffer minor to m a j o r a n d sometimes fatal injuries . In 2007 three major municipal hospitals in Mumbai treated n e a r l y 2 0 0 Fig 1 — Human pyramid formed to break participants injured the dahi handi. The topmost layer often is formed by a light weight child in this festival . These injuries have become a major source of concern in recent years and various measures such as restricting the height of dahi handi , banning children to take part , use of helmets , padding , turfs etc are suggested to minimize these injuries. It is still unclear as to what extent this safety measures are useful in cutting down dahi handi related injuries. In view of above findings, a cross- sectional study was 5,7-9

Department of Orthopaedics, Seth G S Medical College and K E M Hospital, Mumbai 400012 1 MS, Assistant Professor 2 MBBS, MS (Ortho) Student, Resident 3 BPTh Intern, Department of Physiotherapy

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conducted in a major municipal hospital in Mumbai to find out the factors related to injuries during this festival, so that preventive guidelines and safety measures can be formulated. This is a first attempt to analyze the injuries in dahi handi festival. MATERIALS AND METHODS Our hospital treated 139 patients injured during dahi handi festival in September 2010. This included participants directly related to collapse of pyramid as well as unrelated to it. The participants related to collapse of pyramid were reviewed based on a pre planned case record form (Annexure 1). The form was filled by the investigators based on the information gathered from the patients and the accompanying persons at the time of presentation. The clinical data regarding the nature of injury was obtained from the hospital records. Depending upon age, the patients were divided into three groups: below 15 years, 15-30 years and above 30 years. Injuries such as sprains, lacerated wounds, abrasions were classified as minor injuries; whereas injuries such as fractures, chest and abdominal injuries, head injuries, fatalities were classified as major injuries. Based upon the time of injury, patients were divided into morning (before 12 pm), afternoon (12pm to 6 pm) and evening (after 6 pm) groups. Patients were inquired about the approximate height at which the dahi handi was hung above the ground. The number of human layers in the pyramid and patient position in the pyramid was also inquired. Patients were classified into two groups; based upon whether the collapse of the pyramid occurred during formation of pyramid or during descent. Injuries sustained were either during direct impact due to fall from height or due to impact of other participants falling from layers above upon the patient. Patients were inquired about these modes of injuries (Figs 2 & 3). The statistical analysis was performed using SPSS software (version 16.0; SPSS, Inc, Chicago, IL).

Annexure 1 CASE RECORD FORM No. :________________________________________________ Name (Optional) :_____________________________________ Age : ___________ Sex : __________ Type of Injury : ____________________________________ (1) Abrasion, (2) Sprains, (3) Lacerated wound, (4) Head injury, (5) Fractures, (6) Death If Fracture present: (1) Long bone: __________ (2) Spine: __________ (3) Other: ___________ Timing of Injury : (1) morning (2) afternoon (3) evening Occurrence of Injury : (1) While forming Pyramid (2) While descending down Height of Pyramid (in feet) : No. of human layers in the pyramid : Patient Present in which layer : Mechanism of injury : (1) fall from height, (2) somebody falling on body (3) Others (pls specify):

JOURNAL OF THE INDIAN MEDICAL ASSOCIATION, VOL 115, NO 6,

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In our study of the 139 participants, 124 participants were directly involved with the collapse of human pyramid and 15 participants were unrelated to collapse of pyramid. The data analysis of these 124 patients is shown in Table 1.

With the exception of 2, almost all of the participants [122 (98.4%)] were males. The two female participants (both 10 years of age) were belonging to the topmost layer of human pyramid.

Fig 2 — Layer wise patient position

Of all the injuries related to collapse of pyramid, 46(37.1%) were major injuries and 78(62.9%) were minor injuries. There were total 39 patients diagnosed with fractures. Among them, 19 patients had long bone fractures, 3 patients had spine fractures (two cervical and one dorso lumbar), and one of them was diagnosed with paraplegia. There were 10 patients having head injury and one of them subsequently died.

When grouped as per the height of dahi handi, more than half of the injured participants 73(58.9%) were part of the pyramid made to reach the dahi handi placed above 30 feet off the ground and 51 (41.1%) injured participants were part of the pyramid made to reach the dahi handi placed within 30 feet above the ground.

Fig 3 — Time of Injury

breakage of dahi handi while only 21(16.9%) were injured during formation of pyramid. Considering the modes of injuries, around 40(32%) had direct impact injuries due to fall from height, 66(53%) had indirect impact injuries due to fall of another person from layers above and only 2(1.6%) had both direct and indirect injuries. DISCUSSION

From being a community based festival celebrated in wadis of Mumbai 150 years back , Dahi Handi in recent times has transformed itself into highly technical and skill demanding sport . The human pyramids formed are a spectacle worth watching but they carry a high risk of injury. Several attempts to form a pyramid may fail and result in minor, major or sometimes fatal injuries. The number of fractures and head injuries noted in our study reflected the gravity of the alarming situation. These injuries can be grave or may result in permanent disability, as in our study where one patient was brought dead following head injury and one had paraplegia. People from all age groups involved in formation of pyramid are prone to injuries. The topmost layer of pyramid is formed by light weight children who break the handi , while middle and basal layers are formed by strong, tall muscular men . The youngest subject in our study was a 7 year old child who was at the top most layer and the oldest subject being 50 years of age was part of the supportive layer. 69.4% subjects belonged to age group of 16-30 years, this being a direct showcase of predominant youth participation in this festival. The percentage of minors injured is also alarming. In previous reports 7.8% 11

Majority of participants [72 (51.8%)] were part of middle layers .The second, third and fourth layer together constituted almost half of the total number of participants presented to the hospital. Injuries during the festival were seen mostly during descent from the pyramid. Of all the participants, 103(83.1%) suffered injury while descending down after Table 1 — Data analysis of these patients Parameter

Groups

Age Below 15/15-30/above 30 Sex M/F Injuries Minor/Major Time of Injury Morning/Afternoon/Evening Height of dahi handi 30 feet or less/above 30 feet Layer wise position of patient 1/2/3/4/5/6/7 Mode of pyramid collapse Formation/Decent Mechanism of Fall from height/ fall of injury other person on body/both

Results (out of 124) 14/86/24 122/2 46/78 15/46/78 51/73 26/23/34/15/7/10/1 21/103 40/66/2

| 13

minors were injured while we found that in our study 11.3% of participants injured were below 15 years of age. Dahi handi has always been a male dominated festival. But recently the female participation also has increased. Few teams comprise of exclusively female participants . Also the topmost layer participant is often a female child with the skill and flexibility to climb upon all the layers of pyramid to reach the top. In this study the only two female participants had minor injuries and were part of the topmost layers. Hundreds of dahi handis are set up across the city at different locations which are broken throughout the day by the govinda troops. In the morning, local teams set out to break the dahi handis in nearby locality. Such teams usually comprise of few number of participants who are untrained managing to construct a pyramid only upto 3-4 layers. Maximum dahi handis across the city are placed at a height of 25-30 feet, requiring human pyramid formation up to 5-6 layers to break them. Teams with an intention of breaking such dahi handis begin their quest in the afternoon and try to break as many dahi handis one after another. As the day passes, the participants get tired travelling across the city breaking many dahi handis. Gradually fatigue sets in the later part of the day which increases the susceptibility to get injured. The dahi handis placed at an astronomical height of around 40 feet have a huge glamour quotient attached to them. The teams set out to break these dahi handis comprise of 100-150 participants who have been trained by professionals to construct pyramids with 7-8 layers. In this study, 89.2% injuries have occurred in the afternoon and evening time which can be accounted for the fatigue factor and breaking of dahi handis placed at astronomical heights especially in the evening. As seen in our study 83.9% injuries have occurred during descent phase ie, while climbing down after breaking the pot. The reasons for this can be explained as follows:(1) During formation of the pyramid the concentration level among the participants is high. After breaking the dahi handi pot, there is excitement in the whole atmosphere. The participants in the lower layers wanting to catch a glimpse get uneasy, break the formation causing sudden collapse of the pyramid. (2) During formation of pyramid the rectification of error is possible by taking a temporary pause till the pyramid stabilizes. However during descent any error leads to subsequent collapse of the pyramid. (3) People in the lower layers wear supportive gear in the form of harnesses attached to their bodies upon which participants in the upper layer get a foothold during climbing. During descent no such supportive gear can be utilized. (4) During formation of pyramid, participants climb upon the lower layer under direct vision in forward direction, while during descent the participant lays his foot blindly upon the shoulder of the person in the lower layer in a backward direction which increases the chances of errors and subsequent collapse. 11,13

The average age of 124 participants included in the study was found to be 23.6 years (range 7-50 years). Majority of the participants [86 (69.4%)] were between 15-30 years of age, 24 (19.4%) were above 30 years of age and 14 (11.3%) were less than 15 years of age.

More participants were injured as the day progressed. Around 15 (10.8%) were injured in the morning, 46(33.1%) were injured in the afternoon and more than half [78(56.1%)] were injured in the evening.

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(5) During formation, less number of layers are formed thus injuring less number of participants if the pyramid collapses. While during descent if the pyramid breaks, more number of layers being already formed injures more number of participants. We suggest that during practice sessions emphasis should be laid upon safe descent practices to reduce the number of injuries. Preventive measures such as safety nets, padding can be employed. Also extra incentives should be given to the team who descend perfectly without collapsing. Participants in all layers are susceptible to injuries by different mechanisms. Participants in higher layer get injured due to direct fall from height whereas participants in basal layer get injured due to fall of participants in the higher layers on their body. Participants in middle layers are susceptible to injury by both the above mechanisms. The main mechanism noted in our study was injury due to fall of participant in the higher layer on their body. It comprised of 65.8% of total injuries. About 70.5% of injured participants were from first to fourth layer of the pyramid. Dahi handi placed at astronomical heights involves large number of participants to form pyramid which can cause lack of co-ordination and errors thus increasing the likelihood of pyramid breakage. Our study supported the similar findings with more number of injured participants being a part of the pyramid made to break the dahi handi hung more than 30 feet high above the ground. The height of dahi handi is an important factor for incidence of injuries. However in contrast to general perception that increase in the height of dahi handi causes more number of injuries to topmost layers, in our study we have seen that majority of the participants injured were from the middle layers. This can be due to the reasons stated above. Injuries unrelated to human pyramid formation can be due to multiple reasons. Three patients in our study were injured due to the piece of broken dahi handi pot. Few participants travel ahead for early reservation at dahi handi sites. Excitement and hurry in this process leads to the vehicular accidents. Five such patients were encountered in our study. The major limitations of our study is that it was conducted at a referral center, thus only the injured participants referred to our hospital are studied .Also many other factors like the amount of training taken by the participants and possibility of being under the influence of alcohol can relate to the incidence of injuries. These were difficult to quantify and hence not included in the study.

descent practices and restricting the maximum height of dahi handi. Other supportive measures such as helmets, floor padding may be employed, these measures though helpful cannot be completely relied upon to prevent injuries. As majority of injuries are minor injuries, on site first aid centers should be provided by the organizers as it will decrease the burden on hospitals. Changing the form of ladder from hollow pyramidal shape to triplet ladder pattern should be given a consideration as it involves less number of participants and is mechanically more stable .

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Observational Study Prevalence of obesity and its influencing factors among rural and urban school children in Prakasam district of Andhra Pradesh, South India

6 7

CONCLUSION

Dahi handi, celebrated on a mega scale involves large participation of young people in the festival and carries high risk of injury. Majority of injuries occur during descent mostly due to fall of participants in the top layer upon the body of middle layer participants. For minimizing injuries emphasis should be laid upon safe

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REFERENCES Yeolekar ME, Bavdekar SB — Indian festivals: Ethos and health impact. J Postgrad Med 2007; 53: 219-20 (Accessed on 18/03/2011). Commercialization of Indian festivals. http://english. ohmynews.com/articleview/article_view.asp?menu= c10400&no=380272&rel_no=1 (Accessed on 18/03/2011). DJs, fashion shows will rock Govinda this year. http://www.mumbaimirror.com/index.aspx?Page=article&s ectname= News%20-%20City&sectid=2&contentid= 20070830200708300311104683677180 (Accessed on 18/03/2011). Dahi handi becomes a multi-crore festival. http://www.indiatribune.com/index.php?option=com_conte nt&view= article&id=3742:dahi-handi-becomes-a-multicrore-festival& catid=122:politics&Itemid=488(Accessed on 18/03/2011). Injuries spur calls to lower HEIGHT OF HANDIS. http://lite.epaper.timesofindia.com/mobile.aspx?article=yes &pageid= 7&edlabel=TOIM&mydateHid=04-092010&pubname= &edname=&articleid=Ar00700&format= &publabel=TOI (Accessed on 18/03/2011). Krishana Janamastami. http://en.wikipedia.org /wiki/Krishna_Janmashtami (Accessed on 18/03/2011). Stop kids from taking part in dahi-handi: PIL http://articles.timesofindia.indiatimes.com/2009-0730/mumbai/28166372_1_dahi-handi-human-pyramidsminors (Accessed on 18/03/2011). This four govindas will not walk again. http://www.mumbaimirror.com/printarticle.aspx?page= comments&action=translate&sectid=15&contentid= 20100907201009070255319954fe7ac13& subsite= (Accessed on 18/03/2011). Cap height of dahi handis, says state.http:// www.hindustantimes.com/tabloid-news/mumbai/Capheight-of-dahi-handis-says-state/Article1-598725.aspx (Accessed on 18/03/2011). Over 200 ‘Govindas’ injured during ‘Dahi Handi’ celebrations. http://news.oneindia.in/2007/09/05/over-200govindas-injured-during-dahi-handi-celebrations1189001291.html (Accessed on 18/03/2011). Youth scramble for ‘dahi handi’ fest in Mumbai. http://www.merinews.com/article/youth-scramble-for-dahihandi-fest-in-mumbai/139964.shtml (Accessed on 18/03/2011). Govinda sport. http://en.wikipedia.org/wiki/Govinda_sport (Accessed on 18/03/2011). Women to compete for dahi-handi supremacy. http://www.3dsyndication.com/showarticle.aspx?nid=DNA HM35095 (Accessed on 18/03/2011).

Rama Kumari N , Bhaskara Raju I , Surya Prabha T , Patnaik A N

To determine the Prevalence of Obesity among the rural and urban school children aged between 5-16 years in Prakasam District of Andhra Pradesh and to identify the factors influencing childhood Obesity. A cross sectional study followed by a case control study was conducted between February and April 2011. A total of 4213 school children between 5 and 16 years of age were enrolled and data on family history of obesity, dietary habits and physical activity was collected. 1177 students were from rural schools and 3036 from urban schools. Out of 4213 school children, 182 were Obese. The prevalence of Obesity was 4.32%. Prevalence was more in urban school children (4.7%) than in rural school children (3.23%). Snacking of high energy food taken by urban school children was associated with obesity even if the intake was once a week (P<0.002), 2-3 times a week (P<0.001) or daily (P<0.000). Less physical activity was associated with obesity in urban school children (P<0.05). The study concluded that obesity was statistically significant in urban school children than in rural school children. The childhood obesity was associated with consumption of high energy foods and sedentary life styles, brought into light new facts that eating habits and physical activity was not associated with childhood obesity in rural schools, were family history alone was significantly associated. In urban schools, however, consumption of high energy foods and reduced physical activity was significantly associated with childhood obesity. [J Indian Med Assoc 2017; 115: 15-8]

Key words : Childhood Obesity, Junk foods, Physical activity.

ndia was undergoing a rapid epidemiological transition¹. The burden of chronic diseases was overtaking the burden of infectious disease². The World Health Organization designated obesity as a global epidemic². 50-80% of obese children will continue as obese adults³, with all the attendant health risks , such as dyslipidemia, hyperinsulinemia, type 2 diabetes, hypertension, cardiovascular diseases , arthritis, and behavioral problems. Globally the prevalence of childhood obesity varies from over 30% in USA to less than 2% in sub-Saharan Africa. Currently the prevalence of obese school children was 20% in UK and Australia, 15.8% in Saudi Arabia, 15.6% in Thailand, 10% in Japan and 7.8% in Iran . A study of childhood obesity in Pune, Maharashtra showed prevalence of 5.7% . A similar study conducted in Chennai in South India showed obesity prevalence of 3% . With this background in mind, the presence study was undertaken in a remote coastal district of Andhra Pradesh (Prakasam District), where no such studies have been 4,5

7,8

Department of Cardiology, Nizam’s Institute of Medical Sciences, Hyderbad 500 082 MBBS, MD (Med), DM (Cardiol), Associate Professor MBBS, MS, M Phil (Health Systems Management), Professor, Department of Surgery, Gandhi Medical College, Hyderabad 500029 MBBS, MD, DM, (Neurol), Assistant Professor of Neurology MBBS, MD, DM (Cardiol), Addl Professor of Cardiology 1

done. The objective of the study was to know the prevalence of Obesity in both rural and urban school children and to identify the factors influencing childhood obesity. Research Methods and Procedures Study design and Sample size: This was a cross sectional and institutional study and adapted stratified random sampling procedure. The sample size was calculated assuming the prevalence of obesity as children with 95th percentile of Body Mass Index (BMI). The sample size was 4213 of which 1177 children were from rural schools and 3036 from urban schools. The study was conducted between February and April 2011. The principal investigator stayed in Ongole Mandal for nearly two months to complete the study. The survey team consisted of Principal investigator, 6 ANMs and 2 Coordinators. The study was done in two phases: Cross sectional study, where we found the prevalence rate of obesity. It was followed by case control study; where we studied the influencing factors of obesity both in case and controls with appropriate matching. Subjects: The subjects were students between 5-16 years of age in Prakasam district of Andhra Pradesh, Southern state of India. Ongole was a district headquarters of Prakasam District. As of 2001 India census, Ongole had a

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population of 149,589. Ongole has grown in the last decade and currently the city was estimated to have a population of around 1.54 lakhs (App.). Over the years it has developed into a city with good schools and colleges. Lately, the quality of education has become quite good and was comparable to that of most cities in the state. Ongole has a large Hindu population followed by Muslim and Christian population. Approximately 73% of the population lives in rural areas, subsisting mainly on agriculture. From the selected school all the children were recruited for this study. All the school children participated in the study. Attendance rate was 96%. Data Collection: The Institutional Ethical Review board approved the study protocol, and the survey team visited the school after informing the District Collector, District Medical and Health Officer, District Educational Officer and the Head Masters of the school. Informed consent was taken from the parents of the students. The house hold socioeconomic and demographic data such as community, literacy status and occupation of father and mother collected from children, the same was confirmed with school records/parents. Information on the following aspects was collected from the children using a pre-tested and validated questionnaire. Household possession of articles, ownership of parental house and residential status of school children were collected as proxy variables for calculation of socioeconomic index. Information was also collected on family history of obesity and physical activity, which included distance of school from the residence and the mode of transport used to go to school and physical activities such as participation in sports and games, aerobic physical exercises. Frequency and duration of participation in household activities, time spent watching television and playing computer and video games, perception of body image, diet preferences and consumption pattern. Measurements: Balance beam type of weighing scale was used to record weight to the nearest 50 grams and each student was asked to remove the footwear to record the weight . Height was measured with the inbuilt attachment for measuring height, provided in the balance beam type of weighing scale. Each student stood straight with head held in Frankfurt horizontal plane. BMI was calculated using K.N. Agarwal percentiles, children with 95th percentile of BMI were taken as cut-off point. Children with BMI more than this cut-off point with respect to age and sex were considered as obese. Detailed interviews were conducted – family history of obesity, eating habits, and physical activity and recorded in a pre-tested pro-forma designed especially for the purpose. Analysis of Data: The data was stored as physical records and later was transferred to computer for analysis STATISTICA was

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used. The school children were categorized as obese (?95 percentile) using age and sex specific percentile of BMI. Prevalence rates were reported as “per hundred”. Significance of inter group differences was estimated by chi-square test. p value <0.05 was considered significant. Results: Of the 4213 school children screened, 1177 were from rural schools and 3036 were from urban schools. Of the 1177 rural school children, 584 were boys and 593 were girls (Table 1). Of the 3036 urban school children 1651 were boys and 1385 were girls (Table 2). Out of the 1177 rural school children 38 were obese (Prevalence 3.23%). Out of the 3036 urban school children 144 were obese (Prevalence 4.74%). The Overall prevalence of obesity was 4.32%. In both rural and urban schools the prevalence of obesity was more in boys (3.6% and 5.8%) than the girls (2.9% and 3.5%). The prevalence of overall obesity in boys both rural and urban schools was (5.23%) and in girls (3.3%). Family History of Obesity: Family History of the obesity was an important influencing factor in childhood obesity in rural schools children (P < 0.0001) as well as in urban school children (P < 0.0001). Association with Socioeconomic Factors The prevalence of obesity among the school children (both rural and urban) studying in private schools was significantly higher than among those studying in government schools. Similarly, it was significantly higher among the school children of high Socio-Economic Status (SES) compared with those of low SES. The prevalence was also higher among the school children whose parents’ occupations were either service or business than other occupations and among those who were fond of junk foods. The prevalence was significantly lower among those school children who either walked to school or came on bicycle than among the school children who used vehicular transport such as motorcycles or cars. Role of Junk Foods: Diet, vegetarian or mixed was not influencing obesity. Junk Food (Was an informal term applied to some foods that are perceived to have little or th

10,11

Table 1 — Prevalence of obesity in rural and urban school children Area

Obese

NonObese

Odds Ratio

Rural Urban

38 144

1139 2892

1.49 1.02-2.19

Chi-Square Yetes Corr

P Value

4.348

0.033

Table 2 — Prevalence of obesity by sex in rural and urban school children Sex

Rural

Urban

Obese Non-Obese Boys Girls

21 17

563 576

Odds

P Value

Obese Non-Obese 96 48

1555 1337

no nutritional value (ie, Containing “empty calories”) to products with nutritional value, but which also have ingredients considered unhealthy when regularly eaten; or to those considered unhealthy to consume at all.); taken by the urban school children was associated with obesity even if the intake was once a week (P <0.002), 2-3 times a week (P <0.001) or daily (P < 0.000).Whereas, junk foods taken by rural school children once in a week or 2-3 times or daily has no statistical significance. Role of Physical activity: (Defined as any bodily movement produced by skeletal muscles that requires energy expenditure): The prevalence of obesity was significantly lower among children who participated in outdoor games; it was also significantly higher among the school children who did not perform any household activities compared with those participating in various household activities. Similarly obesity was marginally higher among children who were not involved in physical activities such as walking, cycling and jogging. Less Physical activity was associated with obesity in urban school children (P<0.05). (Tables 3 & 4). DISCUSSION

1.42 0.87-2.32 0.17 1.16 0.64-2.12 0.72

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Table 3 — Factors influencing obesity in rural schools Variable

Obese (38) Controls(100) Odds Ratio

Family History

Present 20 Absent 18

Present 14 Absent 86

Diet

Mixed 24 Veg 14 Once 22

Mixed 85 Veg 15 Once 52

Chi- P Value Square

6.83 2.69-17.56

20.10

<0.0001

0.30 0.12-0.78

7.9

<0.01

1.27 0.56-2.89

0.18 < 0.68(ns)

Junk Food 2-3 Times 10 2-3 times 32 0.76 0.30-1.88 (per week) Daily 6 Daily 18 1.22 0.43-3.36

0.20 <0.67(ns) 0.028 <0.85 (ns)

Physical activity

Absent 10 Present 28

Absent 25 Present 75

1.07 0.42-2.71

P= 1

Table 4 — Factors influencing obesity in urban schools Variable

Obese (144) Controls(200) Odds Ratio

Family History

Present 103 Absent 41

Present 45 Absent 155

Mixed 90 Veg 54 Once 28

Mixed 135 Veg 65 Once 70

Diet

Junk Food 2-3 Times 40 (per week) Daily 76

To our knowledge this was one of the studies in the subcontinent to document the prevalence of Physical activity obesity and their associated factors that covered an adequate sample of both rural (villages) and urban (medium town) school children. The prevalence of obesity in urban school children (4.74%) was higher than the prevalence of obesity in rural school children (3.23%), similar to National Nutrition Monitoring Bureau surveys in 2002 . However, the prevalence was lower in this study compared with studies carried out in cities such as Ludhiana, Pune, Delhi and Chennai . The reason for the higher prevalence of obesity (7.4%) in Delhi and Ludhiana studies might be that the students selected for these studies where effluent. In the Delhi study the sample was selected from one school only. The prevalence was marginally higher among girls compared with boys in many international studies conducted in cities. But in our study which was in villages and medium town the prevalence was higher in boys (5.23%) compared to girls (3.3%), these findings are comparable to another study from Hyderabad Metro, Andhra Pradesh14, where both overweight and obesity prevalence was studied. The prevalence of overweight among boys and girls was almost similar (8.0 & 8.2%), but more boys (1.6%) were obese than girls (1%). In our study junk food taken by the urban school children was associated with obesity even if the intake was once a week (P<0.002), 2-3 times a week (P<0.001) or daily (P<0.000). These findings are similar to observations of Sheetal Monga Study . Based on the findings of the study it was recommended that 13

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Absent 100 Present 44

C.I.

ChiSquare

P Value

8.65

5.15-14.60 80.11

<0.0001

0.80

0.50-1.29

0.72

<0.40 (ns)

0.45

0.26-0.76

9.20

< 0.002

2-3 times 90 Daily 40

0.47 4.47

0.29-0.76 2.7-7.4

9.8 38.79

<0.001 0.000

Absent 117 Present 83

1.61

1.00-2.60

3.85

<0.05

consumption of high fat and high energy foods and snaking in between meals should be avoided. CONCLUSIONS

In our study less physical activity was associated with obesity in urban school children (P<0.05). These observations are consistent of previous studies . One of the reasons for less physical activity among urban school children was increased use of vehicular transport. In urban areas, considering the safety of keeping children away from heavy traffic, parents feel more comfortable if their children play indoor games or watch television and, therefore, do not encourage them to participate in outdoor sports and games. The major conclusion drawn from the study was that less physical activity and consuming junk food are associated with a higher prevalence of obesity. Therefore the role of physical activity, games and sports should be encouraged. Facilities should be provided for outdoor games with compulsory hours of sports and games in urban schools. There was an urgent need to educate the urban school children, their parents and the teachers regarding healthy food habits to prevent obesity. Surprisingly, eating habits and physical activity were not significantly associated with childhood obesity in rural school children. Conflicts of Interest : None Declared. [16]

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Journal of Tropical Medcine and public health 1993; 24: 5904. Kaur S, Kapil U, Singh P — pattern of chronic diseases amongst adolescent obese children in developing countries. Curr Sci 2005; 88: 1052-6. Tanner FM — Physical growth, development and puberty. In: forfar and Arneils Text Book of Pediatrics, 4th Eds. Campbell AGM, Mcintosh N. Churchill Livingstone, 1992: 389-446. Tanner JM — Normal growth and techniques of growth assessment. Clin Endocrinol Metabol 1986; 15: 411-28. Agarwal KN — Physical growth assessment in adolescence Indian Pediatrics 2001; 38: 1217-35. National Nutrition Monitoring Bureau — Diet and Nutritional Status of Rural Population National Institute of Nutrition, Indian council of Medical Research Hyderabad, 2002 India. Avula Laxmaiah, N Bala Krishna, V Kamasamudram, N Mohanan — Factors Affecting Prevalence of Overweight among 12-17 years old Urban Children in Hyderabad, India, Brief Epidemiologic Report, Obesity Journal 2007; 15: 138490. Monga S — Obesity among school children (7-9 years old) in India, prevalence and related factors. The 132nd annual meeting (Nov 6-10, 2004) of APHA. Patrick K, Calfas GJ, Zabinski MF, Cella J — Diet, physical activity and sedentary behaviours as risk factors for overweight in adolescence. Arch Pediatr Adolesce 2004; 158: 385-90.

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United States of America, Library of Congress catalog in publication data, 1993; 1445-555. Roland D Miller MD — Anesthesia, 7th ed, New York, Churchill Livingstone 2010; 783-84. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP — Anaesthesia related deaths during obstetrics delivery in the United States from 1979-1990. Anaesthesiology 1997; 86: 277-84. Courtney MA, Bader AM, Hartwell B, Hauch M, Grennan MJ, Datta S — Perioperative analgesia with subarachnoid sufentanil administration. Regional Anesthesia 1992; 17: 2748. Levy DM — Emergency Cesarean Section: best practice. Anesthesia 2006; 61: 786-91. Shende D, Copper GM and Bowden MI — The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section. Anaesthesia 1988; 53: 702-10. Bogra J, Arora N, Srivastava P — Synergistic effect of intrathecal fentanyl and bupivacaine in spinal anaesthesia for caesarean section. BMC Anaesthesiol 2005; 5: 5. Pedersen H, Santos AC, Steinberg ES, Schapiro HM, Harmon TW, Finster M — Incidence of visceral pain during cesarean section: The effect of varying doses of spinal bupivacaine. Anesthesia & Analgesia 1989; 69: 464. Singh H, Yang J, Thornton K, Giesecke AH — Intrathecal fentanyl prolongs sensory bupivacaine spinal block. Can J Anesth 1995; 42: 98791. Seyedhejazi M, Madarek E — The effect of small dose bupivacaine-fentanyl in spinal anesthesia on hemodynamic nausea and vomiting in cesarean section. Pak J Med Sci 2007; 23: 247-50. Choi DH, Ahn HJ, Kim MH — Bupivacaine sparing effect of fentanyl in spinal anesthesia for cesarean delivery. Regional Anesthesia Pain Medicine 2000; 25: 240245. doi: 10.1016/S1098-7339(00)90005-1. Randalls B, Broadway JW, Browne DA, Morgan BM — Comparison of four subarachnoid solutions in a needlethrough needle technique for elective cesarean section. Br J Anaesth 1991; 66: 314-8.

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Observational Study The 21st century revolution in the management of keratoconus Ajay K1 This article aims to update clinical practitioners, particularly non-ophthalmologists, about the revolution that has come about in the management of Keratoconus, due to new developments in the recent years. Keratoconus is an ophthalmic degenerative condition, which has assumed increased importance in the present era, due to increased awareness, the advent of sensitive new diagnostic devices, and the increasing popularity of refractive surgery such as LASIK. In Keratoconus, the cornea assumes a conical shape because of thinning and protrusion. The management of this condition has undergone a sea change in the past decade, and what was once a dreaded disease with eventual progression to low vision can now be halted in its tracks. The new modalities of treatment which are available to tackle Keratoconus include C3R (Corneal Collagen Cross-linking with Riboflavin), Newer Contact Lenses (CLs), Intra-corneal ring segments, Phakic intra-ocular lenses and Lamellar Keratoplasty. This article aims to throw some light on these newer modalities, including a discussion on some of the pros and cons of these methods, in an effort to apprise medical practitioners of their meaning and value. Web-based search engines, ophthalmic journals/textbooks and journal articles accessed through university digital library were used in the study and review of articles on the subject. [J Indian Med Assoc 2017; 115: 19-22]

Key words : Keratoconus, C3R, Contact lenses, ICL, Lamellar keratoplasty.

eratoconus is a non-inflammatory bilateral ectatic disorder of the cornea, leading to gradually progressive painless diminution of vision. Along with Pellucid Marginal Corneal Degeneration and Keratoglobus, Keratoconus forms a group of diseases called Ectatic corneal disorders . Keratoconus is characterised by a slow gradual thinning of the cornea in both eyes, which occurs secondary to a weakening of the Collagen in the cornea . The corneal collagen forms the ground substance of the corneal stroma, which comprises upto 90% of the corneal thickness. The collagen is the main source of strength for the maintenance of normal corneal structure, acting like an inter-linked solid foundation. The weakening of corneal collagen in keratoconus leads to a “bowing down” of the cornea causing a cone-like appearance, hence the name. The “coning” of the cornea and subsequent alteration in corneal curvature causes irregular refraction of incipient light rays, leading to astigmatism and progressive blurring of vision. The past – treatment rarely satisfactory : In earlier days, if a patient was diagnosed with Keratoconus, the ophthalmologist would offer by way of treatment, specs or rigid Contact lenses to improve vision. While this would improve visual acuity of the patient for the time being, eventually, the disease would advance so much as to cause uncorrectable loss of vision. This would necessitate a corneal transplantation (Keratoplasty), which was not definitely an excelling solution. Keratoplasty itself is accompanied by unpredictable astigmatism and it would be rare to restore vision to predisease levels, and the risk of rejection always existed. 1

Department of Ophthalmology, M S Ramaiah Medical College, Bangalore 560054 1 MS, DNB, FCED, FICO Assistant Professor

Owing to its progressive nature, the disease could potentially cause economic and social blindness. Like with most idiopathic degenerative diseases, finding a ‘cure’ for such a disease had been a vexing issue. The present – new hopes in keratoconus treatment: Of late though, Keratoconus has started figuring prominently across ophthalmic discussions, because ophthalmologists seem to have found the weapons to say that this relentless degenerative disease now has a “cure”. The 21st century has heralded new horizons of hope for the treatment of Keratoconus. This debilitating process can apparently not just be stopped; visual acuity also can be improved by modifying the structural characteristics of the cornea. Probably, some more time has to elapse before we can proclaim that Keratoconus has been “conquered”, but there is definite new hope in dealing with this disease. This article aims to throw some light on these newer modalities, including a discussion on some of the pros and cons of these methods, in an effort to apprise medical practitioners of their meaning and value. Epidemiology of keratoconus : The prevalence of Keratoconus reported in literature varies widely based on geographical region and diagnostic criteria used, and was estimated to be between 50 and 230 per 100,000 general population in the second half of the 20th century . In 2009, The Central India Eye and Medical Study found a much higher prevalence of 2.3%± 0.2% (2,300 per 100,000) in the general population aged 30 3,4

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years and above in rural Central India . This increased prevalence can be attributed to increased awareness among general ophthalmologists as well as more sensitive diagnostic devices such as computer-assisted videokerato-graphy (Computerised corneal topography). It could also be due to increasing urbanisation, leading to increased allergic eye disorders which are known to have an association with keratoconus . The incidence of new cases of Keratoconus in the general population has been reported to be between 1.4 and 2.2 cases per 100,000 . Corneal topography scanning helps to definitively diagnose these conditions, due to its ability to give a pictorial representation of corneal curvature, corneal thickness and refractive power across the whole of the cornea . Newer modalities of management of keratoconus : Corneal Collagen Cross-linking with Riboflavin (C3R) is one of the modalities of treatment which provides bright hope for newly diagnosed patients of Keratoconus. Besides C3R, other new modalities of treatment which are available to tackle Keratoconus include Newer Contact Lenses (CLs) (Hybrid CLs, Piggy back CLs, Scleral CLs, Multi-curve CLs such as Rose K CLs), Intra-corneal ring segments (INTACS and Kerarings), Phakic intra-ocular lenses (Implantable Collamer Lens ie, ICL and Toric ICL) and Lamellar Keratoplasty (LK). (i) C3R — Wollensak et al pioneered this pathbreaking modality of treatment of Keratoconus . The concept of C3R is ingenious and appears absolutely logical. The vitamin B2 Riboflavin is infiltrated into the cornea, and Ultra Violet light is used to cause increased cross-linking of the corneal collagen, thus making the cornea ‘stiffer’ and increasing its resistance to bending (coning). The earliest studies on the topics are reporting continued success in arresting Keratoconus in the followup review studies10,11. While C3R is aimed at stopping the further thinning and coning of cornea by stiffening it, it does not change the corneal curvature. So it just stops the disease process from further progress, but is not proved to improve visual acuity which has already been damaged. Indications and contraindications of C3R : C3R is presently indicated in topographically documented progressive keratoconus and in keratoconus patients <20 yrs old, and also in patients of Pellucid marginal degeneration . It is contraindicated in corneal thickness <400 microns, because of danger of damaging endothelium, in previous herpes keratitis, in corneal epithelial healing disorders/melting disorders, pregnancy, corneal scarring and if patient has high visual expectations . Procedure of C3R : C3R procedure slightly differs across different surgeons and practices. Traditionally, the conventional procedure involves treatment incorporating 7-mm-diameter corneal deepithelialization, instillation of 0.1% riboflavin in 20% dextran solution every 2 minutes for 30 minutes and corneal irradiation with UV-A 3 mW/cm for 30 minutes, 50 cm from the cornea.13 Of late, 5

4,6

7,8

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trans-epithelial cross-linking (without doing corneal deepithelialization) and accelerated cross-linking (time for procedure is much lesser than the 60 minutes in traditional cross-linking) are also gaining ground. Time of performance of C3R – the doubts : Some clinicians advocate that C3R should be performed clinically only in “documented” progressive keratoconus, since C3R only arrests the progress of disease and does not reverse the curvature to normal. So if the disease is not “progressing” in the patient, as happens in some cases of keratoconus, C3R may have questionable value in the management. As of now, most ophthalmologists do not consider the spectacle lens correction alone for assessing progression. Most clinicians consider the topographic picture, and look at the minimum corneal thickness, irregularity indices and maximum corneal curvature reading on the topography, to form a comprehensive picture of progress. The clinician has to decide for himself whether s\he would like to advise C3R the moment s/he diagnoses keratoconus, or to “wait” for progression, in which case C3R is definitely indicated. C3R is possible in mild to moderate cases of keratoconus only, because extremely thin corneas encountered in advanced cases would put the innermost corneal endothelium at risk. So the ophthalmologist may also not want to wait too long and risk losing the safe thickness of cornea required to do C3R. The minimum age for C3R has also not been defined, although, patient co-operation may be the only decisive factor here. In our country, other issues involved, especially in peripheral/rural ophthalmic centres, would be the availability of corneal topography machines (computerized videokeratography) and the UV light apparatus. (ii) Newer contact lenses — Fitting contact lenses to a patient of Keratoconus is a difficult task. Traditionally, contact lenses for keratoconus patients have been “hard” or rigid gas-permeable (RGP) type, although specialized “soft” lenses have also been manufactured for the condition. Patient tolerance to the so-called hard lenses is not always assured, and correction may not always prove to be effective. Different ophthalmologists have therefore devised various methods to overcome the obstacles involved. Hybrid lenses are contact lenses which are hard in the center and encompassed by a soft skirt . Piggyback lenses involve the wearing of RGP lenses over soft contact lens, both involving a degree of visual correction, thus ensuring comfort, and visual improvement . Scleral contact lenses can be tried in distorted corneas, and cover a greater proportion of the eye surface, thus offering improved stability and comfort. Scleral lenses have been offered in advanced keratoconus cases where corneal transplantation is the only option, but are increasingly being used for lower grades of keratoconus with corneal contact lens intolerance . 14

The most commonly used contact lens design in keratoconus is a single spherical base-curve lens in rigid gas permeable material. The concept of fitting a bicurve lens design for keratoconus was developed by Soper . The concept of this design uses a steep optical (central) portion of 6 mm, with a second flatter curve of 2 mm width peripherally, as a carrier to better approximate the topography of the steep corneal cone with a flat peripheral cornea. The Rose K system of lenses for Keratoconus is one such among the recent multi-curve lens systems developed . The Rose K lens is described by the manufacturer as a system of multiple curves in the periphery to vary edge lift. There are various multi-curve contact lenses available, and it is not possible to suggest which lens system is better than another, as all have been reported with varying clinical success. Because these lenses must be fit from a trial inventory set, most clinicians are limited by the availability of these sets. These trial sets are also expensive, and this cost factor and lack of easy availability are inconvenient. (iii) Intra-corneal ring segments — Conceptually, this is another ingenious and logical technique, where the shape of the cornea is altered by interspersing Poly Methyl Metha Acrylate (PMMA) ring segments at pre-calculated zones. These segments flatten the centre of the cornea, thus decreasing the induced refractive error in keratoconus. Two main types of ring segments are available today, the INTACS and the KERARINGS, mainly differing in profile (shape and size) and diameter of implantation. Authors have reported successful outcomes with both these segments . The intrastromal corneal ring concept was proposed by Reynolds in 1978 . The initial implants were full rings inserted through a peripheral single corneal incision into a circumferential corneal channel. In order to make its implantation easier and to avoid potential incision-related complications, these implants were refashioned into incomplete rings and ultimately to the C-shape rings. They were renamed and the term ‘intracorneal ring segments’ (ICRs) was then coined . Indications and contraindincations : Conditions for implanting ICRs include a corneal thickness >350 microns at the thinnest location, maximal corneal curvature <60 D, Refractive error (Spherical Equivalent) <-6.0 D and clear cornea with no central scars or stress lines . Contraindications are similar to those for C3R, except that the corneal thickness can be upto 350 microns. Procedure : The implantation of the rings may be performed either with mechanical dissection with specially manufactured instruments to create the tunnels for the ring segments, or with the femtosecond laser technology. The femtosecond laser machine is used to create the intrastromal tunnels of desired size and location and the rings are implanted into the pre-fashioned tunnels. The femtosecond laser assisted implantation is obviously more predictable with lesser chances of perforation during tunnelling, but its availability to all ophthalmic surgeons 17

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would be limited in our country. Long-term stability of intra-corneal ring segments remains the concern of many studies. (iv) Phakic intra-ocular lenses — The Implantable Collamer Lens (ICL) (or in cases with high astigmatism – the Toric ICL) can be used to reduce the high refractive error in keratoconus . The ICL is an intraocular lens which is placed over the natural crystalline lens of the patient through a tunnel in the corneal. The tunnel is fashioned with a special blade called Keratome, and does not require sutures to seal, ie, it is self sealing, as with most cataract procedures now. The ICL has an exaggerated convexity called vault, which allows it to remain clear of the natural lens within the eye, thus avoiding the possibility of a cataract developing. Obviously, any such intraocular lens implantation is to be done after stabilization of the disease process, either with C3R, or, after spontaneous stabilisation which can occur in older age groups (which should be proved with serial topography). Also, the anterior chamber depth measured from the endothelium must be at least 2.8 mm to allow for the vault of the lens. Logically, any intraocular pathology such as cataract, uveitis, glaucoma and personal or family history of retinal detachment are contraindications for this procedure. Phakic intraocular lens can be a single procedure by itself, or may be combined with corneal ring-segments . Phakic intraocular lens implantation being an intraocular surgery, the attendant potential risks and complications involved should not be forgotten, during clinical decision making process, and in patient counselling. (v) Lamellar keratoplasty — In highly advanced cases of keratoconus, such as corneal thickness < 350 microns at thinnest location, and keratometry > 60 D, Keratoplasty remains the final option. In earlier days, full-thickness (or penetrating) keratoplasty was the only option for advanced keratoconus. In full-thickness keratoplasty, the inner-most layer of the cornea called endothelium is one of the main initiators of rejection. If we can transplant the cornea without changing the endothelium of the patient, it would be highly advantageous, since the endothelium is in no way dysfunctional in keratoconus. This has led to the increasing usage of anterior or deep anterior lamellar keratoplasty for keratoconus . In this lamellar keratoplasty, only the superficial cornea comprising of Epithelium, Bowman’s membrane and Stroma is removed, leaving the patient’s Descemet membrance and Endothelium intact. The endothelium of the donor corneal graft is removed and the remaining superficial part of this graft is sutured onto the recipient Keratoconic corneal button. Eliminating the risk of endothelial rejection is especially beneficial in keratoconus, because many such patients are in the younger age group. Indications and contraindications : Indications for Deep Anterior Lamellar Keratoplasty (DALK) would thus include anterior corneal scars, thinnest location < 350 microns, very high refractive error (>-6.0 D Sph or Cyl) and K-max > 65 D. Central large endothelial scars would preclude the procedure and necessitate penetrating keratoplasty. 23

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Of course, the performance of DALK needs trained hands and licensed eye bank, again not yet accessible through all ophthalmic surgeons. Combination of different modalities of treatment : Keratoconus can be treated with a combination of the above treatment modalities. C3R can be used to stabilize the cornea, and after confirming with serial topography, intra-corneal segments can be implanted to redo the corneal shape and improve visual acuity. Phakic intraocular lenses too can be used to improve visual acuity, after confirming stabilization, as already mentioned earlier. The ophthalmologist should only ensure that the specific indications mentioned for the treatment modalities are fulfilled before s/he decides to apply it to the patient, and informed counselling of the patient is mandatory. Conclusion : The management of Keratoconus has been revolutionized in the 21st century, with the arrival of newer modalities of treatment, and ophthalmologists can provide new hope to patients afflicted with this degenerative disease. All clinical practitioners should educate interested or affected patients about the same. REFERENCES 1 Feder RS, Gan TJ — Noninflammatory Ectatic Disorders. In: Krachmer JH, Mannis MJ, Holland EJ, editors. Cornea 3rd ed. Mosby Elsevier 2011; 865. 2 Meek KM, Tuft SJ, Huang Y, Gill PS, Hayes S, Newton RH, et al — Changes in collagen orientation and distribution in keratoconus corneas. Invest Ophthalmol Vis Sci 2005; 46: 1948-56. 3 Krachmer JH, Feder RS, Belin MW — Keratoconus and related noninflammatory corneal thinning disorders. Surv Ophthalmol 1984; 28: 293-322. 4 Kennedy RH, Bourne WM, Dyer JA — A 48-year clinical and epidemiological study of keratoconus. Am J Ophthalmol 1986; 101: 267-73. 5 Jonas JB, Nangia V, Matin A, Kulkarni M, Bhojwani K — Prevalence and associations of keratoconus in rural Maharashta in central India: The central India eye and medical study. Am J Ophthalmol 2009; 148: 760-5. 6 Ihalainen A — Clinical and epidemiological features of keratoconus: genetic and external factors in the pathogenesis of the disease. Acta Ophthalmol Suppl 1986; 178: 1-64. 7 Rabinowitz YS, McDonnell PJ — Computer-assisted corneal topography in keratoconus. Refractive and Corneal Surgery 1989; 5: 400-8. 8 Wilson SE, Klyce SD — Screening for corneal topographic abnormalities before refractive surgery. Ophthalmology 1994; 101: 147-52. 9 Wollensak G — Riboflavin/ultraviolet -A-induced collagen crosslinking for the treatment of keratoconus. Am J Ophthalmol 2003; 135: 620-7.

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10 Wollensak G — Crosslinking treatment of progressive keratoconus: new hope. Curr Opin Ophthalmol 2006; 17: 356-60. 11 Caporossi A, Mazzotta C, Baiocchi S, Caparossi T — Longterm results of riboflavin ultraviolet a corneal collagen crosslinking for keratoconus in Italy: the Siena eye cross study. Am J Ophthalmol 2010; 149: 585-93. 12 M M Sinjab — Quick Guide to the Management of Keratoconus. Springer-Verlag Berlin Heidelberg 2012: 75-7. 13 Rao SK — Collagen cross linking: Current persepectives. Indian J Ophthalmol 2013; 61: 420-1. 14 Abdalla YF, Elsahn AF, Hammersmith KM, Cohen EJ — SynergEyes lenses for keratoconus. Cornea 2010; 29: 5-8. 15 Barnett M, Mannis MJ — Contact lenses in the management of keratoconus. Cornea 2011; 30: 1510-6. 16 Ori Segal, Barkana Y, Hourovitz D, Behrman S, Kamun Y, Avni I, et al — Scleral Contact Lenses May Help Where Other Modalities Fail. Cornea 2003; 22: 308-10. 17 Soper JW, Jarrett HA — Results of a systemic approach to fitting keratoconus and corneal transplants. Contact Lens Medical Bulletin 1972; 62: 152–7. 18 Jain AK, Sukhija J — Rose-K contact lens for keratoconus. Indian J Ophthalmol 2007; 55: 121-5. 19 Pinero D P, Alio J L — Intracorneal ring segments in ectatic corneal disease – a review. Clinical and Experimental Ophthalmology 2010; 38: 154-67. 20 Fleming JF, Reynolds AE, Kilmer L, Burris TE, Abbott RL, Schanzlin DJ — The intra-stromal corneal ring: two cases in rabbits. J Refract Surg 1987; 3: 227-32. 21 Burris TE — Intrastromal corneal ring technology: results and indications. Curr Opin Ophthalmol 1998; 9: 9-14. 22 M M Sinjab — Quick Guide to the Management of Keratoconus. Springer-Verlag Berlin Heidelberg 2012: 63-8. 23 Kamiya K, Shimizu K, Ando W, Asato Y, Fujisawa T — Phakic toric Implantable Collamer Lens implantation for the correction of high myopic astigmatism in eyes with keratoconus. J Refract Surg 2008; 24: 840-2. 24 Coskunseven E, Onder M, Kymionis GD, Diakonis VF, Arslan E, Tsiklis N, et al — Combined Intacs and posterior chamber toric implantable Collamer lens implantation for keratoconic patients with extreme myopia. Am J Ophthalmol 2007; 144: 387-89. 25 Donald Tan, A Anshu — Anterior lamellar keratoplasty: ‘Back to the future’ – a review. Clinical and Experimental Ophthalmology 2010; 38: 118-27.

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Observational Study Visit of 2nd professional MBBS students to Museum and Service Laboratories of Microbiology department Nilotpal Banerjee

400 students of 3rd, 4th and 5th semester of the 2nd professional course of MBBS students (2007 to 2010) were supplied with questionnaire and also were interrogated related to their visit to Museum and service laboratories of Microbiology Department. The students hardly visited the museum and service laboratories located adjacent to their practical laboratory of Microbiology Department. This has been affecting the performance in the examination for obvious reason of not properly remembering the size, shape of the microbes preserved in the museum and also not learning various pretesting steps of the services laboratories, required to answer the related question. Such visits and exposure could solve complexity of memorizing without seeing the materials, thus leading to “blunder answer” in the examination. The matter is simple, but made complex probably because of lack of practice. Inculcation of habits only could solve many problems. [J Indian Med Assoc 2017; 115: 23-4]

ey words : Museum, service laboratories.

he visit of students to Museum was regularly bottom low (0 to 1%). They undergo regular class on the knowledge of Microbes – causative agents, pathogenesis, Laboratory diagnosis but the brief history and photos the great scientists hanging on the wall of the museum are hardly remembered. It simply reflects upon how much or little these students knew about the tireless decades of research, the hurdles, obstacles faced in the process of their discoveries, that todays knowledge rest upon. The students are trained and tuned to their examination result only that they would enjoy today. The stimulating search component has been consistently lacking, thus resulting in tailor-made growth for passing examinations. It is therefore felt that interest in such subject can grow strongly and research stimulation for preparing the very base can bloom it step wise pains experienced by the Scientists for ultimate knowledge are injected in the subject. The aim of to day’s knowledge is not only Para clinical and clinical practice but also need to be anchored into research for future in the fie. Methods of studies undertaken : (1) Observational method, (2) Questionnaire method, (3) Interrogative method. On observation, it was found that hardly any student entered into the museum of Microbiology Deptt. This silent observation on daily, monthly and yearly basis led to

DPH, All India Institute of Hygiene and Public Health, Kolkata; MD (Microbiol), Kasturba Medical College, Mangalore; Assistant Professor, Microbiology Department, Tripura Medical College & Dr BRAM Teaching Hospital, Agartala 799014

painful evaluation on their tendency that was not promuseum at all. Compulsion factor was absent, so no motivation developed. Initially the students in the 3rd semester were taken around by the teacher and that was all. There was ample time everyday after the practical session, taking place in the adjacent students’ practical laboratory but hardly anyone was seen visiting the museum. This important observation of the author led to definite conclusion on the growth and degree of attitude for knowing the scientist. The museum specimens were visited only before the examination. So, interest persisted only for passing an examination and not beyond, by any significant degree. Projection of knowledge on scientists in museum : Name of scientist Correct answer Score on contribution Robert koch 17% Poor Louis Pasteur 15% Poor Watson and Crick 03% Very Poor Semmelweis 01% Do Hansen 08% Do Ronald Ross 19% Do Lavender 21% Do Alexander Flaming 29% Poor Sabin 23% Poor Paul Erlich 0% Very Poor Leishman 16% Do Christian Gram 46 % Fair Neisser 08% Very Poor Edward Jennar 11% Do

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Karl Landsteiner 18% Do Wucherer 06% Do Ridley, Jopling 0% Do Metchnikoff 0% Do • This projection clearly depicts the interest invoked on the fathers of Microbiology family. Discussion and interpretation : There exists a definite need for such visit, to the museum and also to get acquainted with the testing procedures, media preparation, sterilization processes etc. etc. in the service Laboratory. The visits are also required for facing the semester examination and final examination which directly and indirectly could stimulate the pupils for having a grip on the subject. But questionnaire revealed that most students were taken to the Museum and service laboratory sterilization room as part of practical classes in the 3rd semester during introduction. They never made any visit after that and so they lacked in the answer and interpretation of steps related to. They also grew least flowing knowledge on the separation of serum, packing in autoclave, hot air oven with appropriate materials and had least knowledge on everyday happenings like preparation of media, its ingredients, swab preparation, washing of slides and cover slips, source of blood for blood and chocolate agar preparation, pouring of blood, quantity and temperature etc. which are everyday affair in the service laboratory adjacent to the practical laboratory for students. Sitting study by the students in the museum has been zero. This has been observed on daily basis as the author himself had been regularly sitting in the museum in the working hours for study preparation for theory lectures. The site was chosen because the museum was a silent zone for study purpose. When the students used to meet the author in the museum for any query on the topics, they were taken around the museum for clarification of the query and also for stimulation of studying in the museum. That a museum is a enriched practical library media was not realised. When students choose short cut books for theory, the stimulating reading of long books can not even secure place in their study tables. The value of reading standard books it self had been locked in the ulmerah or coated with dust in the corner of the table because of non use. When mere pass is the aim, the probes of the mind do not transform to golden habits. Probably this is also generation gap! How good and how bad is their choice, remains to be answered by time. Time has analysed, inter preted and concluded on the basis of keen observation. Study visit and sitting study in museum : The museum specimens, prepared models and charts of life cycle of parasites provide invaluable natural knowledge of preserved specimens and artificial models

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and life cycle provide the knowledge essential for examination and beyond. But the interest attitude as observed by frequency of visit had been for from adequate by the students of semesters under study. The pitiable scenario has been traditionally continuing in all the present batches too. The teacher mechanically grouping the students and going around the museum in 3 semester has not transformed in even little habit formation. Thus the museum has lost the value for inculcation of knowledge and interest, though the location just adjacent to the practical laboratory. rd

3 Semester 4 Semester 5 Semester rd

0 to 1% 0 to 1% 0 to 1%

Filling and refilling — the melancholy of malaria since independence in India 1

This project aims to study the timeline of national programs in India that have been formulated over the years to deal with malaria. Malaria is India’s most chronic vector borne disease and has plagued our nation for decades. It was the landmark Bhore committee that first stated that malaria had to be dealt with by employing a dedicated national program. Thus, the first national program to curb the menace of malaria, the National Malaria Control Program (NMCP) was launched in 1953. This was followed by the overambitious National Malaria Eradication Program (NMEP) which was met with relative failure. The Urban Malaria Scheme was then launched to deal with this disease, followed by the Modified Plan of Operation (MPO). A slew of similar programs were launched, all of which met with only slight success. After much deliberation and coming to terms with the reality that malaria may not be completely eradicable in a country like India, the government launched the National Anti-Malaria Program in the late 90’s, finally integrating it into the National Vector Borne Disease Control Program. Malaria as a disease cannot be ignored and a holistic approach needs to be adopted to be able to decrease the mortality rate of this disease. This study, titled, ‘Filling and Refilling: The Melancholy of Malaria Since Independence in India’ aims at understanding the timeline of strategies involved in dealing with malaria and a critical analysis of reasons for failure of each attempt. The study also wishes to highlight the manner in which it’s necessary to get to the root cause of this disease, which is the study of the vector itself, to really be able to become a country free of the malady, that is, malaria.

Alarmingly poor Do Do

REFERENCE :

MCI Guidelines -2005, Microbiology Department, Labelled “D”- page 16, (Museum), as amended time to time.

Amitabha Sarkar , Sandip Ghosh

Score

So success of a museum as prescribed by MCI is bottom low, as evident from study. Conclusion and Suggestion : Such lack of visits affect the student’s performance in the viva, theory and practical examination of Microbiology so much so, that examiners wonder why and how such regular basic knowledge is so much lacking among the students. The concluding remark therefore is loud and clear and that is, the students were either not adequately initiated or students ignored the initiations and guidelines of the teacher. Such lack therefore proves costly at the time of examination, students cutting a sorry figure inspite of completion of course syllabus. Repentation after the examination is futile as the student’s grading and scoring have already been completed. The pathetic scenario needs to be reversed by growing a habit among the students so that interest is created, memory centre is automatically switched on and smile persists after coming out of the examination hall. The frown of the examiner on the answers affect the succeeding answers of the student which are natural. Furthermore, today’s performance is likely to affect the examination of other subject on the following day. So, absence of simple golden habits may throw the student out of gear for the succeeding examination too. Why and how should we prepare students in wholesome manner were the points of debatable stimulating study undertaken in the four batches of 2nd professional MBBS course.

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Observational Study

Highlight Projection of adopted methods of study: Obser- Interrogation as vation Replied on Visit

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[J Indian Med Assoc 2017; 115: 25-9]

Key words : Vector borne diseases, NMCP, NMEP, host (human), causative agent (plasmodium), environment (breeding places, rainfall, humidity etc), vector (mosquito).

hey spread and spread till their eyes got sore; then they refilled their machines and sprayed some more”- the famous rhymes of ‘Ode to Mosquito Men’ was made for the malaria workers but also ironically representing the histories of malaria control efforts in India. Malaria is the most chronic vector borne disease in India and also a great hindrance to the progression of national resources. The disease has been prevailing more than centuries and thus always a cause of concern not only for the general population but also for the policy makers. In 1935, it was estimated by the then first director of the Malaria Institute of India (Brigadiar J.A. Sinton) that at least 100 million people suffered and one million deaths took place in endemic areas from malaria, along with the toll of almost equal number of deaths where the disease acted as an underline cause of death.(1) Since then, the malaria control activities have been going on with utmost priority and experiencing different programmatic interventions from control mechanism to eradication envision. Malaria control activity is very complex public health job. PhD, Researcher, Centre for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi 110067 MA, LLB, MBA, Senior Faculty, Department of Health Care & Hospital Administration, Indian Institute of Social Welfare & Business Management, Kolkata 700073 1

Analysing malaria control activities in post independence India is not only limited to technical competence of the programmes but also sought the understanding in epidemiology, entomology, changing social context, political economy of national and international affairs. Malaria occurs when the epidemiological triad (hostagent-environment) gets formed. Identically, the entire malaria control activity comprises of host (human), causative agent (plasmodium) and environment (breeding places, rainfall, humidity etc). Vector (mosquito) is an indispensable part in malaria control as it carries the malaria parasite (plasmodium, which causes the infection) which gets entered and multiplies inside the human body and develops sign and symptom of malaria. Human also acts as a reservoir for plasmodium because the gametocyte (sexual form) takes place inside the human body thus the mosquito bites human to develop and lay eggs. This is the complexity of malaria where human acts both as a host and reservoir for the causative agent of the disease, hence, any anti-malaria activity can not just destroy the reservoir (human) to stop the mode of transmission from agent to host. Concomitantly, the vector has significant role in malaria infection. Out of 45 species of Anopheline mosquito, majorly Anopheles culicifacies (exist in rural areas) and Anopheles stephensi (exist in urban areas) are

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vectors of primary importance in Indian context. Anopheles breeds usually in clean water and even capable to breed in small quantum of water. They also have many behavioral preferences though not exclusive, like some mosquito bites usually human, some usually animal, some are indoor whereas some are outdoor mosquitoes. Further, Anophlese mosquito usually bites during dusk and dawn but can also bite during day time or evening. So, the larval habitats (ecological factor) and host biting preference (behavioural factor) varies at large. This mosquito bionomics is unpredictable and multifarious thus posing huge challenge in vector control activity. Also, environment component are supportive for rapid breeding of mosquito because of rainfall, humidity, unhygienic living condition, lack of self consciousness, nutritional absence and so on. This is the ambit of malaria control activity which public health can only combat with the vector control strategies to stop or reduce transmission of malaria infection. In the first half of the twentieth century, malaria control activity was limited to military cantonments, plantation areas and ports, and paris green was used as only available insecticide. The strategy was to use the paris green in the located drainages and other possible breeding centers to stop growing mosquitoes. National malaria Control Programme is the first anti malaria activity in post independence India. Though, the root of this programme had embedded into the recommendation of ‘Health Survey and Development Committee’, 1946 (Bhore committee) report. It was the recommendation of that committee which convinced the Planning Commission in 1951 to endorse malaria as a top priority programme. Notably, India registered 75 million cases of malaria and 0.8 million deaths at the time of its independence . The Malaria Milestones 1

SIR BHORE COMMITTEE REPORT NATIONAL MALARIA CONTROL PROGRAM NATINAL MALARIA ERADICATION PROGRAM URBN MALARIA SCHEME MODIFIED PLAN OF OPERATION(MPO) MALARIA ACTION PROGRAM ENHANCED MALARIA CONTROL PROGRAM NATIONAL ANTI MALARIA PROGRAM NATIONAL HEALTH POLICY NATIONAL VECTOR BORN DISEASE CONTROL PROGRAM

1946 1953 1958 1971 1977 1995 1997 1999 2002 2004

National Malaria Control Programme (NMCP) : The first malaria control programme started in the year of 1953 with the objective of bringing down the malaria transmission level upto the extent from where it could be possible to cease as a major public health problem and afterward the states were required to curb the transmission level as low as possible . The programme initially catered 200 million of population from the endemic areas and operationalised based on the area wise demarcated unit approach. Till 1957, total 175.5 units were made under the 2

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NMCP . The programme was carried out under the financial assistance of United States Technical Cooperation Mission (USCTM), WHO, UNICEF and Rockefeller foundation . The successful experience of using DDT in other countries had motivated the control programme to cover the human dwellings and cattle sheds with residual insecticide spray (DDT). Also, malaria control teams were made under state anti-malaria control organisation to conduct survey and observe the malaria incidence in the programme areas. Further stress had given on the availability of anti-malarial drugs in the institution so that patient could access and report to the institution . The NMCP was active from 1953 to 1957 and recorded high success (more than 50% decline in malaria prone areas in 1957) . It can be noted that the highly intensified DDT intervention had paved the way for huge success of the programme. The indoor residual spray or DDT was used for the first time in most of the new programme areas which were so far not intervened by any measures of antimalaria activities. The major boost in funding came with international support which could be contextulaised in different political and economical aspects. The funding in malaria rooted in the politics of increasing economic productivity in South America. During and after World War I, US (United States) public health service (and also supported by Rockefeller foundation) promoted hookworm and antimalaria campaign to safeguard the interest of military posted in south America and also ensure the productivity of civilians as the market was dominated by the US businessman and landlords. The same tactic was adopted by the European colonial govt. to ensure the resource drainage from third world (like, India) to first world. Post independence situation in India, public health (along with medical care and education) was viewed as the resource generating investment as India was considered as cheap source of labour .Also, the decade of 1950 was the time of cold war in international affairs between US and USSR. Both the countries were in effort to expand their influence in various decision making platforms (like, United Nation), and involved in successive situation driven strategies to confirm the allegiance from others. The international funding for first Indian anti-malaria programme came at the backdrop of this puzzling international politics. India was not economically developed and technically sound, hence for the both of the need India had to depend on foreign assistance. National Malaria Eradication Programme (NMEP): The two factors worked behind the shifting from control to eradication programme- continuous spray of DDT brought the malaria rate to zero in many countries; and development of the resistance of the vector to the DDT might occur if the spraying continues even after zero reporting of transmission for several years. The phenomena of resistance were rated as serious threat to the 1

sustainability of the programme in the long run. The push for control to eradication had first discussed in the IV International Congress of Tropical Medicine and Malaria in Washington DC in 1955. On the same year, the Eights World Health Assemble also supported the same perception. Finally in the year of 1956, eradication of malaria as a goal had been accepted for all the south east Asian countries under ninth regional committee session of South East Region of WHO, Delhi . The control programme became eradication with an objective to eradicate in next 7 to 9 years. Initially the programme was highly successful (malaria cases reduced to 0.1 million from the estimated 75 million in 1947) and even zero number of death was reported in 1965. The elimination concept had been derived from the military operational strategies; military style operation in Indian public health structure was very common as doctors usually came from military service to IMS (Indian Medical Service) till 1946. The NMEP had been designed in phased approach i.e., preparatory, attack, consolidation and maintenance. Though, NMEP started the programme with attack phase because of the perception that sufficient experience and information already gathered during the NMCP era (1953 – 1957). The major eradication activities were spraying DDT twice in a year according to the appropriate season (like, monsoon and post monsoon), fortnightly surveillance and the proper treatment for all confirmed cases. For vector control activities, mainly chemical control (spraying DDT) and environment management (through source reduction by filling up the breeding places, covering of stored water etc) had given high priority. NMEP was fully central sponsored programme which was unparallel in public health programme around that time. The same unit wise operation of NMCP continued in NMEP. It was thought that 3 years would be adequate under attack phase to continue the activity (mainly spray) in hypoendemic areas, while 3 to 4 years for mesoendemic and hyperendemic areas . The success mainly achieved in the attack and consolidation phase of the programme where termination of transmission of infection through vector control was the agenda. These two phases constituted under the central commitment but the programme’s setback had been experienced majorly in maintenance phase where states were the responsible entities to ensure continuous monitoring. There were technical and administrative criteria to enter into maintenance phase from attack. The technical criterion was epidemiological (competence of laboratory services, sufficient case detection machinery etc) and administrative criteria was the capability of general health service under state patronage to take up the vigilance immediately after the abolition of special organisation for NMEP. Govt. appointed special committee (for assessing these technical and administrative criterions) in 1963 recommended to set up vigilance units under the general health service and would be a part of comprehensive rural health service using 1

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primary health centre was the base of the services. However, lack of political commitment, financial insufficiency, administrative snags, logistic challenges had made the programme to experience failure. Malaria resurgence occurred by 70s in Madhya Pradesh, Gujarat, parts of Rajasthan and Uttar Pradesh, and by 1976 the overall number of malaria positive cases in India rose to 6.4 million. Govt. formed many committees (Hinman committee-1960, Chadha committee-1967, Madhok committee- 1967, First In-depth Evaluation committee1970) to investigate the failure of much dreamt eradication programme. The major findings of these committees were scarcity of external resources, shortage and inappropriate supply of materials including insecticides and scarcity of manpower recognised as administrative challenges. Development of resistance by the vector and drug resistance to plasmodium falciparum in few parts of the country had been identified as two most threatening technical challenges. Apart from the administrative and technical shortcomings, host of operational factors were also instrumental for the setback. It was the period of 1960s and 1970s when India was undergoing industrialisation, rapid migration followed by urbanisation which introduced many environmental and sanitation problems thus operationally it was difficult for the programme to cope with the changed situation in urban areas. Also, the tendency of mudplastering or limewashing of house just immediate after the spray due to religious cause reduced the effectively of the spray. These factors also multiplied by the frequent heavy rainfalls, flood which made the situation more challenged in remote and hilly areas . The NMEP was failed not because of administrative, technical or operational limitations, the cause of these failure had been also influenced by the international activities happened in that time and also the perspective possessed by the Government of India. The boost for NMEP had started when US president Eisenhower expressed the desire of US financial support to WHO worldwide malaria eradication campaign (started in 1955) under the context of cold war politics to vie with USSR in the year of 1956. The ‘politics of secret report’ (as scrutinised by Cleaver in ‘The Official Report’ of the International Development Advisory Board prepared for US president) narrated that the US govt. recognised their own politics of malaria control effort in India where malaria control activity pursued to combat with communist infiltration. American corporate were also close to WHO as they offered fund to WHO which was ultimately channelised to country like India for malaria eradication programme . India shifted from control programme to eradication programme because of the overachievement in NMCP and the recommendation made in World Health Assembly for eradication before the vector could grow resistance against the DDT. That was in brief the fund mobilisation process for NMEP. One of the major reasons of failure was fund availability in malaria programme in 1970s which partly (1)

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attributed to the international situation. Apart from the international conflicts (cold war, domino effect), the US had encountered a long ignored internal indignation in the form of ‘black movement’, ‘feminist movement’ at the last phase of cold war (late 1960s to early 1970s), also the worldwide economic depression in early 1970s and over enthusiasm on neo-Malthusianism (population control) have made the fund cut. Also, WHO understood the problem of vertical programme and the complexity of malaria programme which might prompt it to conduct ‘WHO interregional Conference on Malaria Control in Countries Where Time-Limited Malaria Eradication Is Impractical at Present’ in 1972 . The complexity of malaria programme further can be reviewed under the notion of technological dependency. The successful eradication of small pox might influence the WHO and USTCM experts to overestimate the DDT intervention in malaria programme and envisaged for eradication goal. That was the international context regarding malaria funding. On the other side, govt. of India had also started shifting its main focus on population control (family planning programmes) from malaria programme. It seems that funding decision of the govt. of India was made abruptly during that phase. For example, the fund for malaria programme had rose from $13 million (1968) to $22 million (1971), but again it reduced to $14 million in 1973 in spite of the dire need of speeding up. Further the fund has again increased in 1974-1975 to some $23-29 million despite the strong recommendation for minimum need of $81 million demand from Dr. Gopalan (head, ICMR). Hence, it can be contemplated that the continuous fund cuts weaken the eradication programme in both operational expansion and intensification. Hence, the malaria programme came under the fund crunch situation. Another major flaw in decision making was merging malaria programme with general health service. In attack (and also consolidation) phase of the eradication, the programme worked too successfully but the failure started once it moved to the maintenance phase which was under state’s responsibility. In late 1960s and 1970s the general health service was not well equipped and further accretion of malaria programme had again pushed the overall eradication programme at lost end. Urban Malaria Scheme (UMS): Failure of eradication programme was partly because of lack of concentration in urban areas, and keeping that assumption in mind UMS was launched in 1971. It was also thought that improper attention to urban areas might lead the malarial transmission from urban to rural in a larger scale. In spite of the focused effort to urban areas the malaria cases recoded much higher, and which prompted for more stringent course of action . Modified Plan of Operation (MPO): In the year of 1977, the goal of malaria eradication had been withdrawn and Modified Plan of Operation had been taken to decrease malaria mortality, eliminate malarial deaths and sustain the success achieved so far through continuous reduction of malaria transmission. The major 1

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strategic changes had been done in operational aspects. The areas were demarcated based on the API (Annual Parasitic Index) indicator and accordingly intervention strategies were drawn . The MPO was conceptualised during the Consultative Committee of Experts (Rao committee) and Second In-depth Committee in 1974 where govt. decided to go for a revised strategy (eradication to control) . MPO was influenced by the rapid form of urbanisation and green revolution which collectively created more stagnant water and favourable environment for breeding of mosquito. To address these challenges MPO was comprised with funding booster from government (75% of total budge made for communicable disease was spent on malaria), people’s participation by forming 200000 drug distribution centers (DDC) and fever treatment depots (FTD) had been planned to initiate so that people can access the malaria treatment, and strengthen the research in malariology . The research had given more importance in MPO as it had been found that lack of operational research during NMEP was the cause to unable to understand the field reality (like, amalgamation of malaria with general health service). Strategy wise, MPO had introduced API indicator wise demarcation area. It had given the scope to distribute the available resources (finance, manpower, technological equipments etc) rationally and also effectively as per the epidemiological need. From community aspect also the treatment facility got wider after the establishment of DDC and FTD. Malaria Action Programme : An expert committee was formed after 1994 malaria resurgence at Rajasthan, Manipur and Nagaland, in 1995 at Assam, Maharshtra and West Bengal, and again in 1996 at Rajashthan and Haryana. The committee recommended the guidelines which formulated as Malaria Action Programme in 1995. Hundred per cent central funding was back to malaria programme. Again the areas were demarcated based on the advanced epidemiological parameters: hardcore areas (tribal areas), epidemic prone areas, project areas, triple insecticide resistant areas and urban areas . One major surveillance programme (NSPCD: National Surveillance Programme for Communicable Disease) also had been initiated in 1996 to combat with various disease outbreaks across the country. It was an additional help for malaria programme as it conducted outbreak investigation, epidemic control analysis, laboratory strengthening, training on human resource etc. Enhanced Malaria Control Project (EMCP): On the request of India, World Bank financed the EMCP to intensify the anti-malaria activity particularly in the six core tribal population representing 100 districts and 19 urban areas of 8 states. Also, other infrastructural upgradation took place as the Management Information System (MIS), training were carried out along with advocacy activities using IEC materials. Main objectives 2

were to bring down the malaria morbidity, reduce malaria mortality and sustain the success made so far . Operation wise EMCP bought many innovations to the programme. Under the component of early case detection and prompt treatment, appointment of link workers, introduction of Dipstick test (on spot test) and involvement of private sectors in case detection and treatment were important. EMCP also designed and administered new ways of vector control. Bioenvironmental methods (introduction of Larvivorous fishes, environmental management methods), legislative measures (changes in structural design of buildings to reduce mosquito breeding place), personal protective measures (like, bednet programme) were some of the new initiatives. National Anti-Malaria Programme: Govt. has finally dropped the term ‘National Malaria Eradication Programme’ in 1999 and renamed it as ‘National Anti-Malaria Programme’. Though, the programme has been included shortly within the ambit of National Vector Borne Disease Control Programme . National Vector Borne Disease Control Program (NVBDC): To address the need of convergence and on the background of series of epidemics of vector-borne diseases in the decades of 90s, the NVBDC has been formed in 2004 to control the five diseases (malaria, kalaazar, filarial, japanese encephalitis and dengu). Since then the malaria programme is a part of NVBDC. Finally the entire NVBDC has been included under NRHM (National Rural Health Mission) to ensure increase and appropriate public health focus in rural areas for improved prevention and control of communicable disease . In 2004, the Integrated Disease Surveillance Project (IDSP) has been launched. It is the newer form of NSPCD which reports, analyse the various disease occurrences and operationalised across the country. Malaria was back to international agenda after WHO started a new initiative in 1998, the Roll Back Malaria (RBM) effort. RBM is the global partnership between WHO, UNDP, Unicef and World Bank. RBM is the effort for partnership between national government with NGOs, civil societies, research institutions, private sector, media, development banks and professitional associations. Globally also, the Millennium Development Goal (2000) has also acknowledged the problem and set the goal no. 6 (combating HIV/AIDS, malaria and other disease) and target no. 8 (halt and reverse the incidence of malaria and other major diseases) . 2002 National Health Policy has made the anti-malaria activity as priority by setting the goal of reduction in mortality from malaria and other vector-borne diseases by 50% within 2010 and efficient morbidity control . Also, Intensified Malaria Control Project has been started from 2005 under the aegis of GFATM. It came under the Health Sector Reform strategy which additionally supplements the nation wide malaria control programme with funding, infrastructure and 2

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manpower support. All these initiatives also programmatically, politically and strategically influence the malaria control programme in India. Malaria control is one of oldest and toughest public health problems in India. The complexity of this programme makes it more difficult for the planners to strategies an effective control mechanism. The bionomics of the vector is very complicated and because of that also the vector control activity is also difficult. The history of malaria programmes started with planning of malaria control then shift to eradication and then again shift to control strategy is adducing the same complexity. The malaria programme mostly implemented in vertical approach which gave very littlie scope for intersectoral collaboration. The transmission of malaria can be reduced through vector control which is related to larger socioeconomic factors in India. Even in 2013, there are areas like Garhi (an urban village in New Delhi) which resembles nineteenth century England where the pipe line made for drinking water laid alongside with the drainage root and having umpteen numbers of breeding places. The area is alone housed thousands of migrants where the sanitary condition can not be comparable at all with any mode of civilised society. The malaria control unit has been set up by the Delhi Municipality to surveillance the Garhi and adjacent area, but the problem lies in many layers. Can these breeding places of Garhi only be combated by the surveillance of the DBCs (Domestic Breeding Checker)? Are there any roles for public health engineering? What are the roles of Delhi municipality for ensuring proper urbanisation? Garhi along with many other malaria prone areas of India are waiting for these answers . In NCDC (National Centre for Disease Control, the apex body of disease control), currently 14 Entomologist are in place and 12 positions are vacant. The Entomology is the discipline which deals with the bionomics and without knowing the bionomics vector control strategy is not possible. According to the head of the Entomology department in NCDC, the Entomologists are becoming less important in public health field in India . The activity of malaria control can not be limited to spraying or fogging or surveillance but also need to actively engage the disciplines of epidemiology, entomology, public health engineering and relevant sectors to work collectively. Malaria eradication is a distant dream but not the effective control. 4

REFERENCES 1 Dutta PK — ‘Study of NMEP: A System Approach’. Prachi Prakashan, New Delhi. 1993. 2 Kishore J — National Anti Malaria Program. National Health Programs of India, 5th edition, 2005: 138-54. 3 Cleaver H — “Political Economy of Malaria Decontrol”, Economic and Political Weekly, 1976: Vol XI, No 36, Sept 4th 963-72. 4 Garhi village, New Delhi was visited for the PhD semester-I field work curriculum under the Centre for Social Medicine & Community Health, JNU on November 12, 2013. 5 NCDC, New Delhi was visited for the PhD semester-I field work curriculum under the Centre for Social Medicine & Community Health, JNU on November 11, 2013.

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Case Report A case of aorto-arteritis, presenting with recurrent hypertensive encephalopathy-successively managed with renal angioplasty Rajeev Bhardwaj1, Praveen Bhardwaj2 Hypertension in Children is not very common. When a child presents with hypertension, secondary causes must be ruled out, especially the ones that can be cured. We are presenting a case renovascular hypertension who presented with recurrent hypertensive encephalopathy. [J Indian Med Assoc 2017; 115: 30-1]

Key words : Hypertension, renal artery stenosis, hypertensive encephalopathy.

ypertension (HT) in children is mostly of secondary type. Most of the underlying diseases are rare and a relatively small number of conditions are responsible for HT in over 90% of patients. In a study by Hari et al, renal HT (chronic glomerulonephritis) was the commonest cause (49.2%) and renovascular HT was seen in 15.7%. Takayasus disease was the most common cause of renovascular HT and coarcation of aorta was the commonest cause of HT in infancy and was found in 53.3% of cases . ,

CASE REPORT

A seven years female child presented to the department of Pediatrics on 3.11.06 with complaints of (1) Intermittent headache for one month (2) Vomiting for 3 days (3) Altered sensorium for one day Initially, the headache was mild to moderate in intensity but for the last 3 days the intensity of headache had increased and she started to have vomiting also. For the last one day, she was having altered consciousness and intermittent episodes of stiffening of body with rolling of eye balls. There was no history (H/O), rash or sore throat. There was no H/O cough, breathlessness, palpitation or joint pains. On examination the child was unconscious, not responding to commands but responding to painful stimuli. There was no neck rigidity. Her blood pressure (BP) was 250/170 in right upper limb and 170/ 130 in left upper limb. Left upper limb pulses were week, and there was bruit over left subclavian artery. There was radio radial delay but no radio femoral delay. She was moving all limbs to painful stimuli and right planter reflex was extensor. Chest and cardio vascular examination were normal. INVESTIGATIONS

ESR TLC

- 70mm in first hour - 19200/cmm, with neutrophylls predominating (80%) Urea - 32mg/dl Creatinine - 0.7mg/dl CT head - normal Department of Cardiology, Indira Gandhi Medical College, Shimla 171001 1 DM (Cardiology), Professor 2 MD (Paediatris), Assistant Professor of Paediatrics

Ultrasound (abdomen) right kidney was normal, left was slightly smaller (difference of 2cm). No suprarenal mass was seen. Intra venous pyelography showed normal excretion on right but non functional left kidney. ECG : showed LVH Echocardiography was normal Fundus : examination showed bilateral papilliedema, with grade II arteriosclerotic changes. Initially, her BP was controlled with nitroglycerine infusion. At the same time she was started on amlodipine 2.5mg per day which was increased to 5mg/day Finally her BP was controlled with amlodipine 5 m g B D , enalepril 5mg BD and furosemide 20 mg OD. Her consciousness improved and all s y m p t o m s subsided. She was subjected to angiography( aortic arch angio, abdominal aortogram and Fig 1 — Left subclavian artery showing 90% selective renal stenosis just after the vertebral artery and subclavian angiography). It showed 9o% stenosis of left subclavian artery (Fig 1), osteal stenosis of right renal artery (Fig 2) with gradient of 80mm Hg. Left kidney was smaller and had two renal arteries, upper one of which was small Fig 2 — Abdominal aortogram showing with ~99% osteal stenosis of right renal artery. Left stenosis at origin kidney has two arteries, the upper one of (Fig 2). There was which shows tight stenosis at origin some narrowing in abdominal aorta below the renal arteries without significant gradient. So the

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findings were suggested of type III aorto arteritis with left subclavian artery stenosis with bilateral renal artery stenosis. In view of bilateral renal artery stenosis, enalepril was omitted and she was put on prazocin 2.5mg BD. It was decided to defer her renal angioplasty for 2-3 months in view of active disease and she was put on steroids and was discharged. She again came back on 7th December with altered consciousness and again had to be put on nitroglycerine infusion, as her BP was 220/160mm Hg. This time, her BP was not controlled with oral drugs. In view of resistant HT and recurrent hypertensive encephalopathy, she was taken for angioplasty on 12th December. Lesions were crossed with .014 guide wire. Direct stenting was done to left subclavian artery with 4mm x 20mm stent (Fig 3). Right renal artery was also subjected to direct stenting with 4mm x 16mm stent (Fig 4). There was no residual stenosis/gradient across the lesions. Finally left renal artery, which was small and had severe stenosis at the origin was attempted. It was very difficult to tackle, it was difficult to hook the artery with guiding catheter due to small size of vessel and severe osteal stenosis. So this vessel was initially dilated with 1.5x 20 mm balloon through diagnostic catheter and then it Fig 3 — Left subclavian artery, after direct was possible to hook stenting showing no residual stenosis the artery with guiding catheter and lesion was dilated with 3mm x 20 mm balloon (Fig 5). The stent was not implanted in this artery due to small size of kidney, which was shown to be non functional on IVP. We still dilated it, to Fig 4 — Right renal artery after direct give benefit of doubt, stenting, showing no residual stenosis because there was late excretion of contrast seen through this kidney during angioplasty. Patient tolerated the procedure well. Her renal functions remained normal, she remained asymptomatic and her BP was controlled with just amlodipine 2.5mg OD. She was discharged after two days. Steroids were continued for three months after which, these were tapered over six weeks. Now it is almost five and half years, and she is off all drugs, has normal blood pressure and is asymptomatic since then. DISCUSSION

Renal artery stenosis(RAS) may present as (1) Sudden onset of HT (2) Drug refractory HT (3) Renal insufficiency or sudden worsening of renal function (4) Episodes of flash pulmonary edema (5) Azotemia induced by treatment with angiotensin converting enzyme inhibitors(ACEIs) (6) More than 1.5cm difference between kidneys on renal ultrasound 2

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(7) Secondary hyperaldosteronism Non invasive evaluation of RAS includes captopril renography, duplex D o p p l e r u l t r a s o n o g r a p h y, magnetic resonance imaging, and spiral computerized tomography. Fig 5 — Left renal artery showing good Renal angiogram is result after plain balloon angioplasty current gold standard in diagnosis of RAS. Medical management of RAS includes drugs like ACEIs, angiotensin receptor blockers, diurects, beta blockers and calcium channel blockers . Surgical treatment methods involve surgical endarterectomy and bypass of stenotic lesions. The mortality rate reported with surgery is in the range of 2-9% . Percutaneous transluminal renal angioplasty(PTRA) is treatment of choice in most cases of RAS. The procedure involves conventional balloon angioplasty with or without stenting. The following criteria may be used as a guide for renal artery revascularization: (1) Osteal or proximal stenosis of ? 70% (2) Drug refractory HT (3) Progressive renal insufficiency/ failure (4) Episodes of flash pulmonary edema Overall clinical benefits of PTRA are mainly a decrease in blood pressure in about 2/3 of treated patients and in some cases, a complete cure of high BP. In addition, PTRA is known to have caused a significant decrease in number of daily BP medications taken by the patients . PTRA has not been shown to improve or worsen renal function . However, renal intervention has been shown to delay dialysis and progression of renal failure . Our patient presented with recurrent hypertensive encephalopathy, BP was not controlled with drugs, and responded to PTRA. 3

5,6

REFERENCES

1 Hari P, Bagg A, Srivastva RN — Sustained hypertension in children. Indian Pediatr 2000; 37: 268-74. 2 Messina LM, Zelenock GB, Yao KA — Renal revascularization for recurrent pulmonary edema in patients with poorly controlled hypertension and renal insufficiency: a distinct subgroup of patients with arteriosclerotic renal artery occlusive disease. J Vasc Surg 1992; 15: 73-80. 3 Hanzel G, Balon H, Wong O — Prospective evaluation of aggressive medical therapy for atherosclerotic renal artery stenosis, with renal artery stenting reserved for previously injured heart, brain or kidney. Am J Cardiol 2005; 96: 13227. 4 Novick AC. Surgical revascularization for renal artery disease: current status. BJU Int 2005; 95: 75-7. 5 Alhadad A, Ahle M, Ivancev K — Percutaneous transluminal renal angioplasty (PTRA) and surgical revascularization in renovascular disease? a retrospective comparison of results, complications, and mortality. Eur J Vasc Endovasc Surg 2004; 27: 151-6. 6 Van jaarsveld BC, Krijnen P, Pieterman H — The effect of balloon angioplasty on hypertension in atherosclerotic renal artery stenosis. Dutch Renal Artery Stenosis Intervention Co operative Study Group. N Eng J Med 2000; 342: 1007-14. 7 Korsakas S, Mohaupt MG, Dinkel HP — Delay of dialysis in end stage renal failure: prospective study on percutaneous renal artery interventions. Kidney Int 2004; 65: 251-8.

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Case Report

Congenital malaria in a term neonate mimicking sepsis : a case report

Tuberculosis of calcaneum — a unique presentation Vinod Kumar B P1

Birendra Nath Roy , Radheshyam Purkait , Tryambak Samanta , Suman Ghosh , 4 5 Angshumitra Bandyopadhyay , Mridula Chatterjee

A 35 years old gentleman, an IT personal had a non healing ulcer at the lateral aspect of foot. Two years back he had a swelling there, an incision and drainage cured it by 2 weeks. X-ray showed a lytic lesion at the antero-lateral aspect of calcaneum. Surgical debridement done; Histopathology showed tuberculosis. He underwent DOTS regime and was cured. [J Indian Med Assoc 2017; 115: 32 & 34]

India remains the high endemic region for all types of malaria. In spite of the high burden of vivax malaria in the country, reports on congenital malaria due to Plasmodium vivax are limited in the literature. Neonate with congenital malaria presents with variable manifestations. We report herein a twenty-day-old male infant, who presented with the symptoms of sepsis. A diagnosis of congenital malaria was made based on the demonstration of Plasmodium vivax on both mother and baby’s peripheral blood smear and positive maternal history of vivax malaria during her seventh month of pregnancy. Both were responded dramatically to oral chloroquine. We conclude that congenital malaria should be considered as an important differential diagnosis of neonatal sepsis in malaria endemic regions. [J Indian Med Assoc 2017; 115: 33-4]

Key words : Tuberculosis, Calcaneum, DOTS Regime, CA SO (Stimulan), Antibiotic Impregnation. 4

he diagnosis of painful heel syndrome is quite common in any busy orthopaedics OPD. Though neoplasm and infections are not uncommon in calcaneum, the surgeon does not suspect infection unless there is an obvious history of punctured wound or constitutional symptoms. Even in the scenario of infection, tuberculosis affecting this bone is a rare occurrence.

Key words : Congenital malaria, Plasmodium vivax, Neonatal sepsis.

CASE REPORT

35 years old gentleman Rajesh an IT personal came to orthopaedics OP of Trivandrum medical college, Trivandrum, Kerala with a non healing ulcer at the lateral aspect of foot. 2 years back he had a swelling at the same region; for that he had undergone an incision and drainage in a local hospital. It was healed by 2 weeks. 8 months later he developed pain at heel and it was cured by Non Steroidal Anti Inflammatory Drugs followed by Micronized Rubber chappals. Now he presented with a non healing ulcer at the lateral aspect of foot same region of Incision and Drainage. It was started 1 month back with a swelling at the lateral aspect of the foot for this problem an incision and drainage was done at a local hospital and by 3 weeks time with so many treatments it was not healing so he was referred to Medical College, Trivandrum. He was investigated thoroughly- blood routine done suggestive of infection, CRP was also positive. Culture & sensitivity of pus coming out through the sinus was done and the result (Fig 1). Heavy growth of coagulase positive staphylococci sensitive to cloxacillin and gentamicin grown. X-ray showed a lytic lesion at the antero-lateral portion of the calcaneum. We thought of doing debridement and histopathology mean while started him cloxacillin and gentamicin after looking the renal parameters. Gentamicin given for 10 days as injection and cloxacillin 500mgs -4 times a day for 6 weeks. After getting anaesthesia check up a surgical debridement done, the sinus track identified, it was excised, the lytic area identified with the help of c-arm through debridement done and the specimen send for histopathology. The lytic space filled with vancomycin impregnated purified CA SO4 (Stimulan). Below knee slab given after suture removal at 10 days post operatively a cast given. After 6 weeks walking cast given for 6 more weeks and he allowed to walk. After getting the histo-pathologiacal report which is (Fig 2) he had started anti- tuberculosis treatment (Directly Observed Treatment, Short-course Regime) following Liver Function Tests and Ultrasound of abdomen since he had a past history of jaundice and a 1 MBBS, D Ortho, DNB (Ortho), MNAMS, M Phil, Additional Professor in Orthopedics, Government Medical College, Thiruvananthapuram 695011

Fig 1 — Showing culture & sensitivity of pus

fatty liver. Follow up — X-ray and clinical picture at 3 months shows well healed scar and consolidating radiological evidence (Fig 3). DISCUSSION

Mycobacterium tuberculosis is an organism that causes multisystemic involvement. Although pulmonary tuberculosis is the major manifestation of the disease, multifocal and extra pulmonary tuberculosis has gained medical attention since the emergence of HIV. Most common extra pulmonary manifestation is said to be lymphadenopathy. Of the osteoarticular TB the most common site of involvement is spine. After spine, hip and knee foot is the next site of predilection (<10% in the osteoarticular tuberculosis). In the foot the decreasing order of occurrence are calcaneum, talus, 1 metatarsal and naviculum. A Anil et al studied 39 cases of calcaneal tuberculosis and proposed a classification system for the same which was based on the site of affection and whether or not subtalar joint was affected. (Calcaneal tuberculosis: a study of 39 cases - A Anil; I Dhami; S Kumar; B Nadkarni; G Arora; and NC Mathur.Department of Orthopaedics University College of Medical Sciences Shahdara, New Delhi-110095, India; Journal of Bone and Joint Surgery - British Volume, Vol 84-B, Issue Supp_III, 233) (a) Enthesitic type: erosive lesion at the attachment of tendo Achilles (b) Erosive lesion involving the attachment of plantar fascia (c) Intraosseous lytic lesion without involvement of subtalar st

Fig 2 — Showing histopathological report (Continued on page 34)

ongenital malaria is acquired from the mother to child by transplacental transmission of parasitized maternal erythrocytes during pregnancy or perinataly during labour and is a serious problem in tropical countries including India. It is an important cause of abortions, miscarriages, stillbirths, premature births, intrauterine growth retardation, and neonatal deaths in endemic areas . Although malaria is endemic in India, congenital malaria is considered rare because of the protection provided by the passive acquisition of maternal antibodies and fetal hemoglobin. The nonspecific signs and symptoms of malaria in neonatal period are often confused with sepsis, which leads to delay in diagnosis and treatment . We herein report a twenty-day-old male infant who had presented with intermittent fever, breathlessness, poor feeding, pallor with hepatosplenomegaly and finally diagnosed as congenital malaria due to Plasmodium vivax. 1

CASE REPORT

A twenty-day-old neonate admitted in our pediatric department with complaints of intermittent fever, cough and breathlessness of five days duration. The child was sucking poor at the breast and became less active and playful. The baby was delivered normally at term weighing 2.8 kg to a nonconsanguineous parent with an uneventful perinatal period. On physical examination baby had pallor, tachypnea (respiratory rate: 66/minute), normal heart rate (124/minute) and distended abdomen. Liver was palpable clinically with a span of 9 cm; spleen was also palpable 4 cm below costal margin without any evidence of ascites. A clinical diagnosis of neonatal sepsis was made and relevant investigations were send. Laboratory evaluation showed mild anemia (hemoglobin: 12.3 g/dl), white blood cell (WBC) counts of 12,700/ mm and severe

thrombocytopenia (platelets 17.000/mm ). During examination of peripheral smear to determine the differential white blood cell count, haemoparasites were noted within red blood cells. A thick and thin blood film revealed trophozoites form of Plasmodium vivax with high parasitemia (Fig 1). Other investigations like liver function test, real function test and serum electrolytes were within normal limits. Blood and urine culture revealed no growth. The history of mother was re-viewed. She was a primigravida and had visited antenatal clinic irregularly. In the 7th month of pregnancy she had fever with chills, which on evaluation was diagnosed as Plasmodium vivax malaria and undergone treatment with chloroquine. Repeat examination of peripheral blood smear before delivery could not be possible as mother did not attend antenatal clinic anymore. The placenta was unavailable for further analysis. During the present episode, the mother was re-evaluated at the light of the neonatal diagnosis. She was asymptomatic but her peripheral smear showed presence of scanty Plasmodium vivax trophozoites 3

Department of Paediatric Medicine, NRS Medical College and Hospital, Kolkata 700014 1 MD (Paediatrics), Associate Professor 2 MD (Paediatrics), Assistant Professor 3 MD (Pathology), Assistant Professor, Department of Pathology 4 MBBS, MD Postgraduate Trainee 5 MD (Paediatrics), Professor and Head

Fig 1 — Showing trophozoites form of Plasmodium vivax (Inset: Ring form)

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suggesting the possibility of congenital malaria in the infant. Both were treated with oral chloroquine 10 mg/kg the first and the second day followed by 5 mg/kg the third day. Peripheral smear was repeated after therapy and was negative for malarial parasites on two consecutive days. The baby was discharged and followed up in outpatient department. DISCUSSION

The reported incidence of congenital malaria varies widely from 0.3% to 33% in both endemic and non-endemic areas . Although it can be observed with any of the human malaria species, Plasmodium falciparum has been implicated in most studies from Africa, whereas Plasmodium vivax has been described from non African areas including India . It usually occurs in infants of women who have had clinical attacks of malaria during pregnancy but also occurs, rarely, in infant of women who was asymptomatic throughout pregnancy . The typical signs and symptoms of congenital malaria include fever, restlessness, drowsiness, pallor, jaundice, poor feeding, vomiting, diarrhea, cyanosis, and hepatosplenomegaly . Diagnosis of congenital malaria is often missed in the early neonatal period as the infections are usually asymptomatic with low parasitemia. Although described at birth, symptoms most commonly occur between 10 and 30 days of age which sometimes makes the dilemma of case definition of congenital malaria . This interval between birth and onset of symptoms may be explained by transmission in late pregnancy or during delivery or by presence of transplacentally acquired maternal antibody (IgG). Malaria during pregnancy, particularly close to term, may either protect the infant against malaria infection and severe disease via acquired maternal immunity or may increase the risk of infant mortality, particularly neonatal mortality, by increasing the risk of low birth weight, premature labour, intrauterine growth retardation, placental infection and stillbirth . In most malaria endemic areas, the laboratory diagnosis of congenital malaria is established by the microscopic identification of organisms on Giemsa-stained smears of peripheral thick or thin blood smears. Plasmodial antigen detection or polymerase chain reaction of the blood may be necessary where parasitemia cannot be shown on blood smear . Although, there are no clearly established protocols for the 3

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management of congenital malaria, till now treatment with oral administration of chloroquine (10 mg/kg of base followed by 5 mg/kg of base at 6, 24 and 48 hours) is adequate since there is no exoerythrocytic life cycle in congenitally-acquired vivax infection . This report suggests congenital malaria should be taken in consideration as an important differential diagnosis of neonatal sepsis and also emphasizes the need for routine screening for malaria in sick newborn infants in malaria endemic regions. Emphasis should also be given to awareness regarding use of bed nets in community and adequate treatment and follow up for malaria during antenatal period. 3,7,10

REFERENCES

1 Krause PJ — Malaria (Plasmodium). In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, editors-Nelson’s Textbook of Pediatrics. Vol 1. 18th ed. Philadelphia: Saunders, 2008: 1477-84. 2 Gandhi A, Garg K, Wadhwa N — Neonatal Plasmodium vivax malaria: an overlooked entity. J Infect Dev Ctries 2011; 5: 489-92. 3 Valecha N, Bhatia S, Mehta S, Biswas S, Dash AP — Congenital malaria with atypical presentation: a case report from low transmission area in India. Malar J 2007; 6: 43. 4 Mohan K, Maithani MM — Congenital malaria due to chloroquine-resistant Plasmodium vivax: a case report. J Trop Pediatr 2010; 56: 454-5. 5 Kashyap S — Congenital malaria: a case report. J Indian Med Assoc 2010; 108: 51. 6 Poespoprodjo JR, Hasanuddin A, Fobia W, Sugiarto P, Kenangalem E, Lampah DA, et al — Case Report: Severe Congenital Malaria Acquired in utero. Am J Trop Med Hyg 2010; 82: 563-5. 7 Davies HD, Keystone J, Lester ML, Gold R — Congenital malaria in infants of asymptomatic women. CMAJ 1992; 146: 1755-6. 8 Sankar J, Menon R, Kottarathara AJ — Congenital malaria—a case report from a non-endemic area. Trop Biomed 2010; 27: 326-9. 9 Wiwanitkit V — Congenital malaria in Thailand, an appraisal of previous cases. Pediatr Int 2006; 48: 562-5. 10 Chigozie JU — Congenital malaria: an overview. Tanzania Journal of Health Research 2011; 13:.

(Continued from page 32)

Fig 3 — Showing x-ray and clinical picture

joint – this included the majority of cases in the mentioned study (d) Intraosseous lytic lesion involving subtalar joint Patient usually presents with pain, swelling, tenderness, cold abscess or sinuses in the heel region. X-ray will show osteoporosis, lytic lesion and sometimes coke like sequestrum. Extensive osteoporosis will make the identification of the lesion difficult and a comparative X-ray of the opposite calcaneum will help to solve the situation. Diagnosis can be confirmed with pathological and microbiological evaluation of the biopsied material. Differential diagnosis includes low grade pyogenic infections and rare granulomatous conditions like mycosis,

ACKNOWLEDGEMENT

Dr Digo, Resident in Orthopaedics, Government Medical College, Trivandrum. REFERENCES

1 Bhat Sandhya K, Sastry Apurba S, Sharada Mannur, Nagaraj ER — Tuberculosis of calcaneum : a rare case report. International Journal of Collaborative Research on Internal Medicine & Public Health 2012; 4: 1601-5. 2 Agarwal N, Jain SK — Tuberculous osteits of skull : a case report. Indian J Tuberc 2009; 49: 105. 3 Anil A, Dhami I, Kumar S, Nadkarni B, Arora G, Mathur NC — Calcaneal tuberculosis: a study of 39 cases. Journal of Bone and Joint Surgery - British Volume 2001;84B(SUPP_III):233.

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Case Report Arterial thrombosis in a case of Mycoplasma Pneumonia with Protein S deficiency Abhishek Parlikar1, Rajashree Ratnaparke2, Manjiri Vyawahare3 Pneumonia is the main manifestation of Mycoplasma pneumoniae infection in children. Amongst the extra-pulmonary manifestations of Mycoplasma infection, thrombosis is being increasingly reported over the last two decades. Not many cases are reported from Indian literature. We report the first case from Indian literature where Mycoplasma pneumonia was associated with Protein S deficiency leading to arterial thrombosis. A 12-year-old adolescent male with fever and cough of 8 days had left upper lobe consolidation on chest roentgenogram. He had pain in his right foot with a small area of necrotic skin over its dorsum. The right Dorsalis pedis artery pulsations were absent. Doppler revealed changes of arteritis with lack of flow. He was seropositive for IgM antibody against Mycoplasma pneumoniae and thrombophilia work-up revealed Protein S deficiency. Pulmonary manifestations responded to oral Erythromycin and thrombosis resolved gradually with heparin and warfarin therapy. Recannalization was seen on Doppler after 6 months of therapy and there was no repeat episode of thrombosis as seen at the 1-year-follow-up. Repeat Protein S activity done during the 3rd month follow up was normal. Mechanism of thrombosis in Mycoplasma can either be direct (causing vasculitis) or indirect by causing immune modulation and producing a procoagulant state. Our case probably highlights both these mechanisms where vasculitis and Protein S deficiency contribute to arterial thrombosis. [J Indian Med Assoc 2017; 115: 35-6]

Key words : Mycoplasma pneumonia, arterial thrombosis, Protein S deficiency.

common cause of community acquired pneumonia in children; Mycoplasma pneumoniae is associated with arterial and venous thrombosis. We report a case of Mycoplasma pneumonia with arterial thrombosis, found to have transient Protein S deficiency. CASE REPORT

A previously healthy 12-year-old male presented with fever and dry cough of 8 days duration with pain in the right foot of 2 days duration. Examination — He was pyrexial to 39 C, had tachypnoea (respiratory rate-42 breaths/minute). Pulse oximetry measurements were 92% on room air and 100% on supplemental oxygen by nasal canula. He was hemodynamically stable. Peripheral pulses were well felt except for absent right Dorsalis Pedis pulsation. There was a small area of skin necrosis (15mm x 3mm) on the dorsum of the right foot (Fig 1). Chest examination revealed bronchial breath sounds in the left infraclavicular and mammary region. Other systems were normal. There was no similar past or family history suggestive of thromboembolic states. Chest radiograph revealed left upper lobe consolidation (Fig 2). Blood investigations revealed a high-normal leukocyte count (11,500/mm ) with neutrophilic predominance (82%), Haemoglobin (12.4 gm%) and platelet count (4.20 lakh/mm ) with a high ESR (55mm in first hour). He was seronegative for HIV. Urinalysis was normal. o

brucellosis, sarcoidosis etc. Conservative treatment with BK cast or AFO with fixed ankle in addition to the anti TB drugs will suffice for majority of the cases. Non healing cases may require debridement and curettage. Surgical excision of the lesion is also warranted in case of large osseous isolated lesion. Arthrodesis is coupled along with debridement in the presence of joint involvement.

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Department of Paediatrics, Dr Hedgewar Rugnalaya, Garkheda parisar, Aurangabad 431005 1 MBBS, DCH, DNB (Paediatrics), Senior Registrar 2 MBBS, MD (Paediatrics), Head of the Department 3 MBBS, DCH, Senior Consultant

Doppler study revealed changes of arteritis in right Dorsalis pedis (cord like echogenicity of the blood vessel) with lack of flow. Echocardiography and ultrasound abdomen were normal (Table 1). D - d i m e r a s s a y, fibrinogen levels, Prothrombin and Partial Thromboplastin time were normal. Serum Anti-Nuclear-Antibody, Anti-phospholipid IgM Fig 1 — Showing Necrotic patch on the and IgG antibodies were dorsum of right foot absent. No improvement in the respiratory symptoms despite 48 hours of intravenous Cefotaxime and Amikacin, prompted possibility of an atypical pneumonia. Mycoplasma IgM, done by serum Enzyme Immunoassay was positive. (Value- 21.4, UnitRatio, Interpretation: <9- negative, 9-11- intermediate, >11positive). Oral Erythromycin therapy was initiated (40 mg/kg/day), following which fever subsided within 72 hours. Thrombosis was treated with subcutaneous Low-molecularweight heparin, gradually tapered and overlapped with oral warfarin (to maintain INR between 2.5-3).

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Dorsalis pedis artery became palpable, albeit low volume during the fourth month after discharge. A repeat Plasma Protein S activity, done during this follow-up was normal (80% Range-77-143). In consultation with haematologist warfarin was stopped after 6 months as Doppler ultrasound documented recannalization. Most recent follow-up, one Fig 2 — X-ray chest showing year from admission, left upper lobe consolidation showed no clinical evidence of recurrent thrombosis.

REFERENCES

DISCUSSION

Table 1 — Showing Thrombophilia work-up Result

Plasma Protein C 141 activity (%) Plasma Protein S 62 (low) activity (%) Plasma Antithrombin 120 activity (%) Homocysteine 6 (micromoles/L)

Normal Range

Method used for the Tests

67-195

PLASMA- clotting time based assay PLASMA- clotting time based assay PLASMA- Chromogenic assay

77-143 77-122 5-10

We chose IgM, using Enzyme Immunoassay, as studies prove it as an accurate and cost-efficient tool for the diagnosis of M pneumoniae pneumonia in children4. In our case thrombosis developed 6 days after the onset of fever which is slightly earlier than that reported in previous cases (mean duration-12 days and range: 8 days to 2weeks from the onset of fever 2). A direct mechanism for thrombosis secondary to MpI has been proposed by which it induces various cytokines (interleukin-8, tumour necrosis factor alfa) that elicit vasculitis, as evidenced in our case by raised ESR (55mm) and features of arteritis on Doppler ultrasound. In vitro experimental studies have suggested that lipoglycans from some Mycoplasma species, including M. pneumoniae, could induce procoagulant activity (tissue factor-like activity) by human mononuclear cells . Transient Protein S deficiency detected in our case represents a procoagulant state. Graw-Panzer KD et al hypothesized that thromboembolism can be contributed to by antiphospholipid antibodies induced by 5

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MpI in a patient with underlying protein S deficiency. They also emphasized that the excess risk for thrombosis in protein S deficiency occurs in the presence of other risk factors . In our case there were no other risk factors for thrombosis apart from protein S deficiency. But equally important is the possibility of direct mechanism of Mycoplasma inducing vasculitis and the fact that there was no recurrence of thrombosis in our case after complete treatment of Mycoplasma pneumonia and normalization of protein S levels. So in conclusion it would not be incorrect to hypothesize that thrombosis in Mycoplasma pneumonia was contributed to by transient protein S deficiency and the direct mechanism that induces vasculitis. It is important to confirm the transient nature of protein S deficiency by documenting normal post treatment levels.

In India the prevalence of the Mycoplasma pneumoniae infection (MpI) ranges from 24% in hospitalized children to 27.4% in children with community acquired pneumonias1. Thrombosis as a rare extra-pulmonary manifestation of MpI has been increasingly reported in the western literature. There have been 22 case reports so far, documenting thrombosis secondary to MpI at various sites including the Left Atrium, pulmonary and cerebral vasculature, internal carotid, popliteal and superior mesenteric arteries . A case of Mycoplasma pneumonia (Mp) and pulmonary embolism with Protein S deficiency and antiphospholipid antibodies has been reported in the western literature . We report the first case in Indian literature, where transient Protein S deficiency was found in a case of Mp with thrombosis affecting Dorsalis pedis artery.

Test Name

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1 Kashyap S, Sarkar M — Mycoplasma pneumonia: Clinical features and management. Lung India 2010; 27: 75-85. 2 Mitsugi Nagashimaa, Takashi Higakib, Harumitsu Satoha, Takeshi Nakanoc — Cardiac thrombus associated with Mycoplasma pneumoniae infection. Interactive Cardio Vascular and Thoracic Surgery 2010; 11: 849-51. 3 Graw-Panzer KD, Verma S, Rao S, Miller ST, Lee H — Venous thrombosis and pulmonary embolism in a child with pneumonia due to Mycoplasma pneumoniae. J Natl Med Assoc 2009; 101: 956-8. 4 Waris ME, Toýkka P, Saarinen T, Nikkari S, Meurmann O, Vainionpaa R, et al — Diagnosis of Mycoplasma pneumoniae pneumonia in children. J Clin Microbiol 1998; 36: 3155-9. 5 Mitsuo Narita — Mycoplasma pneumoniae as an UnderRecognized Agent of Vasculitic Disorders. www.intechopen.com/download/pdf/pdfs_id/21617: 38-39. 6 Joo CU, Kim S, Han YM — Mycoplasma pneumoniae induced popliteal artery thrombosis treated with urokinase. Postgrad Med J 2001; 77: 723-724.

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