May 2016 by ejima

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92 24%

291 76%

BMI (kg/m2)

28 26 24 22 20 18 16 1500

Euglycemic Deranged glycemic status

2000

2500 3000 3500 Birth Weight (g)

4000

4500

Developed acute complications of diabetes Reverted to normal Developed diabetes

May 2016 JIMA Advertiser

Dr S S Agarwal

Dr K K Aggarwal

Dr Debasish Mukherjee

Dr Santanu Sen

National President, IMA

Honorary Secretary General, IMA

Honorary Editor, JIMA

Honorary Secretary, JIMA

Volume 114

u Number

u Kolkata u May 2016

CONTENTS Editorial : u Phonosurgery — A revolution in the treatment of voice disorders — Debasish Mukherjee.....................................................................................................................45 Originals and Papers : u Study to evaluate the influence of pre-pregnancy weight, height, BMI and weight gain during pregnancy on birth weight of baby — Shyamal Dasgupta, Poushali Sanyal, Amitava Mukherjee, Shyamali Dutta, Biswajit Ghosh, Sajal Kr Mondal.........................................47 Practitioners’ Series : u Chemotherapy & diabetes : interaction of BMI & steroids on blood glucose levels : a short study — Riyaz Mohammed ....................................................................................................51 u Health Status of children under three years of age residing in slums of Rajkot City, Gujarat, India — Anupam Banerjee, Umed Patel, Pramod Verma, Ankit Viramgami, Mayur Vala............................................................................................................54 Preliminary Report : u Use of volatile production patterns to detect efficacy of antifungal agents against Fungal pathogens — Pritam Sukul.....................................................................................................58 Current Topic : u Eponyms in human anatomy : remembering the great people behind them — Abraham A A .................................................................................................................................66 Pictorial CME : u A rare case of recurrent (consecutive) ectopic pregnancy with fibroid uterus — Owvass Hamied Dar, Maqsood Ahmad Dar, Ghanshyam, Pankaj Sharma ....................................72 Book Review ...............................................................................................................................................73 Supplement ................................................................................................................................................74 42

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Editorial Phonosurgery â&#x20AC;&#x201D; A revolution in the treatment of voice disorders

istorical aspects : Hippocrates described the importance of lungs, trachea, lips and tongue in phonation in the early 5th century B.C. Claudius Galen who was the founder Dr Debasish Mukherjee of laryngology and voice science first recognised the importance of brain in controlling MBBS, DLO, MS phonation and distinguished between speech and voice. In 1805 Manuel Garcia, famous Honorary Editor, JIMA opera singer invented indirect laryngoscopy by using a dental mirror is still a basic tool for visualising vocal folds by otolaryngologists. The term phonomicrosurgery was first introduced by Von Laden in 1962. The term phomomicrosurgery was introduced in 1994. Use of surgical microscope for endolaryngeal microsurgery was introduced by Kleinsasser in 1960. Hirano's description of structured layer of vocal fold in early 20th Century has formed the basis for Phonomicrosurgical techniques. The techniques of laryngoplastic phonosurgery were first introduced by Payr in 1915, but the real concept was created by Isshiki in 1975. Isshiki, a japanese surgeon has the credit for the concept of modern laryngeal framework surgery in the management of voice disorders. It was popularised by Koufman and Zeitels in United States since 1986. It has been practised in India since 1996 and gaining a lot of popularity as a subspeciality of otolaryngology. Definition : Phonosurgery is composed of procedures that are intended to maintain or improve the quality of the voice by correcting defects in laryngeal sound production. These procedures are rooted in a rich medical history that dates back to the early 19th century. There has been a recent convergence of physiologic principles of voice production with surgical technique theory. Recognition of this interdependence has provided a catalyst for collaboration among surgeons, scientists, speech pathologists, vocal pedagogists, and performing artists. We live in a society that is linked to effective communication, and there is a growing population of individuals who have professional voice responsibilities as part of everyday life. This has created a need for the recent developments in phonosurgery and its emergence as a subspecialty of otolaryngology. Phonosurgery : Surgical procedures that maintain, restore, or enhance the human voice. Phonosurgery includes phonomicrosurgery (microsurgery of the vocal folds done through an endoscope), laryngoplastic phonosurgery (open-neck surgery that restructures the cartilaginous framework of the larynx and the soft tissues), laryngeal injection (injection into the larynx of medications as well as synthetic and organic biologic substances), and reinnervation (restoration of the nerve supply) of the larynx. The term "phonosurgery" was coined in the early 1960s. Purpose & Procedure : The term Phonosurgery denotes restoration of Voice by using various surgical techniques. The melody of human voice depends on the vocal ligament an elastic structure of the vocal folds, which is not present in any other species. So there is no experimental model for human voice. Human voice acts as a primary instrument to project our personalities in the society. Voice problems may arise from laryngeal or systemic disease or trauma or misuse. The result of voice dysfunction is sometimes dewasting, endanger the life of professional voice users like singers, actors, politicians, educators etc. Many people, suffering from voice disorders live desperately in society with the opinion that no proper treatment is available for their problems. In fact invention of phonosurgical techniques has created a ray of hope for such victims of voice disorders. Voice problems may be of congenital, traumatic, inflammatory, neoplastic, neurological or functional origin. The diagnosis of voice disorders starts with detailed history from the patient and indirect laryngoscopic examination by the otolaryngologist. For a long time perceptual voice analysis (by hearing the patients voice and judging its quality) has been a basic tool in deciding the prognosis of the patients. Recently computerised objective voice analysis methods like voice spectrograms electroglottography, phonotograms etc are gaining importance in judging the prognosis and also for documentation. The invention of video laryngoscopy, and videolaryngostroboscopy techniques have made diagnosis more precise in the voice care. The management of voice disorders is a team work consisting of otolaryngologist, speech pathologist, Voice coach, psychiatrist, and sometimes plastic surgeons and pediatricians etc. The voice disorders may be of functional or organic (eg.vocal nodules) orgin, and it is sometimes difficult to demarkate between these two as one may predispose the other. Voice therapy plays a greater role in the correction of most of the functional voice disorders which form 80% of voice problems. It also acts as an important adjuvant treatment modality before and after voice surgery or phonosurgery. Techniques : The phonosurgical techniques broadly consists of (I) Phonosurgery over the Vocal folds for voice generation A. Phonomicrosurgery of mass lesions like nodules, cysts, deficits of vocal folds etc. B. Laryngoplastic Phonosurgery (Thyroplasty) for correcting position of vocal fold as in vocal cord paralysis and also for correcting the tension of the vocal fold. C. Nerve muscle innervation techniques. D. Vocal Fold Injection Techniques. 45

J INDIAN MED ASSOC, VOL 114, NO 5, MAY 2016

(II) Phonosurgery for voice resonance. The includes correction of cleft paltate, cleftlip, orthodontic surgery pharyngoplasty and endoscopic sinonasal surgeries. Phonomicro Surgery : Phonomicrosurgical techiques have revolutionised the management of benign vocal fold lesions like vocal cysts, nodules, polyps without damaging the voice. For centuries the benign vocal fold lesions like cysts were managed by direct excision of the mass or cyst over the vocal fold by stripping of the vocal fold either by naked eye direct laryngoscopy or by microlaryngeal surgery. In the recent times this technique is abandoned as it was found to produce scarring of the vocal folds resulting in poor voice. The modern concept of phonomicrosurgery is based on Hirano's principle of structured layer of the vocal folds. In this technique the vibratory epithelium is protected during excision of the mass for preserving the voice. This surgery is done under endotracheal general anesthesia using an operating microscope. The basic procedure consists of injection of vocal fold with normal saline and microflap dissection for removing the mass over the vocal folds by preserving the vibratory epithelium. This technique is also applied for augmentation of vocal folds with fat or fascia for correction of voice for vocal cord atrophy with bowing of vocal folds which may be either congenital or developmental. This surgery has come into practice in India very recently, This has become a ray of hope for correction of voice disorders in professional voice users like singers, politicians, educators etc. Most of the phonomicrosurgery techniques are done with cold, steel instruments reserving the laser for more vascular lesions, as the laser produces heat and scarring of the vocal fold. Laryngoplastic phonosurgery : This is otherwise known as thyroplasty, or laryngeal frame work surgery. This is of 4 types. 1. Thyroplasty type I : This is also known as medialisation laryngoplasty (M.L) Indications : (A) Unilateral vocal cord paralysis, paralytic dysphonia : Thyroplasty type I has largely replaced the teflon injection technique, which was practised for several years in the management of paralytic dysphonia. In this technique, under local anaesthesia a window is cut in the thyroid lamina in the neck on the paralysed side and the piece of thyroid cartilage is depressed inwards towards the midline until the normal cord touches the paralysed cord, thus closing the glottic gap resulting in normal voice. The thyroid cartilage in the window is held in place with a silastic block. As this surgery is done under local anaesthesia patients voice can be monitored on the operating table itself. This technique is sometimes supplemented by another technique called arytenoid rotation to close large posterior glottic gaps in vocal cord paralysis. This is the commonest type of thyroplasty in practice. The success rate is of about 80%. (B) Other indications M.L. are vocal cord atrophy, bowing of the vocal cord etc. 2. Thyroplasty type II : In this technique the vocal folds are displaced laterally away from the midline under local anaesthesia. This technique is presently applied in the management of spastic dysphonia. 3. Thyroplasty type III : In this technique the vocal cords are pushed back posteriorly thus shortening the vocal folds resulting in lowering of the pitch. This technique is commonly applied in the management of puberity Dysphonia a developmental disorder of larynx in males, refractory to voice therapy. By applying this technique the high pitched voice or feminine voice in males can be converted into low pitched or normal voice. 4. Thyroplasty type IV : Thyroplasty Type-IV of Isshiki also described as Cricothyroid Approximation. It is indicated for raising of pitch in females who have male voice (Androphonia) Nerve muscle innervation techniques : Nerve muscle pedicle surgery involves implanting a portion of sternohyoid muscle with its intact motor branch from ansa hypoglossi into a paralysed posterior cricoarytenoid muscle. This is indicated in the management of bilateral vocal cord paralysis of varied aetiology. The operation has not been universally satisfactory because of its varried success rate. Laryngeal injection techniques : For several years injection of Teflon into the vocal folds has been practised for correction of paralytic dysphonia. Eventhough it has been largely replaced by techniques of thyroplasty and arytenoid rotation it is still indicated for preventing aspiration in children with vocal fold paralysis. Injection of fat and collagen are widely practised for correction of paralytic dysphonia as temporaty methods before proceeding to thyroplasty techniques. Conclusion : Introduction of phonomicrosurgery and laryngoplasitc phonosurgery techniques has revolutionised the management of voice disorders. It has created a ray of hope for victims of voice problems thus forming a new subspeciality in the field of Otolaryngology.

Originals and Papers Study to evaluate the influence of pre-pregnancy weight, height, BMI and weight gain during pregnancy on birth weight of baby Shyamal Dasgupta1, Poushali Sanyal2, Jhuma Biswas3, Chiranjit Ghosh4, Biswajit Ghosh5, Sajal Kr Mondal6, Shyamali Dutta7, Amitava Mukherjee8

To study the influence of different maternal variables on birth weight, as it is the most important and valuable indicator for neonatal survival. It is a prospective one year study in a tertiary institute to evaluate the effect of maternal anthropometric variables on birth weight. A total of 125 mothers were followed up till delivery to collect the data of different variables and analysed by (a) Statistica Version 6 and (b) Medcalc Version 11.6. The study shows the mean as well as standard deviation and standard error of different variables like age, prepregnancy maternal weight, weight gain in pregnancy, BMI and birth weight in tabulated form. Correlation matrix and regression equation shows that most variables have significant relation with birth weight of which weight gain has the strongest one (0.52, p<0.0001). Study showing statistically significant result of most of the variables of mother and alteration of these with social and economic intervention definitely improves the outcome of neonates in relation to their survival. [J Indian Med Assoc 2016; 114: 47-50]

Key words : Pre-pregnancy weight, BMI, Weight gain, Birth weight.

eonatal and infant mortality and obviously morbidity is directly related to the birth weight of the baby and probably the most important and rerliable indicator for their survival . Though the causes of low birth weight are multifactorial, maternal anthropometric indices are important birth weight determinant . Determination of standard maternal anthropometric variables affecting birth weight is important to suggest appropriate remedial measures. We conducted a hospital based study to find out the influence of different variables like pre-pregnancy weight of mother, maternal height, weight gain during pregnancy and pre-pregnancy BMI on birth weight of baby with their statistical significance.

anthropometric indices on birth weight was conducted at a tertiary teaching institution from 1st January 2011 to 31st December 2011. Women included in the study were those who attended the antenatal clinic between 15-20 days of conception from 1st January 2011 and who delivered a term baby within 31st December 2011. The weight at 1520 days of conception (Âą 7 days of first missed period of almost regular cycle) is considered as the initial weight at conception, that is, pre-pregnancy weight . Period of gestation was calculated from the first day of the last menstrual period and a first trimester ultrasonography. The lowest correlation coefficient in our study is 0.21 and after multiplying by a constant, the minimal sample size in relation to our study comes to 96. The actual number of samples taken is 125 which is enough to get a conclusion. The sample selection was done after excluding multiple pregnancy (with USG), smokers, polyhydramnios, any doubt about the period of gestation and any other factors which may be a confounding factor of weight gain. Weighing was done at each antenatal visit and at term within one week by using a weighing machine (adult) with minimum clothing after correction of zero error to nearest 100 gram. Height was taken on level ground, without footwear against the wall to nearest 0.5 cm. Baby weight was taken without

1,2

MATERIAL AND METHOD

A prospective study regarding influence of maternal Department of Obstetrics & Gynaecology, IPGME&R, Kolkata 700020 MD, DGO (Obstet & Gynaecol), Assistant Professor, At present : Associate Professor, RG Kar Medical College, Kolkata 700004 MD (Obstet & Gynaecol), Senior Resident MBBS, MD (Obstet & Gynaecol), Assistant Professor, Bankura Sammilani Medical College, Bankura 722 102 MBBS, MS (Obstet & Gynaecol), RMO cum Clinical Tutor, RG Kar Medical College, Kolkata 700004 MD (Obstet & Gynaecol), RMO cum Clinical Tutor MD (Obstet & Gynaecol), RMO cum Clinical Tutor, Calcutta National Medical College and Hospital, Kolkata 700014 MD, DGO (Obstet & Gynaecol), RMO cum Clinical Tutor MD (Obstet & Gynaecol), Associate Professor 1

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.

â&#x20AC;&#x201D; Hony Editor

J INDIAN MED ASSOC, VOL 114, NO 5, MAY 2016

clothes with a standard weighing machine after correcting zero error. Data analysis was done by the following software –(1) Statistica Version 6 [Tulsa, Oklahoma: Statsoft Inc.2001] and (2) Medcalc version 11.6 [Mariakenke,Belgium: Medcalc Software 2011]. RESULTS

As per sample selection criteria a total of 125 pregnant women were followed up till delivery at hospital who delivered live born singleton babies within 31st December, 2011. The Table 1 summarises the characteristics of the study population. It shows that the mean age at conception is 24.78 years with a range of 1738 years (S.D 4.29, S.E 0.38). The pre-pregnancy weight ( Mean 54.19 kg, with a range of 38 to 91 kg, S.D 6.33, and S.E 0.57) and maternal height (mean 157.64 cm, with a range of 147 to 167 cm, S.D 4.16 and S.E 0.37) are the two parameters used to calculate the BMI, the mean of which is 20.93. The average birth weight of the babies is 2821 gm (range 1608gm to 4130 gm), with S.D 595.60 and S.E 53.27. The mean weight gain is 9.53 kg (range 7.50 to 14.00 kg, S.D

STUDY TO EVALUATE THE INFLUENCE OF PRE-PREGNANCY WEIGHT, HEIGHT, BMI — DASGUPTA ET AL

1.12 and S.E 0.10). The data related to female babies (*) and male babies(+) is also documented in the same table and shows that the range of BMI of mother and baby weight in relation to female babies are slightly lower without any statistical significance, which is an incidental finding. In Table 2, the correlation matrix shows a statistically significant correlation of pre-pregnancy weight, weight gain, height of mother and BMI with baby weight. The data of female babies(*) and male babies(+) are separately tabulated and show almost same result, but with slight variation. The scatter plot of BMI versus baby weight shows slight but definite positive correlation between the variables (Fig 1). In the Table 3, showing Multiple regression analysis in relation to baby weight, weight gain in pregnancy shows the most significant (p<0.0001) positive correlation. Among the other variables, though height and prepregnancy weight are positively related, only the data in relation to height is weakly statistically (p=0.0242) significant.

32 30

In our study the mean total weight gain for all women is 9.53 ± 1.2 which is slightly higher than the mean of a study conducted among Indian women but comparable to the same study among higher income group . In our study the mean pre-pregnancy BMI is 20.93 ± 2.1 , (which is derived from height and prepregnancy weight) but is much less than the BMI obtained in a western study done by Murrin C et al, which is 23.74 ± 4.21 . It may be explained by the difference in the ethnic groups of the study population. A study conducted on Indian mothers in Karnataka shows comparable results to our study regarding BMI, height and prepregnancy weight (18.4 ± 2.4 kg/m , 154.2 ± 5.2 cm and 43.4 ± 6.6 kg) . In our study the mean birth weight is 2821 + 595.60 4500 which is very close to the above study. In another study on Asian babies, the maternal height and maternal weight data were very close to our study but BMI was much higher than that of our study (24.8 kg/m ) . 4

26 24

22 20 18

16 1500

2000

2500 3000 3500 Birth Weight (g)

Fig 1 — Scatterplot : BMI versus Baby Weight

4000

2 7

Table 1 — Descriptive Characteristic of Study population (Total no., n=125) (female babies , n=57*) (male babies, n=68 +) Parameters

Minimum

Maximum

Mean Limit - 95%

Confidence Limit + 95%

Confidence deviation

Standard error

Standard

Age of Mother (years)

17.00 *17.00 +17.00

38.00 *38.00 +37.00

24.78 *25.08 +24.52

24.02 *23.89 +23.52

25.54 *26.28 +25.51

4.29 *4.51 +4.12

0.38 *0.60 +0.50

Pre pregnancy Weight (kg) +38.00

38.00 *43.00 +91.00

91.00 *74.00 +52.65

54.19 *51.50 +50.96

51.07 *50.14 +54.30

53.31 *53.16 +6.82

6.33 *5.69 +0.83

0.57 *0.75

Weight gain In pregnancy (kg) +7.50

7.50 *7.50 +13.00

14.00 *14.00 +9.75

9.53 *9.27 +9.49

9.33 *8.97 +10.00

9.73 *9.57 +1.06

1.12 *1.14 +0.13

0.10 *0.15

Height of Mother (cm)

147.00 *150.00 +147.00

167.00 *165.00 +167.00

157.64 *157.18 +158.03

156.90 *156.29 +156.92

158.38 *158.12 +159.14

4.16 *3.57 +4.58

0.37 *0.47 +0.56

BMI Pre pregnancy (kg/sq.metre)

17.19 *17.19 +17.19

33.83 *29.64 +33.83

20.98 *20.90 +21.05

20.60 *20.35 +20.51

21.36 *21.49 +21.58

2.15 *2.08 +2.22

0.19 *0.28 +0.27

Baby birth Weight (gram)

1608 *1608 +1650

4130 *3950 +4130

2821 *2732 +2895

2715.60 *2590.76 +2741.08

2926.47 *2874.08 +3049.54

595.60 *533.89 +637.20

53.27 *70.72 +77.27\

*Female babies’ data

+ Male babies’ data

DISCUSSION

BMI (kg/m2)

J INDIAN MED ASSOC, VOL 114, NO 5, MAY 2016 Table 2 — Correlation Matrix (Pearson’s Correlation Coefficient R values) (n = 125) Prepregnancy Weight Baby Weight Total

Weight gain in pregnancy

Height of Mother

B.M.I.

Age

0.46

0.54

0.41

0.33

0.21

Female babies 0.39

0.64

0.31

0.29

0.27

Male babies

0.44

0.46

0.36

0.18

0.50

Table 3 — Multiple Regression Analysis (n = 125) Regression Equation (in relation to baby weight), R2 – adjusted - 0.3530 Independent variables

Coefficient

P value

Zero order correlation

Coefficient (r) Age 19.7468

1.881

0.0623

Pre pregnancy weight

24.5169

2.102

0.0331

0.4634

Height

28.9898

2.283

0.0242

0.4141

Weight gain

221.9748

4.349

<0.0001

0.5361

Constant

0.2067

-4746.3560

A study on similar context which showed higher BMI at the first antenatal visit shows a greater percentage of body fat among the offspring (birth weight) with statistical significance . The correlation matrix of different variables (Table 2) shows that the variables like age are very weakly sensitive for birth weight prediction. On the other hand, prepregnancy weight and weight gain in pregnancy are more significantly related to birth weight than BMI and height of mother. It is very close to the observation of the study conducted by N Shamsun et al . The scatter plot shows a positive correlation of BMI with baby weight. It is comparable to another study , where they show that the maternal pre-pregnancy weight, BMI and weight gain of different groups are very sensitive anthropometric variables in relation to birth weight. Multiple regression analysis (Table 3) shows that apart from other maternal anthropometry, weight gain during pregnancy has an independent role in determining birth weight which is very close to other observations . On the other hand, the independent variables height and weight both are significant, but the significance is slightly higher with height. This differs marginally from the analysis of another study , probably due to other confounding factors 8

6,10

9 10

like obesity, diabetes, hypothyroidism, which may result in IUGR babies in women with increased pre-pregnancy weight. Lastly, the predictive equation of birth weight was determined from our study, but for universal acceptance, a larger multicentric study is required for different race of people and different ethnic groups. CONCLUSION

Pre-pregnancy weight, height, BMI and weight gain during pregnancy are important maternal factors influencing birth weight of term babies. Any management, specially pre-pregnancy (girl child) immunisation, sanitation, and antenatal nutrition through different nutritional programmes organised by the government may improve the birth weight. This may directly influence the mortality and morbidity rates of neonates in our country.

REFERENCES 1 Yasmin S, Obrin D, Paul E, Costello A — Neonatal mortality of low birth weight infants in Bangladesh. Bull World Health Organ 2001; 79: 608-14. Cifuentes J, Bronstein JM — Mortality in low birth weight infants accordin g to level of neonatal at hospital of birth. Paediatrics May 2002: 109: 745-51. Deshmukh JS, Motghare DD, Zodpey SP, Wadhwa SK — Low birth weight and associated maternal factors in an urban area. Indian Pediatr 1998: 35: 33-6. Shobeiri F, Nazari M — Patterns of weight gain and birth weight amongst Indian women. Iran J Med Sci Jun 2006: 31: 94-7. Murrin C, Segonds-Pichon A — Self-reported prepregnancy maternal body mass index and infant birth weight. Ir Med J 2007; 100: Suppl 20-3. Phaneendra Rao RS, Prakash KP, Sreekumaran Nair N — Influence of pre-pregnancy weight, maternal height and weight gain during pregnancy on birth weight. Bahrain Medical Bulletin 2001: 23: 22-6. Tan KH, Yeo GSH. Influence of maternal height, weight and body mass index on birth weight in an Asian population. The internet journal of Gynaecology and Obstetrics 2009: 11: 15. Reynolds RM, Osmond C, Phillips DIW, Godfrey KM — Maternal BMI, parity and pregnancy weight gain : Influence on offspring adiposity in young adulthood. The Journal of Clinical endocrinology & metabolism 2010: 95: 5365-9. Samsun N — Maternal anthropometry as a predictor of birth weight. Public Health Nutrition 2007: 10: 965-970. Frederick JO, Williams MA — Pre pregnancy body mass index, gestational weight gain, and other maternal characteristics in relation to infant birth weight. Maternal and child health Journal 2008: 12: 557-67.

Practitioners' Series Chemotherapy & diabetes : interaction of BMI & steroids on blood glucose levels : a short study Riyaz Mohammed1 A study was conducted to determine the interaction and interrelationship of BMI and steroids on blood glucose levels on 383 cancer patients on chemotherapy. During the study we have seen that prediabetics and patients with high BMI are prone to develop diabetes which could have been precipitated due to steroids. A BMI between 25 and 30 should be viewed as medically significant and worthy of therapeutic intervention, especially in the presence of risk factors that are influenced by adiposity, such as hypertension, hyperglycemia, insulin resistance, dyslipemia, cancer. The present study was done to highlight strict glycemic control, (FBS < 110 & PLBS< 140-160 mg/dL) [J Indian Med Assoc 2016; 114: 51-3]

Key words : Chemotherapy Prediabetes High BMI Interrelationship Diabetes Steroids.

lucocorticosteroids (steroids) have profound effects on glucose metabolism, particularly on postprandial hyperglycemia. Patients with cancer often receive steroids as a component of their chemotherapy, as a measure to treat or pre¬vent nausea, or as adjuvant therapy. Instances of hyperglycemia during chemotherapy are known. Incidents, implications and literature on this subject are not easily available in India. Hence this study was conducted to make chemotherapists in India aware of the incidence and measure the blood sugar level before, during and after chemotherapy in diabetes and more so in un-established cases of diabetes as revealed in this study. Occasionally an unknown diabetes mellitus case can even develop severe complications like DKA. During the study we have seen that prediabetic and persons with high BMI are prone to develop diabetes which could have been precipitated by steroids.

nary artery disease, CVD or acute and chronic complication of diabetes were excluded from the study. A detailed history and examination was carried out, and baseline investigations like HBA1C, serum creatinine, microalbuminuria, lipids, retinal examination, chest X-ray and ECG were done. Majority of the chemotherapeutic agents are given with dexamethasone in a dose of 8 – 16 mg and in cases of multiple myeloma the dexamethasone is given as high as 40 mg. Most of the times dexamethasone causes derangement of blood sugar levels. RESULTS

Among the 383 patients studied, 291(75.97%) cases remained at normal glycemic levels throughout chemotherapy and 92(24.02%) developed a derangement of their blood sugar levels. (Table 1). Out of 92 patients, average BMI was (Table 2). 92 • 30 patients 24% with average BMI of 27.45 +/- 2, • 48 patients 291 with average BMI 76% of 34.95 +/- 3 , • 14 patients with average BMI of 42.50 +/- 2. Euglycemic Deranged glycemic status

MATERIALS AND METHODS

Three hundred eighty three cases undergoing chemotherapy in BIACI& RC were selected randomly and studied. Their pre, concurrent and post-chemo blood sugar levels were recorded at 2nd, 3rd, 7th and 14th day. The Age, Sex, and BMI of the patients were noted along with diagnosis and the chemotherapy being given. The patients having fasting blood sugar level of 100-125mg/dl were identified and from them gathered information and included in the s t u d y. P a t i e n t s h a v i n g H y p e r t e n s i o n , C o r o MD (Gen Med), Dip Diabetology, PGC Diabetology (USA), DFM (UK), PDCR, PGC Diabetology (IMA-AKN Sinha), Consultant Physician and Diabetologist, Department of Internal Medicine, Basavatarakam Indo-American Cancer Hospital and Research Centre, Hyderabad 500034 1

Table 1 51

J INDIAN MED ASSOC, VOL 114, NO 5, MAY 2016

CHEMOTHERAPY & DIABETES : INTERACTION OF BMI & STEROIDS ON BLOOD GLUCOSE LEVELS — MOHAMMED

Sixty eight cases (17.75%) reverted to normal glycemic status & 24 patients (6.26%) developed diabetes. Out of these 24, 20 cases developed diabetes and 4 cases developed acute complication like Diabetic ketosis and accelerated hypertension induced left ventricular dysfunction. These patients have BMI more than 32+/- 5. (Table 3). Only one case having normal BMI went in to complications and developed DKA in our study. The patient was a case of acute lymphocytic leukemia, which was given LAsparaginase and High dose steroid. The majority of patients who developed diabetes had BMI which was higher than normal and had various maladies like Ca Breast, NHL, and Multiple Myeloma for treatment with chemotherapy.

Table 2

DISCUSSION

After going through all the references which were predominantly from western literature , many a times managing hyperglycemias is complicated. These patients may require higher doses of insulin to get blood sugar under control. Especially, patients who require large doses of steroids like cases of multiple myeloma, acute lymphocytic leukemia, Non-Hodgkin’s lymphoma, CNS lymphoma. In these cases the insulin requirement may vary from 100- 150 units of insulin per day. It has been shown that patients on L-Asparaginase, Streptozocin and Cytokine interferon – alpha are associated with drug induced insulin dependent diabetes mellitus. Prediabetes is the state in which some but not all of the diagnostic criteria for diabetes are met. Prediabetes is also referred to as borderline diabetes, impaired glucose tolerance (IGT), and/or impaired fasting glucose (IFG). Impaired fasting glycaemia or impaired fasting glucose (IFG) refers to a condition in which the fasting blood glucose is elevated above what is considered normal levels but is not high enough to be classified as diabetes mellitus. It is considered a pre-diabetic state, associated with insulin resistance and increased risk of cardiovascular pathology, although of lesser risk than impaired glucose tolerance (IGT). IFG sometimes progresses to type 2 diabetes mellitus. There is a 50% risk over 10 years of progressing to overt diabetes. A recent study cited the average time for progression as less than three years • WHO criteria: fasting plasma glucose level from 6.1 mmol/l (110 mg/dL) to 6.9 mmol/l (125 mg/dL). • ADA criteria: fasting plasma glucose level from 5.6 mmol/L (100 mg/dL) to 6.9 mmol/L (125 mg/dL). Impaired glucose tolerance (IGT) is a pre-diabetic state of dysglycemia, that is associated with insulin

diabetes; particularly under these conditions. Obesity is a state of excess adipose tissue mass. The most widely used method to gauge obesity is the body mass index (BMI), which is equal to weight/height (in kg/m ). Other approaches to quantifying obesity include anthropometry (skin-fold thickness), densitometry (underwater weighing), CT or MRI, and electrical impedance. BMI: 1) <18.5 - Underweight 2) 18.5 -24.9 - Normal 3) 25 – 29.9 - Overweight 4)30 -39.9 - Obesity 5) > 40 - Morbid obesity A BMI between 25 and 30 should be viewed as medically significant and worthy of therapeutic intervention, especially in the presence of risk factors that are influenced by adiposity, such as hypertension and glucose intolerance, insulin resistance, dyslipidemia & cancer. However the present study was done to highlight the importance of maintaining strict glycemic control, (Target glucose levels are < 110 mg/dL pre-meal and < 140–160 mg/dL 2 hours postprandial) regular follow up of cases who have developed drug induced diabetes and maintaining strict glycemic control which prevent any further target organ damage due to uncontrolled glycemic status.. We are continuing our study to establish the interrelation of diabetes and cancer chemotherapy agent.

1-7

20 76

Developed acute complications of diabetes Reverted to normal Developed diabetes

Table 3 resistance and increased risk of cardiovascular pathology. IGT may precede type 2 diabetes mellitus by many years. IGT is also a risk factor for mortality. The possible mechanism which was attributed to hyperglycaemia and DKA and HONK were in our patients are as follows: (1) Steroid induced diabetic ketoacidosis (2) Chemotherapy induced insulin dependent diabetes mellitus leading to diabetic ketoacidosis (3) Steroid induced glucose intolerance superadded to ketoacidosis (probability of early starvation may lead to it) As all of us know that steroid do cause diabetes and certain chemotherapeutic agents also induce diabetes which could be temporary? We have observed and found there is also an important role of high BMI in patients who are receiving chemotherapy. Hence, the idea of highlighting the importance (of patients with high BMI) developing

CONCLUSION

Many Physicians and Endocrinologists do know that obese persons (high BMI) are prone to develop diabetes during the course of chemotherapy (as shown in the study), Hypertension, CAD, dyslipidemia, etc. This study is very significant as it outlines the necessity of awareness and precautions to be observed when dealing with patients with raised BMI without diabetes mellitus who are also likely to go in to hyperglycaemic and in extreme cases even ketoacidosis. They need urgent identification and management otherwise they are likely to go into complications. Some other patients without diabetes mellitus can become diabetic and require regular management like any other diabetic. Patients with high BMI and prediabetic patients are prone to develop diabetes. We have given special attention to such patients as these patients can be prevented from developing diabetes. A BMI between 25 and 30 should be viewed as medically significant and worthy of therapeutic intervention, especially in the presence of risk factors that are influenced by adiposity, such as hypertension, hyperglycemia, insulin resistance, dyslipemia, cancer. The present study was done to highlight strict glycemic control, (FBS< 110 & PLBS< 140-160 mg/dL).

ACKNOWLEDGMENT

Our thanks to management of Basavatarakam IndoAmerican Cancer Hospital and Research Centre for permitting this study and its publication. We also thank the Medical oncologist, Surgical oncologist, Radiation oncologist of the indo-American cancer hospital who supported us in this study.

REFERENCES 1 Induced hyperglycemia and tumour chemotherapy –experimental and clinical studies,osinkysp et,al, chemotherapy 1990. 2 Weiser MA, Cabinillas et al, department of internal medicine,cancer 2004 sep1:101(5) : 1100- 1 relation between duration of remisson and hyperglycemia during induced chemotherapy in ALL. 3 Influence of type 2 diabetes and cancer future directions. clinical practice of oncology 2005 (1) 48- 53. 4 Prevalence of transient hyperglycemia during induction chemotherapy in pediatric ALL. Stefanic R lowas MD et al , pediatric hematology- oncology, science university ,Poland ,Oregon published online on 3rd march 2009. 5 Glucose intolerance during adjuvant chmeotherpy for breast cancer, tamos hickish et al online march 24th 2009, journal of national cancer institute 2009-10-101(7)537. 6 Pediatric blood cancer 2009:52:814-818, prevalence of transient hyperglycemiain L-aspaginate is significant in ALL. 7 Furnary AP, Wu Y, Bookin SO — Effect of hypergly¬cemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract 2004;10:21-33. 8 The ACE/ADA Task Force on Inpatient Diabetes. American College of Endocrinology and American Diabetes Association consensus statement on inpa¬tient diabetes and glycemic control: a call to action. Diabetes Care 2006;29:1955–1962. 9 Clement S, Braithwaite SS, Magee MF — Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004;27:553–591. 10 Umpierrez GE, Isaacs SD, Bazargan N — Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002;87:978–982. 11 Krinsely J — Effect of an intensive glucose man¬agement protocol on the mortality of critically ill adult patients. Mayo Clin Proc 2004:79:992-1000. 12 Furnary AP, Zerr K, Grunkemeier G — Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999;67:352-362. 13 Furnary AP, Gao G, Grunkemeier GL — Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary ar¬tery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1007-1021.

Practitioners' Series

HEALTH STATUS OF CHILDREN UNDER THREE YEARS OF AGE RESIDING IN SLUMS OF RAJKOT — BANERJEE ET AL

Health Status of children under three years of age residing in slums of Rajkot City, Gujarat, India Anupam Banerjee1, Umed Patel2, Pramod Verma3, Ankit Viramgami4, Mayur Vala4 This study was designed to assess the health status and utilization of various health services among the children less than three years of age, residing in the slums of Rajkot city and was a part of a Multi Indicator Cluster Survey (MICS). Each slum area was designated as a cluster. The Rajkot Municipal Corporation (RMC) had 257 slum areas within its boundary limits. In stage one 30 clusters were selected proportionate to their size. In second stage 60 households were selected from each cluster. A total of 344 children less than three years of age were found in the 1800 households surveyed. The under three sex ratio was 965.71. The prevalence of low birth weight was 19.9%. The complete vaccination coverage in children between one to two years of age was 68.2%. Vitamin A coverage among the eligible children during the August 2010 round of the biannual Vitamin A campaign was 44.2%. Exclusive breast feeding in children less than six months of age was 81.8%. Registration of the children in the Mamta Sessions (Health and Nutrition Day) and in the local Anganwadi centre was 41%. There were 13.7% children who had presence of any morbidity during the survey. The study found that special focus needs to be given on the increasing the enrollment of the children in the Mamta Divas sessions as well as in the local anganwadis. Focus should also be given on improving the quality health care offered to the beneficiaries in these centers. [J Indian Med Assoc 2016; 114: 54-7]

Key words : Multi indicator cluster survey, cluster, quadrant, households, mamta sessions, complete vaccination, drop-out rate. Each ‘slum area’ was designated as a cluster. The Rajkot Municipal Corporation (RMC) had identified 257 slum areas within the 23 different wards of the city. A ward-wise list of the slums of Rajkot city was obtained from the health department of the RMC. In stage one, 30 clusters were selected proportionate to their size. From each cluster 60 ‘households’ were selected for detailed evaluation. A ‘household’ was considered as a group of persons who usually lived together and ate from the same kitchen. For adequate representation of the entire cluster, the slum area was divided into four quadrants. From each quadrant 15 households were selected for detailed questioning and examination. Questions regarding various aspects pertaining to the health status and utilization of health services were asked to the mothers of all the children less than three years of age, who were found in the 1800 households surveyed. The Government of Gujarat had launched the Mamta Abhiyan (Health and Nutrition Day) in 2006 to increase the effective delivery of comprehensive maternal and child care . Various services (antenatal, intranatal, post natal care, early neonatal care, vaccination details, growth monitoring, infant and young child feeding) rendered to the mother and child are documented in a pictorially designed informative card known as the ‘Mamta Card’.

hildren and women are classically recognized as the vulnerable sections of any society. Slums areas of a city are high risk areas for various disease transmissions. Maternal and child heath indicators among slum dwellers show that their health status is two to three times worse than those in the other urban areas . Recognizing the seriousness of the problem, the 11th Five Year Plan has launched the National Urban Health Mission with special focus on the slums and the urban poor . This study was formulated to evaluate the heath status of children residing in the slum areas of Rajkot city. 1

MATERIAL AND METHOD

This study was a part of a ‘Multi Indicator Cluster Survey’ (MICS) undertaken to assess the health status and utilization of various health services by the slum dwellers of Rajkot city. Located in the center of the Saurashtra region of Gujarat, Rajkot is the headquarters of Rajkot district.

Department of Community Medicine, PDU Government Medical College, Rajkot 360001 1 MD (PSM) Assistant Professor 2 MD (PSM) Associate Professor 3 MD(PSM), DIH Professor & Head 4 MBBS, Resident

Details of the vaccination status of Table 1 – Salient features of the population in the slums all the children between one to two Criterion being studied Number/n/N Percentage years of age were obtained by oral recall and verification of Demographic features : Mamta/vaccination cards (when Total Number of households studied 1800 available). Coverage of the booster Total population surveyed 8454 doses of DPT and OPV was elicited Total number of children < 3Years age 344 4.1 Average family size* 4.7 from all the children between two to Overall Sex Ratio 906.20 three years of age. Details of breast Under 3 sex ratio 965.71 feeding were asked for all the children. Place of Delivery (of under 3 years children) : Various activities of the Mamta Most common place of delivery – “HOSPITAL” 298/344 86.6 Deliveries occurring in Government Hospital 154/344 44.8 Abhiyan (registration, attendance Registration of Birth : pattern, growth monitoring and Births registered 304/344 88.4 counseling) were assessed by looking Birth certificate present 294/304 96.7 into the Mamta Cards and specifically Birth Weight : asking regarding the same to the Birth Weight taken 291/344 84.6 Low Birth Weight (<2.5Kgs) [among children weighed]58/291 19.9 mothers of the children. Registration of the children in the Anganwadis was *Average family size=Total population surveyed in 30 clusters divided by number of also enquired. All the children who households studied were present during the survey were examined for signs of severe malnutrition and severe palmar pallor as per the guidelines children had received a dose of Vitamin A during August of the Integrated Management of Neonatal and Childhood 2010 round. Illness (IMNCI) modules . The mothers were asked Table 3 shows the pattern of breast feeding observed in regarding the perception of their child’s health. Those the children. The rate of exclusive breast feeding in mothers who complained of any health related ailment in children less than six months of age was 81.8%. their children (during the time of the survey) were further Table 4 deals with some of the activities carried out in asked questions aimed to elicit the treatment seeking the Mamta sessions. Weight is noted in 61.9% of all the pattern as well as the very basic quality of treatment rendered. children who had the Mamta card. However only 25% of A pre-tested structured performa was used to collect the data. The survey was conducted during October and Table 2 — Vaccination coverage in one to two year old children November 2010 by the intern and post graduate students (n=107) of the department under watchful guidance and observation of the department faculty. All the data were Name of Vaccine Vaccinated (%) entered and analyzed using Epi Info software Version BCG 94.4 3.3.2 . 4

OBSERVATIONS

A total of 344 children less than three years of age were found in the 1800 households surveyed. The various salient features of the population and the children are given in Table 1. A Mamta Card or a vaccination card was available in 225 out of 344 (65.4%) of the children. It is observed in Table 2 that the vaccine with the maximum coverage is BCG (94.4%). The common places of vaccination were Government hospital (Urban Health Centre or Corporation Hospital or the district Hospital) in 46.5% of the children, followed by Anganwadi centers (28.7%) and private hospital (24.8%). Out of 106 children between two to three years of age, 65 (61.3%) received the booster doses of DPT and OPV between the ages of 16-24 months. An effort was made to elicit the number of children who had received a dose of Vitamin A during the August 2010 session of the bi-annual round of pulse Vitamin A campaign. It was seen that 68 (44.2%) out of 154 eligible

BCG Scar Present* DPT1 DPT2 DPT3 OPV1 OPV2 OPV3 Measles Vitamin A(First dose) Full Immunization† Drop Out Rate‡ Complete Vaccination§ DPT1 to DPT3 OPV1 to OPV3

97.0 89.7 86.9 76.6 91.6 86.9 79.4 74.8 57.0 68.2

19.6 13.1 12.2

* Base = All children who had received BCG injection. BCG scar was looked for in the left upper arm. † Full Immunization: A child receiving all these vaccines – BCG, 3 doses of DPT, 3 doses of OPV (excluding Polio 0) and 1 dose of Measles. ‡ Drop Out Rate = Coverage of first dose minus coverage of third dose. § Complete vaccination dropout rate = Highest coverage antigen dose (in our case BCG) minus lowest coverage antigen dose (in our case Measles).

HEALTH STATUS OF CHILDREN UNDER THREE YEARS OF AGE RESIDING IN SLUMS OF RAJKOT — BANERJEE ET AL

J INDIAN MED ASSOC, VOL 114, NO 5, MAY 2016

all the 144 parents (whose children were registered), had proper understanding of their child’s growth pattern. Out of 344 children surveyed, 141 (41%) were registered in the Anganwadi centers. Visible severe wasting was noted in nine (2.8%) out of 318 children who were physically present during the survey. Bilateral pedal oedema and severe palmar pallor were noted in one (0.3%) and 13 (4.1%) of the 318 children respectively. Three hundred and twelve (90.7%) out of the 344 mothers felt that their child was ‘healthy’. There was no significant difference in the opinion of the mothers across the different age groups (<1 year, 1-2 years, 2-3 years) of the children (c = 1.59, P = 0.81). Their opinion regarding the health status of the children did not vary significantly across the different sexes of the children (c = 0.38, P = 0.83). There were 47 mothers (13.7%) of the 344 children who had some complain regarding their children’s health during the time of the survey. The common complaints were – common cold (10.2%), fever (5.5%), and diarrhea (1.5%). Forty out of the 47 children (85.1%) who were having some complain were taken for treatment. The commonest place of seeking treatment was private hospitals (82.5%). Out of the 19 children who had fever, two (10.5%) were tested for Malaria parasites; while one out (20.0%) of the five children who had diarrhea was given Oral Rehydration Solution (ORS) during the episode of the illness by the treating doctor. 2

Table 4 — Activities in the Mamta Sessions Criterion Registration and attendance: Registration of children (In Mamta sessions) Registered children attending Mamta sessions regularlyi.e. every month

n/N

144/344

41.9

98/144

68.1

73/118

61.9

45/73

61.6

36/45

80.0

99/137

72.3

Growth Monitoring and Counseling: Weight noted in Mamta Card (among children visiting the last Mamta session and having the Mamta Card) Parents counseled about the weight gain (in those children whose weight is noted in the Mamta Card) Proper understanding of the weight (among those parents counseled) Mothers counseled regarding infant and young child feeding (among all children registered and reported to be attending the Mamta Sessions in the last 3 months)

DISCUSSION

The percentage of children with full vaccination in our study is 68.2%. There has been no increase in the rate from 2006 (68.0%) which was obtained from the MICS undertaken in the Rajkot city slum areas . The rates are higher than that observed for the slum areas of Surat (25.1%), in a similar survey of 2007 . Though Vitamin A (first dose) and Measles are intended to be given at the same age, none the less a vast gap of 17% is observed in this present survey. This has however improved as compared to that of the MICS of 2006 where the gap between Measles and Vitamin A (first dose) was 37% . The low coverage of the bi-annual Vitamin A during August 2010 session (44.2%) leaves a lot of scope of improvement. Bhanderi et al reported Vitamin A coverage of 76.9% for August round of 2007 in the rural areas of Anand district of Gujarat . In a survey conducted in the rural areas of Surendranagar district (which happens to be adjacent to Rajkot District) it was found that 59.1% of the eligible children had received the Vitamin A dose in August 2007 round of Vitamin A campaign . In the MICS conducted in the slums of Rajkot city and Bhavnagar city10 in 2006 it was found that 6.4% and 28.6% respectively of under two years age children had been started on breast feeding within the first hour of birth. Though this has increased to 61% in the present survey, it leaves a lot to be achieved especially considering that fact that initiation of breast feeding within the first hour of birth can reduce 22% of all neonatal mortality . Exclusive 6

Table 3 — Pattern of breast feeding in the under three age group children Criterion

n/N

Timing of initiation : Within 1 hour 211/344 Between 1-4 hours 86/344 Between 4-24 hours 21/344 Beyond 24 hours 26/344 Colostrum Offered : Yes 272/344 Currently receiving breast feeding as per age : Less than 1 Year 130/131 Between 1-2 Years 79/107 Between 2-3 Years 26/106 Exclusive breast feeding* received in children less than 6 months of age: Child age < 1 month 6/6 1 - < 2 months 13/16 2 - < 3months 10/13 3 - < 4months 11/12 4 - < 5 months 7/9 5 - < 6 months 7/10 Overall 54/66

(%) 61.3 25.0 6.1 7.6 79.1 99.2 73.8 24.5

100 81.2 76.9 91.7 77.7 70.0 81.8

*Exclusive breast feeding: Only those children who were given breast milk, without any addition of water or other any other food items (other animal milk, other liquid, soft mushy food etc.) were considered as ‘exclusively breast fed’.

breast feeding for the first six months can cut down about 15% of all child deaths . In the MICS conducted in the rural areas of Surendranagar district of Gujarat in 2008, the rate of exclusive breast feeding in children (less than six months of age) was 50% . Bhanderi et al found the registration of children in the Mamta Abhiyan of rural areas of Anand district of Gujarat to be 90.5% in 2007 . The registration level of 41.9% in the present survey is compounded by the huge fallout or gap in the rendering of services to those registered in the Mamta Abhiyan sessions: as is evident by the attendance profile of the children and monitoring and counseling of the growth and feeding of the children (Table 4). The low (41%) registration of the under three children in the local Anganwadi centers is also an issue of concern. The neighboring district of Surendranagar had shown the registration of children (under three years) in the Anganwadi centers as 44.6% in the year 2007-2008 . In spite of so much repeated advertisements in print as well as in the mass media regarding the necessity of blood testing in cases of fever (for Malarial Parasites) and use of ORS in cases of diarrhea, their practice in real life by the doctors has remained abysmally low in the children who had these illnesses during the survey. The study undertaken in the slums of Rajkot city has highlighted the lacunae existing in the health status of the under three children. However, in any survey of this nature, the fallacy of recall bias should also be kept into consideration. This study elicited data predominantly of a quantitative nature. The causative factors behind the observations were not a part of the survey. Reasons as to why Vitamin A coverage (both with routine vaccination as well as in the bi-annual rounds) remains low need to be identified and addressed on a priority basis. Improvement in the quality of the Mamta Abhiyan sessions undertaken by the government in the Anganwadi centers of the city

will help in increasing the overall knowledge of the parents of the children which will ensure more client centered, demand driven quality health care delivery in the future. REFERENCES 1 Rao BT, Thakur JS — Vulnerability assessment in Slums of Union Territory, Chandigarh. Indian J Community Med 2007; 32:189. 2 National Urban Health Mission (NUHM). Available from: hhhp://www.uhrc.in/module-Content Express [Accessed on 2011 May 05]. 3 Vital Statistics Division, Commissionerate of Health, Medical Services, Medical Education and Research, Gujarat State, Gandhinagar: Health review draft, Gujarat 2007-2008, December 2008. Available from: gujhealth.gov.in/Draft%20Health%20Review.pdf [Accessed on 2008 Dec 30]. 4 Integrated Management of Neonatal and Childhood Illness Modules. Ministry of Health and Family Welfare, Government of India, New Delhi 2003. 5 Centers for Disease Control and Prevention. Epi Info version 3.3.2, 2005. Available from: www.cdc.gov/epiinfo/. [Accessed on 2005 Feb 09]. 6 Report on Multi Indicator Cluster Sampling survey in slums of Rajkot City conducted by Department of Community Medicine, PDU Medical College, Rajkot 2006. 7 Sharma R, Desai VK, Kavishvar A. Assessment of immunization Status in the Slums of Surat by 15 Clusters Multi Indicators Cluster Survey Technique. Indian J Pub Heath 2009; 34:152-55. 8 Bhanderi DJ, Mukherjee SM, Gohel MK, Christian DK — An Evaluation of the Utilisation of Reproductive and Child Health Services provided by Government to the Rural Community of Anand District, Gujarat. Indian J Pub Heath 2009; 53: 250-52. 9 Report on Multi Indicator Cluster Sampling survey in villages of Surendranagar District conducted by Department of Community Medicine, PDU Medical College, Rajkot 2008. 10 Report on Multi Indicator Cluster Sampling survey in slums of Bhavnagar City conducted by Department of Community Medicine, Government Medical College, Bhavnagar 2006. 11 Kishore J. Reproductive and Child Health Program-II. In National Health Programs of India. 9th ed. New Delhi: Century Publications; 2011. p 153.

Preliminary Report

USE OF VOLATILE PRODUCTION PATTERNS TO DETECT EFFICACY OF ANTIFUNGAL AGENTS — SUKUL 59

tests in the laboratory; however this requires time . To reduce the time of continuous real-time monitoring, diagnosis and treatment risk new sensor technologies like E-noses are being developed for more rapid results . 7

Use of volatile production patterns to detect efficacy of antifungal agents against fungal pathogens

MATERIALS AND METHODS

Pritam Sukul1 Conventional culture methods for in vitro laboratory diagnosis of fungal pathogens and preclinical evaluation of antifungal drug responses are very time consuming and require skillful technical experts. Few fungi are known to produce different volatile fingerprints. The objective of this project was to examine the potential for using qualitative volatile fingerprints by using a hybrid electronic nose system for anti-fungal susceptibility testing for a more rapid screening approach. Initial studies were carried out with three fungicides and an antioxidant to determine the ED50 and ED90 values to use for examining volatile production patterns. These studies were carried out on solid agar media ( for Aspergillus fumigatus) and in liquid nutrient broth media (for Candida albicans). The growth rate curves under different concentrations of these antifungals were used to determine the ED50 and ED90 values. Subsequently, the volatile production patterns of cultures of A. fumigatus and C. albicans were studied using an Electronic-nose (E-nose) system respectively after 72-120 and 24-72 hours incubation on solid malt extract agar (MEA) at 25°C. The data obtained from E-nose experiments were statistically analysed by using principal component analysis (PCA) and cluster analysis (CA) to show the discrimination and difference between growth responses of these two species relative to the control and blank media. The best results for treatment discriminations were obtained in different PCA and CAs after specific times of incubation for different antifungals. the best results were obtained for benomyl and tebuconazole against A. fumigatus after 96 hours, fluconazole and tebuconazole against C. albicans after 48 hours. From this study it was concluded that this alternative path for rapid screening could be beneficial for laboratory diagnosis and treatment as well as providing a measure of whether any drug resistance build up is taking place. It may also have applications in pre-clinical and clinical evaluation of new potential drugs. [J Indian Med Assoc 2016; 114: 58-65]

Key words : antifungal susceptibility testing, cluster analysis, electronic nose, effective dose 50% & 90%, malt extract ager, metal oxide sensors, metal-oxide-silicon field-effect-transistor, principal component analysis, parts per million, ventilator associated pneumonia, volatile organic compound.

constipation, abnormal and uneven diet Candida can invade the blood stream and the spores can affect some humid tissue and organs like lung, bronchial tissue etc . Aspergillosis includes infection, allergy and fungal growth. In the past A. fumigatus was regarded as a week pathogenic fungus but in immunocompromised patients there is a significant increase in infections and an unexpected high mortality rate, due to invasive aspergillosis . VAP can be caused by colonization of the respiratory tract by Candida. Nearly 70% of VAP cases are reported to involve C. albicans . There is an increased risk of bacterial infection together with C. albicans because bacteria like Pseudomonas can easily interact with this fungus . The two above named fungi can easily be identified and diagnosed by conventional mycological confirmatory

spergillosis and Ventilator Associated Pneumonia (VAP) are the most common microbial infections due to colonization of bronchopulmonary tissue . These two fungal infections of human has a vast geographical distribution . These diseases are spreading rapidly worldwide including Europe and America. Aspergillus fumigatus and Candida albicans are two of the main causative organisms for these two diseases respectively . A. fumigatus is a saprophytic fungus which helps in carbon and nitrogen recycling in the environment. It lives in soil and grows on organic waste materials . Because the spores are mainly air borne conidia infection predominantly occurs in bronchopulmonary tissue . On the other hand C. albicans is a natural flora of the humancolon . It lives with other microbial organisms as a parasite. Because of excessive use of antibiotics, 2,3

2,9

3,4

Fungal species: Two fungal species Aspergillus fumigatus and Candida albicans were used from two seprately incubated colonies in this study as positive controls to estimate effective dose 50% (ED50) and effective dose 90% (ED90) effects of some antifungal agents. This was an in vitro study which was done in Applied Mycology laboratory of Cranfield Health of Cranfield University, England. Malt Extract Agar (MEA) and Nutrient Broth: MEA medium was used as a growth culture medium for both of the fungi. It was prepared by mixing distilled water and MEA powder (CM0059, Oxoid, UK). The mixture was shaken and autoclaved for 30 minutes. The cooled medium was poured into 9 cm Petri plates (sterile). Nutrient broth was prepared by adding nutrient broth powder (CM0001, Oxoid, UK) in distilled water and autoclaved for 30 mins. The autoclaved, cooled medium was poured into 250 ml sterile conical flaks. Antifungal Drugs and Antioxidants: Three antifungal drugs Benomyl, Tebuconazole, Fluconazole and antioxident n-Propyl Gallate were used for both of the fungi in the in vitro studies. Drugs were supplied by the Applied Mycology GP as a stock solution with a concentration of 1000 ppm, 1000ppm and 2000ppm respectively. The first two stock solution were kept at 4°C and the third solution was kept at 20° C incubation room. Forth stock solution with a concentration of 200 ppm was prepared by mixing the above antioxidant with ethanol. Spectrophotometer: Optical densities of liquid cultures were measured by using a M350 Double Beam UV-visible spectrophotometer (Camspec, UK) in the Applied Mycology laboratory of Cranfield Health. It contains 7 cuvette cells. The absorbance of liquid culture medium of Candida albicans was analysed at 640nm. E-nose: This system to detect volatile organic compounds had a hybrid array of 12 Metal Oxide sensors and 10 Metal-Oxide-Silicon Field-Effect-Transistor sensors and a humidity sensor. The E-nose system used in this study was an Applied Sensor 3320 model (Applied Sensor Group, Sweden). It contains a 12 position carousel for temperature controlled vial inoculation prior to analysis. Heating regimes of up to 65°C can be set using the software. The 10 MOSFET sensors operate in the temperature range 140°C - 170°C. A software system was used to control the sampling and to analyse the sensor data. A vacuum pump pulls an air sample by a hollow tube in a small chamber with an array of sensors . At first the 7

MSc in Clinical Research with Laboratory Research Project from Cranfield University, England, UK 58

standardization of active elements of sensors is done by clean and non-humid air flow and flow of reference gases. After that the sample handler brings the sensors to an odourant. The VOCs produced by the sample react with active element on the sensor. As a result the steady state condition achieved in sensor specific time is recorded as the sensor response data in the single-processing unit. After getting a reading, a washing gas like alcohol fume is passed over sensors for a while (maximum 1 minute) to wash the active elements of sensors. In the next step the standardization is again done by reference gas to prepare the E-nose for another study cycle. Thus using an E-nose system we can identify, estimate, distinguish and characterize any unknown odour by following the mechanism of human olfaction . In Vitro study: ED50 and ED90 are the effective doses (ED) of antifungal agents at which the growth of mycelia and germination of spores are reduced at 50% and 90% respectively. The ED50 and ED90 values of the antifungal agents were calculated by plotting growth rate data which were obtained from growth rate measurement on MEA plates and in Nutrient Broth media. After this the confirmatory in vitro test for values (obtained from growth rate measurements) were carried out using the Applied Sensor 3320 E-Nose. The MEA Petri plates (with and without known ED values) were inoculated with both fungi and incubated. Plates with A. fumigatus were incubated for 72, 96 and 120 hrs and for C. albicans incubation was done for 24, 48 and 96 hours. Cultured samples were taken after each scheduled time and were examined in the E-nose system to analyse the production patterns of volatile organic compounds. E-Nose technology was used to detect the ED50 & ED90 value of antifungal agents against A fumigatus and C albicans. Preparation of spore suspensions: According to requirement, the spore cell suspensions of both A. fumigatus and C. albicans were prepared in Universal bottles (25ml) separately but in a similar way from 15-20 days old colony (on pre-cultured on MEA) with the help of a sterile metal loop wire within the biological safety cabinet to prevent contamination. Growth rate measurements: (a) Experiments with Benomyl and Tebuconazole: Different quantities of the stock solution of these two fungicides were mixed with molten MEA media within a biological safety cabinet to obtain a series of treatment concentration dilutions of 0.01ppm, 1.0ppm, 5.0ppm and 10ppm (ppm=µg/ml) respectively. Three sterile Petri plates (9cm) were poured with each treatment concentration media and control (3 MEA replicate plates) and were used for both the fungi separately. One drop of 0.5 mm diameter spore suspension was taken from the Universal bottle with the sterile metal wire-loop and inoculated at the centre of each Petri 7

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plates within a sterile flow bench. A total of 15 plates were inoculated with A. fumigatus and C. albicans respectively. A second set of experiments with 30 Petri plates (15 for each antifungal drug) with same treatment concentration and fungicides were also used for A. fumigatus. Here the main difference was that the spore suspension for inoculation was made from 15-20 days old colony stored in 4°C incubation room instead of 25°C incubation room (used for spore suspension for set 1). This was done to observe any expected difference in treatment response between the two sets due to the difference in inoculation temperature (external parameter) for making spore cell suspension. Petri plates of both sets were inoculated at 25°C. Every day the mycelial extension of mycelia (in mm) for A. fumigatus were measured in two directions at right angle to each other with a ruler at the same time of the day. After measurement the Petri plates were kept at 25°C in closed plastic bags to prevent contamination with other microorganisms. The measurements were taken for 8 days. The mean of two diameters were taken daily for each replicate of each treatment and control. The collected data were plotted in MS-Excel (Program of MS-office version 2007, Product of Microsoft Corporation) to obtain growth curves. For Ccndida comparison between different cell growth in amended antifungals qualitatively for 8 days. Key used was ‘x’- very little growth; ‘xx’- slow growth; ‘xxx’- increasing growth; ‘xxxx’- good growth; ‘xxxxx’very good growth. (b) Experiment with Fluconazole: The inoculation and measurements were taken for 8 days as described previously for A. fumigatus and C. albicans. This experiment was also repeated only for A. fumigatus against higher concentrations of 10 - 100 ppm because lower concentrations had no effect. After inoculation, measurements were taken for 8 days. (c) Experiment with Antioxidant: Stock solution of nPropyl Gallate was mixed with molten MEA and used at six different concentrations (1.0, 5.0, 25.0, 50.0, 100.0 and 200.0 ppm) against growing colonies of Aspergillus and five different concentrations (1.0, 5.0, 25.0, 50.0 and 100.0 ppm) against Candida. For benomyl and tebuconazole the other methods were same as described primarily. (d) Growth experiment in liquid culture: Liquid culture of nutrient broth was used for growth measurement of Candida. Only benomyl was excluded from this study because of its low efficacy against C. albicans (observed in growth rate measurement experiment). Other two drugs were mixed with nutrient broth separately in different quantities to get the required treatment dilutions of 0.1, 1.00 and 5.00 ppm. Three replicate conical flasks (max vol. - 250 ml) were used for each treatment concentration and control (only nutrient broth media). Each conical flask contained 150 ml of liquid medium was inoculated with 1.5 ml of spore cell suspension (7.45×106 CFU/ml;

0.633mean absorbance at 640nm). From the next day the optical density of treatments were measured by M350 spectrophotometer in 1ml cuvettes at 640 nm wavelength. The density was measured with respect to a cuvette with 1 ml of sterile water as a blank. Two readings were taken every day at two times at an interval of 6 hours. After each reading the flasks were kept at 25°C in the dark in the shaker. From the next day of inoculation the measurements were taken for 6 days. The growth curves were obtained by plotting the optical density against time in MS-Excel. Calculation of Effective Dose (ED) values: ED values of all the antifungal agents against both fungi were calculated from their growth curves by plotting growth rates against corresponding dose. Experiment for early detection of volatile production and differentiation between treatments using volatile production patterns: Antifungal susceptibility testing by Benomyl and Tebuconazole against Aspergillus and by fluconazole and tebuconazole against Candida was done using E-nose. Molten MEA media were poured in 9 cm plastic Petri plates with previously calculated ED50 and ED90 values of benomyl, tebuconazole and fluconazole. The spore suspensions were made to a concentration of 1×106 spores/ml by using a haemocytometer for each species from 15-20 days old colonies. 30 Petri plates were used in total for A. fumigatus (5 plates for each treatment, control & blank or negative control) and 25 plates were used for C. albicans (5 plates for each treatment and control). 100 µl of spore suspension was inoculated in the centre of each Petri plate and was spread with a sterile glass spreader over the whole surface of the medium. After this the plates were incubated at 25°C in the dark. They were incubated for 72, 96 and 120 hours and for 24, 48 and 72 hours repetively. At every time point 2 cm diameter plugs of agar were sampled randomly from each replicate plate with a sterile cork borer. The sampled plugs were kept in sterile glass vials. The vials were capped with a screw-top lid and a septum. After this the vials were left for an hour to equilibrate. At the end of the hour headspace of each vial was analyzed with the E-nose. Data analysis : Data obtained from growth rate experiments were analyzed by Microsoft Office Excel (version 2007). The PCA on obtained data was done by the inbuilt NSTSenstool software of E-nose 3320. The CA of these data was also done using Statistica 8. PCA is a complex unsupervised and multidimensional statistical method for linear pattern recognition. Here two or three dimentional plot is used to evaluate an n-dimentional analysis. It helps to correlate multidimensional data by exposing their similarities and dissimilarities. The

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difference between multidimensional data is more elaborately analyzed by another multivariate, linear pattern and unsupervised statistical method called cluster analysis (CA). This is also an unsupervised and multivariate analysis which enhances the diffrences between response vectors in n-dimentional space. In this method a particular cluster set is analyzed regarding higher degree of similarities between samples within a cluster rather than within different cluster. The results obtained from PCA and CA were refined by eliminating outlier (responses 25-50% higher than the mean of other replicates) and redundant sensors (value near 0) from experiment. These sensors generally have no effective contribution in the difference or correlation between treatments. Generally higher value for particular PC contributes more score to PCA loading plots and indicates towards discriminating sensor. RESULTS

growth responses. The significant identification of microscopic growth response and treatment differentiation are very difficult in such early stages but the PCA and CA of volatile production pattern by using Enose system can help in early detection and differentiation between antifungal treatments. The PCA of the response of the hybrid sensor based Enose to inaculated treatment of ammended MEA (at ED50 and ED90 of benomyl and tebuconazole) and positive control of A. fumigatus togather with blank MEA (negative control) after 72, 96 and 120 hours and similarly for C. albicans with ammended MEA with the ED50 and ED90 of fluconazole and tebuconazole and positive controle after 24,48 and 72 hours were presented in PCA plots to account the data which are described by the principal components. The hierarchical CA of these data by using Euclidean distance were done to meassure the distance between sample forming clusters and Ward’s linkage method to create the distance between the clusters. The CA dendrogram showed distinct clusters of treatment groups, controles and blank.

In vitro Studies to determine ED50 and ED90 values: To determine the ED50 and ED90 values of antifungal agents against A. fumigatus, daily mycelia extension on control and amended MEA plates were DISCUSSION measured and plotted. Similar liquid culture studies with C. albicans by measuring and plotting mean absorbance Conventional culture methods are time consuming and values obtained from plain and amended nutrient broth always costly. Early detection and rapid identification is media. After determining the ED50 and ED90 values of antifungal agents the growth responses to the effective doses of benomyl and tebuconazole against A. fumigatus and fluconazole and tebuconazole against C. albicans were analysed by PCA and CA of volatile fingerprints obtained from the E-nose system. Calculation of Effective Dose values of antifungal agents: Growth rates relative to control were used to calculate the 50% and 90% of effective doses (ED50 & ED90) of employed antifungal agents against both of the fungal species (Table 2). In liquid media the highest employed doses of tebuconazole and Fig 1: Radial mycelia growth rate measurement of A. fumigatus on solid MEA fluconazole were regarded as the 90% effective (control) and MEA at 1.0, 5.0, 25.0, 50.0, 100.0, 200.0 ppm of n-Propyl Gallate at 25°C over time. dose. Any less effective or ineffective treatment as n-Propyl Gallate was excluded and not accounted in the following Table (Table 2) of ED50 and ED90 values. Electronic nose detection of differences between cultured ED50 and ED90 concentrations: After the calculation of ED50 and ED90 values, the rapid discrimination between growth responses of A. fumigatus and C. albicans against calculated effective doses (ED50 and ED90) of employed antifungal drug treatments was measured in this in vitro study. This was the final objective of this study. The 72120 hours period was chosen for A. fumigatus and 24-96 hours period was taken for C. albicans Fig 2 : Growth curve of A. fumigatus against dose of n-Propyl Gallate for early detection and differentiation of their

Table 1 — Comparative growth for C albicans of control and against 0.1, 1.0, 5.0 and 10.0ppm concentration of tebuconazole day 0 inoculation

day 1 set1

day 2 set1

day 3 set1

day 4 set1

day 5 set1

day 6 set1

Concentration of fungicide : no of observation Control d1 d2 xxx d3 xxx

xx xxx xxx

xxx xxxx xxx

xxxx D

xxxx xxxx

0.1ppm d2 d3

d1 xx xx

xxx xxx xxx

xxxx xx xx

xxx A

xx xx

1ppm d2 d3

d1 xx xx

xx xx xx

xxx xx x

xxx Y

x xx

5ppm d2 d3

d1 x x

xx xx xx

xx x xx

xx O

10ppm d2 d3

d1 x x

xx x x

day 7 set1

xxxx D xxx A xxx Y

day 8 set1

xxxxx xxxxx xxxxx xxx xx xx x x xx

xx x x F x x

O x F

x x x F x x

essential in the fields of Antifungal susceptibility testing relatively effective against Aspergillus. Due to having a (AST) for treatment actualisation. An E-nose system was low efficiency it was excluded from further experiments. used for rapid assessment of treatment responses of The discrimination between growth responses of A. antifungal drugs against A. fumigatus and C. albicans. fumigatus growing on plain media (control), media Firstly the conventional culture methods were used in both amended with the ED50 and ED90 of benomyl and solid and liquid media to determine the effective doses of tebuconazole and negative control or blank (only media) employed antifungal agents against those two fungi. Then were measured after 72-120 hours. Highest the volatile production patterns were analysed to rapidly discriminations were obtained after 120 hours for benomyl discriminate between fungal species growing against and 72 hours for tebuconazole. Even the discrimination amended treatments, controls (un-amended) and blanks between these two drugs were successfully observed after (only media without fungal species). The early detection 96 hours. and differentiation between treatment responses were done within 120 hours and 72 hours of incubation for A. fumigatus and C. albicans respectively by analysing their volatile fingerprints. Similar studies were done with ten microbial organism including A. fumigatus and C. albicans for rapid identification of each individual . Three antifungal drugs benomyl, fluconazole and tebuconazole were used against the fungal isolates. In culture studies, among these Fig 3 : Growth rate measurement of C. albicans in liquid Nutrient Broth (control) three drugs benomyl and tebuconazole were and Nutrient Broth at 0.1, 1.0, 5.0 ppm of fluconazole at 25°C over time effective against A. fumigatus and fluconazole and tebuconazole were effective against C. albicans. The ED50 and ED90 values were calculated only for these cases (Table 2). Higher doses of fluconazole were also remain ineffective against A. fumigatus. In this study benomyl was not used in further against Candida and fluconazole was excluded from E-nose experiments with Aspergillus. Higher doses of antioxidant (n-Propyl Gallate) were Fig 4 : Growth curve of C. albicans against dose of fluconazole 6

USE OF VOLATILE PRODUCTION PATTERNS TO DETECT EFFICACY OF ANTIFUNGAL AGENTS — SUKUL 65

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production. In a study of four dermatophyte species responses ED50 & ED90 values for different antifungal agents: after 96 hours incubation where Fungal Species except the media all other Aspergillus fumigatus Candida albicans parameters were constant5. This Set 1 Set 2 study did not show any influence of media on fungal growth. I have Antifungal agents and measured the ED values in the EEffective Dose nose experiment with Candida on Benomyl ED50 0.3ppm 0.25ppm Not effective solid MEA media and the discriminations I have obtained Benomyl ED90 1.23ppm 0.57ppm Not effective were according to expectations. I Tebuconazole ED50 2.16ppm 2.16ppm 0.99ppm have used the spore suspension with 106 CFU/ml for inoculation Tebuconazole ED90 4.22ppm 4.18ppm 5ppm in E-nose experiments. In my opinion a higher spore Fluconazole ED50 Not effective Not effective 1ppm (Example; Figure 3 & 4) concentration would be able to Fluconazole ED90 Not effective Not effective 5ppm (Example; Figure 3 & 4) give quicker results. Due to having faster growth rate the n-Propyl Gallate ED50 72ppm (Example; growth responses and Figure 1 & 2) Not applicable Less effective so Not applicable discriminations are more rapidly n-Propyl Gallate ED90 162ppm (Example; identifiable Candida. Such Figure 1 & 2) Not applicable Less effective so Not applicable studies can authenticae the use negative controls or blank by Table 3 — Best discrimination of volatile fingerprints found for different antifungal agents PCA. This study can potentialy against fungal pathogens in PCA and CA contribute to the preclinical drug data bank of pharmaceutical Fungal Species industries for future antifungal drug Aspergillus fumigatus Candida albicans research and clinical evaluation Antifungal agents and Effective Dose Hours for highest degree of discrimination results (personal conversation between me and my research supervisor Benomyl ED50 & ED90 120 hours Not applicable Professor Naresh Magan, Director Tebuconazole ED50 & ED90 72 hours Not applicable of research, Cranfield Health). Recent studies have also shown the Benomyle , ED50 & ED90 & 96 hours differentiation between Tebuconazole , ED50 & ED90 (Example; Figure: 5) Not applicable dermatophyte infection in humans Fluconazole ED50 & ED90 and Not applicable 48 hours and animals8. Development in Tebuconazole ED50 & ED90 (Example; Figure: 6) sensor technologies can bring a revolutionary change and perfection Among these two drugs tebuconazole showed relatively of in vitro treatment analysis in future. Table 2 — The calculated effective dose (ED50 & ED90) values of employed antifungal agents

rapid response and efficacy than benomyl. The growth responses of C. albicans growing on media (control) and those amended with the ED50 and ED90 of fluconazole and tebuconazole were measured in the E-nose system after 24-72 hours. The best discriminations were obtained from the PCA and CA after 48 hours. Both of the drugs had shown almost equal efficiency against Candida. The sensor responses of two drug samples and control samples were obtained as distinctly separate clusters but the sensor responses against ED50 and ED90 values of individual drugs were obtained as a mixed cluster. Different studies have shown relevant influence of culture media on volatile production patterns of microorganisms 10. However, there are some contradictory results regarding influence of media on volatile

ACKNOLEDGEMENTS

My sincere thanks and gratitude to my supervisor Professor Naresh Magan (Director of research Cranfield Health, UK), Neus Plans Pont and Esther Baxter (Technitian Applied Mycology Laboratory, Cranfield Health, UK) for their consistant help and support throughout my project to make it a success. REFERENCES 1 Azoulay E, Timsit Jean-F, Tafflet M, Lassence A de, Darmon M, Zahar Jean-R, et al — Ventilator-Associated Pneumonia and Subsequent Pseudomonas Candida Colonization of the Respiratory Tract: American College of Chest Physicians, CHEST 2006; 129: 110–7 2 Davis C—- Candida albicans. [Descriptions of Fungi and Bacteria]: www.cabi.org (CAB ABSTRACTS): CAB I n t e r n a t i o n a l , 2 0 0 8 . http://www.cababstractsplus.org/abstracts/Abstract.aspx?A cNo=20056400871 (accessed Jan 15, 2009)

3 Jones W — Tired, Headaches, Irritable, Aches A. fumigatus - 96h And Pains? It Could Be Benomyl and Tebuconazole ED50/ED90 Ward`s method Candida!: isnare.com Articles, Euclidean distances 2 0 0 8 . Blank-1 http://www.anysubject.com/c Blank-2 Blank-4 ED50-T-4 andida-treatment-candidaControl-3 Blank-3 infectionalbicansED50-T-3 ED50-T-1 candida-symptom.asp ED50-T-2 ED50-B-1 (accessed Jan 15, 2009) ED50-B-4 ED50-B-2 4 Latgé Jean-P — Aspergillus ED50-B-3 Control-1 Control-4 fumigatus and Aspergillosis: Control-2 ED90-B-4 American Society for ED90-B-1 ED90-B-2 Microbiology: Clin Microbiol ED90-T-3 ED90-B-3 Rev 1999;12: 310-350. ED90-T-2 ED90-T-1 ED90-T-4 http://www.pubmedcentral.ni 0 200 400 600 800 1000 1200 1400 h.gov/articlerender.fcgi?artid =88920 (accessed Jan 15, Linkage Distance 2009). 5 Magan N, Sahgal N, Monk B, Fig 5 : PCA score plot differentiating between plain MEA (blank), A. fumigatus growing on Wasil M — Trichophyton plain MEA (control) and ED50 and ED90 of benomyl and tebuconazole treatments after 96 species: use of volatile hours [Upper left picture]. CA of blank, A. fumigatus growing as control and against ED50 and fingerprints for rapid ED90 of benomyl and tebuconazole treatments after 96 hours. (Key: B – benomyl and T – identification and discrim tebuconazole) [Upper right picture] ination: British Journal of Dermatology 2006; 155: 1209-16. C. albicans-48h 6 Moens M, Smet A, Naudts B, Fluconazole andTebuconazole ED50/ED90 Verhoeven J, Ieven M, Jorens Ward`smethod P, et al — Fast identification of Euclidean distances ten clinically important microControl-1 Control-4 organisms using an electronic Control-2 Control-3 nose: Letters in Applied F-ED50-1 F-ED90-3 Microbiology 2006; 42: 121-6. F-ED50-4 F-ED50-2 7 Nagal HT, Gutierrez-Osuna R, F-ED90-1 T-ED50-3 Schiffman SS — The WHO F-ED50-3 F-ED90-4 and WHY of ELECTRONIC F-ED90-2 T-ED50-4 NOSES: IEEE SPECTRUM T-ED90-3 T-ED50-1 1998; 35: 22-31. T-ED90-1 T-ED90-2 8 Sanghal N, Magan N — T-ED50-2 T-ED90-4 Fungal volatile fingerprints: discrimination between 0 500 1000 1500 2000 2500 3000 3500 dermatophyte species and Linkage Distance strains by means of electronic nose: Sensors and Actuators Fig 6: PCA score plot differentiating between C. albicans growing on plain MEA (control) B, In Press. and ED50 and ED90 of fluconazole and tebuconazole treatments after 48 hours [Upper left 9 The Aspergillus website picture]. CA of C. albicans growing as control and against ED50 and ED90 of fluconazole and [owned by Fungal Research tebuconazole treatments after 48 hours. (Key: F – fluconazole, T – tebuconazole) Trust]- Aspergillosis, 2008. [Upper Right picture] http://www.aspergillus.org.uk/ aspergillosisframeset.html (accessed Jan 15, 2009) 10 Turner, Anthony PF, Magan N — Electronic noses and disease diagnostics: NATURE REVIEWS. Micro-biology 2004; 2: 161-6.

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EPONYMS IN HUMAN ANATOMY : REMEMBERING THE GREAT PEOPLE BEHIND THEM — ABRAHAM

Eponyms in human anatomy : remembering the great people behind them Abraham A A1

Bowman's Capsule :

Eustachian Tube :

It is located at Glomerulus of nephron. It is named after William Bowman(1816-1892) English anatomist and surgeon. Later he became an eye specialist. Other structures named after him are Bowmans glands in the olfactory mucosa and Bowmans membrane which is the limiting membrane in the cornea.

It is also known as auditory or pharyngotympanic tube. It connects the pharynx to the middle ear. In adults it is about 35 mm long, named after Bartolomeo Eustachi (1514-1574). One of the founders of science of human anatomy, he is known for his studies of the internal ear and was the first to describe malleus, stapedius and cochlea. He was the first person to study the anatomy of the teeth, first and second dentition. He also discovered the adrenal glands.

Bundle of His : Anatomy is one of the basic pillars of modern medicine. It may be said that from this trunk other branches of medicine are formed. In the earlier centuries many people had done research and revealed to the world the secrets of human anatomy. Many structures in the body are known after people who had discovered it eg, nodes of ranvier after French anatomist Louis Antoine Ranvier. But editions of Terminologia Anatomia, the official Latin nomenclature book had leftout these people's names. It is given only in Latin terminologies. These terminologies look very long and dull to people whose mother tongue is not English. Some of the common eponyms in human anatomy and a brief history of the people behind them have been described. This is one way of remembering those great people who had done excellent work in our field centuries ago. [J Indian Med Assoc 2016; 114: 66-70]

Some of them are very interesting. eg, loop of Henle named after Jakob Henle. There are seven other structures in the body which are named after him.

ew Websters dictionary describes eponym as “a real or imaginary person after whom something is named. It comes from Greek, epi means upon and onyma, a name. All eponyms in human anatomy are named after persons who had discovered it or had done pioneer work in it, except the following: (i) Adams apple after biblical character Adam (ii) tendo achillis after the Greek mythological character Achillis (iii) cornu ammonis, a synonym for hippocampus proprus after Egyptian God of sun, Ammon – Ra (iv) gasserian ganglion, sensory ganglion of trigeminal nerve : in 1765 a student named this ganglion in honour of his professor Gasser Johann Laurentivs. Some of the eponyms like bundle of His, Mc Burney's point are frequently used. But some are rarely used. A search on google.com for eponyms in human anatomy yielded a list of 158 . The Latin anatomical nomenclature published as Terminologia Anatomica (TA) does not give eponyms' official status. Only three eponyms have surpassed this decision and changed into proper terms . Purkinje for stratum purkinjense for middle layer of cerebellar cortex, golgi for complexus golgieusis, and cornu ammonis for the Epyptian God of sun Ammon –Ra. But TA gives a list of 392 most common eponyms as an index at the end of the book . Some of the eponyms in medicine are named after patients in whom they were detected first. eg, Christmas disease after Stephen Christmas. Described below are some of the common eponyms we frequently come across. With that is given a brief history of those great people, when they lived, which countries they belonged to, and their other contributions to science.

It is part of the conducting system of heart, begins at AV node crosses AV ring, descends along the postero-inferior border of ventricular septum. It is named after Swiss cardiologist Wilheim His Junior, (1863-1934). His father Wilheim His Senior (1831-1904) was a famous anatomist. The acute angle between cardia, at the junction of the stomach and the oesophagus is known after him. (The angle of His.) He also invented the microtome.

Circle of Willis :

Key words : Eponyms, human anatomy, anatomical nomenclature.

Aqueduct of Sylvius : It connects the third and fourth ventricles in the brain. It is also known as mesencephalic or cerebral aqueduct. Its blockade can lead to hydrocephalus. It is named after Franciscus Sylvius (1614-1672) who was a Dutch physician and anatomist. But some workers think it is wrongly attributed to Sylvius . The sylvian fissure or the lateral sulcus of the brain is also named after him. This divides frontal and parietal lobe above, from the temporal lobe below. 3

Cerebral arterial circle or the Willis polygon is a circle of arteries that supply blood to the brain. It comprises anterior cerebral arteries (left and right), anterior communicating artery, internal carotid arteries (right and left), posterior cerebral arteries (left and right), posterior communicating arteries (left and right). It is named after Thomas Willis (1621-1673)the English physician. He was a founder member of Royal Society. He played an important role in developing the branches of anatomy, neurology and psychiatry.He was the first to number the cranial nerves in the order we know now. He did detailed work on the brain. He coined the term mellitus in diabetes mellitus. Considerable anatomic variations occur in circle of Willis. Based on a study of 1413 brains, classical circle is only seen in 34.5% of the population.

It is seen at the junction of pancreatic duct and common bile duct. It is named after the German anatomist Abraham Vater (1684-1751), who first described it in an article published in 1720.

Bartholin's Glands and Ducts : Bartholin's glands are two in number, located slightly below and to the left and right of the opening of vulva. They secrete mucous to lubricate the vagina. They are equivalent to bulbourethral glands in the male. Ducts lead from the Bartholin's gland to the surface of vulva. They are named after Danish anatomist Caspar Bartholin the younger (1655-1738).

Broca's Area : It is the region of the frontal lobe linked to speech. Pierre Paul Broca (1824-1880) French anatomist and physician described it.

MBBS, MD, Associate Professor, Departmen of Anatomy, Yenepoya Medical College, Mangalore 575018 66

Fallopian Tube : It is the tube which lies on the upper border of the broad ligament, opens medially into the superolateral angle of the uterus, laterally opens into the peritoneal cavity. It is named after Gabriele Falloppio (1523-1562) the Italian anatomist and physician. The aqueductus Fallopii, the canal through which facial nerve passes after leaving auditory nerve, is also named after him.

Gasserian Ganglion : It is a sensory ganglion of the trigeminal nerve that occupies a cavity (Meckels cave) in duramater, near the apex of the petrous part of the temporal bone. Gasser Johann Laurentius (1723-1765) was an Austrian anatomist who was a professor at University of Vienna. In 1765 one of his students, Anton Balthasar Raymund Hirsch described the ganglion in his graduation thesis , naming it in the honour of his professor . 5

Golgi Apparatus :

Cooper's ligament of the breast are suspensory ligaments that maintain the structural integrity. Sir Astley Paston Cooper was an (1768-1841), English surgeon and anatomist. Other structures that bear his name are, Cooper's fascia, a covering of the spermatic cord, Cooper's pubic ligament, the superior pubic ligament, Cooper's stripes, a fibrous structure in the ulnar ligaments.

It is a modification of the smooth endoplasmic reticulum with close packing of a number of layers. They are concerned with collection and transport of cellular enzymes and chemicals in the form of secretory vesicles and lysosomes. They are actively involved in the metabolic process. It is named after Italian physician and pathologist Camilo Golgi (1843-1926). He also discovered a tendon sensory organ (golgi receptor) and received Nobel prize in 1906 for studies of the nervous system along with Santiago Ramon Y Cajal. He is also known for golgi stain, a nervous tissue staining technique, golgi enzyme, golgi cells of cerebellum, golgi I nerve cells with long axons, golgi II cells with short or no axons.

Edinger Westphal Nucleus :

Graffian Follicle :

It is also known as accessory oculomotor nucleus. It is the accessory parasympathetic cranial nerve nucleus of oculomotor nerve. It is named after Ludwig Edinger, anatomist and neurologist who demonstrated it in foetus in 1885 and Karl Freidrich Otto Westphal (neurologist and psychiatrist) who demonstrated it in adults.

It is the basic unit of female reproductive biology and is composed of roughly spherical aggregates of cells found in the ovary. It was discovered by Dutch anatomist and physician Regnier de Graaf.

Ampulla of Vater :

Cooper's Ligament :

Haversian Canal : It is the basic unit of bone composed of concentric layers

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around a central vessel. It is known after Clopton Havers (16571702) a British physician who did pioneering research in the microstructure of the bone.

Hesselbach’s Triangle : It is formed by rectus abdominis medially, inferior epigastric vessel superiorly and laterally, inguinal ligament inferiorly. It is named after Franz Kaspar Hesselbach (1759-1816). He was a German anatomist and surgeon known for this work in hernia operations. Other structures which bear his name are Hesselbach’s fascia which is cribriform fascia and Hesselbach’s ligament which is interfoveolar ligament

Hunters Canal : It is an aponeurotic tunnel in the middle one-third of the thigh, extending from the apex of the femoral triangle to the opening in adductor magnus. It is named after John Hunter (1728-1793) who was a Scottish surgeon.

Islets of Langerhans : These are clumps of closely packed cells in the pancreatic parenchyma which produce insulin and glucagon. They contain a mixture of acidophilic and basophilic cells. They were discovered by German anatomist Paul Langerhans (1847-1888) at the age of 22. There are one million islets in an adult pancreas.

Jacobsons' Nerve :

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Loop of Henle : In the functional unit of kidney, nephron, loop of Henle connects proximal convoluted tubule with distal convoluted tubule. The loop descends to medulla and then returns to the cortex. It is named after the German anatomist, physician and pathologist Friedrich Gustav Jakob Henle (1809-1885). He wrote Hand Book of Systematic Human Anatomy. Other anatomical structures associated with his name are crypts of Henle, microscopic pockets in the conjunctiva of eye; Henle's fissure, fibrous tissue between cardiac muscle fibres; Henle's ampulla, ampulla of uterine tube; Henle's layer, outer layer of cells of root sheath of a hair follicle; Henle's ligament, tendon of the tranverse abdominalis muscle; Henle's membrane, brucks layer forming the inner boundary of the choroid of the sheath connective tissue which supports outer layer of nerve fibres in the funiculus; Henles spine, the suprameatal spine that serves a landmark in mastoid area. Robert Koch was his student.

Mackenrodt's Ligament : It is located at the base of broad ligament which contains the uterine artery and vein. It is named after German gynaecologist AK Mackenrodt (1859-1925).

Foramen of Megendie : It is the median foramen of the fourth ventricle of the brain. It is named after French physician Franeois Magendie.

Malphigian Corpuscle :

It is a branch of glossopharyngeal nerve. It arises from the petrous ganglion and ascends to tympanic cavity through a small canal on the undersurface of the petrous part of temporal bone on the ridge which separates the carotid canal from jugular fossa. It is known after Ludwig Levin Jacobson (1783-1843), who was a Danish anatomist. He was a specialist in comparative anatomy. He discovered the vomeronasal organ and vomeronasal cartilage in the ear.

There are two corpuscles. 1. Renal : initial filtering component of nephron of the kidney 2. Splenic : lymphoid nodules (white nodules) follicles in the white pulp of the spleen. It is named after Marcello Malphigi (1628-1694), Italian physician and biologist regarded as the father of microscopical anatomy and histology. Other structures named after him are malphigi layer which is a layer of skin, composed of stratum basale and stratum spinosum.

Kerckring Fold or Valve :

Mc Burney's Point :

These are large valvular flaps projecting into lumen of the bowel. These are composed of reduplication of the mucous membrane, the two layers of fold being held together by submucous tissue. It's function is to slow down the food and increase the rate of absorption. It is named after Theodor Kerckring (1638-1693) a Dutch anatomist. He is also credited with describing Kerckring’s ossicles which is an occasional ossification centre in occipital bone which appears in 16th week of gestation.

It is a point on the right side of abdomen, at the junction of lateral one-third and medial two-third of a line joining umbilicus and anterior superior iliac spine, which corresponds to the base of appendix. It is named after Charles Mc Burny, US surgeon (1845-1913). In 1894 he described the incision, although it has been described earlier by Louis L Mac Arthur. Mc Burney introduced rubber gloves to be used during surgery to improve asepsis.

Koch’s Node : SA node is also known as Koch’s node.It is also known as node of Keith and Flack. Koch Walter Karl was a German surgeon known for his work on the motor centres of heart. He coined the term sinus node.

Meckels' Diverticulum : It is a true congenital diverticulum,which is a small bulge in the small intestine. It is present at birth and was first described by Fabricius Hildanus in 16th century, later named after German anatomist Johann Friedrich Meckel (1781-1833) who described its embryological origin. His grand father had also the same

name. So to avoid confusion, grandfather is referred as the Elder (1724-1774) Other structures named after him are Meckel’s cartilage, a cartilagenous bar from which mandible is formed, Meckels space or cave, a cavity in duramater over the petrous part of temporal bone that covers the trigeminal ganglion; Meckels' ganglion, sphenopalatine ganglion; Meckels' ligament, portion of anterior ligament that fastens the malleus to the wall of the tympanic membrane.

Foramina of Monro : It connects lateral ventricle with third ventricle in the midline of the brain. It is named after Scottish physician Alexander Monro (1733-1817) who described it in 1783, but was previously identified by 17th century anatomist Raymond Vieussens. Monro Sulcus, a groove in lateral wall of the third ventricle, marking the boundary between thalamus and hypothalamus is also known after him. Actually he is known as Alexander Monro Secundus, because there were three generations of physicians by the same name.

Muller's Muscle : It is a smooth muscle adjoining levator palpebrae superioris that helps to raise the upper eye lid. It is named after Heinrich Muller (1820-1864) the German anatomist. It is also called Rouget’s muscle after French physiologist Charles Marie Bengamin Rouget. Sometimes it is called Muller Rouget muscle to honour both. Another structure named after him is muller's trigone, part of tuber cinereum, folding over the optic chiasm of the brain.

Nodes of Ranvier : They are gaps (one micrometre in length) formed between myelin sheaths. The myelin sheath of long nerves were discovered by German pathological anatomist Rudolf Virchow in 1854. French anatomist Louis Antomic Ranvier later discovered the nodes. Ranvier refined histological techniques and his work on nerve fibres became world renowned .

Purkinje Fibres : These are specialised myocardial fibres that conduct electrical stimulus that enable the heart to contract, situated in the inner ventricular walls just beneath endocardium. They were discovered by Jan Evangelista Purkyne in 1839, also pronounced Purkinje (1787-1869), best known for discovery of Purkinje cells, large neurons with many branching dendrites in the cerebellum. Other discoveries include Purkinje images ie, reflections of objects from the structures of the eye. He introduced scientific terms plasma and protoplasm. He was the first to use a microtome to make wafer thin slices of tissues. He discovered sweat glands in 1833 and published a thesis describing types of finger prints.

Pouch of Douglous : It is an extension of peritoneal cavity between rectum and posterior wall of uterus. It is named after Scottish anatomist Dr James Douglous (1675-1742). Other structures named after him are, Douglous fold, a fold of peritoneum forming the lateral boundary of Douglous pouch; Douglous line, the arcuate line of the sheath of rectus abdominis.

Schwann Cells : They are named after German physiologist Theoder Schwann (1810-1882). He developed cell theory. Discovery and study of pepsin and invention of the term metabolism are his other achievements.

Sphincter of Oddi : It is the sphincter at the junction of the duodenum and common bile duct (CBD), named after Italian physiologist and anatomist, Ruggero Oddi (1864-1913).

Sternal Angle of Loius : It is the junction between manubrium and the body of the sternum, named after French anatomist Pierre Charles Alexander Louis.

Thebesian Veins : They are the smallest cardiac veins. These are numerous small veins arising from the muscular wall of the heart and draining independently into the atria. They are named after Adam Christian

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Thebesius (1686-1732) German anatomist, known for his studies of cardiac circulation. Other structures which bear his name are Thebesian foramina, orifice of thebesian valve; Thebesian valve, valve of coronary sinus.

Stensen's Duct : It is the parotid duct connecting the gland to the mouth. It is named after Neils Stensen, a Danish anatomist (1638-1686). He also made contributions in the field of geology and paleontology. He put forward the revolutionary concept of fossils, that they are remains of ancient living organisms.

Wirsung Duct : It is the duct joining pancreas to CBD, named after German anatomist Johann George Wirsung (1589-1643).

Wharton's Duct : It is the submandibular salivary duct that connects the gland to the floor of the mouth, initially described by English anatomist Thomas Wharton (1614-1673).

Santorini Accessory Pancreatic Duct : It is named after Italian, Giovanni Domenico Santorini (1681-1737) He is also credited with following structures: Santorini cartilage, corniculate cartilage of larynx; Santorini concha, superior nasal concha; Santorini fissures, vertical fissures in anterior part of cartilage of external accoustic meatus; Santorini minor caruncle, location of opening of accessory pancreatic duct to the duodenum; Santorini muscle, bundle of muscular fibres that draw angle of mouth laterally; Santorini vein that passes through parietal foramina and links superior saggital sinus with veins of scalp; Santorini plexus, plexus of veins found in the cave of Retzius.

Sinus of Valsalva : It is an aortic sinus, one the anatomic dilatations of ascending aorta which occurs just above the aortic valve. There are three aortic sinuses, left, right and posterior. It is named after Antonio Maria Valsalva (1666-1723) an Italian anatomist. His name is associated with Valsalva manoeuver. Anatomical structures named after him are Valsalva antrum of the ear, Valsalva muscle and taeniac valsalva. Valsalva muscle is a band of vertical muscle fibres on the outer surface of the tragus of the ear, innervated by temporal branch of facial nerve.

Conclusion : In ancient times when the branch of anatomy originated, the common languages used were Greek and Latin. So all the nomenclature were also from these languages. When the number of terminologies increased ,there was need for a standard version. So in 1895 Society of German Speaking Anatomists,

who met in Basel in Switzerland approved the first Latin anatomical nomenclature - Nomina Anatomica. But it was not accepted worldwide. The International Anatomical Nomenclature Committee was formed in 1936 in Paris to revise and suggest a more acceptable list. So first official international terminology came out and was named Parisiensia Nomina Anatomica. No eponyms were used in this book. After the publication of its 6th edition, again problems arose about terminologies. In 1998 a new extended and revised list of nomenclature was accepted by Federative International Committee on Anatomical Terminology (FICAT). It was published as Terminologia Anatomica. This book also ommited eponyms from the main list. Only three had found place in the book. But it has given an index of most common eponyms as a separate part, at the end of the book. Arguments for not including eponyms in the main list are many. They think these are source of inconsistency, uncertainty and error. All the names are western. So a western bias is inevitable. There will be differences of spelling when transliterated from other languages to Roman letters. eg, Kupffer cells. Another argument put forward is that the person named does not own the structure eg, “Montgomery did not own tubercles” , Ranvier his nodes. All this may hold good for the pure anatomist. But for other people like clinical anatomists, clinical practitioners, eponyms are a welcome relief from monotonous Greek and Latin words. They are shorter, save space and paper and also always easy to remember. They instill a personal touch by means of a name rather than words from dead languages. The people, whose mother tongue is not English, will like a name like Adams apple, rather than long words like prominentia laryngea. These eponyms help us remember the pioneers in the field of anatomy and medicine whose research had unravelled the mysteries of human body, when technologies were at their infant stages. It is like a piece of history, giving a nostalgic feeling. It is our duty to give these great people their rightful place in the history of evolution of human anatomy which is studied by all medical students on their way to become good doctors. REFERENCES

1 Wikipedia — List of human anatomical parts named after people. www.en.wikipedia.org/wiki/ (accessed on January 28, 2010). 2 Federative Committee on Anatomical Terminology — Terminolgia Anatomia. New York: Thieme, 1997: 36. 3 Leite dos Santos AR, Fratzoglou M, Perneczky A — A historical mistake : the aqueduct of Sylvius. Neurosurg Rev 2004; 27: 224-5. 4 Bergman RA, Afifi AK, Miyauchi R — Circle of Willis. In: Bergman RA, editor. Illustrated Encyclopedia of Human Anatomic Variations. URL http:www. Anatomy atlases.org/Anatomic variants/cardisor text/Arterier/circle of wills/sbtn/ (accessed November 6, 2009). 5 Porter N — Merriam Webster Dictionary. New Jersy: G&C Merriam Co, 1913: 132. 71

Pictorial CME J INDIAN MED ASSOC

Book Review VOL 114, NO 5, MAY, 2016

A RARE CASE OF RECURRENT (CONSECUTIVE) ECTOPIC PREGNANCY WITH FIBROID UTERUS

40 years old patient, G4P1L1 came to hospital with complaint of severe pain abdomen and spotting. The patient had history of amenorrhoea for 7 weeks and urine test done for pregnancy was positive. P1 was full term normal delivery at home which was followed by first ectopic pregnancy after 1year which had presented with ruptured right tubal ectopic pregnancy with shock and was treated with total right salpingectomy. Second ectopic pregnancy occurred after 3 years and had presented with unruptured live left tubal ectopic pregnancy which was treated conservatively by left sided salpingotomy. An interstitial fibroid (4x4.5cm) was seen in the anterior wall of the uterus at each time. Transabdominal ultrasound revealed empty endometrial cavity with left adenexal mass and well defined gestational sac with foetal node corresponding to 6 weeks 5 days (Fig 1). Cardiac pulsations were present at the time of scan. So diagnosis of recurrent (consecutive) ectopic pregnancy was made. Minimal free fluid was seen in pouch of Douglas and in perilesional area. Fibroid measuring 5 x 5cm was seen along anterior wall of the uterus (Fig 2). Emergency laparotomy was done subsequently and diagnosis was confirmed. Based on patient’s request, hysterectomy with left sided total salpingectomy was done. Postoperative period was uneventful. Department of Radiodiagnosis, Owvass Hamied Dar GMC Hospital, Jammu 180001 Maqsood Ahmad Dar MBBS, DMRD (Radiodiagnosis), Ghanshyam Dev Senior Resident Pankaj Sharma MBBS, MD (Med), Senior Resident of Medicine MBBS, MD, Professor and Head of the Department MBBS, DMRD, DNB, PDCC (Radiodiagnosis), Senior Resident of Radiodiagnosis, Lady Hardinge Medical College, Delhi 110001

Fig 1 — Showing Left Adenexal Ectopic Pregnancy with Well Defined Gestational Sac Containing Foetal Node (U-uterus; F-foetal node; GS- gestational sac; LA-left adenexal)

Fig 2 — Showing Empty Uterus with Fibroid along Its Anterior Wall with Left Adenexal Ectopic Pregnancy with Foetal Node (Uuterus; F-fibroid; LA-left adenexa; G-gestational sac)

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Oxford and IBH Publishing Co.Pvt. Ltd. New Delhi, Bombay, Calcutta. 84-165). One microgametocyte gives rise to eight ( not 5-8 p 29 ) microgametes.

THIS treatise of malaria in a small compass contains almost all the aspects of the disease in fifteen well -balanced chapters. An interested reader gets almost all the facts of malaria within the grip.This hellps to create interest in the mind of the readers.

The recent evidence of chondroitin sulphate A (CSA), not chondroitin sulphate B (P 66) for placental sequestration (as mentioned in the text ) has considerably weakened (Cook GC, Zumla Al (Eds)-Manson’s Tropical Diseases ( 22 Edn). 2009. Elsevier. Book Aid International, Sabre Foundation. 1215). Along with IL-1, IL-6 and IL-8, mentioned in the text, other important cytokines involved are IL-12 and IL-18. Recently a great deal of interest has been shown in IL-12 and IL-18. Recently a great deal of interest has been shown in IL-12 having protective role on malaria, protectiong both mice and rhesus monkeys from sporozoite challenge and killing parasites by No. Burkitt’s lymphoma (pp 145-46 ) has been written almost in toto from Manson’s Tropical Diseases without citing any reference (Cook GC-Manson’s Tropical Diseases. 20 Edition. 1996. ELBS with W.B. Saunders. 1149). nd

Each chapter of this book is well planned and comprehensive, with ample references. Boredom has been carefully avoided. The compilation is reader friendly.

Malaria (Third Edition) — By Gupta BD and Maheswari RK.2013. United India Periodicals Pvt Ltd, New Delhi 110002, pp-542, Rs.295.00.

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Some interesting features of this manual need highlighting. Cleopatre, the queen of Egypt used to sleep under the mosquito net; chloroquine resistant strains of P.falciparum first developed on the Thai-Combodia border in 1962 and in India, it was first detected in Assam in 1973 (ch 1); citing an article published in the Lancet (2010 ) the pertinent question has been raised, whether the statistics on malaria deaths in India is grossly underestimated(ch 2) ; in India DDT resistance in the vectors was first reported in Tamilnadu in 1955 (ch 3); the level of peripheral parasitaemia underestimates the true numbers of parasites within the body (ch 6 ); chloroquine in clinical trial acts as an investigational antiretroviral in humans with HIV1/AIDS and as a potential antiviral agent against chikungunya (ch 11 ); pyronaridine is a new highly active blood schizonticidal drug developed in China (ch 11); mismatched pharmacokinetics can play a role facilitating development of resistance (ch 12); malaria kills in a year what AIDS kills in 15 years (ch 13); mosquito nets treated with insecticides provide much more effective protection by killing mosquitoes as well as repelling them (ch 14).

Some important pharmacological aspects which have not been included are (1) appearance of primaquine resistant P.falciparum strains and P.falciparum strains and P.falciparum gametocytes,(2) mutation in pvmdr1 (Y 9 76F etc) that has been associated with chloroquine resistance. Qinghousu derived alkoloids are found from leaves of Artemesia annua ( not Artemisia annua P 2,201). The dose of primaquine in falciparum malaria is given in one day ( not for 1-2 days P 192). The chapter on drug resistant malaria has recently been added which is attaractive and informative. The authors have rightly stated that further studies are needed on the eg2 gene to determine whether it a reliable genetic marker.

A close scrutiny of some of the facts and features mentioned in this book, however, is necessary. In the historical overview some serious mistakes have crept in. It has been written that in 1897 Welch discovered P.falciparum (P3). Actually in 1889 Celli and Marchiafava in ltaly described P.falciparum,which malaria parasite had been detected first by Laveran in 1880. (Bruce- Chwatt L J - Essential Malariology. 1980. William Heinemann Medical Book Ltd, London WCIB 3HH 5-6). The malaria parasite observed by Laveran was later proved to be P.falciparum. The period that elapses from a blood meal to lay eggs by the mosquito is termed ‘gonotrophic cycle’(notgeotropic cycle’ P 22 ). The anopheline larvae do not obtain air from plant roots (P 22 ). It is written that the larvae have no palmate hairs present on the abdominal segments (P 24 ), but in fact the larvae possess palmate hairs on the abdominal segments. ‘Anopheline and Culicine’ (P 25) are not familes. The family under which the mosquitoes belong is Culicidae. The tribes are Anophelini (not Anopheline P 25) under which comes the genus Anopheles and Culicini (not Culicine P 25 ) under which comes the genes culex; under the tribe Aedini comes the genus Aedes and under the tribe Mansonini (not Mansonia P 25) comes the genus Mansonia.

It is not understood why there are contradictory statements related to artemisinin resistant P. falciparum in P 251 it is written, “Resistance has been reported to almost all antimalarials except artemisinin and its derivatives” and in P 250, “Artemisinin resistant malaria has arisen in Western Cambodia and has spread/emerged on the Thailand Myanmar border. In fact artemisinin resistance is now a hot topic. In the book only the name of the gene (pfatpase 6) is there, but not the mutant codons (one such codon is A 769 N ) from French New Guinea has already been described (Doundrof et al, New England Jounal.2004). The gene is pfmlrl (not pfmdr P 236,249 etc). Pvdhfr (p249) is there in the book but pvcrt and pvmdrl genes are consipicuously absent. The y976F mutation in pvmdrl has been associated with Chloroquine resistant P.vivax parasites. Some gross anomaly is there related to malariometric indices. For classification of endemicity of malaria spleen rate in chidren 2-9 years ( not 2-10 years P 337-33 ) is counted (C/O Bruce Chwatt L J.1980.P 147). Presentation of a well -know subject like malaria requires precision and Utmost caution.

In this book. A dirus is kept in the bracket with A.balabacencis (P 25 ). In reality they are two distinct species and both the vectors are present in India ( Nagpal BN, Sharma VP Indian Anophelines. 1995.

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Sathyamangalam, Tamil Nadu, Medical Camp Kancheepuram, Tamil Nadu, CME On Eye & Systemic Disease Virudhunagardist., Tamil Nadu, CME On New Born Chennaicity, Tamil Nadu, CME On Infertility Kancheepuram, Tamil Nadu, CME On Ophthamology Chennaicity, Tamil Nadu, Measles Immunnization Day Virudhunagardist, Tamil Nadu, General Body Meeting Kancheepuram, Tamil Nadu, Orthopaedic Outreach Program Kancheepuram, Tamil Nadu, Orthopaedic Outreach Program Thiruvananthapuram, Kerala, CME On DepressiveTI Thiruvananthapuram, Kerala, CME On Documentation And Prevention Kunnamkulam, Kerala, CME And General Body & CME On Depressive Disorders Kolenchery, Kerala, CME On Initiating Insulin In Diabetes The Earllier Tellicherry, Kerala, CME On Short Febrile Illess Mysore, Karnataka, Measles Immunnization Day Mundargi, Karnataka, Immunization Day Tellicherry, Kerala, Awareness On Measles Immunisation Thiruvananthapuram, Kerala, CME On Electro Physiologist Thiruvananthapuram, Kerala, Cme On Approach To Chest Pain Tellicherry, Kerala, Measles Immunisation Salem, Tamil Nadu, Aao Gaon Chale Chennaicity, Tamil Nadu, Awarenes On Cancer & Aids Chennaicity Tamil Nadu, , Eye Camp Bareilly, Uttar Pradesh, Blood Donation Camp Tellicherry, Kerala, World Austism Awareness Day Tellicherry, Kerala, Awareness On Gunaecology Thiruvananthapuram,Kerala, CME On Current Status In Management Of Dyslipidemia Chennaicity, Tamil Nadu, World Health Day Kancheepuram, Tamil Nadu, World Health Day Chennaicity, Tamil Nadu, CME On World Health Day Kancheepuram, Tamil Nadu, World Health Day Kancheepuram, Tamil Nadu, Orthopedic Knowledge Update Program: Osteoarthritis & Cardiovascular Co-morbidities - Management Of Disc Disease: Past, Present & Future Chennaicity, Tamil Nadu, Talk On Oligohydraminous Bukhtiarpur,Bihar, Test Chennaicity, Tamil Nadu, Cme On Update In Emergency Medicine Tellicherry, Kerala, Executive Meet Kunnamkulam, Kerala, Women’s Day Celebrations Patiala, Punjab, World Health Day Nizamabad, Andra Pradesh, Awareness Program On Who Day Bhavnagar, Gujarat, World Health Day Bhavnagar, Gujarat, World Hemophilia Day Mundargi, Karnataka, World Health Day Mysore, Karnataka, World Health Day Tellicherry, Kerala, Who Day Awareness Tellicherry, Kerala, Beat Diabetes Awareness Tellicherry, Kerala, Medical Camp Of Diabetes Thiruvananthapuram, Kerala, Cme On Diagnosis And Nomenclaturem Salem, Tamil Nadu, Awareness On Who Day Kancheepuram, Tamil Nadu, Kancheepuram, Public Awareness Program On Diabetes” Chennaicity, Tamil Nadu, Camp On Diabetic & Hypertensionmil Kancheepuram, Tamil Nadu, World Health Day Tuticorin, Tamil Nadu, Who Day Rally Chennaicity, Tamil Nadu, Speech On Parenting Bareilly, Uttar Pradesh, Who Day Celebrateakh Kashipur, Uttarakhand, Who Day Celebratenga South Calcutta, West Bengal, World Health Day Ludhiana, Punjab, World Heart Dayra Mumbai, Blood Donation Camp Salem, Tamil Nadu, Free Diabetic Camp Chennaicity, Tamil Nadu, Star Health For Special Children Chennaicity, Tamil Nadu, Cme On Gestational Diabetesmellitus Tuticorin, Tamil Nadu, Cme Chennaicity, Tamil Nadu, Launch Of Health Insurancer For Special Childern Kancheepuram, Tamil Nadu, World Health Day Mumbai, Maharashtra, Installation Of Incoming President And His Team

Chennaicity, Tamil Nadu, Camp On Diabetic Detection Chennaicity, Tamil Nadu, Cme On Iaoh Chennaicity, Tamil Nadu, Cme Program On World Health Day Chennaicity, Tamil Nadu, Cme Lecture Chennaicity, Tamil Nadu, Adolescent Advice Classes Chennaicity, Tamil Nadu, World Health Day Cme Programme Chennaicity, Tamil Nadu, World Health Day Chennaicity, Tamil Nadu, Program On Adolescent Problem Kancheepuram, Tamil Nadu, Cme On Liver Diseases In Pregnancy Kashipur, Uttarakhand, Special Meeting Virudhunagardist., Tamil Nadu, Blood Donation Camp Chennaicity, Tamil Nadu, National Hub For Health Care Instrumentation Development (Nhhid) Seminar Chennaicity, Tamil Nadu, Seminar On Health Care Instrument Development Chennaicity, Tamil Nadu, Instrumentation Seminar Mundargi, Karnataka, World Hemophilia Daya Mumbai, Maharashtra, CME On Diabetes Mumbai, Maharashtra, CME On Who Day Theme Diabetesami Salem, Tamil Nadu, Awareness Message On Haemophilia Day Sathyamangalam, Tamil Nadu, Bmd&Bmi Camp Virudhunagardist., Tamil Nadu, CME On Diabetology Salem, Tamil Nadu, CME On Management Of Spinal Injuries Salem, Tamil Nadu, Awareness Message In Heritage Day Nizamabad, Andra Pradesh, Awareness Program On World Liver Day Nizamabad, Andra Pradesh, Chali Vendram Programme Bhavnagar, Gujarat, World Cycle Day Bangalore, Karnataka, CME Salem, Tamil Nadu, Blood Donation Camp Kancheepuram, Tamil Nadu, CME On Vaccinology Kancheepuram, Tamil Nadu, CME Program On Vaccinology: Polio Vaccine Switch: Topv To Bopv - Update On Pneumococcal Vaccine Cancer Cervix & Hpv Vaccine Chennaicity, Tamil Nadu, Round Table Meet Chennaicity, Tamil Nadu, CII Health Summit 2016l Chennaicity, Tamil Nadu, CII - Tamil Nadu Health Summit 2016 Bangalore, Karnataka, CME Thiruvananthapuram, Kerala, CME On Diabetes Thiruvananthapuram, Kerala, CME On Ipv And Opv Switch Tellicherry, Kerala, Cme Introduction Of Idipv & Topv To B Opv Switch Tellicherry, Kerala, General Body Meetmil Nadu, Salem, Awarenss Messsage On Earth Day Go Green Salem, Tamil Nadu, Awareness Message On Book Day Mumbai, Maharashtra, CME On Cardiology Virudhunagardist., Tamil Nadu, Awareness Cap On Cancer Virudhunagardist., Tamil Nadu, Blood Donation Camp Salem, Tamil Nadu, Free Diabetic Awarness Camp Chennaicity, Tamil Nadu, CME On Management Of Acute Stroke Tuticorin, Tamil Nadu, CME On Obs & Gyn Kancheepuram, Tamil Nadu, Motivation Program For Medical College Durg, Chhattisgarh, World Malaria Day Bangalore, Karnataka, Summer Camp Mumbai, Maharashtra, Aao Gaon Chalen Salem, Tamil Nadu, Awareness Message On Malaria Day Nizamabad, Andra Pradesh, CME On Surgical And Medical Emergencies Related To Ortho Thiruvananthapuram, Kerala, CME On Medicolegal Aspects Sathyamangalam, Tamil Nadu, Camp On Cardiology Thiruvananthapuram, Kerala, CME On Clinical Approach And Management Of Polyarthritis Tellicherry, Kerala, Inauguration Of Tellicherry Chapter Of Chamber Of Commerce Thiruvananthapuram, Kerala, CME On Newer Vaccines Thiruvananthapuram, Kerala, CME On Abdominal Pain In Children Tellicherry, Kerala, Road Show InaugurationL NAD Sathyamangalam, Tamil Nadu, CME On Fever In Children Nizamabad,Andra Pradesh, Free Health Check-up Camp Bihar, Protest Rally Against Clinical Establishment Act Bangalore, Karnataka, CME On Nephrology,Urology And Infertility Thiruvananthapuram, Kerala, Cme On Pulmonary Rehabilitation In Copd Chennaicity, Tamil Nadu, 85% Saves Lives Campiaon Kashipur, Uttarakhand, Health Camp

Supplement 77

J INDIAN MED ASSOC, VOL 114, NO 5, MAY 2016

Do’s and Don’ts of Prescription writing

Introduction All of us write prescription daily. How many of us follow the guidelines? How many of us are aware of the fact that there are specifications for the size of the paper to be used. Every prescription should been certain patient details along with the doctor’s information too. Regarding medicines, the guideline says that they should be prescribed preferably by generic name. The dosage form, strength, instructions and total quantity of medicines and total duration should be legibly written. In case of computer generated prescriptions the doctor should sign as close as possible to the last drug mentioned. Minimum size of the prescription blank should be 14 x 21 cm. (A5 size).

Prescription Format Doctor’s (Prescriber’s) Full Name Qualification (eg.M.B.B.S., M.D.) Reg. No: (specify alphabets specifying pathy) Reg. No. Full Address, Contacts: (telephone no, email etc) D1

Prescription Serial Number Patient’s full Name Patient’s Address and Phone number Sex …….…. Age ….....… Weight ……...….. Rx 1) Name of Medicine , As far as possible, generic name in capital letters. Strength , dosage form dosage instruction , duration & total quantity 2) …….....………… “Or any other chapter generic medicine as per choice of patient.”

Date:…...........…….

D10

M3,

Doctor’s signature & date Doctors stamp

Dispensed By: Name and Address of Medical Store, Date of dispensing : If entire prescription is not dispensed, specify name or number of medicine and quantity dispensed. Name and Address of Medical Store, Date of dispensing :

A Guide to the Prescription Format Sr. Particulars No. D1 Doctors full name D2 Doctor’s Qualifications D3 Registration No.

D4 Address of doctor

D5 Contacts D6 Date of prescription

Sr. No.

D7 Doctor’s signature & date D8 Doctor’s Stamp D9 Prescription serial number D10 P1 Patient’s full name

Requirements & Necessities

As per the Rule 65 (10) prescription shall be signed by the person issuing it with her/his usual signature and, therefore, the prescription shall have full signature of prescriber with date. To authenticate prescription and also to avoid misuse of blank prescription and to protect patient from quacks and un-qualified doctors, the prescription should have doctor’s rubber stamp containing his full name, qualifications and registration number below his signature. For traceability and purposes of record the prescriptions must be serially numbered.

Rx-supercription As a matter of practice the prescription may bear Rx-supercription. As per Rule 65 (10), prescription shall specify the name and address of the, person for whose treatment it is given. P2 Patient’s full address As per Rule 65 (10), prescription shall specify the name and address of the person for whose treatment it is given. It is also essential for follow up of patient, or to get in touch with patient in case of dispensing or prescribing errors and also essential for recall of medicines, if required. Therefore, the prescription shall bear patients full address. P3 Patient’s sex As certain drugs are gender specific, sex of the patients should be mentioned on prescription. P4 Patient’s age The drug dosages may differ with age of patient and, therefore, prescription must bear patient’s age. P5 Patient’s weight The drug dosages may vary with weight of the patient, therefore, prescription may bear patients weight. M1 Name of the a) The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Medicine Regulation, 2002 under Indian Medical Council Act 1956 under Code of Medical Ethics at 1.5 prescribes as “Every physician should as far as possible prescribe drugs with Generic names and he/she shall ensure that there is a rational prescription and rational use of drug”. The name of medicine should be by generic name in capital letters in legible manner. b) If the prescriber is not sure about generic name he shall add following instructions on the prescription above her/his signature. “Or any other cheaper generic medicine as per choice of patient.” M2 Strength of drug Prescription shall invariably bear strength of the medicine. Eg. PARACETAMOL TABLETS 500 mg., Amoxicillin Capsules 250 mg. M3 Dosage from Prescription shall bear a proper dosage form of medicine prescribed.ego Tablets, Capsules Syrups, Creams etc. M4 Dosing instructions Prescriptions shall bear proper dosing instructions that could be easily understood by patient. M5 Total quantity of Prescription shall specify duration of the treatment and medicine and duration total quantity of the medicine for that duration. of medication. eg. Medicine 1 – 1 tab x 2 times a day for 7 days =14 tabs

General guidelines for Doctors / Prescriber

Requirements & Necessities It is statutory requirement to mention name of the prescriber on case or credit memo of the drugs under Rule 65(3) and it is also necessary to authenticate prescription. To know the competency and genuineness of prescribe, the prescription should bear Doctor’s primary qualification such as MBBS/BAMS followed by subsequent qualification. for eg MBBS, MD. Prescription shall bear the registration number of doctor’s registration with their respective council. The registration number should be prefixed with letters indicating the council in which doctor has registered her/his name. For example: Allo. (Allopathic), Intgrtd. (Integrated Medicine), Homeo. (Homeopathic), Dental (Dentist), Vet. (Veterinary), etc. It is statutory requirement to mention the address of the prescribe on the cash or credit memo of the drugs under Rule 65 (3) and the patient and pharmacist should know where the prescriber is practicing and, therefore, prescription shall bear complete address of clinic / hospital where the prescriber is practicing. The prescription shall have telephone number (Land line / Mobile) and e-mail of prescriber. These details will help patient as well as pharmacist to contact doctor, if required. As per the Rule 65 (10) prescription shall be dated. The date of prescription is also essential to know the validity of prescription and to avoid misuse of such prescription.

Particulars

1. 2. 3. 4. 5. 6. 7.

Changes in prescription: If any changes are warranted in prescription please issue fresh prescription. Do not use prescription pad with the name of medical store, Doctors should not use prescription pads, with pre-printed messages, like “Available at XYZ Medical Stores”. Do not print names of more than one doctor on the prescription. One should avoid having names of two or more doctors on the same prescription pad (even if it is a husband and wife team). Do not use prescription pad of another doctor. A doctor should not use another doctor’s prescription pad, even with her / his consent. Conversely a doctor should not allow other doctor to use her / his prescription pad. Precaution about computer generated prescription. If the doctor types or generates her / his full recognizable dated signature in ink. She / he must sign as close as possible to the last drug listed in the prescription. Prescription of certain medicines by specialist. Certain medicines can be supplied on the prescription by specific specialist only. For example, Sidenafil Citrate can Venerologist. Letrozole can be prescribed by a Cancer specialist only. Recognize the services of Pharmacist:- As per internationally recognized practice, especially followed in the developed world, doctors should recognize importance of services of pharmacist as they are required to supervise sale of medicines under the law and also responsible for counseling the patients. The pharmacist is trained to recognize therapeutic incompatibility, absorption incompatibility, etc of medicines in addition to various facets of pharmacological effects of medicine. In view of the above, the doctors should consider her / him as resource person and his / her view should be considered with due regard to her / his knowledge.

Dr. Jyoti Chauhan M.S.,FICMCH, Sagar (M.P.)

MAY 2016 JIMA Advertiser

POST BOX NO. 11249

JOURNAL OF THE INDIAN MEDICAL ASSOCIATION: IMA House, 53 Sir Nilratan Sarkar Sarani (Creek Row), Kolkata - 700 014 Phones: (033) 2236-0573, 2237-8092, Fax: (033) 2236-6437, E-mail : jima1930@rediffmail.com, Website: www.ejima.in ; www.ima-india.org, www.ima-india.org/ejima Head office: Indian Medical Association, IMA House, Indraprastha Marg, New Delhi - 110 002 Telephones: +91-11-2337 0009, 2337 8680, Fax: +91-11-2337 9470, 2337 0375, Telegram: INMEDICI, New Delhi - 110 002, Email: hsg@ima-india.org; Website: www.ima-india.org

MAY 2016

Regd. No. WBENG/2557/57

Date of Publication : 30th Every Month

If not delivered please return to Journal of the IMA (JIMA) IMA House, 53 Sir Nilratan Sarkar Sarani (Creek Row), Kolkata - 700 014 (India)

Published and Printed by Dr Santanu Sen on behalf of Indian Medical Association and printed at Prabaha, 45A, Raja Rammohan Roy Sarani, Kolkata 700009, Editor: Dr Debasish Mukherjee, National President (IMA): Dr SS Agarwal, Honorary Secretary General (IMA): Padma Shri Dr KK Aggarwal. E-mail: hsg@ima-india.org; Website: www.ima-india.org