Madurai Medical Journal Edito rial Board PATRONS
Dr. N. Sethuraman, M.S., M.Ch.(Uro), MNAMS.(Uro), FICS. FOUNDER CHAIRMAN
Dr. S. Gurushankar, M.B.B.S.
From the
Editor's Desk
VICE CHAIRMAN
BRECON 2009
ADVISORS
My dear friends,
Prof. Dr. V.N. Rajasekaran, Ph.D., M.D., DTM&H MEDICAL DIRECTOR
Prof. Dr. N. Krishnamurthy M.S., M.Ch.(Uro), D.H.&HM. BGL, M. Phil(Tamil), M.A(Phi&Rel) PGDIM., PGDHRM.
ACADEMIC DIRECTOR
EDITOR IN CHIEF
Dr. G. Amarnath, M.B.B.S., DMRT., MBA. MEMBERS
Dr. T.R. Murali, M.S., M.Ch.(Uro). Dr. Ramesh Ardhanari, M.S., M.Ch.(GE) Dr. K. Sampath Kumar, M.D., DNB., DM.(Nephro) Dr. A.R. Raghuram, M.S., M.Ch.(CTS), D.N.B., FIACS. Dr. M. Krishnan, M.D., D.A. Dr. P. Krishnamoorthi, M.D., FIAMS., FCGP., Dr. Indira Athappan, M.D., DGO. Dr. T. Mukuntharajan, M.B.B.S., DMRD. Dr. D. Meikandan, M.D., DCH., DM. (Neuro) Dr. N. Maharajan, M.D., DA. Dr. S. Balasubramanian, M.S.(Ortho), Dr. R. Sivakumar, M.D., DNB.(Cardio) Dr. S. Selvamani, DNB. (GM), DNB. (Cardio), Dr. S. Kumar, M.D. (Anaes), Dr. K. Selva Muthu Kumaran, M.Ch.(Neuro) Dr. S. Senthil Prabahar, M.D.(Derm) Dr. D.R. Nageswaran, M.B.B.S., DLO., DNB.
Greetings! I know many of you will be eagerly waiting to read my Column as I do get very excellent feedback on the various issues I single out to discuss. This gladdens my heart and over the years we have come to understand each other very well in addressing the common issues we face and that is what best we can do for our patient who has nobody but us to depend on in his hour of calamity. To commemorate the International woman's day on the 8th of March 2009 the Meenakshi Mission Hospital and Research Centre Madurai in involvement with the Association of Radiation Oncologists of India (Tamil Nadu and Puducherry Chapter) is organizing the 13th annual National Conference of the Breast Cancer Foundation 窶的ndia on the 7th and 8th of March 2009. Breast cancer is on the rise and has overhauled Cancer of the Uterine Cervix as the leading Cancer among the urban women population of the four metropolitan cities of India. This will gradually replicate on other cities in due course. Various experts in the field of Molecular Biology, Pathology, Imaging Sciences, Surgical, Medical and Radiation Oncology from across the various parts of the country are going to take part in the two days deliberations that is going to address various issues from recent advances in screening, cytogenetics, histopathology, Newer techniques in Imaging, Surgical, Medical and Radiation therapy apart from the Panel discussions on Management controversies in the Early, Locally advanced, and Metastatic Breast Cancer. One complete session is dedicated to the discussions on intriguing cases with audience's participation.
Dr. Narendra Nath Jena, M.B.B.S., DFM., PG. Diab., FAEM.
Free papers are welcome in the competitive section.
CO-ORDINATION & COMPILATION
We are also demonstrating Breast conservation Surgery with Breast implants for Brachytherapy in the workshop.
Mr. V.M. Pandiarajan, Sr.Manager - Marketing Mr. R. Saravanan, M.Sc., M.B.A., PGDFRM., Mr. P. Madhusudhanan, B.A., PGDHM.,PGDCA., M.B.A., PGDFRM., Mr. K. Siva Subramanian, B.Sc., PGDFRM.,
We have taken special care in outlining the scientific programme and have requested the speakers to address the issues that are practical in the Indian context apart from highlighting the recent advances. Kindly refer to the detailed programme overleaf.
EDITORIAL ADDRESS
Meenakshi Mission Hospital and Research Centre (Run by S.R. Trust) Lake Area, Melur Road, Madurai - 625 107 Tamilnadu, INDIA Phone : 0452 - 2588741 - 750, 4263000 Fax : 0452 - 2586353 E-mail : mmhrc@sancharnet.in Website : http://www.meenakshimission.org Thee Classic Printers, 27 Kakathope Street, Madurai - 625 001 & 0452 - 2323819, 2624466, 4381603
So at the end of the day even though I did not single out any specific issues for discussions as per the usual practice, I believe it is a greater pleasure and opportunity to welcome you all to BRECON 2009, and give us the gratification of once again in serving you with the best of things forever.
Dr. G. Amarnath Sr. Consultant - Radiation Oncologist, Editor in Chief - MMJ Mobile : 98421 24100 E-mail : amarnathmmhrc@rediffmail.com
Up coming events....
MEENAKSHI MISSION HOSPITAL AND RESEARCH CENTRE
XIII Annual National Conference of Breast Cancer Foundation - India 7th & 8th March, 2009
MADURAI
Venue
lin Hea
MMHRC
pa ssi on
Organised by
g
wi th C om are and C
In association with
Meenakshi Mission Hospital and Research Centre Conference Hall - I A/C Madurai, Tamilnadu
ASSOCIATION OF RADIATION ONCOLOGISTS OF INDIA TAMILNADU & PONDICHERRY CHAPTER
Breast Cancer Foundation - India
Faculty
President
Vice President
Dr. Sanjay Sharma
Dr. S. Parameshwaran
Secretary
Founder Secretary General
Dr. J.K. Singh
Dr. M.K. Mahajan
Joint Secretaries
Treasurer
Dr. Mohan Vamsy Dr. N. Gopinath
Dr. S. Jhaver
Dr. S. Alex. A. Prasad Dr. G. Amarnath Dr. Bagyam Dr. Balu David Dr. S. Bhoopal Dr. Devanand Dr. Elizabeth K. Abraham Dr. Ganapathy Ramanan Dr. P. Gangadharan Dr. Guhan Dr. T. Gunasagaran Dr. Hemanth Raj Dr. J. Jeba Singh Dr. K. Kallur Dr. G. Kilara Dr. K.S. Kirushna Kumar Dr. Mahadev Pothiraju Dr. B.K.C. Mohan Prasad Dr. P.K. Muthukumaraswamy Dr. Praful Desai Dr. Preeti Jain Dr. T. Raja Dr. R. Rajaram Dr. Rajkumar Dr. T. Rajkumar Dr. B.S. Ramesh Dr. Ranjan Mahapatra Dr. Ravishankar Dr. Rejiv Rajendranath Dr. Rohini Sridhar Dr. Sanjay Chandrashekar Dr. Sanjay Sharma Dr. T.K. Sarparajan Dr. K.S. Sekar Dr. V. Srinivasan Dr. Subhashini John Dr. J. Surendran Dr. S. Vasanthamalai Dr. Vijay Anand Reddy Dr. R. Vijaya Bhaskar
Editor
Dr. (Mrs.) Manisha Singh
Association of Radiation Oncologists of India Tamilnadu & Pondy Chapter President
Vice President
Dr. G. Amarnath
Dr. M. Nagarajan
Secretary
Joint Secretaries
Dr. S. Alex A. Prasad
Dr. R. Rathnadevi Dr. S. Balaji
Treasurer
Executive Committee
Dr. L. Padmanaban
Dr. R. Mohanram Dr. R. Subramaniam Dr. J. Surendran
Scientific Committee Dr. G. Amarnath Dr. S. Bhoopal Dr. Devanand Dr. J. Jebasingh Dr. K.S. Kirushnakumar Dr. B.K.C. Mohan Prasad
Dr. P.K. Muthukumaraswamy Dr. S. Parameshwaran Dr. Ramesh Dr. T.K. Sarparajan Dr. S. Vasanthamalai Dr. R. Vijayabhaskar
Organizing Committee - BRECON 2009 Dr. G. Amarnath
Dr. K.S. Kirushnakumar
Mobile : +91-98421 24100 E-mail : amarnathmmhrc@rediffmail.com
Mobile : +91-98421 13003 E-mail : drkskk@yahoo.com
Dr. J. Jebasingh Mobile : +91-94426 19775 E-mail : jjebasingh@gmail.com
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Chennai Madurai Chennai Kanchipuram Madurai Madurai Trivandrum Chennai Cochin Coimbatore Chennai Chennai Madurai Bangalore Bangalore Madurai Chennai Madurai Madurai Mumbai Patna Chennai Chennai Coimbatore Chennai Bangalore Chennai Tuticorin Chennai Madurai Chennai Mumbai Madurai Chennai Chennai Vellore Chennai Madurai Hyderabad Madurai
Programme 07-03-2009 Saturday 8 - 9 am
Registration / Breakfast
TIME 9 – 9.30 am
TOPIC
SPEAKER
Key Note Address
Dr. Praful Desai Professor Emeritus Tata Memorial Hospital Mumbai
9.30 – 9.45 am
Epidemiology in Breast Cancer
Dr. P. Gangadharan Amrita Institute of Medical Sciences, Cochin
9.45 – 10 am 10 – 10.15 am 10.15 – 10.30 am 10.30 – 10.45 am 10.45 – 11 am
Prognostics and Predictive Factors in Breast Cancer
Christian Medical College, Vellore
Dr. Subhashini John
Molecular Diagnostics in Breast Cancer
Cancer Institute, Chennai
Reporting Guidelines for Breast Cancer Pathology
RCC, Trivandrum
Digital Mammography Elastography
Apollo Specialty Hospitals, Chennai
PEM / PET. CT
Dr. K. Kallur
Dr. T. Rajkumar Dr. Elizabeth K.Abraham Dr. Bagyam
HCG, Bangalore
11.15 – 1.00 pm
Workshop on Breast Conservation Surgery – Brachytherapy Moderator Dr. B K C Mohan Prasad Madurai Medical College and GRH Madurai
Dr. Hemanth Raj Apollo Specialty Hospitals, Chennai Dr. R. Vijaya Bhaskar MMHRC Madurai Dr. T.K. Sarparajan Apollo Specialty Hospitals, Madurai Dr. K.S. Kirushna Kumar MMHRC Madurai Dr. V. Srinivasan Kamakshi Memorial Hospital Chennai
Early Breast Cancer 2 - 2-15 pm
Surgery
Dr. Hemanth Raj Apollo Specialty Hospital, Chennai
2-15 - 2-30 pm
IMRT
Dr. Vijay Anand Reddy Apollo Specialty Hospital, Hyderabad
2-30 - 2-45 pm
TARGIT and Brachytherapy
Dr. B.S. Ramesh Bangalore Institute of Oncology Bangalore
2-45 - 3 pm
Chemotherapy
Dr. T. Raja Apollo Specialty Hospitals, Chennai
3 – 3-15 pm
Targeted Therapy
Dr. S. Alex. A Prasad Chennai Cancer Care, Chennai
3-15 – 3-30 pm
Endocrine Therapy
Dr. Devanand Apollo Specialty Hospital, Madurai
3-30 – 3-45 pm
Meta analysis of RT
Dr. K.S. Kirushnakumar Meenakshi Mission Hospital and Research Centre, Madurai
3. 45 – 4 pm
Meta analysis of Systemic Therapy
Dr. J. Jeba Singh Meenakshi Mission Hospital and Research Centre, Madurai
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Programme 4 – 4.45 pm
Panel Discussion
Controversies in the Management of EBC
Dr. Sanjay Sharma, Chairperson Bombay / Lilavati Hospital, Mumbai
Dr. Ravishankar, Moderator Tuticorin Medical College, Tuticorin. Dr. B. K. C. Mohan Prasad Madurai Medical College, GRH Madurai
Dr. T. Gunasagaran Meenakshi University Chennai
Dr. P.K. Muthukumaraswamy Madurai Medical College, GRH Madurai
Dr. Vijay Anand Reddy Apollo Specialty Hospital, Hyderabad
Dr. S. Vasanthamalai Madurai Medical College, GRH Madurai
Dr. Rohini Sridhar Apollo Specialty Hospital Madurai
4.45 – 5-15 pm
Guidelines in EBC Management
Dr. Sanjay Sharma, Chairperson Bombay / Lilavati Hospital, Mumbai
Dr. B.K.C. Mohan Prasad, Moderator Madurai Medical College, GRH Madurai
Dr. Balu David Arignar Anna Cancer Institute Kanchipuram
Dr. T. Gunasagaran Meenakshi University Chennai
Dr. Ganapathy Ramanan Madras Cancer Care Foundation Chennai
5-15 - 6 pm 7 pm
General body meeting of Breast Cancer Foundation- India Inauguration / Cultural Programme
08-03-2009 Sunday 9- 10.15 am
Proffered Papers Locally Advanced Breast Cancer
10.30 – 10.45 am
Current Strategies of Care
10.45 – 11 am
Neoadjuvant CT
11 – 11.15 am
Surgery
Dr. K.S. Sekar Global Hospitals Chennai
Dr. P.K. Muthukumaraswamy Madurai Medical College, GRH Madurai
Dr. R. Vijaya Bhaskar Meenakshi Mission Hospital and Research Centre, Madurai
11.15 – 11.30 am
Breast Reconstruction
Dr. B.K.C. Mohan Prasad Madurai Medical College GRH, Madurai
11.30 – 11.45 am
Radiation Therapy
Dr. Mahadev Pothiraju
11.45 – 12 noon
Meta Analysis of Systemic Therapy
Apollo Specialty Hospitals, Chennai
Dr. Guhan Sri Ramakrishna Institute of Oncology Coimbatore
12 Noon-12-15 pm
Inflammatory Breast Cancer
Dr. V. Srinivasan Kamakshi Memorial Hospital Chennai
12-15- 12 –25 pm
Assessment of Nodal Status in Breast Cancer Dr. T. Gunasagaran Meenakshi University Chennai
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Programme 12 -25- 1-15 pm
Panel discussion
Dr. G. Kilara
Controversies in the Management of LABC
Curie Institute of Oncology Bangalore Dr. G. Amarnath MMHRC Madurai
Dr. R. Rajaram Royapettah Hospital, Chennai
Dr. Gopinath Bangalore Institute of Oncology Bangalore
Dr. Rajkumar GKNM Coimbatore Dr. Rohini Sridhar Apollo Specialty Hospital, Madurai
Metastatic Breast Cancer 2 – 2.15 pm
Hormone Response and Non Response Disease Cyber Knife in Metastatic Breast Cancer
2.15 – 2.30 pm
Dr. Rejiv Rajendranath Cancer Institute Chennai
Dr. Sanjay Chandrashekar Apollo Specialty Hospitals, Chennai
2.30 – 2.45 pm
Radiation Therapy in Bone Metastasis
Dr. J. Surendran Kamakshi Memorial Hospital, Chennai
2.45 – 3.00 pm
Young Woman with Breast Cancer Treatment Strategies, Fertility issues and Pregnancy Case Discussions
3 - 4 pm
R E G IS T R A T IO N F O R M 1 3 th A n n u a l N a tio n a l C o n feren ce o f B rea st C a n cer F o u n d a tio n – In d ia 7 th a n d 8 th M a rch 2 0 0 9 N am e… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … ..
Dr. Preeti Jain Mahaveer Cancer Samsthan Patna Dr. Sanjay Sharma, Chairperson Bombay / Lilavati Hospital, Mumbai Dr. Ganapathy Ramanan, Speaker Madras Cancer Care Foundation, Chennai
Registration Details
D ele gate P o stgrad u ate
(C ertificate fro m H O D to b e en clo sed )
Student
Rs. 600
Delegate
Rs.1200
M ailin g A d d ress: … … … … … … … … … … … … … … … … … … … … … … … … … …
C ity… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … P in … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .. T elep h o n e… … … … … … … … … … … … … . H o sp ital… … … … … … … … … … … … … M o b ile… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … . E -m ail… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .. V e g.
N o n . V e g.
A cco m m o d atio n req u ire d
Y es
No
R egistratio n F ees… … … … … … … … … … … … … … … … P .G .S tu d en t… … … … … … … … … … … … … … (C ertificate fro m H O D ) A cco m m o d atio n (1 d a y ren t) in ad v an c e T o tal R s… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … . P A Y M E N T D E T A IL S E n clo sed D D /C h eq u e fo r R s… … … … … … … … … … .C h eq u e/D D N o … … … … … … … … D ated … … … … … … … … … … … … … … … … … B an k … … … … … … … … … … … … … … .. (D em an d D raft fav o rin g B R E C O N 2 0 0 9 p a yab le at M ad u rai) (A d d R s. 3 0 fo r o u t statio n ch eq u es) C o m p leted fo rm to b e se n t to C o n feren c e S ec retariat BR EC O N – 2009 D ep t. o f R a d ia tio n O n co lo g y M e e n a k sh i M issio n H o sp ita l a n d R e se ar c h C e n tr e L a k e A r e a , M e lu r R o a d , M a d u r ai – 6 2 5 1 0 7 , T am il N a d u E -m ail: m m h rc b r ec o n 2 0 09 @ re d iffm a il.c om
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Welcome to All
MMJ - February
REVIEW ARTICLE
Dr. K.V. Karthikeyan
Dr. K. Selvamuthukumaran
M.Ch. (Neuro)
M.Ch. (Neuro)
Consultant Dept. of Neuro Surgery
Sr. Consultant Dept. of Neuro Surgery
Abstract Meningiomas are the most common benign tumors of brain.
Olfactory Groove Meningioma
Meningiomas arising from the olfactory groove at the basifrontal region is 8% of all meningiomas. Because of its skull base location and the surrounding major neuro vascular structures, total removals of these tumors require sound anatomical knowledge and meticulous neurosurgical techniques. Here we present such an interesting case.
Key Words Meningioma - Olfactory groove Falx cerebri- Duroplasty
INTRODUCTION
A 45 yr old female from west Bengal came with complaints of Headache for 2 months duration, Vomiting on and off with recent onset memory disturbance with occasional behavioral disturbance. On examination: Patient is conscious , oriented obeying. Higher mental function examination showed to be very abulic and withdrawn. She had difficulty in registration and recalling with retained past memories. Speech was normal. Frontal lobar function examination was found to be defective. Patient had anosmia in both nostrils with bilateral papilloedema. Other cranial nerves found to be normal. Spino motor system was normal. Patient came with Computed Tomography (CT) scan brain, which showed a well-defined contrast-enhancing lesion in the anterior skull base more from the left side crossing to opposite side with mass effect. Magnetic Resonance Imaging (MRI) T1, T2 with Gadolinium contrast shows well circumscribed, uniformly contrast enhancing lesion in anterior skull base attaching to cribriform plate lifting the frontal lobe and with dural tail. Provisionally diagnosed as olfactory groove meningioma. Patient was planned for elective tumor removal via anterior skull base approach. Anterior sub frontal approach was planned (2). Patient was positioned supine with brow up position so that the frontal lobe will fall away from field to minimize brain retraction. A bicoronal skin incision was made and flap raised. 8 burr holes were placed and single free bone flap was raised across the midline. Superior sagittal sinus was protected. Both the frontal air sinuses were cranialised so that the base could be reached easily. Dural hitches taken all around. Then dura was opened on either
CORRESPONDING AUTHORS
Dr. K.V. Karthikeyan
Dr. K. Selvamuthukumaran
M.Ch. (Neuro)
Consultant, Dept. of Neuro Surgery Meenakshi Mission Hospital and Research Centre Madurai - 625 107 Phone : 91 452 2588741 Mobile : 98400 92818 E-Mail : doctorkuk@yahoo.co.in
M.Ch. (Neuro)
Sr. Consultant, Dept. of Neuro Surgery Meenakshi Mission Hospital and Research Centre Madurai - 625 107 Phone : 91 452 2588741 Mobile : 98943 56498 E-Mail : neuroselva73@yahoo.co.in
6
MMJ - February
side in the base and reflected. Left frontal lobe was retracted gently and the CSF was let out. Only a part of the tumor was seen and was crossing to the opposite side behind the falx.
Fig 3. Single free bone flap raised across the midline and Sagittal sinus is protected
To gain access to the tumor the anterior part of Sagittal sinus was ligated and cut. Then the falx was cut opened and the tumor was reached. Arachnoid dissection was made and tumor was separated from the adjacent frontal lobe. There was firm attachment to the basal dura. Tumor was slowly detached from the dura by cauterization so that the tumor was devascularised. Because most of the supply was from the basal dura mainly by the ethmoidal vessels (6). Then tumor debulking was done with loop cautery and removed in piece meal. Both the optic nerves were preserved. Olfactory tract on left side could not be preserved because of tumor infiltration. At the posterior end of the tumor the ACA was identified and separated and also the perforators to the hypothalamus. Tumor was removed in total and dura was found to be attached to tumor not infiltrated by it, so dura was not removed. Hemostasis was achieved and dural closure was done with pericranium in watertight fashion. Bone was replaced and fixed. Wound closed in layers. The procedure lasted for 8 hours.
Fig 4. Dura opened at the base
FALX CEREBRI
Fig 1. Contrast MRI axial section showing well circumscribed uniformly enhancing lesion at the frontal base
Fig 5. Dura opened on both sides and the both frontal air sinus have been cranialised Sagittal Sinus
Tumor
Fig 6. Single bone flap replaced and fixed after the procedure
Fig 2. Contrast MRI coronal showing lesion arising from the frontal base at olfactory groove 7
MMJ - February
Irritation : By irritating the underlying cortex, meningiomas can cause seizures. New-onset seizures in adults justify neuroimaging (eg, MRI) to exclude the possibility of an intracranial neoplasm.
No Tumor
Fig 7. Post operative CT scan showing total removal of the lesion
Compression: Localized or nonspecific headaches are common. Compression of the underlying brain can give rise to focal or more generalized cerebral dysfunction, as evinced by focal weakness, dysphasia, apathy, and/or somnolence. Stereotypic symptoms: Meningiomas in specific locations may give rise to the stereotyped symptoms listed in the Table. These stereotypical symptoms are not pathognomonic of meningiomas in these locations; they may occur with other c o n d i t i o n s o r l e s i o n s. C o nve r s e l y, meningiomas in these locations may remain asymptomatic or produce other unlisted symptoms.
Postoperative period was uneventful. And patient slowly improved and her symptoms also improved over next 10 days. Postoperative scan showed total removal of the lesion with the area was filled with CSF. Patent was discharged at 10 th day and after one month she was doing well.
Specifically olfactory groove meningiomas produce Anosmia with possible ipsilateral optic atrophy and contralateral papilledema (this triad termed Kennedy-Foster syndrome) (3)
Discussion Meningiomas may occur intracranially or within the spinal canal. They are thought to arise from arachnoidal cap cells, which reside in the arachnoid layer covering the surface of the brain. Meningiomas commonly are found at the surface of the brain, either over the convexity or at the skull base. In rare cases, meningiomas occur in an intraventricular or intraosseous location. The problem of classifying meningioma is that arachnoidal cells may express both mesenchymal and epithelial characteristics. Other mesodermal structures also may give rise to similar tumors (eg, hemangiopericytomas or sarcomas). The classification of all of these tumors together is controversial. The current trend is to separate unequivocal meningiomas from other less welldefined neoplasms. Undoubtedly, advances in molecular biology will allow scientists to determine the exact genomic aberration responsible for each specific neoplasm.
Management is usually surgical and the surgical strategies for managing olfactory groove meningiomas are : To avoid undue retraction of the frontal lobes, these tumors are best approached through a low craniotomy. This is achieved by removing the supraorbital rim. A unilateral approach is usually sufficient. The midline burr hole should be placed just above the front nasal suture. By entering the frontal sinus and removing the orbital rim, a low approach is provided. To allow adequate visualization, the falx should be sectioned after ligating the most anterior aspect of the SSS. Every attempt should be made to preserve at least one of the olfactory nerves. These tumors receive their blood supply through various sources: the ethmoidal branches of the ophthalmic arteries, branches from the middle meningeal artery, and the carotid arteries. These tumors often invade the ethmoid sinuses and, at times, the sphenoid sinus.
Meningiomas produce their symptoms by several mechanisms. They may cause symptoms by irritating the underlying cortex, compressing the brain or the cranial nerves, producing hyperostosis and/or invading the overlying soft tissues, or inducing vascular injuries to the brain. The signs and symptoms secondary to meningiomas may appear or become exacerbated during pregnancy but usually abate or improve in the postpartum period.
Care should be taken to identify and preserve both optic nerves. Note that the usual relationship between the optic nerves and the 8
MMJ - February
A, Swiatkowska K, Sakowski J, Patrzyk R, Zwoliński J, Prudlak E. Przegl Lek. 2007;64(9):601-5. Polish. PMID: 18510084 [PubMed - indexed for MEDLINE]
carotid arteries might not hold true owing to displacement of these vital structures by tumor.
4. [Operative treatment of anterior cranial base meningiomas] Nowak A, Marchel A. Neurol Neurochir Pol. 2006 Nov-Dec;40(6):484-92. Polish. PMID: 17199174 [PubMed - indexed for MEDLINE]
Tumor arterial supply and perforator arteries to the hypothalamus must be differentiated because both arise from the anterior circulation. There are various approaches to the anterior skull base (4).
5. Giant olfactory meningiomas: the pterional approach and its relevance for minimizing surgical morbidity. d'Avella D, Salpietro FM, Alafaci C, Tomasello F. Skull Base Surg. 1999;9(1):23-31. PMID: 17171078 [PubMed - in process]
A. Anterior subfrontal, B. Lateral subfrontal C. Pterional (5) D. Endoscopic Trans nasal removal (1)
6. Anterior ethmoidal artery: microsurgical anatomy and t e c h n i c a l c o n s i d e r a t i o n s . W h i t e D V, S i n c o f f E H , A b d u l r a u f S I . Neurosurgery. 2005 Apr;56(2 Suppl):406-10; discussion 406-10. PMID: 15794837 [PubMed - indexed for MEDLINE]
Simpson's grading for Meningioma surgery and recurrence;
Source of support - Nil Conflict of Interest - None declared
Grade I - Complete removal of tumor along with involved dura and bone Grade II - Complete tumor removal with coagulation of dural attachment
Congratulations...
Grade III - Complete tumor removal without resection or coagulation of attachment Grade IV - Subtotal tumor removal Grade V - Tumor decompression Recurrence rates for Grade I- 9%; II- 19%; III – 29%; IV – 39%; V- 49 % Role of stereo tactic radiosurgery for small meningiomas in Inaccessible regions are gaining importance. But they are at very earlier stages. Embolisation of the feeding arteries can be useful prior surgery for highly vascular lesions to reduce the vascularity.
NATIONAL AWARD
Conclusion Olfactory groove meningiomas are easy to diagnose but require sound anatomical knowledge and microsurgical technique to remove it totally without any residual deficit. Hence we presented such an interesting case here.
Ramnad Branch of Indian Academic of Paediatrics was given a National Award. Regarding this Dr. Sethuraman said, "By giving a sweet salt mixture to a child with diarrhoea the child could be saved from diarrhoea and prevent its after effects. This award was presented for creating all awareness in the whole district.
References 1. Endoscopic transnasal resection of anterior cranial fossa meningiomas. de Divitiis E, Esposito F, Cappabianca P, Cavallo LM, de Divitiis O, Esposito I. Neurosurg Focus. 2008;25(6):E8. PMID: 19035705 [PubMed - in process]
The Chairman of Indian Space Research Organization (ISRO) Sri. Madhavan Nair presided over the meeting on January 22nd at Bangalore during the 46th Annual National Conference.
2. Giant olfactory groove meningioma: ophthalmological and cognitive outcome after bifrontal microsurgical approach. Gazzeri R, Galarza M, Gazzeri G. Acta Neurochir (Wien). 2008 Nov;150(11):1117-25; discussion 1126. Epub 2008 Oct 21. PMID: 18936875 [PubMed - indexed for MEDLINE] 3. [Meningiomas of the anterior cranial fossa: clinical and radiological presentation--report of 2 cases]Plucińska I, Całka K, Jaźwiec P, Bojarski B, Czerniewicz-Kamińska
This award was presented to the president of the Ramnad District Branch. Dr. T.S. Sethuraman by the Dr. Deepak Ukra president of the All India Paediatric Association.
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MMJ - February
REVIEW ARTICLE
Dr. N. Srivatsa
Dr. Venugopal Konanki
Dr. R. Ravichandran
M.S., D.N.B. (Gen. Surg), D.N.B. (Uro)
M.S., DNB. (Uro)
M.S., DNB. (Uro)
M.S., M.Ch. (Uro)
Resident Dept. of Andrology & Urology
Consultant Dept. of Andrology & Urology
Sr. Consultant Dept. of Andrology & Urology
Sr. Consultant and Head Dept. of Andrology & Urology
Abstract Voiding Dysfunction (VD) is a common problem accounting for as much as 40% of paediatric urological problems in our country. VD presents as Day time wetting. Most of these disorders start as functional and remain so for variable periods of time before resulting in structural damage. However, most of these disorders are missed resulting in long term morbidity. The challenge for the clinician is to differentiate a pathologic pattern of urgency / incontinence due to an underlying urologic disorder from benign conditions related to incomplete or abnormal toilet training. A careful, compassionate approach is more than sufficient to treat many of these children. Synonyms and Related Keywords Voiding Dysfunction, Overactive Bladder, Detrusor Instability, Functional Voiding Disorder, Infantile Bladder, Hinman-Allen Syndrome, Detrusor HyperReflexia, Urinary Tract Infection, Sexual Abuse.
Dr. T.R. Murali
Voiding Dysfunction INTRODUCTION
Case 1 8 year old, otherwise healthy female child, presented to our clinic with complaints of daytime incontinence. She had no history of other Lower Urinary Tract Symptoms (LUTS) or fever. She had attained full bladder control at the age of 4 years. There was no apparent cause for anxiety in this child. Careful evaluation of her history revealed sexual abuse by a house servant. Counselling of the child and to her parents were all that was necessary to cure this child. No medications were ever necessary. Case 2 7 year old female child, staying with her mother was brought to our clinic with the complaints of increased frequency of micturition, once in 15 to 20 minutes. Her teachers in school were upset and thought she was feigning her symptoms. Refusal to permit her to use the bathroom so often resulted in wetting of her dress. She felt humiliated and her scholastic performance had dropped. She had no other LUTS/fever. She had been partially evaluated for Urinary tract infection (UTI) and treated empirically as UTI without much benefit. Detailed evaluation revealed that the child was concerned not being with her father and though she liked her mother, she was afraid of her for being strict. Repeated sessions of counselling and psychotherapy and ensuring that father was with her till she recovered led to successful cure of this condition. We had to employ anti-cholinergic agents in her for a brief period to reinforce her confidence. She is now off medications and doing well. CORRESPONDING AUTHOR
Dr. R. Ravichandran
M.S., DNB. (Uro)
Sr. Consultant, Dept. of Andrology & Urology Meenakshi Mission Hospital and Research Centre Madurai - 625 107 Phone : 91 452 2588741 Mobile : 94426 48266 E-Mail : drravi99@rediffmail.com
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Case 3
2. Dysfunction of Pelvic Floor muscles – DYSFUNCTIONAL VOIDING 3. Decreased Force of Detrusor Contraction – UNDERACTIVE BLADDER
9 years old girl, playful, and with normal developmental milestones was referred to us with recurrent culture documented UTI. She had attained full bladder control at the age of 4 and half years of age. Detailed history revealed that being very playful; she postponed her voiding till last minute, sometimes leaking before she reached the bathroom. There was also history of constipation which was being treated with laxatives by the referring paediatrician. Urinary culture at our centre was also positive. We treated the infection and evaluated her with a Urodynameic Evaluation (UDE) Voiding Cystourethrography (VCUG) and cystoscopy. There was no reflux. However, the bladder was trabeculated and she had high voiding pressures with an in-coordinate sphincter. She has been since then started on skeletal smooth muscle relaxants, α-blockers and behavioural therapy for retraining her voiding pattern. She will require long term pharmacotherapy. Failure to comply might result in permanent bladder damage and probably renal failure.
Evaluation Commences with a detailed & structured assessment of clinical history, a focused physical examination and a urine analysis. A bladder scan, Post Void Residual Urine assessment and Uroflow-EMG help in establishing the diagnosis. Further tests like evaluation of the upper tracts, VCUG and Urodynamic evaluation are indicated in some selected cases. History is always obtained from both the child and parents/caretakers. The history should take into account, the peri-natal history, developmental milestones, child's mental status like attentiveness, toilet training process, family issues, history of any possibility of sexual abuse and current voiding & bowel regimen. History of medications and family history of bowel and voiding issues should be obtained.
These are samples from a myriad of spectrum of voiding disorders we encounter in our centre on a daily basis.
Physical examination should rule out spinal Dysraphism (sacral tuft of hair, dermal vascular malformations in spinal region, sacral dimples, lipomeningocele, and absence of gluteal cleft with flattened buttocks). Neurological examination to assess the muscle power, deep tendon reflexes, perineal sensation, gait and co-ordination are necessary.
Definition Voiding dysfunction is due to an underlying neurologic, anatomic, infectious or functional basis. The hallmark symptoms of VD are Urgency, Frequency and Incontinence. It usually presents as day time wetting in a child who had previously gained full bladder control or in a child aged 4 years or more. Incidence: Overall rates range from 1% – 10%. The incidence of VD in children aged 6 years or more is 2% to 4%. (1)
Local examination should exclude labial adhesions in girls, meatal stenosis and phimosis in boys. Rashes in genital region or perineum must be ruled out. Voiding symptoms may be Transient, Intermittent or Persistent.
Sex Prevalence Is more common in females than males (7% Vs 3%). (1)
Transient symptoms may last for a few days and are commonly a result of non specific urethritis or periurethral irritation due to vaginitis or UTI. It may also be due to local factors like detergents, mechanical or chemical irritation from urine – soaked underclothes or tight undergarments.
Impact These children may experience severe social and emotional problems due to VD VD significantly affects quality of life Increases the risk of UTIs Delays the resolution of Vesico Ureteric Reflux (VUR), if present Extreme cases of functional voiding disorders may cause permanent renal damage.
Persistent Voiding Symptoms are usually a result of structural defects like ectopic ureters. Intermittent Voiding symptoms classically fit into the definition of VD. OVERACTIVE BLADDER (OAB) (2,4) results from uninhibited Detrusor contractions during filling phase of the bladder and reflects as Urgency & Urge Incontinence. There is usually no increased
Causes 1. Uninhibited Detr usor Contractions – OVERACTIVE BLADDER (OAB) 11
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frequency of micturition, pain abdomen or fever, differentiating it from UTI. The child may try to avoid leaks by various manoeuvres like standing on tiptoes, crossing legs or squatting with heels pressed into the perineum.
intra-vesical voiding pressures, incomplete voiding, dilatation of the upper tracts and rarely, renal damage. These patients require detailed urological evaluation. Underactive Bladder Syndrome (Lazy bladder), results when there is infrequent voiding (3 or less voids/24 Hours) with abdominal straining. It may be a variant of normal voiding pattern. Urological evaluation is necessary.
OAB results from lack of inhibitory cerebral control over Detrusor contractions during filling phase. Causes include maturation delay, prolongation of infantile bladder behaviour or abnormal toilet training habits.
Other causes of day time wetting are Vaginal reflux Labial adhesions Ectopic ureters Possibility of sexual abuse/ mental trauma Occult neuropathic dysfunction Intense concentration on playing or watching Television
If OAB has a neurological component, then it is an organic disorder and is termed to as Detrusor Hyperreflexia. OAB can cause UTIs or can occur as a result of recurrent UTIs. OAB can contribute to the persistence of Vesico-Ureteric Reflux (VUR) or its recurrence after Ureteric re-implantation. When OAB is associated with constipation, it is termed to as Dysfunctional Elimination Syndrome. It may be due to direct effect of retained fecal material distending the recto-sigmoid colon or due to shared neural input.
Further evaluation Urodynamic Evaluation (UDE) is necessary in select cases to rule our neurologic onlay to VD. UDE is an Invasive test. It is carried out in cases with high index of suspicion. Indications include 1. Suspected neurological abnormality 2. Nocturnal enuresis 3. Pubertal child 4. VD associated with fecal incontinence 5. Recurrent UTIs 6. Persistent symptoms after treating UTI 7. Bladder trabeculations 8. Sphincter activity on VCUG 9. Small capacity bladder 10. Detrusor hyper reflexia 11. Non- neurogenic neurogenic bladder A few UDE tracings are depicted below.
Giggle Incontinence (2) is occurrence of involuntary complete bladder emptying induced by laughter. It typically occurs in children aged 5 – 7 years. The voiding pattern is otherwise normal. It is not a form of stress incontinence or due to a lax external urethral sphincter. Etiology is not known. It usually resolves spontaneously with age. Dysfunctional Voiding is not synonymous with VD. This entity is one of the most severe types of VD. It results from failure of co-ordinated relaxation of urethra and pelvic floor muscles during voiding. If associated with a neurologic abnormality, it is referred to as Detrusor Sphincter Dys-synergia. Exact aetiology is unknown. It is thought to result from deviation of normal development of urinary control. Infants employ pelvic withholding manoeuvres to prevent urinary leakage and slowly gain day time control. Such manoeuvres are unnecessary once day time bladder control is achieved. If these manoeuvres persist, they become involuntary and result in Dysfunctional Voiding. The most common attributable cause found is Overtraining of bladder. Undue premature parental pressure on the infant to gain bladder control is hence to be discouraged. The ideal time to start toilet training is 18 months of age.
Fig. 1 UROFLOW EMG NORMAL
Dysfunctional Voiding presents from mild to severe forms. Severe forms are progressive and may mimic neurogenic bladder or anatomic bladder outlet obstruction. Children with this disorder have high 12
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Fig. 2 UROFLOW EMG - +VE SPINCTER ACTIVITY Fig.6 UDE- Lazy Bladder
MRI of the spine may be indicated in very select cases with stigmata of neurologic abnormalities. Treatment Overactive Bladder (OAB) The goal of treatment of OAB is to foster the development of cerebral inhibition of Detrusor contractions during bladder filling so that urgency and urge incontinence do not occur. No known medication or procedure can accomplish this. Several approaches to address the issue include Bladder retraining program (most important tool in the treatment) Supportive anti-cholinergic medications till bladder is retrained and Fig. 4 Prophylactic antibiotics when appropriately indicated. UDE More than 75% children have full resolution of OVERACTIVE symptoms within a 3 month intense treatment protocol BLADDER of bladder re-training. Constipation should be addressed to whenever present on priority basis. Vaginal Reflux Teaching proper voiding technique Reverse sitting position on commode Upright position over commode after voiding. Labial Adhesion Fig. 5 Labial separation UDE Bland petroleum jelly DYSFUNCTIONAL Estrogen cream VOIDING Local inflammation and infection should be attended to. Fig. 3 UDE NORMAL
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Dysfunctional Voiding (3) Is the most worrisome disorder Similar pattern to neurogenic bladder or BOO. Severe cases are called non-neurogenic neurogenic bladder (Hinman – Allen syndrome) (7) Bladder retraining programme and Biofeedback therapies are the cornerstones of treatment. Kegel exercises help in relaxation of pelvic floor muscles. Severe forms of the disorder may necessitate Suppressive antibiotics Anti-cholinergics and clean intermittent catheterization(CIC) Alpha blockers Botulinum – A toxin injection Neuromodulation Bladder Augmentation
Prognosis Most uncomplicated cases of VD resolve spontaneously or with appropriate clinician support. A 14% per annum spontaneous resolution rate has been reported in most series. Recurrence of symptoms in adulthood is a common feature in children with OAB. Management of adult OAB is relatively easier. The prognosis is guarded in those few children with Dysfunctional Voiding who do not respond to appropriate intervention. Such children end up with end stage renal disease. Patient education The foundation of treatment of VD lies in educating the child and parents about the disorder and in effecting a successful biofeedback therapy, especially in children with Dysfunctional Voiding Syndrome (6).
Underactive Bladder Syndrome Timed voiding CIC in resistant cases
After note VD is more common in prevalence than we clinically estimate. All clinicians should have a compassionate and open mind to the approach of these problems. Successes of treatment of these disorders lie in counselling, appropriate medications as and when necessary and prompt urological & psychologist referrals when deemed necessary.
Urological consultation 1. Suspicious neurological or anatomic etiology 2. Not responding to behavioral modification 3. Constant continuous incontinence 4. Recurrent UTI 5. Vesico Ureteral Reflux (VUR) 6. Suspected renal damage Complications
References 1.
Persistence of day time wetting may markedly disrupt the social lives of older children and negatively affect the self esteem. Drop in scholastic performance with failure of drive to perform well or indulge in extracurricular activities will have long term impact on adult life of such children. Repeated wetting episodes may result in skin irritation and rashes with superseded secondary bacterial & fungal infections. Recurrent UTIs however remain the most burning complication of VD. Persistence of VUR may negatively affect the growth of the child (5). Renal damage is a rare but a dreaded complication of VD. Since VD is functional, all efforts must be made to prevent renal damage in such children.
2.
3.
4. 5.
6.
7.
Hellerstein S, et al. Outcome of overactive bladder in children. Clin pediatr(phila). Jul-aug200; 42(6):553-6. Chandra M et al. Giggle incontinence in children: A manifestation of Detrusor instability. J Urol. Nov 200; 168(5):2184-87. Cain MP et al. Alpha blocker therapy in patients with Dysfunctional voiding and urinary retention. J Urol. Oct 2003; 170(4-2):1514-15. Greenfield SP. The overactive bladder in childhood. J Urol. Feb 2000; 163(2): 578-9. McKenna PH et al. Voiding Dysfunction associated with incontinence, Vesico ureteral reflux and recurrent urinary tract infections in children. Curr opin Urol. Nov 2000; 10(6):599-606. McKenna PH et al. Pelvic floor muscle retraining for pediatric voiding dysfunction using interactive biofeedback. J Urol. Sep 1999; 162(3):1056-62. Valram DE et al. non-Neurogenic Bladder and chronic renal insufficiency in childhood. Pediatr Nephrol. Feb 1995; 9(1):1-5.
Source of support - Nil Conflict of Interest - None declared
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REVIEW ARTICLE
Dr. Shankar Hippargi M.B.B.S., FAEM.
Jr. Consultant Dept. of Accident & Emergency Medicine
Abstract Cardiac arrest has been a fatal emergency of all times. Despite considerable efforts to improve the treatment of cardiac arrest, most reported survival outcome figures are poor. We did a retrospective study on revival of
A Retrospective Study on Revival of Cardiac Arrests in the Department of Accident and Emergency Medicine
cardiac arrests in our Emergency Department (ED), which showed astonishing outcomes and some interesting facts.
Key words Cardiac arrest survival, CardioPulmonary Resuscitation (CPR), American Heart Association (AHA), In-hospital cardiac arrest, reversible causes of cardiac arrest.
INTRODUCTION
Cardiac arrest has been a fatal emergency of all times. Each day thousands of people are stricken by cardiac arrest, and unfortunately more than 95% of them die even before they reach the hospital (1). The patients who manage to reach the hospital will die in the emergency departments because of the lack of training of the emergency room physicians in handling cardiac arrests. Despite considerable efforts to improve the treatment of cardiac arrest, most reported survival outcome figures are poor. Background When people suffer cardiac arrest, their life and death is defined in six minutes. These are the most crucial minutes of their life and
if not managed effectively, these six minutes may be the last six minutes of their life, hence “Time lost is, life lost.� Managing a cardiac arrest is a biggest challenge for any physician. Training programs in handling cardiac arrest (Advanced Cardiac Life Support ) are not very popular in India, as in the western world and no wonder the results are much poor. Studies on witnessed CORRESPONDING AUTHOR
Dr. Shankar Hippargi
M.B.B.S., FAEM.
Jr. Consultant, Dept. of Accident & Emergency Medicine Meenakshi Mission Hospital and Research Centre Madurai - 625 107 Phone : 91 452 2588741 Mobile : 97904 47214 E-Mail : drshank@rediffmail.com
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cardiac arrests done worldwide show an initial revival rate of about 44-54% (2).
Distribution 73% (33) were medical cases, 20% (9) were trauma and 7% (3) were surgical.
Study We did a retrospective study on the revival of patients in cardiac arrest in the Department of Accident and Emergency Medicine of Meenakshi Mission Hospital and Research Center- Madurai and found some interesting facts. Even though our results were much better than the developed nations and our patients had a very satisfying recovery it may be too early to comment on this, in view of the small number of patients in this study. The details of this study are as follows Study method : Retrospective study Study period : 1 year ( Feb 2008 to Jan 2009 ) Study set up : Department of Accident & Emergency Medicine- MMHRC No. of patients : 45
The first rhythm during cardiac arrest is an important indicator for the final outcome of patient. The survival till discharge was much higher in patients whose initial rhythm was ventricular fibrillation (VF) and ventricular tachycardia (VT), whereas patients with asystole and pulseless electrical activity (PEA) had poor outcomes, especially PEA cases, where we had 3 cases but none of them had ROSC in ED (Fig.2).
Inclusion criteria All cardiac arrests in the ED All witnessed cardiac arrests brought to our ED Unwitnessed cardiac arrests, who had a detectable cardiac rhythm on arrival Exclusion criteria Unwitnessed cardiac arrests who are in asystole on arrival Patients in respiratory arrest (gasping) with a palpable pulse Important definitions (3) Cardiac arrest: Cardiac arrest is defined as cessation of cardiac mechanical activity, confirmed by the absence of a detectable pulse, unresponsiveness and apnoea. Witnessed cardiac arrest: A witnessed cardiac arrest is one that is seen or heard by another person or an arrest that is monitored.
The duration of resuscitation has a significant effect on the outcome of resuscitation. In our study the average duration of resuscitation was 28.22 min (range 5min- 110min). The duration of resuscitation was more in some patients who had recurrent arrests in ED. The average duration of resuscitation in patients who survived till discharge was 26.5 min (5min- 35min). In our study we found that patients receiving CPR for more than 35min did not survive. The two most important intervals affecting patient survival are collapse-to-first CPR interval and collapse-to-first defibrillation interval. Every minute delay in defibrillating a patient from VT/VF, reduces his chances of survival by 7 to 10% (1), hence
Return of spontaneous circulation (ROSC):
ROSC is defined as continuous presence of palpable pulses for more than 20 minutes following resuscitation. We included 45 patients in our study who met the inclusion criteria and others were excluded from the study. Of the 45 cardiac arrests; 39 were in ED, 1 in radiotherapy Out Patient Department (OPD), 1 in thread mill test room, 2 in radiology department and 2 were out of hospital arrests. All were witnessed cardiac arrests. 16
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“Time is life”. Maximum number of DC shocks given during resuscitation in a patient who survived till discharge was 10 shocks of 200J each (Biphasic). Discussion Reviving a patient from cardiac arrest is like bringing a dead patient back to life again and this gives the greatest pleasure and utmost satisfaction to any physician. We followed the ACLS 2005 guidelines given by the American Heart Association for resuscitating our patients and found it to be very effective, as evidenced by our results. Cardiopulmonary resuscitation (CPR) if done appropriately gives very satisfying results. Cardiac arrest in elderly Cardiac arrest in elderly population had some motivating findings in our study (Fig.3). Cardiac arrest in trauma On contrary to MI, cardiac arrest in trauma had grave prognosis (Fig. 4) Most of the patients involved in trauma belonged to younger age groups and had multiple injuries. Most of these patients presented to emergency department with shock and respiratory failure and went into cardiac arrest in the ED. Even after maximum efforts, interventions (intubation, intercostal drainage tube insertion, pericardiocentesis) and blood transfusion; only 4 out of 9 patients could be revived in ED but unfortunately none survived till discharged (Fig. 4). All most all the patients who died in ED had significant thoracic injury with uncontrollable internal hemorrhage and even though they reached us in the “Golden Hour” they could not be revived with best possible efforts. Hence blunt thoracic injury was the leading cause of trauma related deaths in ED.
The most common cause of cardiac in elderly was myocardial infarction (MI), there was no other associated cause. 81.25% (13 out of 16) of MI related cardiac arrests were revived in ED and 54% (7 out of 13) survived till discharge. All these patients came with acute MI, had cardiac arrest in ED where they were resuscitated successfully and shifted immediately to cardiac catheterization lab, where they underwent percutaneous transluminal coronary angioplasty (PTCA) by our interventional cardiologists. All the 7 patients recovered well and went home walking on their own feet even though all these patients had multiple co-morbidities (Fig.4). These figures are astonishing and inspirational, hence age and co-morbidities should not be the criteria in terminating resuscitation efforts in any patient. Cardiac arrest in patients with younger age groups
Cardiac arrest secondary to hypovolemic (Hemorrhagic) shock following road traffic accident is most difficult to treat and it's a real challenge for any emergency physician. Reversible causes of cardiac arrest One of the key factors of our high revival rate of cardiac arrest patients is addressing and correcting all reversible causes of cardiac arrest during or immediately after resuscitation. The reversible causes of cardiac arrest are as follows
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v v v v v v v
Hypoxia Hyperkalemia Hypokalemia H+ ion (Acidosis) Hypovolemia Hypoglycemia Hypothermia
v v v v
Tamponade (cardiac) Tension pneumothorax Tablets / Toxins Thrombosis Myocardial infarction Pulmonary embolism
Simple bedside investigations such as arterial blood gas analysis, glucometer sugar, a 12-lead electrocardiogram and a brief history and rapid clinical eximination can rule out or rule in the most probable causes of cardiac arrest and giving a rapid correction can reverse the cardiac arrest. In most of the cases we address and correct all these reversible causes of cardiac arrest before we terminate our resuscitation efforts. This is the most important key for our soaring success rate (Fig.5).
Conclusion Cardiac arrest is an expected event in a hospital set up The type of arrest is highly predictive of survival rather than age and co-morbidities Cardiac arrest in trauma has the worst prognosis Survival from cardiac arrest is an useful measure of performance of the emergency department The standard of care given in our emergency department is on par with international standards There is no substitute for a dedicated team work Cardiac arrest is not the end of life, it's a new beginning…
One more important reversible cause of cardiac arrest not mentioned in the ACLS guidelines is “ANAPHYLAXIS”. We had one such case who had anaphylaxis, bronchospasm and respiratory arrest, followed by cardiac arrest, which was revived successfully in our ED, and patient went home walking after 5 days.
Aknowledgements Dr Narendra Nath Jena (Consultant, Emergency Department) and the Emergency Department staff Dr Sanjay Manoj Joseph (CRRI) for presenting this study in Annual Clinical Society Meeting at MMHRC, which won the second prize Mr Rakesh Saroj (Biostatician), for helping mein data analysis Intensive Respiratory Care Unit staff All the Doctors of MMHRC family for making our efforts count. References Team work: Reviving a patient from cardiac arrest is a team work, hence having a well trained team and an able team leader is an invaluable asset for any hospital. Our department has a well trained nursing and paramedic team, where everyone knows their roles and responsibilities and they work in good coordanation during such an event. Because of this team work, we were able to maintain consistency in reviving cardiac arrests throughout the year (Fig.6)
1) http://www.americanheart.org/presenter.jhtml?identifier=448 accessed on 20-2-2009 2) American Journal of Critical Care. 2007; 16: 240-247 3) Cummins RO, Chamberlain D, Hazinski MF, et al. Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation Resuscitation Councils of Southern Africa. Resuscitation. 1997;34:151–183
Source of support - Nil Conflict of Interest - None declared
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Letters to the Editor
Dr. A.R. Raghuram M.S., M.Ch. D.N.B., FIACS.
Cardio Thoracic Surgeon
professionals in the United States. Billions more are spent in the provision of free samples and direct-toconsumer advertising. The gifts, however,are not really “free.” Even small gifts can influence physicians' behavior; they may help to create a mindset of entitlement among doctors and may promote allegiance to companies seeking to sell products (2).
Sir, Physician – Industry Relationship is degenerating into a nexus in recent times with resultant detrimental patient service. Unnecessary drugs are prescribed for extraneous non-medical reasons. Regrettably medical representatives have taken the role of teachers for some doctors regarding new developments in drugs! The awe and respect that a doctor used to command in the society is no longer in evidence. Our profession, once held as a noble one, is now equated with business. The latest issue of New England Journal of Medicine carries an article on this relationship and is printed below with due permission from the concerned Journal.
Increasingly, industry giveaways are under attack and subject to a growing number of bans and restrictions, including voluntary measures and legal requirements. The Association of American Medical Colleges (AAMC), for instance, has urged all medical schools and teaching hospitals to adopt by July 1, 2009, policies prohibiting physicians, faculty or staff members, residents, and students from accepting any industry gifts, including industry-supplied food and meals unrelated to accredited continuing medical education (CME) programs. According to the AAMC guidelines, “industry-supplied food and meals are considered personal gifts and will not be permitted or accepted within academic medical centers" (3). The association's standards cover gifts from equipment and service providers as well as those from the pharmaceutical and medical device industries and apply regardless of whether gifts or meals are provided at the institution or another site. Perhaps one quarter to one third of medical schools — andsome health care delivery organizations — have implemented such policies, and more are likely to adopt them soon.
Physician–Industry Relations — Will Fewer Gifts Make a Difference? Source: The New England Journal of Medicine Vol 360 Pages 557-559 Pub date 5-2-2009 Author Robert Steinbrook, M.D. Downloaded from www.nejm.org by Arani Raghuram Mch (CTS) on February 11, 2009. Copyright © 2009 Massachusetts Medical Society. All rights reserved. Reproduced with permission from the Publishing division of the Massachusetts Medical Society. The most common industry payments to physicians have taken the form of gifts, such as meals, tickets to sporting or cultural events, and pens, mugs, and other tchotchkes that prominently feature the names of companies or their products (1).
In response to widespread criticism and to forestall further restrictions and regulation, the leading trade associations of the pharmaceutical and medical device industries have revised their voluntary codes of conduct on interactions with health care professionals. The codes call for the prohibition of some gifts, such as stethoscopes, noneducational
Although some physicians decline gifts from industry, meals and other goodies are an important component of the approximately $7 billion that drug companies spend annually on promotion to medical 19
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promotional products, tickets, entertainment, and recreation, and for the restriction but not the elimination of others, such as meals. The revised code of the Pharmaceutical Research and Manufacturers of America (PhRMA)took effect in January 2009, and all 32 member companies have adopted it (4). The revised code of the Advanced Medical Technology Association (AdvaMed) takes effect in July 2009.5 Both codes apply only in the United States and encourage but do not require external verification of compliance. Not all the provisions are new; for example, PhRMA's previous code banned tickets, entertainment, recreation, and trips, but AdvaMed's did not. The Biotechnology Industry Organization, another prominent trade association, has so far not adopted a comparable code.
Code of Medical Ethics, which states that gifts accepted by physicians “should primarily entail a benefit to patients and should not be of substantial value,” also defined as $100 or less. The association's code considers “permissible” gifts of minimal value, such as pens and notepads, as long as they “are related to the physician's work,” as well as gifts such as textbooks and modest meals “if they serve a genuine educational function.” The academic medical centers and other o r g a n i z a t i o n s t h a t f o l l ow t h e A A M C ' s recommendations will make many changes that go beyond the industry's codes. In addition to prohibiting the provision of all industry supplied food and other gifts, these institutions will restrict sales representatives' access to physicians, initiate central management of the distribution of pharmaceutical samples, “strongly” discourage participation by faculty members in industrysponsored speakers' bureaus, limit commercial support of CME activities, and ban ghostwriting of professional presentations (3 ).
According to PhRMA, the provision of pens, notepads, mugs, and other promotional items of small value that remind doctors of a company's name or product “may foster misperceptions that company interactions with healthcare professionals are not based on informing them about medical and scientific issues.” 4 Sales representatives can no longer provide such items or “dine-and-dash” meals (meals eaten without a company representative being present), take-out meals, or restaurant meals.
In Massachusetts, a cost-containment law that takes effect in July 2009 mandates reforms of industry conduct. The law bans some gifts to physicians from pharmaceutical and medical device manufacturers, restricts others, and requires the online disclosure of fees, payments, or subsidies “with a value of at least $50” related to sales and marketing activities. The state's Department of Public Health is establishing a marketing code of conduct for these companies that will be at least as strict as the PhRMA and AdvaMed codes; companies must adopt and comply with the new state code. After the regulations take effect, fines of up to $5,000 will be charged for each violation. According to the department, “six other states and the District of Columbia set requirements on these industries, but none are as strong or comprehensive as the proposed Massachusetts regulations.” The major controversy in Massachusetts is whether the state will require disclosure of consulting fees and research grants or only paymentsrelated to sales and marketing. Physician–industry relationships are in flux, and furtherchanges and new state and federal laws and regulations are likely As a result of the revised codes, more doctors are likely to buy their own pens, mugs, and stethoscopes— and their own lunch. Nonetheless, the extent to which gifts of food and other items will actually decrease will not be known for some time. Terms such as “occasional” and
The only prohibitions in the current codes are on the provision of entertainment, recreation, and items unrelated to either medical education or practice. Sales representatives can still provide “modest” and “occasional” meals in office or hospital settings in connection with informational presentations — qualifications meant to ensure that the provision of any meal “is merely incidental to a substantive interaction with a healthcare professional.” 4 Industry-sponsored restaurant meals are still allowed for meetings with company employees other than sales representatives or for events involving a presentation by a physician. And “occasional” gifts of educational items are still permitted as long they are “not of substantial value ($100 or less)” and have no value to physicians outside the health care setting. Thus, giving a physician a DVD or CD player is “not appropriate,” even if the player might be used to provide patient education, whereas it is permissible to give a textbook, a subscription to a medical journal, or an anatomical model for use in an examination room. The industry codes are similar but not identical to the provisions of the American Medical Association's 20
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5. Advanced Medical Technology Association. Code of ethics on interactions with healthcare professionals. Revised December 2008. (Accessed January 16, 2009, at http:// www. advamed. org / MemberPortal/About/ code/.)
“modest” are open to interpretation. And the gifts of food and educational items that are still allowed could influence physicians' behavior and benefit industry. It is also uncertain whether the provision of fewer gifts will lead to a decrease in overall spending on professional promotion or will merely shift spending to other sales and marketing activities. Dr. Steinbrook (rsteinbrook@attglobal.net) is a national correspondent for the Journal.
Copyright © 2009 Massachusetts Medical Society.
Readers to kindly make a note of The Editor in Chief of the Madurai Medical Journal (MMJ) invites Readers views on the above subject. Editors view in the next issue of MMJ after analyzing Readers rejoinder on the subject in debate.
References 1. Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician–industry relationships Engl J Med 2007; 356:1742-50. 2. Brennan TA, Rothman DJ, Blank L, et al. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA 2006; 295:429-33. 3. Industry funding of medical education: report of an AAMC task force. Washington, DC: Association of American Medical Colleges, June 2008. (Accessed January 16, 2009, at http://www.aamc.org/ industry funding.) 4. Pharmaceutical Research and Manufacturers of America. Code on interactions with healthcare professionals. Revised July 2008.(Accessed January 16, 2009, at http://www. Phrma.org/code on interactions with healthcare professionals/.)
Also read para 8 under General News for Supreme Courts observations.
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s w e N l a r e GGeenneral News The Bench said “This is necessary to avoid harassment to doctors who may not ultimately be found to be negligent. We further warn police officials not to arrest or harass doctors unless the facts clearly come within the parameters laid down by the apex court in Jacob Mathew's case; otherwise, the policemen will themselves have to face legal action.”
Doctor can't be held liable for error of judgment New Delhi: A doctor cannot straightway be held liable for medical negligence simply because a patient has not favourably responded to treatment or surgery has failed, the Supreme Court has held.
The Bench said “While this court has no sympathy for doctors who are negligent, it must also be said that frivolous complaints against doctors have increased by leaps and bounds particularly after the medical profession was placed within the purview of the Consumer Protection Act.”
A Bench consisting of Justices Markandey Katju and R.M. Lodha on Tuesday said: “A medical practitioner is not liable to be held negligent simply because things went wrong from a mischance or misadventure or through an error of judgment in choosing one reasonable course of treatment in preference to another. He would be liable only where his conduct fell below the standards of a reasonably compe)tent practitioner in his field.”
The Bench said “The courts and consumer fora are not experts in medical science and must not substitute their own views for that of specialists. It is true that the medical profession has to an extent become commercialised and there are many doctors who depart from the Hippocratic oath for their selfish ends of making money. However, the entire medical fraternity cannot be blamed or branded as lacking in integrity or competence just because of some bad apples.”
The Bench set aside an order passed by the National Consumer Disputes Redress Commission, which held Dr. Martin F. D'Souza of the Nanavati Hospital, Mumbai, guilty of negligence on a complaint from Mohd Ishfaq, who was treated for renal and severe urinary tract infection.
Sometimes despite the best effort, the treatment of a doctor failed, the Bench said. “For instance, sometimes despite the best effort of a surgeon, the patient dies. That does not mean that the doctor or the surgeon must be held guilty of medical negligence, unless there is some strong evidence to suggest that he is. On the facts of this particular case, we are of the opinion that the appellant [Martin F. D'Souza] was not guilty of medical negligence.
Writing the judgment, Justice Katju said: “While doctors who cause death or agony due to medical negligence should certainly be penalised, it must also be remembered that like all professionals doctors too can make errors of judgment, but if they are punished for this no doctor can practise his vocation with equanimity. Indiscriminate proceedings and decisions against doctors are counter-productive and serve society no good. They inhibit the free exercise of judgment by a professional in a particular situation.”
Family Wel i h s k a n come to Mee
Therefore, whenever complaints were received against a doctor or hospital, the consumer forum or criminal court, before issuing notice, should first refer the matter to a competent doctor or a committee of doctors, specialising in the field where negligence was attributed. Only after that doctor or committee “reports that there is a prima facie case of medical negligence should notice be issued to the doctor/hospital concerned.”
Dr. M. Palanisamy M.D. (Gen. Med)
Consultant Dept. of Medicine
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MMJ - February
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MMJ - February
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Doctor's Diary
MMHRC wishes the following couple a Happy and Prosperous wedded life
Selvi. J. Sugapratha
( A Page to serve)
Contact The Editor Madurai Medical Journal Meenakshi Mission Hospital and Research Centre Lake Area, Melur Road, Madurai - 625 107
Selvan Er. A.B. Anand
Wanted.... A duty Medical Officer for 40 bedded Hospital at Karur Duty : 8 Hours / Day Salary Rs. 20,000/Free Accommodation
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Contact
33, Muthu Nagar, Karur - 639 002 Mobile : 99525 51199, 99525 54499 Phone : 04324 - 235499, 648069
The Director
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MMHRC expresses its deepest condolence for the demise of
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D/o. Dr. S. Jagadeesan, Bagavathi Hospital, Madurai and
Date 15-2-2009
26, Ramanujam Nagar, Kovai Road, Karur - 639 002 Phone : 04324 - 231597 E-mail : amaravathi_karur@sancharnet.in Fax : 04324 - 231222
MBBS
AKC Hospital, Tanjore
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Mr. A.M. Thangaraj
A 200 beds mission hospital needs the following specialists. Physician, M.D., Gynaecologist, DGO., or M.D., (Gynaec) Junior Medical Officer, MBBS
F/o. Dr. T. Mukuntharajan MBBS., DMRD. Senior Consultant Meenakshi Mission Hospital, Madurai
Attractive Salary with free quarters Contact
Mr. V.M. Oysul Karunai
The Administrator
F/o. Dr. Jibreel Oysul, BDS. Junior Consultant Meenakshi Mission Hospital, Madurai
Leonard Hospital Batlagundu - 624 202, Dindigul Dist. Tamilnadu Phone : 04543 - 265256, 262041, 262340
23
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MMJ - February
MEDICAL FACULTY ACCIDENT & EMERGENCY MEDICINE Consultant - Dr. Narendra Nath Jena, M.B.B.S., DFM., PG. Diab.,FAEM.,
Jr. Consultant -
Dr. H. Shankar, M.B.B.S., FAEM.,
ANDROLOGY & UROLOGY Dr. T.R. Murali, M.S., M.Ch.(Uro), Sr. Consultant - Dr. R. Ravichandran, M.S., DNB.(Uro), Consultant - Dr. Venugopal Konanki, M.S., DNB.(Uro), Sr. Consultant -
ANAESTHESIOLOGY Sr. Consultant - Dr. M. Krishnan, M.D., D.A., Sr. Consultant - Dr. S. Abdul Samath Jawahar, M.D.(Anaes.) D.A.,
Sr. Consultant Sr. Consultant Consultant Consultant Consultant Consultant Jr. Consultant Registrar
-
Registrar Registrar Registrar
-
Dr. K.S. Anand, M.D., (Anaes) Dr. N. Maharajan, M.D., D.A., Dr. Nancy A. Francis, M.B.B.S., D.A., Dr. I. Joseph Raajesh, M.D., Dr. Kannan, D.A., DNB., Dr. K.M. Senthilkumar, D.A., DNB., Dr. J. Ananth, M.D., (Anaes) Dr. B. Manikandan, M.B.B.S., D.A., Dr. M. Geethanjali, M.D., (Anaes) Dr. J. Rajesh, M.B.B.S., D.A., Dr. V. Poornima, M.B.B.S., D.A.,
OBSTETRICS AND GYNAECOLOGY E.N.T. SURGERY Consultant - Dr. D.R. Nageswaran, M.B.B.S., DNB., DLO., Hony. Director - Dr. R. Bhuvaneshwari, M.D., DGO., Registrar - Dr. O.R. Vishnu Prasanna, M.B.B.S., DLO., Sr. Consultant - Dr. S. Padma, M.D., DNB. (O&G), Consultant - Dr. Mahalakshmi Sivakumar, FEMALE INFERTILITY M.B.B.S., DGO., DNB., Sr. Consultant - Dr. Indira Athappan, M.D. (OG), Jr. Consultant - Dr. P. Pallavi, DGO., DNB.(O&G), GASTROENTEROLOGY Registrat - Dr. M. Heerabanu, M.B.B.S., DNB. (O&G) SURGICAL Sr. Consultant - Dr. Ramesh Ardhanari, M.S., M.Ch.(GE), ONCOLOGY Jr. Consultant - Dr. N. Mohan, M.S., DNB., MEDICAL ONCOLOGY Hon. Visiting MEDICAL Dr. J Jebasingh, M.D. (RT),DM.(Onco), Consultant - Dr. S. Devi Prasad, M.D., DM. (GE), Consultant HAEMATOLOGY Sr. Consultant -
Dr. P. Krishnamoorthi, M.D., FIAMS., FCGP.,
IMAGING SCIENCES Hon. Consultant - Dr. N.S. Mani, M.B.B.S., M.D., DMRD., Sr. Consultant - Dr. T. Mukuntharajan, M.B.B.S., DMRD., Consultant - Dr. N. Karunakaran, DMRD., DNB., Jr. Consultant - Dr. R. Ganesh, DMRD., DNB., INTENSIVE RESPIRATORY CARE UNIT Sr. Consultant - Dr. K.S. Anand, M.D., (Anaes)
RADIATION ONCOLOGY Sr. Consultant - Dr. K.S. Kirushna Kumar, M.B.B.S., M.D., Sr. Consultant - Dr. G. Amarnath, M.B.B.S., DMRT., MBA., SURGICAL ONCOLOGY Consultant - Dr. R. Vijaya Bhaskar, M.S., M.Ch. (Surg. Onco) Consultant - Dr. O.L. Sadasivam, M.S., FICS., Registrar - Dr. K.R. Gunaseelan, M.S., OPHTHALMOLOGY Sr. Consultant - Dr. N. Sirish Kumar, M.D., DNB., FRCS. (Ophthal) Registrar - Dr. Janaki, M.B.B.S., D.O., Registrar - Dr. Vijaya Natarajan, M.B.B.S., DNB (Ophthal)
CARDIOLOGY Lab Service & Quality - Dr. R. Sivakumar, M.D., DNB. (Cardio) CMO - Dr. Annsbal Dsouza Sekar, M.B.B.S., - Dr. S. Selvamani, DNB.(GM), DNB.(Cardio) - Dr. M. Sampathkumar, M.D., DM. (Cardio) MEDICINE ORTHOPAEDICS SURGERY - Dr. N. Ganesan, M.D.,D.M.(Cardio) Sr. - Consultant - Prof. V.N. Rajasekaran, Ph.D., M.D., DTM&H Sr. Consultant - Dr. P. Krishnamoorthi, M.D., FIAMS., FCGP., Sr. Consultant - Dr. M. Muthusamy, M.S., D.Ortho., Sr. Consultant - Dr. V. Sathya Narayana, M.S., Consultant - Dr. M. Palanisamy, M.D., D.Ortho, DNB., CARDIAC ANAESTHESIOLOGY Consultant - Dr. V. Rama Krishnan, M.S., (Ortho) Consultant - Dr. P. Purushothaman, M.D., Sr.Consultant - Dr. S. Kumar, M.D., Registrar - Dr. R.M. Kalirajan, M.B.B.S., DNB., FCGP., Jr. Consultant - Dr. R. Purusothamam Lal, Jr.Consultant - Dr. K. Balamurugan, M.B.B.S.,D.A., DNB M.B.B.S., D.Ortho., DNB.
Sr. Consultant Sr.Consultant Sr.Consultant Hon. Visiting Consultant
MICROBIOLOGY CARDIO THORACIC SURGERY Hon. Visiting - Dr. K. Padmini, M.D., Sr. Consultant - Dr. A.R. Raghuram, M.S., M.Ch., DNB.,FIACS., Consultant Consultant - Dr. R.M. Krishnan, M.S., DNB., M.Ch.(CTS) NEPHROLOGY Sr. Consultant - Dr. K. Sampath Kumar, M.D., DNB., DM.(Nephro), Registrar - Dr. M. Ramakrishnan, M.D., DNB., (Nephro), COUNSELLING & PSYCHIATRY Consultant - Dr. M. Karthikeyan, M.D., (Psychiatry) NEUROLOGY Visiting - Dr. D. Meikandan, M.D., DCH., DM (Neuro) DENTAL SURGERY Consultant Hon.Visiting - Dr. M.R. Gnaneswaran, M.D.S., Consultant - Dr. T.C. Vijay Anand, M.D., DNB. (Neuro) Consultant Jr. Consultant - Dr. Jibreel Oysul, B.D.S., MBA., Registrar - Dr. J. Kavitha, B.D.S., NEURO SURGERY Sr. Consultant - Dr. K. Selva Muthu Kumaran, M.Ch., (Neuro) DERMATOLOGY Consultant - Dr. K.V. Karthikeyan, M.Ch., (Neuro) Sr. Consultant - Dr. S. Senthil Prabahar, M.D., (Derm) D.D., DIABETOLOGY Consultant
-
Dr. S. Ravikumar, M.B.B.S., F. Diab.,
NUCLEAR MEDICINE Consultant
- Dr. M.S. Senthilnathan, M.D., (Nuc.Med)
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PAEDIATRICS Sr. Consultant - Dr. A. Kannan, M.D., Registrar - Dr. Uma Muralidharan, M.B.B.S., DCH., PAIN CLINIC Sr. Consultant - Dr. M. Krishnan, M.D., D.A., PATHOLOGY Hon. Visiting - Dr. Sivakami Saravanan, M.D.,
Consultant
PLASTIC SURGERY Sr. Consultant - Dr. N. Panchavarnam, M.S., M.Ch., Hon. Visiting - Dr. P. Sureshkumar, M.S., M.Ch.,
Consultant
SPINE SURGERY Sr. Consultan - Dr. S. Balasubramanian, M.S., (Ortho) Chief Spine Surgeon
MMJ - February
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