JUNE-2012

JUNE-2012

(1)

JUNE-2012

(2)

JUNE-2012

(3)

JUNE-2012

(4)

JUNE-2012

(5)

JUNE-2012

(6)

JUNE-2012

(7)

&217(176 (GLWRULDO ◆ (QYLURQPHQWDQGKXPDQKHDOWK²6XELU*DQJXO\  2ULJLQDOVDQG3DSHUV ◆ 6ZLQHIOX+1LQIOXHQ]D DZDUHQHVVSURILOHRIYLVLWRUVRIVZLQHIOXVFUHHQLQJERRWKV LQ%HOJDXPFLW\.DUQDWDND²5*9LYHNL$%+DODSSDQDYDU063DWLO $9-RVKL3UDYHHQD*XQDJL0UV 6XQDQGD%+DONL  ◆ 5HSURGXFWLYHWUDFWLQIHFWLRQDQGKHDOWKVHHNLQJEHKDYLRXURIHOLJLEOHFRXSOHV²DQDSSUDLVDO ²%DLMD\DQWL%DXU$QLPD+DOGDU6DQNDU1DWK-KD5XQD%DO0ULQDO.DQWL.XQGX $UDWL%LVZDV/LQD%DQG\RSDGK\D\  ◆ 0HDVXUHPHQWRIILUVWUD\RIIRRWZLWKUHIHUHQFHWRKDOOX[YDOJXV²'HHSDN6+RZDOH .DQDNODWD9,\HU-LJHVK96KDK  ◆ 7KUHH\HDUVDXGLWRIWKHHPHUJHQF\SDWLHQWVLQWKHGHSDUWPHQWRI(17RIDUXUDOPHGLFDOFROOHJH ²'HEDVLV%DUPDQ6DWDGDO0DQGDO6DLOHVZDU*RVZDPL5DEL+HPEUDP  6SHFLDO$UWLFOH ◆ 3ULPDU\SHUFXWDQHRXVFRURQDU\LQWHUYHQWLRQYHUVXVSKDUPDFRLQYDVLYHVWUDWHJ\ ²6DURM0DQGDO'KLPDQ.DKDOL 3UHOLPLQDU\5HSRUWV ◆ $SSOLFDWLRQRIDPQLRWLFPHPEUDQHWUDQVSODQWDWLRQLQFDVHVRIV\PEOHSKDURQ²$PLW33DWHO 'LSDOL56DWDQL6KZHWDPEDUL6LQJK6KDFKL'HVDL  ◆ &HOOEORFNF\WRORJ\LQSOHXUDOHIIXVLRQ²,QGUDQDWK*KRVK6XELU.XPDU'H\$QMDQ'DV 'HERM\RWL%KDWWDFKDUMHH6XELU*DQJRSDGK\D\  ◆ 6WXG\RIPXWDWHGSSURWHLQE\LPPXQRKLVWRFKHPLVWU\LQXURWKHOLDOQHRSODVPRIXULQDU\EODGGHU ²$QDGL5R\FKRZGKXU\5DQMDQ.U'H\$QMDOL%DQG\DSDGK\D\3DODVK%KDWWDFKDU\D 5LWD%DVX0LWUD5LMX'XWWD  ◆ )RUHLJQERGLHVLQEURQFKXV²\HDUVH[SHULHQFHDW,3*0( 5.RONDWD²6XGLS.XPDU'DV %LNUDPMLW6LQJK$UXQDEKD6HQJXSWD  &DVH1RWHV ◆ +HUSHV]RVWHUPLVWDNHQIRUUDGLFXORSDWK\DQGEDFNSDLQ²3UDJ\D$1DLU  ◆ 3ULPDU\QRQ+RGJNLQ VO\PSKRPDRIEUHDVWZLWKVFDOSLQYROYHPHQWLQIROORZXS ²DQXQFRPPRQSUHVHQWDWLRQ²6DQWRVK.XPDU0RQGDO6RXPLWD*KRVK6HQJXSWD 6KLEDVLVK%KDWWDFKDU\D6ZDSDQ.XPDU6LQKD  ◆ 7XEHUFXORVLVRIWKHJDOOEODGGHUFOLQLFDOO\PLPLFNLQJFDUFLQRPD²DFDVHUHSRUW ²6DQJHHWD6KDUPD5DQL%DQVDO1LYHVK$JUDZDO$QMDOL.KDUH99%KDURVD\  ◆ *DVWURLQWHVWLQDOVWURPDOWXPRXU²DFDVHUHSRUW²65$JDVKH333DWLO0$3KDQVRSNDU $VODP6KLYDQL6+.XONDUQL  ◆ 6FKPLGWV\QGURPH²DUDUHSRO\HQGRFULQRSDWK\²'HEDSUDVDG&KDNUDEDUWL .VKLWLVK0DOOLN$PULW.%KDWWDFKDU\\D  $VVRFLDWLRQ1RWH,0$+4 

JUNE-2012

(8)

Editorial Environment and human health

T

he importance of environment on human health has been well recognised since the days of the industrial revolution. The industrial revolution era began in the late 18th and early 19th centuries first, it started in Britain and then spread to other nations. It was a revolutionary change as it led to an entirely new method of how work was done. There were now several factories with complex machines manufacturing all kinds of products under what is called mass production; large industrial cities with new jobs that caused people to move in large numbers looking for employment; the transportation system was revolutionised through use of steam-powered machines (fuelled by coal) giving rise to trains, steam ships and also the invention of cars. As factories and business enterprises grew in large numbers in a given location, this led to the rise and growth of cities as people moved from the rural areas into urban areas in search of jobs. The industrial revolution created an industrial society where the living conditions were much better than that of living in the rural society. There was an increase in the availability of food, clothing and shelter, healthcare, educational opportunities and better wages. The mass production of productions caused prices to drop, making products once only available to the rich to be now affordable to the poor. However, in spite of the technological and socio-economic advancement during this era through mechanisation of agriculture, factories and transportation system, it also gave rise to dreadful sanitary and public health conditions in which people had to live and work. The explosion in urban growth created unforeseen sanitary and public health problems that was a result of overcrowded cities. This dense population of people living in cities caused the widespread occurrence of diseases such as tuberculosis (TB) and cholera thus, creating epidemics especially among the poorer class. This small example beautifully illustrates the importance of caring for the environment in conjunction with rapid industrial development if human health has to be preserved. Even at the present day and age, multiple lines of evidence suggest that environmental problems can have a substantial impact on human health. Unsafe water supply, sanitation and hygiene are responsible for 3% of all deaths worldwide. But the poorest developing countries are the worst affected; 99% of these deaths occur in developing countries and 90% of those dying are children. At the global level, air pollution is estimated to be responsible each year for approximately 800 000 premature deaths, or 1.4% of all deaths worldwide. This burden of disease is most important in developing countries, causing an estimated 39% of years of life lost in south-east Asia (eg, China, Malaysia, Viet Nam) and 20% in other Asian countries (eg, India, Bangladesh). There are potential risks to environment and health from improper handling of solid wastes, one of the biggest and most pertinent environmental health related issue in our country. Direct health risks concern mainly the workers in this field, who need to be protected, as far as possible, from contact with wastes. There are also specific risks in handling wastes from hospitals and clinics. For the general public, the main risks to health are indirect and arise from the breeding of disease vectors, primarily flies and rats. The organic fraction of municipal solid waste is an important component, not only because it constitutes a sizeable fraction of the solid waste stream, but also because of its potentially adverse impact upon public health and environmental quality. A major adverse impact is due to its attraction of rodents and vector insects for which it provides food and shelter. Houseflies may be important in 356

JUNE-2012

EDITORIAL

the transmission of enteric infections, particularly those responsible for infantile diarrhoea and dysentery. Disease transmission by houseflies is greatest where inadequate refuse storage, collection and disposal (leading to increased breeding) is accompanied by inadequate sanitation. Further, rubbish may contaminate groundwater with nitrates, heavy metals and other chemicals. Incineration of wastes may pollute the air with particulates and oxides of sulphur and nitrogen. The slag and ashes from incinerators may result in chemicals that are rich in heavy metals and other potentially toxic substances. These impacts are not confined merely to the disposal site. On the contrary, they pervade the area surrounding the site and wherever the wastes are generated, spread or accumulated. Unless an organic waste is appropriately managed, its adverse impact will continue until it has fully decomposed or otherwise stabilised. Uncontrolled or poorly managed intermediate decomposition products can contaminate air, water and soil resources. Infrequent collection and rapid decomposition of wastes provide an attractive feeding and breeding site for flies, rats and other scavengers. Human and animal faecal matter or hospital wastes are often mixed with the refuse. Vectors and pathogens multiply. Domestic and on occasion industrial, solid wastes are disposed of in open spaces within residential areas. Collection and disposal of refuse can consume up to 50% of a municipal operating budget. In many otherwise good systems, only 50-70% of the refuse is regularly collected. The problem is organisational rather than tech-

(9)

357

nical. Refuse disposal is often a non-profit making business and thus is treated as an unwanted side-effect of development. Attention should be paid to storage, collection, transport, and intermediate transfer to bulk transport and final disposal. The United Nations Environment Programme has been celebrating World Environment Day on June 5 every year since 1973 to raise awareness about the need for all of us to save the environment. The date was chosen because the UN Conference on the Human Environment began in Stockholm on June 5, 1972. Representatives of 113 countries, 19 inter-governmental agencies and more than 400 inter-governmental and non-governmental organisations congregated in Sweden’s capital for this purpose. A declaration containing 26 principles about the environment and development was passed at the meeting and an action plan with 109 recommendations was also drawn up. For 2012, the theme is ‘Green Economy: Does it include you?’ According to the UN Environment Programme, a green economy is ‘one that results in improved human well-being and social equity, while significantly reducing environmental risks and ecological scarcities’. As members of the medical fraternity it is essential for us to contribute effectively towards this goal. Professor and Head of the Department of Radiotherapy, NRS Medical College and Hospital, Kolkata 700014 and Hony Editor, JIMA, Kolkata 700014

Disclaimer

SUBIR GANGULY

JIMA assumes no responsibility for the authenticity or reliability of any product, equipment, gadget or any claim by medical establishments/institutions/manufacturers or any training programme in the form of advertisements appearing in JIMA and also does not endorse or give any guarantee to such products or training programme or promote any such thing or claims made so after. — Hony Editor

JUNE-2012

(10)

Originals and Papers Swine flu (H1N1 influenza) : awareness profile of visitors of swine flu screening booths in Belgaum city, Karnataka R G Viveki1, A B Halappanavar2, M S Patil3, A V Joshi3, Praveena Gunagi3, (Mrs) Sunanda B Halki4 The 2009 flu pandemic was a global outbreak of a new strain of H1N1 influenza virus often referred colloquially as "swine flu". The objectives of the study were : (1) To know the sociodemographic and awareness profile of visitors attending swine flu screening booths. (2) To reveal sources of information. The present cross-sectional study was undertaken among the visitors (18 years and above) attending swine flu screening booths organised within the Belgaum city during Ganesh festival from 28-08-2009 to 03-09-2009 by interviewing them using predesigned, pretested structured questionnaire on swine flu. The data was collected and analysed using SPSS software programme for windows (version 16). Chi-square test was applied. Out of 206 visitors, 132 (64.1%) were males and 107 (51.9%) were in the age group of 30-49 years;183 (88.8%) had heard about swine flu. More than a third of the visitors (38.3%) disclosed that there was a vaccine to prevent swine flu. Majority responded that it could be transmitted by being in close proximity to pigs (49.0%) and by eating pork (51.5%). Newspaper/magazine (64.6%), television (61.7%), and public posters/ pamphlets (44.2%) were common sources of information. The present study revealed that doctors/ public health workers have played little role in creating awareness in the community. The improved communication between doctors and the community would help to spread correct information about the disease and the role that the community can play in controlling the spread of the disease. [J Indian Med Assoc 2012; 110: 358-61]

Key words : Swine flu, H1N1 influenza, pandemic, knowledge, attitude.

T

he 2009 flu pandemic was a global outbreak of a new strain of H1N1 influenza virus often referred colloquially as swine flu. Its outbreak began in the state of Vera Cruz, Mexico in April 2009 and then it was reported in other parts of the world. In June WHO and US Centers for Disease Control (CDC) declared the outbreak to be pandemic1. While only mild symptoms like fever, sore throat, cough, headache, the majority of people experience muscle/ joint pains and nausea, vomiting or diarrhoea, some have more severe symptoms. Those at risk of a more severe infection include asthmatics, diabetics, obese, immunocompromised, children with neurodevelopmental abnormalities, pregnant women and those with cardiac diseases. Usually small outbursts of influenza occur regularly in winter but occasionally pandemics sweep across the world. Influenza still remains a disease to recon with. Seasonal epidemics around the world kill thousands of people annually2. Soon after the outbreak of H1N1 virus in the United States and Mexico, the Government of India started screenDepartment of Community Medicine, Belgaum Institute of Medical Sciences, Belgaum 590001 1 MD (Commun Med), Associate Professor 2 MD (Commun Med), Professor and Head of the Department 3 MD (Commun Med), Assistant Professor 4 MSc (Stat), Statistician cum Assistant Professor Accepted August 30, 2010 358

ing people coming from the affected countries at airports for swine flu symptoms. The first case of swine flu in India was found on the Hyderabad Airport on 13th May 2009, when a man travelling from US to India was found H1N1 positive. Subsequently, more confirmed cases were reported and as the rate of transmission increased in the beginning of August 2009 with first death due to swine flu in India in Pune, panic began to spread. The 2009 swine flu outbreak had indeed attacked India affecting mostly its main cities. As of 7th January 2010, total 27,5,22 cases were confirmed to have been having this pandemic flu with 1035 deaths. The country's most affected states included Karnataka with 1914 cases and 133 deaths, Maharashtra with total of 4699 confirmed cases and 284 deaths, New Delhi with 9510 swine flu cases with 83 deaths, Tamil Nadu 2070 cases with 7 deaths, Kerala with 1456 cases with 34 deaths and Haryana with 1916 cases and 33 deaths. It is more likely that true count of cases is much higher than the reported ones as some patients may never seek medical attention3. Since the first report of oseltamivir - resistant pandemic influenza A (H1N1) 2009 virus in June 2009, more than 200 cases of resistant virus have been reported worldwide. Active surveillance for antiviral resistance in pandemic (H1N1) 2009 virus needs to be maintained by clinicians, laboratories and agencies and all such cases should be investigated and promptly notified to relevant agencies

JUNE-2012

(11)

SWINE FLU (H1N1 INFLUENZA) : AWARENESS PROFILE OF VISITORS OF SWINE FLU SCREENING BOOTHS — VIVEKI ET AL 359

including WHO4. From Belgaum district, out of 1,98,841 individuals screened for swine flu from10-08-2009 to 23-10-2009, 328 samples were sent for laboratory testing and 39 cases were confirmed to have swine flu5. In Karnataka, Belgaum belongs to one among the highly affected districts as it is closer to most affected nearby place – Pune, Maharashtra. Common sharing with many demographic and economic ties with this neighbouring state and major transportation routes were major leading factors for its vulnerability to swine flu. The present study may provide valuable information and some important clues to the policy makers and research workers engaged in the prevention and control of swine flu in the community. MATERIAL AND METHOD Swine flu (H1N1 flu) screening booths were organised at 8 distinct market places within Belgaum city, Karnataka, jointly by Belgaum Institute of Medical Sciences (BIMS), Belgaum and City Corporation, Belgaum during Ganesh festival from 23-08-2009 to 03-09-2009 with support of staff from the department of community medicine, nursing students, corporation staff, BIMS final year students. Screening booths were functioning from 8.00 hours to 20.00 hours for screening the suspected cases and referring them to swine flu (H1N1) OPD, BIMS Hospital for further examination and laboratory testing, if required. Simultaneously, the visitors of these screening booths above 18 years of age were interviewed using predesigned, pretested structured questionnaire on swine flu containing information regarding sociodemographic profile, knowledge about cause, transmission, prevention and control, attitude and practices, and sources of information about swine flu. This cross-sectional study included 224 visitors. However, 18 did not give verbal consent for participation in the study. Thus, 206 were the study subjects. For convenience, age was divided into 5 groups as 18-29 years, 30-39 years, 4049 years, 50-59 years and 60 and above. This data was collected, compiled, tabulated and analysed using statistical package for social science (SPSS) 16 version. Chisquare test was applied to test the significance of difference in the knowledge profile of male and female visitors. However, the present study is subjected to certain limitations, since it was conducted among only the visitors attending swine flu screening booths. The present study measured views of a specific population at a specific point in time, their knowledge, attitudes reflect the information available at that point of time and therefore are not stable. The perceived seriousness, vulnerability, behavioural change in relation to swine flu outbreak, knowledge on its incubation period, period of communicability, signs and symptoms could not be measured in this study. All these variables could have given new dimension to this study. OBSERVATIONS Out of 206 visitors attending swine flu screening

booths, 132 (64.1%) were males and 107 (51.9%) were in the age group of 30-49 years;183 (88.8%) had heard about swine flu. Majority ie, 86 (41.7%) studied up to secondary level and 88 (42.7%) were engaged in semi/unskilled activities (Table 1). One hundred and twenty-nine (62.6%) were knowing that one could get swine flu from someone having it, while 79 study subjects (38.3%) disclosed that there was a vaccine to prevent swine flu. Regarding knowledge about transmission, around half of the subjects thought that one could get swine flu by being in close proximity to pigs (49.0%) and by eating pork (51.5%), while only 94 (45.6%) were aware about its transmission by infected droplets (Table 2). Majority thought that swine flu could be prevented and controlled by using face masks (57.8%), isolation of cases (49.5%) and by vaccination (47.1%). Around one-third of the subjects (33.5%) did not know about its prevention and control. The viral nature of the illness was known to only 36 subjects (17.5%). Majority (74.8%) were ready to undergo swine flu testing if asked by the doctor, while only 63 (30.6%) were ready to permit a person with swine flu to stay at home and seek medical care. Newspaper/magazine (64.6%), television (61.7%), public posters/pamphlets (44.2%) were the common sources of information about swine flu. DISCUSSION Swine flu (H1N1 influenza) after emerging from Mexico has caused the first pandemic of the century. If people are to respond appropriately during an outbreak of infectious disease, they need to have some basic knowledge about disease transmission, availability of vaccines, effective medical treatment, etc6. Belgaum district has a population of 42, 14,505 comprising 51.0% males with average literacy rate of 64.4% (female literacy rate 52.5%) and 76.0% being from rural Table 1 — Distribution of Cases according to Sociodemographic Status Characteristics

Age group in years : 18-29 30-39 40-49 50-59 60 and above Education status : Illiterate Primary Secondary Higher Secondary College and above Occupation : Unemployed Semiskilled/unskilled Student Professional

Males (n=132)

No of cases (%) Females Total (n=74) (n=206)

26 38 27 23 18

(19.7) (28.8) (20.5) (17.4) (13.6)

15 30 12 11 6

(20.3) (40.5) (16.2) (14.9) (8.1)

9 16 54 29 24

(6.8) (12.1) (41.0) (22.0) (18.1)

6 (8.1) 19 (25.7) 32 (43.2) 9 (12.1) 8 (10.8)

15 (7.3) 35 (17.0) 86 (41.7) 38 (18.4) 32 (15.6)

26 67 21 18

(19.7) (50.8) (15.9) (13.6)

33 21 14 6

59 88 35 24

(44.6) (28.4) (18.9) (8.1)

Figures in the parentheses denote percentages

41 68 39 34 24

(19.9) (33.0) (18.9) (16.5) (11.6)

(28.6) (42.7) (17.0) (11.7)

JUNE-2012

360

(12)

J INDIAN MED ASSOC, VOL 110, NO 6, JUNE 2012

Regarding prevention and control of swine flu, using face masks (57.8%), isolation of cases Male Total (n=132) (n=206) (49.5%) and vaccination (47.1%) were responded by majority of the Swine flu is transmitted by : Droplets coming from coughs and sneezes 63(47.7) 31 (41.9) 94 (45.6) χ 2=10.24, visitors. Kamate et al8 found face of infected person p>0.1 masks (36.6%) and vaccination Touching something with flu virus on it 33 (25.0) 19 (25.7) 52 (25.2) at df=7 (36.4%) as most effective methods. Being in close proximity to pigs 65 (49.2) 36 (48.6) 101 (49.0) In a study by Dube et al 10 in Being in close proximity to infected persons 79 (59.8) 43 (58.1) 122 (59.2) Canada, 80% of respondents By eating pork 67 (50.8) 39 (52.7) 106 (51.5) Consuming contaminated water/food 29 (22.0) 34 (45.9) 63 (30.6) thought A (H1N1) pandemic infecMosquito bite 31 (23.5) 16 (21.6) 47 (22.8) tion as a serious disease which Don't know 41 (31.1) 33 (44.6) 39 (18.9) would occur frequently without Swine flu can be prevented and controlled by* : 7 2 Using face masks 78 (59.1) 41 (55.4) 119 (57.8) χ = 5.93, vaccination. Seale et al reported quarantine as the most effective Vaccination 68 (51.5) 29 (39.2) 97 (47.1) p>0.1 Herbal remedies 41 (31.1) 27 (36.5) 68 (33.0) at df=5 measure for preventing swine flu. Isolation of cases 65 (49.2) 37 (50.0) 102 (49.5) Use of herbal preparations for its Antiviral drugs like tamiflu 34 (25.8) 12 (16.2) 46 (22.3) prevention and control was reDon't know 35 (26.5) 28 (37.8) 63 (30.6) sponded by 68 (33.0%) visitors. Swine flu is caused by : 2 Virus (H1N1) 24 (18.2) 12 (16.2) 36 (17.5) χ = 12.69, Only 36(17.5%) knew that swine Immunodeficiency 18 (13.6) 22 (29.8) 40 (19.4) p>0.05 flu is caused by virus (H1N1) Inherited disease 06 (04.5) 08 (10.8) 14 (6.8) at df=7 which was similar to that found in Don't know 84 (63.6) 32 (43.2) 116 (56.3) Udaipur study -2009 (18.2%)8 Figures in the parentheses denote percentages; *Multiple responses while much higher figures (95.4%)were quoted by Balkhy et al9. Immunodeficiency 7 area, spread over 13,415 sq km area as per 2001 census . as a cause of swine flu was expressed by 40 subjects (19.4%) It was observed that 183 visitors (88.8%) had heard which was relatively lower than that found in Saudi study about swine flu which was relatively higher than the find(27.6%)9. In a study by Yang Hsu11 in Singapore, 82.2% ings in another similar study by Kamate et al8 (83.1%). study subjects felt that pandemic response measures were More than half (50.5%) of the visitors thought that there essential while only 14.6% felt that they were excessive; was a threat of swine flu to the local community. After the 85.0% 0f respondents estimated that A (H1N1) pandemic first case of swine flu in Hyderabad, India on 13 May 2009, influenza as a severe enough to take special precautions its rate of transmission increased in the beginning of Auto prevent it as reported by Dube et al10. There was no gust 2009, with first death in India due to swine flu in Pune, statistically significant difference in the over all knowlpanic began to spread everywhere including Belgaum. edge profile of male and female visitors in the present study Belgaum was more vulnerable for its infection as it is loas shown in Table 2. cated on Pune–Bangalore National Highway (NH4), around The data on attitude and practices towards swine flu 344 km away from Pune. revealed that majority (59.2%) were not ready to permit a Seventy-nine visitors (38.3%) thought that there was a person with swine flu to stay at home and seek medical vaccine to prevent swine flu. This could be due to wrong care. Around three-fourths of the study subjects (74.8%) impression about availability of vaccine created by some were ready to undergo swine flu testing if asked by doctor. local practitioners who were conducting swine flu camCommon sources of information about swine flu were newspaigns by giving some medicines (homeopathic) to propaper / magazine (64.6%), television (61.7%), public posttect the persons from swine flu. The study conducted in ers / pamphlets (44.2%). Kamate et al8 reported television Saudi by Balkhy et al9, 47.1% study subjects responded (38.6%) and radio (2.0%) as sources of information while about availability of vaccine against swine flu, which was in Saudi study9, television (84.2%), newspaper/ magazine higher than that in present study. The data on knowledge (51.1%) were found to be major sources of information about transmission revealed that only 94 (45.6%) were about swine flu. aware about its transmission by droplets from infected Doctors/public health workers (19.4%) have played inpersons which is lower than that found in Saudi study sufficient role in creating awareness in the community, 9 (95.5%) , could be due to poor access to correct sources which is similar to that found in Saudi study (16.1%)9. of information in the community about this new disease. ACKNOWLEDGMENT Around half of the study subjects thought that it could be transmitted by being in close proximity to pigs (49.0%) Authors extend sincere thanks to all the study particiand by eating pork (51.5%). In previous study8, 48.7% re- pants, staff from the department of community medicine, spondents disclosed that Swine flu was caused by pigs. nursing staff, BIMS final year students, city corporation Table 2 — Distribution of Cases according to Awareness Profile

Awareness profile

No of cases Female (n=74)

Significance

JUNE-2012

(13)

SWINE FLU (H1N1 INFLUENZA) : AWARENESS PROFILE OF VISITORS OF SWINE FLU SCREENING BOOTHS — VIVEKI ET AL 361

staff for co-operating with us during the study period. Authors acknowledge the Director, Belgaum Institute of Medical Sciences, Belgaum for permitting to carry out the present study. REFERENCES 1 Chan M — World now at the start of 2009 influenza pandemic (11-06-2009). Geneva: World Health Organisation, 2009. 2 Mahanty S — Swine flu (H1N1 influenza) – the latest outbreak. Dream 2009; 11: 39-42. 3 CDC — H1N1 flu/H1N1 flu and you. Centers for Disease Control & Prevention 10-02-2010. Retrieved 26-02-2010. www.cdc.gov/h1n1flu/9a.htm. 4 WHO — Update on oseltamivir-resistant pandemic A (H1N1) 2009 influenza virus: January 10. Wkly Epidemiol Rec 2010; 85: 37-40. 5 Distrtict Surveillance Unit, Belgaum — H1N1 Influenza Daily Report Abstract. Belgaum: District Surveillance Unit, 2009: 1-4. 6 Seale H, McLaws ML, Heywood AE — The community atti-

7 8

9

10

11

tude toward swine flu and pandemic influenza. Med J Aust 2009; 191: 267-9. District Statistics Department — Statistical view of Belgaum District. Belgaum: District of Statistics Department, 2007: 5-11. Kamate SK, Agrawal A, Choudhary H, Singh K — Public knowledge, attitude and behavioral changes in an Indian population during the influenza A (H1N1) outbreak. J Infect Developing Countries 2010; 4: 7-14. Balkhy HH, Abolfotouh MA, Al-Hathlool RH, Al-Jumah MA — Awareness, attitudes and practices related to the swine influenza pandemic among the Saudi public. BMC Infect Dis 2010; 10: 42. Dube E, Gilca V, Sauvagean C, Bouliaune N, Boucher FD, Bettinger JA, et al — Canadian family physicians' and pediatricians' knowledge, attitudes and practices regarding A (H1N1) pandemic vaccine. BMC Res Notes 2010; 3: 102. Yang Hsu L — Surveys of knowledge, attitude and practice on the influenza A (H1N1) pandemic. Ann Acad Med Singapore 2010; 39: 42.

Discover a truly unique & result oriented approach to healing! Achieve amazing success in your practice! This is a once in a life opportunity to learn directly from NMT Founder Dr. Leslie S. Feinberg, DC-USA Hyderabad : August 24-26, 2012 New Delhi : August 29-31, 2012 Contact : Mr. SHIAK- 9949027360 ; [email protected] ; WWW.NMT.MD

National Institute of Medical Science Trunk Road, Near Mawsumi Hospital, Silchar-788001, Assam Affiliated to IGNOU & Other Universities : Your initiative our support Web: www.jaycreation.org; www.nimssil.com; E-mail: [email protected]; Mobile : 09435072209; Tel.: 03842-230152

Course

- Diabetology - Tuberculosis - Sexual Disease - Rheumatology - Psychiatry - Clinical Cardiology - Family Planning - Radiology (Radio Diagnosis) - Paediatrics

Eligibility

Admission Notice Course

M.B.B.S. / Bachelor of AYUSH

- Hospital Management

(Postal Mode)

Course fee Rs. 10,000/-

Duration 6 months

- Pain Management

Eligibility M.B.B.S./Bachelor of AYUSH B.Sc./B.Sc.Nursing or any other paramedical course or Homeopathy (Postal Mode) Duration 6 Months

- Diploma in Medical Laboratory 10+2 with Science subject Technology (DMLT) minimum 45% marks. Course approved by Govt. of - Ultrasonography MBBS/ Bachelor of AYUSH Duration 2 years Course fee Rs.15,000/- (Practical Classes mandatory) India and AICT Hostel available Course fee: Rs. 25,000/- \annum Duration 6 months Prospectus for each course is available against Bank Draft of Rs. 300/in favour of ‘Secretary, National Institute of Medical Science’ payable at ‘Silchar’ Course fee Rs.10,000/-

JUNE-2012

(14)

Originals and Papers Reproductive tract infection and health seeking behaviour of eligible couples — an appraisal Baijayanti Baur1, Anima Haldar2, Sankar Nath Jha3, Runa Bal4, Mrinal Kanti Kundu5, Arati Biswas6, Lina Bandyopadhyay7 A community-based cross-sectional study was conducted in Paschim Midnapur district of West Bengal during March 2009 to August 2009 to find out the prevalence of reproductive tract infection and the health seeking behaviour. The respondents were 2000 currently married women (15-49 years age group) selected by stratified multistage random sampling. House to house visit and data collection by interview technique was done by faculty members of community medicine of Calcutta National Medical College and other medical colleges through predesigned and pretested schedule. The prevalence of reproductive tract infection was 11.7%, which was higher in 30-35 years age group (19.4%). Reproductive tract infection was indirectly proportional to literacy status. Prevalence of reproductive tract infection was significantly higher among those who did not use sanitary napkin / clean sun-dried domestic clothes. The occurrence of reproductive tract infection was lower who used to practise barrier method of contraception. Majority of symptomatic females complained about vaginal discharge (29.2%). Information, education, communication regarding small family norms, reproductive hygiene and contraceptive practice to be enhanced in the community through intervention (interpersonal communication and mass media) in future to reduce the reproductive tract infection morbidities. [J Indian Med Assoc 2012; 110: 362-5]

Key words : Reproductive tract infection, contraceptive, health seeking behaviour.

R

eproductive tract infections (RTIs) and sexually transmitted infections (STIs) have been recognised as a major public health problem. In spite of having infections many women do not seek any advice or treatment1. In India in community-based studies, the range of self reported morbidity has been reported to vary from 39-84%2,3. The consequences of RTIs are numerous and potentially devastating. Some of RTIs are associated with poor pregnancy outcome and high morbidities and mortalities in neonates and infants. In developing countries both the incidence/ prevalence of RTIs/STIs are very high, they rank second as the cause of healthy life lost among women of reproductive age group after maternal morbidity and mortality4. In the existing situation, prevention of RTI is a part of integrated Reproductive and Child Health programme Department of Community Medicine, Calcutta National Medical College, Kolkata 700014 1 MBBS, DMCW, DPH, MD (Commun Med), Associate Professor 2 MBBS, DMCW, MD (Commun Med), Additional Professor 3 MBBS, MD (Commun Med), Assistant Professor 4 MBBS, MD (Obstet Gynaecol), Associate Professor of Obstetrics and Gynaecology 5 MBBS, MD (Obstet Gynaecol), Assistant Professor of Obstetrics and Gynaecology 6 MBBS, MD (Obstet Gynaecol), Professor 7 MBBS, DPH, MD (SPM), Public Health Specialist, AIIH&PH, Kolkata 700073 Accepted May 10, 2010 362

(RCH-II). Among women non-sexually transmitted RTIs are even more common5. So, with these above perspectives, the present study was undertaken with the specific objectives of assessing the prevalence of RTI morbidity among currently married women of reproductive age groups and to study their health seeking behaviour. MATERIAL AND METHOD This was a community-based cross-sectional observational study among eligible couples of West Midnapur district of West Bengal, during the period of March to August 2009. The respondents were currently married women of 15-49 years of age, selected by stratified multistage random sampling. The sample size was calculated by considering prevalence of RTI as 50% and permissible level of error as 5% and was computed as 1600. Out of total 29 blocks of West Midnapur district, 3 blocks (Keshpur, Chandrakona-II, Nayagram) had been selected randomly. From each rural block, 2 sub-centres and from each sub-centre area, 2 villages had been selected randomly. Out of total 3 municipalities of the district, 2 municipality areas (Midnapur and Kharagpur-I) were selected randomly and from each municipality, 2 wards were selected randomly.

JUNE-2012

REPRODUCTIVE TRACT INFECTION AND HEALTH SEEKING BEHAVIOUR OF ELIGIBLE COUPLES — BAUR ET AL

So a total of 12 villages (4 from each block) and 4 wards (2 wards from one municipality) had been chosen for study purpose. Thus a total of 16 areas had been selected throughout the district (3 blocks x 4 villages + 2 wards x 2 municipality = 16). From each area 125 currently married women were interviewed by house to house visit through predesigned and pretested schedule by the faculty members of the department of community medicine, so a total of 2000 (16 x 125 =2000) women were included in the survey. Finally data for all parameters were analysed both manually and by computer feeding. We have not collected data regarding multiple exposure of women due to technical reasons. Social class was determined from per capita monthly income6. OBSERVATIONS Out of total 2000 surveyed women, only 233 (11.7%) of them reported symptoms suggestive of RTI. It was observed that majority (69.7%) of respondents belonged to nuclear family. Most of them (56.7%) belonged to below proverty line (BPL) group (per capita income below Rs 500) followed by poor social class ( Rs 500-1499) (37.3 %). Majority of the women were illiterate (29.4%) followed by secondary educated group (28.4 %). Table 1 revealed the relationship between sociodemographic determinants and RTI. Prevalence of RTI was maximum in 30-35 years age group (19.4%) and Table 1 — Sociodemographic Variants and RTI among Respondents Sociodemographic variants

No of symptomatic RTI cases (%)

Age group (in years) : 36 (n=514) Education : Illiterate (n=588) Just literate (n=351) Primary (n=436) Secondary (n=568) Graduate and above (n=57) No of living children : Nil (n=171) 1 (n=466) 2 (n=808) 3 (n=372) 4+ (n=183) Napkin/clean cloth use : Yes (n=376) No (n=1624) Total (n=2000)

233 (11.7%)

1 (4.3%) 51 (11.3%) 55 (8.7%) 74 (19.4%) 52 (10.1%)

Level of significance X2 = 38.01; df = 4; p=0.0000048

76 43 49 60 5

(12.9%) (12.2%) (11.2%) (10.5%) (8.8%)

X2 = 2.23; df=4; p=0.6928

9 50 87 45 42

(5.3%) (10.7%) (10.7%) (12.0%) (22.9%)

X2 = 30.55; df = 4; p=0.0000038

19 (5.0%) 214 (13.1%)

X2 = 19.58; df = 1 p=0.0000097

(15)

363

minimum in below 18 years age group (4.3%). The difference was statistically significant (p = 0.0000048). Prevalence of RTI was higher in illiterate group (12.9%), followed by just literate group (12.2%) and least in graduate and above educated group (8.8%). This differences was not significant statistically (p = 0.6928). RTI prevalence was more among BPL group (12.1%) and lowest (6.3%) in upper middle social class and above higher income group (Rs3000-4999 and above). RTI prevalence was higher (22.9 %) among those who had 4 and above children, followed by 12.0%, 10.7%, 10.7% and 5.3 % were found in case of women with 3,2,1 and no child respectively and the difference was statistically significant (p= 0.0000038). It was also evident from Table 2 that the prevalence of RTI was more among Cu-T adopters (25.9%), 14.7 % among those who used to intake oral contraceptive pill (OCP) followed by 12.9% in case of permanent method adopters and least (1.64%) among those who used to practise barrier method of contraception. This difference was also significant statistically (p =0.00000000). The prevalence of RTI was significantly higher among those who used ordinary clothes (13.1%) than sanitary napkin /clean sun-dried domestic cloths users (5.0%). The respondents used water from multiple sources for bathing. Out of total sufferers, 50.6% used pond water for bathing (Fig 1). Fig 2 revealed that 29.2%, 9.9%, 14.6%, and 4.7% of the respondents experienced RTI symptoms like vaginal discharge, pain abdomen, low back pain and dysuria respectively. Regarding health seeking behaviour it was evident from Table 3 that, majority of the respondents (53.8%) opined that they prefer to attend government hospital. Whereas 26.7 %, 6.5 % and 4.3 %, of the respondents favoured private practitioners, homeopaths and health workers respectively. A quite good number of respondents (30.7 %) preferred quacks in their need. DISCUSSION A rather low prevalence of RTIs (11.7%) in married women of age group 15-49 years was reported from this Table 2 — Occurrence of RTI Cases In Relation to Contraceptive Practice Contraceptives use

No of symptomatic RTI cases (%)

No method (n=652) Condom (n=61) OCP (n=387) Cu-T (n=27) Ligation (n=775) Vasectomy (n=2) Others (n=96) Total (n=2000)

54 (8.3%) 1 (1.64%) 57 (14.7%) 7 (25.9%) 100 (12.9%) 0 14 (14.6%) 233 (11.7%)

Level of significance X2=105.97%); df=5; p=0.00000000

JUNE-2012

364

(16)

J INDIAN MED ASSOC, VOL 110, NO 6, JUNE 2012

Fig 1 — Different Sources of Water for Bathing among RTI Cases* *Multiple response

Fig 2 — Symptomwise Distribution of RTI Cases* *Multiple response

study in West Table 3 — Distribution of Cases Midnapur, probably according to Health Seeking Behaviour Practice (n=2000)* due to accessibility of No of cases (%) healthcare services. Facility/ provider Others have reported Private practitioner 533 (26.7%) high rates of RTIs in Government hospital 1076 (53.8%) 50 (2.5%) c o m m u n i t y - b a s e d Nursing home Quacks 613 (30.7%) 3,7,8 studies . The Ayurveda 4 (0.2%) prevalence of RTIs / Homeopathy 129 (6.5%) 85 (4.3%) STDs was found to be Health worker 49% in a rural area of *Multiple response district of Agra (UP)7 and 70% in rural areas of Haryana8. Prevalence of RTI observed by studies done in slum and rural areas of Chandigarh reported to be 21.6%9 and 17.7%10 respectively and was 35.3% in rural areas of Meerut11 and 51.9% in rural area of Sirmour (HP)12. The prevalence of RTI in the present study was maximum in 30-35 years age group (19.4 %), which did not corroborate with the findings of other studies11,12. Rathor et al13 reported maximum prevalence of RTI in the age group of 40-49 years. Higher prevalence of RTI was found among women with lower literacy status as observed by Pant et al11 and Sharma et al12. Prevalence of RTI was maximum in case of Cu-T adopt-

ers whereas it was less among those who used to practise barrier method of contraception, which corroborated by the findings of Sharma et al12. But the findings of the present study did not corroborated with the findings of Pant et al11 where RTI was more prevalent among women who had sterilisation. The prevalence of RTI was significantly higher (p =0.0000097) among women who used general cloths as compared to sanitary napkins and clean sun dried domestic clothes users. Similar observations were found by Sharma et al12. Commonest presentation among RTI sufferers was vaginal discharge (29.2%) similar to findings of Sharma et al12. In the present study regarding health seeking behaviour, maximum number of respondents (53.8%) preferred government hospital and 30.7% of the respondents even prefer to attend quacks whereas one hospital-based study14 in Nepal revealed that the patients with vaginal discharge preferred traditional healers and pharmacists also. It can be concluded from the present study that community-based awareness generation programme about small family norms, maintenance of reproductive hygiene through use of sanitary napkins and or clean sun-dried domestic cloths and practice of barrier method of contraception, as well as education, all are essential to reduce RTI morbidities. Special emphasis should be provided to involve local quack practitioners about RTIs/ STIs for early referral to higher health facility. So for quack practitioners, training programme should be arranged for early identification and referral of the patient by syndromic approach. IEC activities to be strengthened among women of reproductive age groups through mass media and interpersonal communication starting from grass-root to tertiary care level also. ACKNOWLEDGEMENT The authors deeply acknowledge the financial support from State Family Welfare Bureau, Government of West Bengal for conducting the study. The authors are also thankful to the district authority and all the participants for co-operation. REFERENCES 1 Kishore J — National Health Programs of India. 8th ed. New Delhi: Century Publication, 2007: 129. 2 Bang RA, Bang AT, Baitule M, Choudhury T, Sarmukaddam S, Tab O — High prevalence of gynaecological diseases in rural Indian women. Lancet 1989; i: 85-8. 3 Latha K, Kanani SJ, Maitra N, Bhattacharya RV — Prevalence of clinically detectable gynaecological morbidity in India: results of four community based studies. J Family Welfare 1997; 43: 8-16. 4 Ministry of Health and Family Welfare — National Guidelines

JUNE-2012

REPRODUCTIVE TRACT INFECTION AND HEALTH SEEKING BEHAVIOUR OF ELIGIBLE COUPLES — BAUR ET AL

5 6 7

8

9 10

11

12

13

on Prevention, Management and Control of RTIs including STIs: NACO Module. New Delhi: Ministry of Health and Family Welfare, Government of India, 2007: 1. Park K — Park's Textbook of Preventive and Social Medicine. 20th ed. Jabalpur: Banarsi Das Bhanot, 2009: 359-70. Agarwal AK — Social classification: the need to update in the present scenario. Indian J Commun Med 2008; 33: 50-1. Nandan D, Misra SK, Sharma A, Jain M — Estimation of prevalence of RTIs / STDs among women of reproductive age group in district Agra. Indian J Med Sci 2002; 37: 110-3. Aggarwal AK, Kumar R, Gupta V, Sharma M — Community based study of reproductive tract infections among ever married women of reproductive age in a rural area of Haryana. Indian J Commun Med 1999; 31: 223-8. Palai P, Pillay V, Singh A — Prevalence of vaginal discharge in a urban slum of Chandigarh. Med Gazette 1994; 138: 431-2. Thakur JS, Swami HM, Bhatia PS — Efficacy of syndromic approach in management of reproductive tract infection and associated difficulties in rural area of Chandigarh. Indian J Commun Med 2002; 27: 110-3. Pant B, Singh JV, Bhatnagar M, Garg SK, Chopra H, Bjapai SK — Social correlates in reproductive tract infections among married women in rural area of Meerut. Indian J Commun Med 2008; 32: 52-3. Sharma S, Gupta BP — The prevalence of reproductive tract infections and sexually transmitted diseases among married women in reproductive of group in a rural area. Indian J Commun Med 2009; 34: 62-4. Rathor M, Swami SS, Gupta BL, Sen V, Vyas BL, Bhargava A, et al — Community based study of self reported morbidity of reproductive tract among women of reproductive age in rural area of Rajasthan. Indian J Commun Med 2003; 28:

(17)

365

117-21. 14 Rizvi N, Luby S — Vaginal discharge, perceptions and health seeking behaviour among Nepalese women. J Pak Med Assoc 2004; 54: 620-4.

40th Annual Meeting of

The RESEARCH SOCIETY FOR THE STUDY OF DIABETES IN INDIA 26, 27, 28 October 2012

Chennai Trade Center, Nandambakkam, Chennai, India The annual RSSDI is a mega event in Diabetology which attracts doctors from all over India and neighboring countries. Eminent speakers from India and abroad will take part in orations, Plenary session, Debates and workshops. For Online Registration Visit : www.rssdi2012.com Delegates Fees Member Non-Member Student * Accompanying Person

Up to 31stAug’ 12 4500 6000 2500 4000

Up to 30thSep’ 12 8000 10000 3000 6000

After 30thSep’12 & spot 15000 15000 No Registration 10000

For registration send DD in favour of ‘RSSDI2012’ payable at ‘Chennai’ *Student ID / letter from Professor or Institution Meeting Secretariat: Dr.C.R.Anand Moses, RSSDI 2012-Organizing Secretary 22,Casa Major Road,Egmore,Chennai-600 008; Mobile: 94448 99071, Email: [email protected]

JUNE-2012

(18)

Originals and Papers Measurement of first ray of foot with reference to hallux valgus Deepak S Howale1, Kanaklata V Iyer2, Jigesh V Shah3 A study was carried out on 58 healthy volunteers. None of the volunteeres had any foot complaints. This was done to study Indian feet, as foot is an important part of human anatomy and its certain deformities eg, hallux valgus, can be very disabling. We have studied anatomical angles between 1st and 2nd rays of foot eg, angle of hallux valgus and angle of slant of distal facet of medial cuneiform and have shown significant correlation between them and development of hallux valgus. The coefficient of correlation (r) calculated between these two angles is significant, showing that this angle influences the angle of hallux valgus and hence development of hallux valgus. These are anatomical angles and indicate shapes of medial cuneiform and 1st metatarsal. Hence these seem to be inherited, making the feet anatomically predisposed to develop hallux valgus. This view is supported by Gray’s Anatomy. The extrinsic factors such as narrow toes, closed, footwear worn for an extended period do increase the angle of hallux valgus. So, in predisposed feet, this is one of the extrinsic factor which can lead to development of hallux valgus. On studying these two angles, orthopaedicians should be on alert and should advise such individuals on wearing foot- friendly footwear. [J Indian Med Assoc 2012; 110: 366-9]

Key words : Angle of hallux valgus, angle of slant, development of hallux valgus, metatarsus primus varus.

‘‘M

an’s foot is all his own. It is unlike any other foot. It is the most distinctly human part of his whole anatomical make-up. It is a human specialisation. It is his hallmark and he will be known by his feet from all other animals’’1. The foot is a specialised structure. It possesses a record of man’s pre-history which in completeness and legibility surpasses that of any other structure of the body. Indeed, the foot is a specialised structure adapted to the pattern of bipedal locomotion and to additional stresses imposed upon the hind limb. During the transition of the foot from an arboreal ape’s foot to the terrestrial, change has predominantly affected the 1st and the 2nd rays (Hicks defined a “ray” as a cuneiform and metatarsal for medial three rays). The most important change which distinguishes man even from other primates2 is that, the opposability of the hallux in the apes has given way to the stability of the hallux and the 1st ray in the human foot. The 1st and the 2nd rays play a crucial role in foot function of weight bearing, body support and locomotion. Their deformities and affections, therefore, are disabling. Forefoot deformities Department of Anatomy, Kesar SAL Medical College, Ahmedabad 380060 1 MS (Anat), Associate Professor 2 MS (Anat), Professor and Head of the Department 3 MD (Forensic Med), Associate Professor of Forensic Medicine Accepted November 16, 2011 366

constitute 90% of all foot deformities. And those affecting the 1st ray are the commonest. Among these hallux valgus is the most disabling when this ray is abnormal in its weight bearing function is mainly taken over by 2nd ray. Any defect or deficiency in the 1st ray would impair the foot’s entire mechanism which is taken over by the 2nd ray. Hence it is important to understand the normal relationship between constituents of 1st ray of foot. Some of the parameters were studied earlier by Morton3 Harris and Beath4, Hardy and Clapham5,6 but only two of them were statistically correlated. Based on anatomical observations and some statistical correlations, these authors blamed some abnormality of the 1st ray7 and its effect on the 2nd ray in causation of hallux valgus. However, while examining the earlier work on the1st ray, it was observed that not all the measurements were quantified or statistically correlated with each other. The angle of slant was not quantified or correlated. Data on studies of normal Indian feet were not available. The study is carried out with an aim to establish and compare the values for bony configurations of the first and the second rays in the Indian feet and to show statistical correlation between two parameters which will suggest the anatomical factors predisposing to hallux valgus. As these measurements indicate norms in Indian feet, they are important clinically. Forefoot deformities can be diagnosed, their severity judged and the line of treatment decided upon, based on the degree of deviation from the

JUNE-2012

MEASUREMENT OF FIRST RAY OF FOOT WITH REFERENCE TO HALLUX VALGUS —

normal. These measurements are also useful in judging the results of corrective procedures adopted and in suggesting preventive measure. MATERIAL AND METHOD The present study was carried out on 58 healthy volunteers (a sample consisting of medical students between the ages of 18 to 23 years – 43 males and 15 females) at LTM Medical College, Mumbai. None of the volunteers had any foot complaints. There was no history of trauma. Their footwear consisted chappals or open toed sandals used newly for fifty per cent of the walking hours. Occasionally some wore closed toed shoes. Methods : (1) Roentgenograms of both right and left feet of volunteers were taken on the same x-ray plate. (2) Both feet without shoes were kept on the film holder, slightly separated from each other with lateral borders of feet parallel to lateral margins of film cassette. Thus, the distance between the film and the object is reduced to a minimum to avoid distortion. (3) Volunteers sat on the xray table with their knees held together and their feet on the x-ray film holder as shown in Fig 1. (4) Central beam was directed at an angle of 15º to the perpendicular from an anteroposterior direction over the point midway between 1st metatarsal heads for bilaterally symmetrical shadows. (5) Target-film distance was kept at 100 cm. (6) The amount of distortion was calculated by the following formula CF = D–d / D, where D = target film distance and d = object film distance. Distortion was negligible and hence insignificant. Measurements : Dried x-ray films were collected and markings were made.

Fig 1 — Diagrammatic Representation of the Position of Volunteer for Standard Dorsoplantar Skiagram of Foot

HOWALE

ET AL

(19)

367

The following parameters were recorded to measure foot. (1) Measurement of the angle of hallux valgus – The long axes of the proximal phalanx of the big toe and 1st metatarsal are drawn the angle (x) opening out distally, between these two axes, is the angle of hallux valgus (Fig 2)8. (2) Measurement of the slant of the distal facet of medial cuneiform (angle of slant) – A tangent was drawn at the maximum curvature of the distal articular surface of the medial cuneiform to represent the plane of the 1st cuneometatarsal joint. Two points were marked at the Fig 2 — Diagrammatic Represenmost medial ends of tation Showing the Angle of the Hullux Valgus cuneometatarsal and cuneonavicular joints and they were joined to represent the medial border of the medial cuneiform. The proximal outer angle (x) formed by these two lines gives the angle of slant of the distal articular facet of the medial cuneiform (Fig 3)9. According to Gambol and Yale, this latter line is parallel to midline of foot, which is difficult to define10. X-ray was done among feet of 12 students, 1st without wearing shoes and then with wearing narrow toed shoes to see their effect on angle of hallux valgus. Calculations : (1) Mean, standard error (SE), mode and range were calculated for all the recorded values. (2) Statistical correlation coefficient ‘r’ showing interdependence is calculated between the angle of hallux valgus and angle of slant. (3) Fig 3 — Diagrammatic Significance of coefficient of corRepresentation Showing relation is calculated by applythe Angle of Slant ing ‘t’ test.

JUNE-2012

368

(20)

J INDIAN MED ASSOC, VOL 110, NO 6, JUNE 2012

OBSERVATIONS Total number of volunteers was 58 (15 females, 43 males) and total number of feet studied was 116. The angle of hallux valgus (in degrees) is depicted in Table 1. Table 1 — Showing Angle The angle of slant of the disof Hallux Valgus tal facet on medial cuneiform (in Parameter Total degrees) is depicted in Table 2. Mean 9.93 Coefficient of correlation SE 4.666 between this angle of slant and Mode 9.56 0-22 the angle of hallux valgus was Range 0.60-19.26 r=0.2825, t=3.145. The value of Mean+2SE % of feet 93.9% ‘t’ is significant. Therefore, there is a significant positive Table 2 — Showing Angle of correlation between these Slant angles. This helps us to state Parameter Total that the angle of slant influ- Mean 116.18 7.75 ences the angle of hallux val- SE 118.74 gus and so development of Mode Range 80-135 hallux valgus. Mean+2SE 100.69-131.67 % of feet 95.6% DISCUSSION Proximal phalanx of the big toe is not in line with the 1st metatarsal. Normally, it is deviated towards lateral toes which gives it, a slight normal valgus position. This is represented by angle formed by long axes of 1st metatarsal and proximal phalanx of the big toe and is called the angle of hallux valgus. It is the usual metatarsophalangeal angle (Normal 10º). In hallux valgus, this angle increases with consequent effect on dynamic weight bearing11 resulting in metatarsalgia. The factors affecting the angle of hallux valgus are follows. Bony factors — These are important as they make the foot unstable and predispose to the valgus of the big toe. Among these, the important one is metatarsus primus varus(MPV). It occurs when the first metatarsal is medially deviated in a non-weight bearing foot. It is observed by many workers that the medial deviation of the 1st metatarsal at the cuneometatarsal joint may be secondary to, an excessive slant of medial cuneiform12 which will carry the 1st metatarsal along with it medially; causing MPV and predisposing to hallux valgus. Muscles — All the tendons surrounding the 1st ray are not attached to the 1st metatarsal head but attached to the phalanges9. As the majority of the muscles acting on the big toe do so from the fibular side13 and if there is muscular imbalance, they will pull the hallux laterally and increase the angle of hallux valgus. Extensor hallusis longus plays a primary role as there is no extensor expansion on the dorsum of the big toe. Therefore, this muscle loses its soft tissue connection from the dorsum of the first phalanx and becomes the chief muscle to have a ‘bow-string’ action on the big toe and initiate its lateral deviation, which

is maintained by other muscles coming from the fibular side. Therefore, only the phalanx of the big toe is pulled laterally. This mechanism comes into play when the first metatarsal shifts medially due to increased angle of slant. Extrinsic factor (pointed toe shoes) — Feet in pointed shoes show a substantial increase in the angle of hallux valgus. Fashionable tight toed shoes push the hallux laterally. If this occurs over a long period of time, the medial collateral ligament of the first metatarsophalangeal joint is stretched and the lateral one contracts. These changes are progressive and the phalanx becomes fixed in a permanent laterally deviated position. When present data are compared with that observed by Hardy and Clapham5 (15.7) the present values are less (9.93). The hot and humid climate in our country is not very conducive to wearing closed shoes for a long period of time. As the group for the present study used open toed sandals or chappals, only fifty per cent of the day time, the mean angle of the hallux valgus is less than that found by Hardy and Clapham5, and hence our footwear habits seems to be healthy. The plane of angle of slant normally slants medially and backwards. The increased obliquity of the innermost cuneometatarsal joint as a cause of metatarsus primus varus was suggested by Lapidus12 and Kelikian13. All these workers stated that metatarsus primus varus is the cause/predisposing factor of hallux valgus. However, this angle was not quantified. Therefore, in this study this angle was measured against the medial border of medial cuneiform which is parallel to the midline of foot10. It is seen from the present study that the plane of the facet slants medially and backwards making an angle of 116.18º ± 15.49 (100.59º - 131.67º) and shows the anatomical basis of predisposition to hallux valgus. Increase in this angle causes metatarsus primus varus and it should be measured for causation of hallux valgus. The shape of medial cuneiform is inherited. Gray2 says that this is a genetic predisposition and hallux valgus occurs mainly in such persons. It is advisable that an orthopaedician should observe the shape of cuneometatarsal joint and if there is any excessive medial deviation of the joint is found, he should become alert and warn the patient of its consequences. Significant correlation between hallux valgus and angle of slant showed that anatomically foot can be unstable and can predispose to hallux valgus. Predisposing factor is excess slant above 116º which makes first metatarsal slant more medially causing metatarsus primas varus and in turn causing hallux valgus. This should alert the orthopaedicians. They should observe the shape of cuneometatarsal joint and if he finds excessive medial deviation of this joint, he should become alert and warn the patient of its consequences. Correlation indicates a link mechanism between vari-

JUNE-2012

MEASUREMENT OF FIRST RAY OF FOOT WITH REFERENCE TO HALLUX VALGUS —

ous intrinsic components of the 1st ray and if any one of them is abnormal, it changes the normal relationships bringing about the deformity of the 1st ray. It is observed that closed and pointed toed shoes do have a deleterious effect on the hallux and do form a precipitating cause of hallux valgus. Broad toed footwear is healthier for the feet and it is recommended. REFERENCES 1 Hall MC — The Locomotor System–Functional Anatomy. New York: Charles C Thomas, 1965: 401-6. 2 Williams PL, Warwick K, editors — Gray’s Anatomy. 36th ed. London: Churchill Livingstone, 1980: 413-7, 498-501, 612. 3 Morton DJ — The Human Foot. New York: Columbia University Press, 1935: 45, 60, 109, 167, 183. 4 Harris RI, Beath T — Short first metatarsal and its clinical significance. J Bone Joint Surg Am 1949; 31: 553-65. 5 Hardy RH, Calpham JCR — Observations on hallux valgus based on controlled series. J Bone Joint Surg Br 1951; 33: 376-91. 6 Hardy RH, Calpham JCR — Hallux valgus: predisposing anatomical causes. Lancet 1952; i: 1180-3. 7 Morton DJ — Foot disorder in general practice. JAMA 1937: 109: 1112-9. 8 Lidge RT — Hallux valgus: surgical correction by three in one technique. In: Bateman JE editor. Foot Science. Philadelphia: W B Saunders, 1976: 188-210. 9 Haines RW, McDougall A — The anatomy of hallux valgus. J Bone Joint Surg Br 1954; 36: 272-93. 10 Gamble FO, Yale I — Clinical Foot Roentogenology. Baltimore: Williams and Wilkins, 1966: 151, 156, 200, 246-7. 11 Mitchell CL — Osteogomy bunionectomy for hallux valgus. J Bone Joint Surg Am 1958; 40: 41-9. 12 Lapidus PW — Operative correlations of metatarsus varus primus in hallux valgus. J Surg Gynaecol Obstet 1934; 58:

HOWALE

ET AL

(21)

369

183-91. 13 Kelikian H — Hallux Valgus and Allied Deformities of the Forefoot and Metatarsalgia. Philadelphia: WB Saunders, 1965: 1, 3, 7, 9, 10, 11, 22, 29, 37, 38, 46, 59, 60, 61, 369.

JUNE-2012

(22)

Originals and Papers Three years audit of the emergency patients in the department of ENT of a rural medical college Debasis Barman1, Satadal Mandal2, Saileswar Goswami3, Rabi Hembram3 Surgical audit is a systematic, critical analysis of the quality of surgical care provided, with the aims of improving quality of care, continuing education for surgeons, and guiding appropriate use of health resources. Emergency service is an integral part of any discipline of clinical medicine and it is considered as an indicator of quality of healthcare system. A three years record based, retrospective, cross-sectional study was carried out in the department of ear, nose and throat (ENT) of Midnapore Medical College, Paschim Medinipur, West Bengal to identify the total attendance of various emergency patients, diagnosis made thereafter, the mode of interference and outcome and the potential problems in the quality of care provided to the community. A total of 9051 patients had been admitted/attended in the ENT emergency from January 2008 to December 2010 who were included in this audit. Detailed statistical analysis of the data showed male: female (2.38:1) with the peak in the first decade of life. Majority of the patients were from Medinipur sadar (58.43%). The total otological cases were maximum (42.41%) in comparison to nose (28.98%) and throat (28.60%). The most common ear emergencies were earache due to impacted wax, acute suppurative otitis media, foreign body ear and the trauma/injury. Chronic suppurative otitis media with complications were the least. Amongst the sinonasal emergency, the most common aetiology was the epistaxis and foreign body nose in children. The different types of foreign body impaction in the throat and the inflammatory condition of throat or the inspiratory stridor due to upper airway obstruction were the main emergency situation recorded. Some cases were fatal. The overall mortality was 0.44%. [J Indian Med Assoc 2012; 110: 370-4]

Key words : Audit, emergency, ear, nose, throat.

A

n audit of clinical practice is the analysis of data either prospectively or retrospectively to determine both quantitatively and qualitatively of the work load of an institution or individual department. It includes numbers of admissions, patients’ demographics, various complications and mortality1. ENT emergencies are specialised job and special instruments and equipment are required to tackle the crisis. ENT emergency cases are of varied nature ranging from accidental foreign body impaction to severe inspiratory stridor or epistaxis. Since with the increasing problems of subversive activity and also with the increasing incidence of highway accidents in this district, the ENT and headneck emergencies are on a rise and thus invite a challenging problem to an attending junior doctor. Sometimes mismanaged case may lead to fatality. The department of ENT, Midnapore Medical College runs 24 hours emergency service on a 3-tier basis– interns, junior Department of ENT, Midnapore Medical College, Paschim Medinipur 721101 1 DLO, MS, DNB (ENT), Associate Professor 2 MS (ENT), RMO cum Clinical Tutor 3 MS (ENT), Assistant Professor Accepted September 21, 2011 370

residents /senior residents and RMO/senior MO. A three-year audit from January 2008 to December 2010 is presented in this study to evaluate the types of cases attending ENT emergency services, their outcome covering the academic and research aspects. This study is designed with the aim to identify potential problems in the quality of care when ENT emergency services are provided to the community in Midnapore Medical College. MATERIAL AND METHOD All emergency patients admitted to ENT department over a 3-year period from January 2008 to December 2010 were recorded in this study. Data were recorded on patients’ age, gender, occupation, date of admission, geographic distribution, aetiology of disease/trauma if any, presenting complaints and the treatment offered to them. Emergency patients referred from other departments were also included in this study. Data were gathered for number and nature of surgical procedures, hospital stay, complications and death if any. Consent from ethical committee of the hospital was taken. The database was used to analyse the different parameters. The data were collected from emergency case registrars, ENT outdoor and indoor registrars and operations registrars of Midnapore Medical College, Paschim Medinipur.

JUNE-2012

THREE YEARS AUDIT OF THE EMERGENCY PATIENTS IN THE DEPARTMENT OF ENT — BARMAN ET AL

OBSERVATIONS Between January 2008 and December 2010, the department of ENT, Midnapore Medical College offered general and specialised emergency services to 9051 patients in total. Amongst these male/female distribution is shown in Fig 1. Therefore on an average about 3017 patients/year and about 8.26 patients/day attended the ENT emergency of Midnapore Medical College. Midnapore Medical College serves not only the patients from all the subdivisions of both Purbo and Paschim Medinipur districts, but also from the adjoining parts of Orissa (Fig 2). The youngest patient in this study was 6 months old and the eldest was 83 years old with the peak in the first decade of life. Most emergency cases ie, 42.41% attended for ear related causes (Fig 3). The number of otological emergency cases were maximum (n=3839) in this study (Table1). The commonest presentation of otological emergency was pain in the ear due to impacted wax (26.8%). Table 2 shows the various sinonasal emergency cases of which epistaxis was the commonest presentation (54.89%). About 4.57% of patients attended emergency with the history of foreign body nose, but no such foreign body was detected clinically and radiologically.

Fig 1 — Gender Distribution of the Emergency Cases Attending Department of ENT

Fig 2 — Cases Attending from Various Places

Fig 3 — Ear, Nose and Throat Emergency Cases Depicted Separately

(23)

371

Trauma was the main cause of epistaxis (45.2%), followed by hypertension (23.54%) and idiopathic cause (22.6%). Sinonasal neoplasm presented with epistaxis comprised about 3.33% of cases and sinusitis presented with epistaxis were about 1.74% in this study. Amongst the throat related emergency cases fish bone impaction in the throat was the most common finding (57.2%), followed by coin in the oesophagus (2.94%), artificial denture impaction and meat bone impaction were 1.35% and 1.27% respectively. Laryngotracheal and bronchial foreign bodies were detected in minimum number of cases comparatively. Surprisingly in about 6% of cases no such foreign body was detected in throat particularly fish bone (Table 3). Acute tonsillopharyngitis (9.89%) complicated with different neck space abscess formation, hypopharyngeal malignancy (9.49%) presented with stridor, and cut throat injury (1.78%) were the other important observations. The overall total mortality was 0.44% in 3 years study period and the most common cause of mortality in ENT emergency cases was found to be upper airway obstruction due to hypopharyngeal malignancy (n=12). Unfortunate death was also noted in few cases of foreign bodies obstructing the upper aerodigestive tract, uncontrolled epistaxis, complicated CSOM and cut throat injury. But CSOM with intracranial complication had the highest case fatality rate (27.27%), followed by cut throat injury (10.87%) and hypopharyngeal malignancy (4.88%) (Table 4). DISCUSSION An audit of surgical outcome can be seen as the final step in what has been termed the “journey of care” for both the individual patient and for the population as a whole2. When outcomes are open to scrutiny; data validation is a vital component of meaningful clinical audit. It outlines in greater detail the progress and problems in surgical audit3. Otorhinolaryngological emergency cases remain the serious clinical problems because of the specificity of this anatomical region. In western set up most serious emergency cases may result from shortness of breath and epistaxis4. Throat related emergency cases were maximum (41.18%) in one Indian study5. But in this study the

JUNE-2012

372

(24)

J INDIAN MED ASSOC, VOL 110, NO 6, JUNE 2012

tending resident doctor may confront some problems to tackle the foreign body impaction in ENT Clinical diagnosis No of cases (%) Average case/year region. Because for the safe removal of foreign body requires extensive training and resources as Earache due to impacted wax 1029 (26.8 %) 343 Acute suppurative otitis media(ASOM) 1005 (26.18 %) 335 well. Traumatic injury to external ear 547 (14.25 %) 182.33 Majority of the foreign body can be removed Foreign body ear 486 (12.66 %) 162 as a day care basis and thus duration of the hospiDiffuse otitis externa 332 (8.65 %) 110.66 tal stay is minimised. However pharyngeal, oesophFurunculosis 161 (4.19 %) 53.67 ageal and laryngeal foreign body should be conTraumatic rupture of ear drum 76 (1.98 %) 25.33 CSOM with extracranial complication 181 (4.71 %) 60.33 firmed by skiagraphy and repeat skiagraphy is manCSOM with intracranial complication 22 (0.57 %) 7.33 datory before taking any surgical interference. General anaesthesia (GA) is often required for pharynTable 2 — Clinical Diagnosiswise Distribution of Sinonasal geal, laryngeal oesophageal, bronchial or impacted forEmergency Cases (n=2623) eign body. Clinical diagnosis No of cases (%) Average case/year In the present study fish bone impaction in the throat Epistaxis 1440 (54.89%) 400 is the most common emergency. It occurs most commonly Foreign body nose 627 (23.9%) 209 in children but can be found in adults also6. Oropharynx Fracture nasal bones 180 (6.86%) 60 was the commonest site in children and base of the tongue, Faciomaxillary injury 136 (5.18%) 45.3 No foreign body found in nose 120 (4.57%) 40 vallecula, pyriform sinus were the other sites for fish bone Septal abscess 62 (2.36%) 20.67 lodgement in adults. In 6% of patients no fish bone was Acute/chronic rhinosinusitis 58 (2.21%) 19.3 identified even after skiagraphy though there were foreign body sensations. It may be due to local trauma or ulcerTable 3 — Clinical Diagnosiswise Distribution of Throat Related ation by the foreign body itself during its spontaneous Emergency Cases (n=2589) Clinical diagnosis No of cases (%) Average case/year propagation. Small fish bone in the tonsillolingual sulcus is sometimes difficult to remove. Infrequently it may enter Fish bone throat 1481 (57.2%) 493.67 the tongue and is propagated anteriorly into the body of Coin in oesophagus 76 (2.94%) 25.33 the tongue by muscular contraction7. Meat bone throat 33 (1.27%) 11 Denture in oesophagus 35 (1.35%) 11.67 Coin in the oesophagus was another common emerBronchial foreign body 6 (0.23%) 2 gency (2.94%) particularly in children. The commonest site Laryngotracheal foreign body 5 (0.19%) 1.67 of impaction of coin is just below the level of cricopharynx. No foreign body found 156 (6%) 52 As the pharyngeal constrictors are stronger than oesophAcute tonsillopharyngitis 256 (9.89%) 85.33 ageal smooth muscle, a coin can lodge in the slot shaped Peritonsillar abscess 37 (1.43%) 12.33 Parapharyngeal abscess 14 (0.54%) 4.67 cricopharyngeal sphincter for a long time without going Retropharyngeal abscess 21 (0.8%) 7 further down through the oesophagus in most of the cases7. Ludwig’s angina 11 (0.42%) 3.67 In comparison to coin impaction, artificial denture in Palatal injury 85 (3.28%) 28.33 oesophagus (1.35%) and meat bone oesophagus (1.27%) Cut throat injury 46 (1.78%) 15.33 were observed in older age group. History is important in Acute epiglottitis 15 (0.58%) 5 Acute laryngotracheal bronchitis 54 (2%) 18 these cases since one or two denture without any metallic Juvenile laryngeal papilloma 4 (0.15%) 1.33 hook is not always being radio-opaque. Barium cotton Pharyngeal malignancy 23 (0.89%) 7.67 swallow skiagram is helpful in those cases. Laryngeal neoplasm 223 (8.6%) 74.83 Sharp foreign body like wire may present late to casuOedema larynx 8 (0.3%) 2.67 alty with retropharyngeal abscess8. Respiratory distress Table 4 — Distribution of Cases with Mortality (n=40) is not uncommon with this complication and early tracheoClinical diagnosis No of mortality stomy is found to be helpful5. cases All the oesophageal foreign bodies need urgent Hypopharyngeal malignancy with stridor (n=246) 12 (4.88%) oesophagoscopy under GA and the procedure should alForeign bodies in upper aerodigestive tract (n=1636) 8 (0.49%) ways be done by trained personnel. Sometimes fatality Uncontrolled epistaxis (1440) 9 (0.62%) may occur by slightest trauma due to thinness of the oeCSOM with intracranial complications (n=22) 6 (27.27%) sophageal wall in an inexperienced hand9. Cut throat injury (n=46) 5 (10.87%) Foreign body impaction in the larynx is mainly accidental ear related emergency cases were maximum (42.41%) in in nature and usually presents as a respiratory emergency comparison to nose and throat and the daily attendance of that requires urgent intervention to save the patient’s life10. Tracheobronchial foreign bodies are one of the major emergency patients were about 8.26/day. The foreign body impactions in ENT region are found to be the common causes of morbidity and mortality in paediatric age group11. emergency and sometimes produce fatal outcome. The at- Many patients with laryngeal foreign bodies are extremely Table 1 — Clinical Diagnosiswise Distribution of Otological Emergency Cases (n=3839)

JUNE-2012

THREE YEARS AUDIT OF THE EMERGENCY PATIENTS IN THE DEPARTMENT OF ENT — BARMAN ET AL

dyspnoeic. However in some cases chronic symptoms are also observed due to adaptation of laryngeal sensory receptors to sharp impacted foreign body. Foreign body in the bronchus may present with cough, choking, asthmatoid wheeze and obstructive signs like atelactasis or lung abscess9. In 3 years study 6 cases of bronchial foreign bodies had been referred to higher centers in Kolkata as there is no facility of bronchoscopy at this rural medical college till date. Acute tonsillopharyngitis presenting with sore throat and fever comprised about 9.89%. Peritonsillar abscess (1.43%) presented with odynophagia, halitosis, unilateral earache and features of toxicity. These cases are to be differentiated with parapharyngeal abscess. Any case of deep neck space abscess formation needs CT scan and urgent drainage to prevent further complication. Urgent tracheostomy is a life saving procedure and total 102 cases of emergency tracheostomy operations were done during the 3 years study period. The common causes were hypopharyngeal malignancy with stridor, acute retropharyngeal abscess, upper airway obstruction due to foreign body and cut throat injury. Referred cases from other departments such as head injury, road traffic accidents were also managed by tracheostomy. Sudden apnoea, cardiac arrest may occur during the procedure. Cut throat injury (1.78%) either homicidal or suicidal is not very uncommon in this district due to the various factors mainly rural political turmoil. Five cases of homicidal cut throat injuries were noted, death occurred due to involvement of the great vessels of neck. Twelve cases of ultimate death were recorded due to hypopharyngeal malignancy presented with stridor. Fatality recorded in 8 cases of impacted foreign body in upper aerodigestive tract. Otological emergencies are quite common (42.41%) in this study as compared to one Russian study12 of 28% of the total hospitalised ENT patients. Earache was the most common complaint in the otologic emergency and impacted wax (26.8%) was the most common clinical diagnosis. In one Italian study13 ASOM comprised one-third of total cases seen in paediatric practice. Other common causes of earache in this study were ASOM (26.18%), foreign body ear (12.66%), diffuse otitis externa (8.65%), furunculosis (4.19%). Foreign body ear may be of vegetable (38.27%), non-hygroscopic non-metallic (49.79%), metallic (4.32%) and animate types (7.61%). In non-cooperative children or impacted foreign body, it should be removed under GA using operating microscope. Unskilled removal of foreign body may injure ear drum, ossicles and facial nerve5. Incidence of traumatic injury to external ear was high (14.25%) in this study which reflects the increased incidence of political violence in this district of West Bengal. Ear injury may be associated with head injury and bleeding from the ear may be the ominous sign. Neglected cases of CSOM presenting with extracranial complication (4.71%) and intracranial complication (0.57%)

(25)

373

are required immediate surgical interference. The incidence of complicated otitis media was on higher side as compared to 1.64% by Indian analysis5. Death occurred in 6 cases of intracranial complications (brain abscess-4, meningitis-2) during the study period. It proves that complicated CSOM are much more prevalent in this part of this country due to lack of health awareness, poverty, etc. Sinonasal emergency admissions constitute 28.98% in this series as compared to 24.41% in another Indian study5. The most common cause of epistaxis was traumatic. A few numbers (3.91%) of epistaxis cases had been referred from the medicine department for different aetiologies like uraemia, bleeding diathesis and endocrine disorders. In more than 85% of cases of epistaxis anterior nasal space (ANS) packing was helpful to control bleeding and the rest 15% of patients were needed postnasal space (PNS) packing. PNS packing is very much unpleasant event both to the patient and the surgeon as well. PNS packing may be associated with some major complications like stroke, infarction, and toxic shock syndrome, etc. Continuous monitoring of the patient having PNS pack is necessary for management of posterior epistaxis. Extensive research training for proper application of ANS and PNS packing to all the residents is mandatory in ENT department. Majority of the foreign bodies in nose were removed by hook as a day care basis. Few cases of old retained nasal foreign bodies were removed under GA with endotracheal intubation. Fracture nasal bones and faciomaxillary injury forming another group of ENT emergency as a result of firearm injuries reflects the increased violence in this district of West Bengal. At the end of this audit programme, it was found that there was one death per 226 of patients. Terminal stages of hypopharyngeal malignancy were the major causes of death in this study but the individual case fatality was highest in cases of CSOM with intracranial complication which is also supported by another study5. Cases of otogenic brain abscess or meningitis occasionally required the neurosurgical back-up which is not available at Midnapore Medical College right now. Similarly radio-oncology department is not yet well equipped in this centre. This may be the reason of increased mortality from hypopharyngeal malignant disorders and the highest case fatality from CSOM with intracranial complication. REFERENCES 1 Bilal A, Salim M, Muslim M, Israr M — Two years audit of thoracic surgery department at Peshwar. Pak J Med Sci 2005; 21: 12-6. 2 Herbert MA, Prina SL, William SJL — Are unaudited records forming an outcome registry database accurate? Ann Thorac Surg 2004; 77: 1960-4. 3 Justo RN, James EF, Sarget PH — Quality assurance of paediatric cardiac surgery: a prospective 6 years analysis. Paediatr Child Health 2004; 40: 144-8. 4 Cancura W — Otorhinolaryngoscopic emergency in practice. Wein Med Wochenschr 1982; 132: 357-9.

JUNE-2012

374

(26)

J INDIAN MED ASSOC, VOL 110, NO 6, JUNE 2012

5 Saha S, Chandra S, Mandal PK, Das S, Mishra S, Rashid MA, et al — Emergency otorhinolaryngological cases in Medical College, Kolkata– a statistical analysis. Indian J Otolaryngol Head Neck Surg 2005; 57: 219-25. 6 Lannigan FI, Newbegin CI, Terry RM — An unusual subcutaneous neck lump. J Laryngol Otol 1985; 102: 385-6. 7 Ghosh P — Foreign bodies in ear, nose and throat (prediction and management). Indian J Otolaryngol Head Neck Surg 1999; 51: 2-5. 8 Sen MK — Foreign body in esophagus with acute retropharyngeal abscess. Indian J otolaryngol Head Neck Surg 1993; 45: 171-2. 9 Jackson C, Jackson CL — Bronchoesophagology. Philadelphia: WB Saunders, 1950: 13-245.

10 Hazra TK, Ghosh AK, Roy P, Roy S, Sur S — An impacted meat bone in the larynx with an unusual presentation. Indian J Otolaryngol Head Neck Surg 2005; 57: 145-6. 11 Hathiram TB, Grewal DS, Pathan SK, Chandrakiran C, Gaikwad N, Joshi V, et al — Unusual cases of foreign bodies in air passages in children. Indian J Otolaryngol Head Neck Surg 1999; 51: 9-14. 12 Palchum VT, Kunnelskaia NL, Kislova NM — Emergency diseases of the ear (comprehensive statistical data). Vestn Otorinolaringol 1998; 6: 4-10. 13 Pestalozza G, Romagndi M, Tessetore E — Incidence and risk factors of acute otitis media and otitis media with effusion in children of different age group. Adv Otolaryngol 1988; 40: 47-56.

JUNE-2012

(27)

JUNE-2012

(28)

Special Article Primary percutaneous coronary intervention versus pharmaco-invasive strategy† Saroj Mandal1, Dhiman Kahali2

T

he dawn of reperfusion era more than 3 decades ago revolutionised the management of ST-elevated myocardial infarction (STEMI). Over the years, reperfusion therapy has matured, as a consequence of numerous trials that have defined the optimal class of fibrinolytic agents, timing of therapy, adjunctive medications and the role of primary percutaneous coronary intervention (PPCI). Randomised controlled trials (RCTs) have clearly demonstrated PPCI is the preferred reperfusion strategy for patients with STEMI if it can be performed in a timely manner and by experienced operators. Within 3 hours of symptom onset, thrombolysis is as good as PPCI. The PRAGUE-2 trial: A trend in favour of fribinolytic therapy when administerd within 3 hours of symptoms versus PPCI. The CAPTIM trial : Randomised 75 PPCI cases per year, team experience >36 PPCI / year. • Delay to invasive strategy; prolonged transport (doorto-balloon) - (door-to- needle) time is >1 hour; medical contact-to- balloon time is > 90 minutes.

Primary Percutaneous Coronary Intervention : • Currently there is general concensus that PPCI is the preferred approach when delivered rapidly and in high volume centre. • Keeley et al performed a quantative analysis of 23 trials and demonstrated PPCI compared with FT in STEMI resulted in reduced mortality (7% versus 9%, p=0.0002), reinfarction (3% versus 7%, p12 (n=9) 5 4 Department of ENT, IPGME&R, Kolkata 700020 1 DLO, MS (ENT), RMO cum Clinical Tutor 2 MBBS, MS (ENT), Postgraduate Trainee; At present: Resident, Tata Memorial Hospital, Mumbai 400012 3 DLO, MS (ENT), Associate Professor 397

come group comprised 12 patients and the rest 5 were in the high income group. Classical triad of chocking, cough and noisy respiration with diminished air entry on examination is not always seen but suggestive history obtained in most of the cases. Only 2 patients presented with severe respiratory distress and cyanosis in emergency; oxygen saturation was 50-60%. They were transferred directly to OT and removal of foreign body done by bronchoscopy. One of them required tracheotomy. Four patients were treated in paediatric ward for laryngotracheobronchitis. Tracheostomy had already done in these cases. To rule out any aspirated FB, bronchoscopic examination was done which revealed FB in all these cases ie, dried leaves, pen ring, groundnut and pea seeds. In 3 cases collapse of lung was detected during routine pre-operative check-up for other operations. Three cases were treated for prolonged lower respiratory tract infection; after 1½ to 2 months suspicion of bronchial FB arose. Rest of the patients presented with noisy respiration after aspiration of FB; many of them became asymptomatic at the time of presentation. Detail history and suspicion of FB aspiration was the main parameter for diagnosis. Clinical examination revealed probable site of lodgment. X-ray detected only radioopaque FB. Collapse of a segment of lung due to complete obstruction of a bronchus was seen in few cases. All patients received pre- and postoperative antibiotic coverage and injectable steroid to prevent muscosal oedema. FB was removed with rigid bronchoscope, flexible bronchoscope and rigid telescope along with rigid bronchoscope had seemed to be helpful to detect small or transparent FB. Tracheostomy needed in some patients to help

JUNE-2012

398

(50)

J INDIAN MED ASSOC, VOL 110, NO 6, JUNE 2012

removal of FB which was very difficult to remove through glottis. (1) Tracheostomy was done in 3 cases – in one case due to cyanosis and in another 2 due to repeated slippage of FB from subglottic level. (2) In 4 cases tracheostomy was done prior to attending the ENT department when they were treated in paediatric ward. (3) Vegetable FB like groundnut, grams caused (a) swelling of bronchus by absorbing water producing complete obstruction, (b) releasing volatile oils causing chemical reaction, (c) breaking into pieces during removal. (4) Transparent FB was difficult to identify. (5) Removal of FB could not be done in 2 cases due to enclosure by granulation tissue. Most of the patients released after 48 hours except 5 who developed chest infection. Site of lodgement of FB was in the subglottis (n=4), trachea (n=4), carina (n=5), left bronchus (n=25), right bronchus (n=14). Of all the cases, the interesting one was of a 3½ years old female child suffering from repeated respiratory tract infection referred from paediatric ward for bronchoscopy. It revealed whistle in right bronchus. The second one was of a 15-month-old male child who was admitted in a medical college (paediatrics ward ) with pneumothorax of right side treated with water sealed drainage. CT scan revealed emphysematous right lung with left mediastinal shift. Child was having recurrent respiratory tract infection for last 3 months. Bronchoscopy revealed one Bengal gram in right bronchus. DISCUSSION In the present study it was found that detail clinical history and high degree of suspicion is the mainstay of diagnosis. Al-Hilau1 from Dubai also had similar opinion. Clinical history of choking followed by recurrent spasmodic cough was found to be the most important element

in making diagnosis. According to him, sensitivity of diagnosis from history were 93.7% cases which is similar to our observation. X-ray is helpful in very few cases–vegetable FB/radiolucent FB couldn’t be seen in x-ray. Metallic FB can be easily seen. Long standing FB, which have caused, consolidation can be confirmed by x-ray. However when there is any suspicion of FB in airway whatever may be the x-ray findings, bronchoscopy is mandatory. Harlan et al2 opined that radiographic imaging shouldn’t alter the decision of surgical intervention (bronchoscopy). Vegetable FB like ground nut, Bengal gram are very difficult to remove because they become fragmented early during removal. Seeds with hard cover like tamarind, jackfruit seed frequently slips during holding. Singh3 had similar experience. It is the common belief that most of the FB lodge in right bronchus because of anatomical consideration. In the present study it has been observed that in younger children FB mostly lodged in left bronchus. One study by Ghosh4 had similar observation. Presentation of similar object (duplicate of FB) by the parents usually helps a lot in planning of removal. Mortality rate is negligible and mainly due to anaesthetic hazard. In the present series death viewed in one case was due to hazard of anaesthesia. REFERENCES 1 AL-Hilau R — Inhalation of foreign bodies by children : review of experience with 74 cases from Dubai. J Laryngol Otol 1991; 105: 466-70. 2 Harlan RM, Andrew BS, Randal C — Utility of conventional radiography in the diagnosis and management of paediatric airway foreign bodies. Ann Otol Rhinol Laryngol 1998; 89: 434-6. 3 Singh PP, Lade H, Goyal A, Dhaliwal A — Tracheobronchial foreign bodies–a retrospective study. Asian J Ear Nose Throat 2004; 2: 20-4. 4 Ghosh P — Why mucous plugs commonly cause left lung collapse. Indian J Paediatr 1987; 54: 583-6.

IMAGE BUILDING FOR HOSPITAL’S PROFITABILITY

Is your hospital operating with lesser profit? Here’s a sure mode of maximizing by glancing through best seller authored by eminent professionals: Brig (Dr.) O.P.Khanna MBBS,MHA (AIIMS), Satish Kini, I.I.T. Bombay, MBA Dr. A.P. Chaudhari MBBS,MBA, & Joshua Khan PGDHA,HR (Italy) (10,000, copies sold)

# # # # # # # # #

If thinking of new hospital or expansion then glance at: # HEALTHCARE SPACE DESIGN Publisher: Singapore Best interiors & exteriors with 1500 pictures Rs.3,950/# NEW HOSPITAL FACILITIES with best architectural designs, layout, maps & landscape (size 11"x11") Rs.6,550/# HOSPITALS: Planning, Design, Management Rs.1850/# Step by step in hosp planning & design Rs.750/# Hospital Planning (W.H.O.) Rs.395/Mode of order:MO/DD/Cheque sent to: Secretary C A Trust, 5 Empire Theatre Road,Opp T&D Colony,Jabalpur Cell # 0-90111-39983, Email:[email protected] ; Courier/Speed Post @ Rs.80

Marketing of Hospital Services Marketing of Hospital Services The Essence of Hosp Management Instant Solution to Hospital Problem Arts & Commerce of Hospital Management Quality Management in Hospital :ISO 9001 Financial Management for Hospital Computer for Doctors Recent trends in Indian Hospitals

Rs.225 Rs.250 Rs.250 Rs.275 Rs.395 Rs.675 Rs.495 Rs.495 Rs.475

JUNE-2012

(51)

Case Note Herpes zoster : mistaken for radiculopathy and back pain Pragya A Nair1 Herpes zoster should be considered as one of the differential diagnosis in acute pain of short duration on one side of the body with or without skin lesions. Pain, a prodromal manifestation of herpes zoster may be mistaken for various disease conditions, leading to hasty unwise investigation, therapy and surgical interventions. There is a need to identify prodrome and skin eruptions of herpes zoster, so that early antiviral therapy can be started in elderly patients who are at higher risk of developing postherpetic neuralgia. [J Indian Med Assoc 2012; 110: 399]

Key words : Herpes zoster, pain, radiculopathy.

H

erpes zoster (HZ) results from the reactivation of the varicella zoster virus which causes chicken pox as a primary infection1. After primary infection the virus becomes latent in the cranial nerve, dorsal root, and autonomic ganglia of the nervous system. The classic presentation of HZ is a burning or tingling pain in the skin, although some patients complain of numbness or pruritus. The skin may be very sensitive to touch (hyperaesthesia)2. These symptoms are usually noted from 1-2 day to 2-3 weeks prior to any noticeable skin eruption and may be mistaken for other diseases. In the prodormal phase patients may also experience symptoms such as generalised malaise, myalgia, headache3, fever, chills or stomach upset. Here a case of HZ mistaken for radiculopathy and back pain is reported. CASE REPORT A female aged 65 years, presented to orthopaedic outpatient department with severe back pain since 4 days with few skin lesions over right knee joint. Investigation — Patient was admitted, advised for x-ray lumbosacral spine (AP and lateral views), which was found to be normal. Initial treatment — She was prescribed NSAIDs in injection form with no relief. Few more lesions appeared over right leg with excruciating, throbbing pain started radiating over right lower limb also. Patient was advised physiotherapy where she was given hot water fomentation, interferential therapy (IFT), transcutaneous electrical nerve stimulation (TENS) and positioning was taught. With that also there was no relief. Patient was unable to tolerate the pain, then on 3rd day, looking over skin lesions, skin reference was done. Treatment proper — Patient was diagnosed as HZ involving L3, L4, L5 dermatomes on right side. Tablet acyclovir (800 mg) five 1 MD, Associate Professor of Skin and VD, Pramukhswami Medical College and HM Patel Centre for Medical Care and Education, Karamsad 388325

times a day was started, with a short course of steroid4, injection NSAIDs were stopped, and patient was put on oral NSAIDs. She responded within a day of therapy. Tablet amitryptiline (25mg) twice a day was started, which lessened the duration of postherpetic neuralgia. DISCUSSION In patients coming with acute pain of short duration with or without skin lesions, HZ should be considered in differential diagnosis, as pain may precede from few days up to a week before skin lesions appear. During the prodromal stage, pain may prove a diagnostic challenge, and can be mistaken for appendicitis, renal colic, trigeminal neuralgia, heart and gall bladder diseases. Hence, a careful history taking concerning the nature of pain and sensory changes5 is needed to differentiate between zoster and other diseases, to avoid unwise investigation, therapy and surgical interventions. There is need to identify prodrome and skin eruptions of HZ, so that early antiviral therapy can be started in elderly patients who are at higher risk of developing postherpetic neuralgia6. REFERENCES 1 Goddard R — The reawakening of a sleeping little giant. Emerg Med J 2005; 22: 383-6. 2 Wareham DW, Breuer J — Herpes zoster. BMJ 2007; 334: 1211-5. 3 Gnann JW Jr, Whitley RJ — Herpes zoster. N Engl J Med 2002; 347: 340-6. 4 Johnson RW, Dworkin RH — Treatment of herpes zoster and postherpetic neuralgia. BMJ 2003; 326: 748-50. 5 Bukman KA, Gaines RW Jr, Kashani SR, Smith RD — Herpes zoster: a consideration in the differential diagnosis of radiculopathy. Arch Phys Med Rehabil 1988; 69: 132-4. 6 Goh CL, Khoo L — A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Int J Dermatol 1997; 36: 667-72.

Cheap, secured, Felicilitating and Attributing study in China, Russia, Ukraine, Philippines, British Guyana Sons & daughters of many doctors at present studying in prestigious & MCI Listed Colleges in above mentioned countries. Contact for admission : Dr Angani Swamy Varma, MBBS DGO (Obstetrician & Gynaecologist) Email: [email protected]; Mobile: +91-7799178888, 9866734031, Website: www.anganis.com

MBBS

MBBS

399

JUNE-2012

(52)

Case Note Primary non-Hodgkin's lymphoma of breast with scalp involvement in follow-up — an uncommon presentation Santosh Kumar Mondal1, Soumita Ghosh Sengupta2, Shibasish Bhattacharya3, Swapan Kumar Sinha4 Primary non-Hodgkin’s lymphoma of the breast is a rare tumour accounting for 0.04 to 0.5% of all malignant breast tumours. The aim of this case presentation is to report such rare entity with an uncommon presentation. A 48-year female presented with rapidly growing firm mass in right breast (upper outer quadrant) and fine needle aspiration cytology (FNAC) was performed for clinical suspicion of breast carcinoma. Cytological examination of smears showed large cells arranged discretely, though occasional small clusters were also seen. The cells had high nuclear-cytoplasm (N-C) ratio and prominent nucleoli. Based on cytomorphology, differential diagnoses of high grade non-Hodgkin's lymphoma and poorly differentiated carcinoma was made. A tru-cut biopsy was suggested for confirmation. Histologic examination revealed diffuse large cells (monomorphic type) with prominent nucleoli. The tumour cells were reactive for CD45, CD20, and negative for cytokeratin, CD30, CD3 and CD5. A histopathologic diagnosis of non-Hodgkin's lymphoma of diffuse large B cell lymphoma type was confirmed. The patient was treated with combined chemotherapy and radiotherapy. After one year, the patient developed a swelling in the scalp and proved to be diffuse large B cell lymphoma by tru-cut biopsy. Now, the patient was treated with chemotherapy alone. Two-year follow-up of the case was uneventful. Since FNAC is initial diagnostic tool for breast lesions, a differential diagnosis of breast lymphoma should always be kept in mind, especially in poorly differentiated malignant tumours. Such cases need to be confirmed by histopathology and immunohistochemistry. [J Indian Med Assoc 2012; 110: 400-1 & 403]

T

Key words : Breast, primary lymphoma, non-Hodgkin’s lymphoma.

he female breast is rarely affected by primary non-Hodgkin’s lymphoma (NHL), accounting for 0.04% to 0.5% of all malignant breast lesions1. It comprises 1.7-2.2% of all extranodal lymphomas2. Most of the breast lymphomas are of B-cell type and diffuse large B-cell (DLBCL) is the most common histological subtype3. It is difficult to distinguish primary breast lymphoma (PBL) from lobular carcinoma and poorly differentiated carcinoma by fine needle aspiration cytology (FNAC)4. As breast lumps are aspirated for a primary diagnosis and lymphoma is very rare at this site, a misdiagnosis may be given during cytological examination. Moreover, mammographic and clinical findings are not always very helpful to differentiate lymphoma and carcinoma. Hence, cytologic misdiagnosis is highly possible unless the index of suspicion is very high. Biopsy and immunohistochemistry are required to confirm the diagnosis in these cases. CASE REPORT A 48-year-female presented with a rapidly growing tumour in the right breast of 3 months' duration. She was referred from the surgical outpatient department (OPD) to the cytologic clinic of Department of Pathology, Medical College, Kolkata 700073 1 MBBS, MD (Pathol), Associate Professor 2 MBBS, MD (Pathol), Assistant Professor of Pathology, NRS Medical College, Kolkata 700014 3 MBBS, MD (Gen Med), DM (Med Oncol), Assistant Professor of Medical Oncology 4 MBBS, MD (Pathol), Professor and Head of the Department 400

pathology department for FNAC. Examination — A firm mass of 5.4x 4.2 cm size was noted in the upper outer quadrant of right breast. Local tenderness was present but overlying skin was normal. No lump or abnormality was palpable in the left breast. Bilateral axillary examination did not reveal any enlarged lymph node or lump. Chest and cardiovascular examination was normal. Investigations — Routine haematological and biochemical investigations were within normal limits. Clinically the case was suspected of carcinoma of breast. Aspirate from the tumour yielded blood mixed material. Smears showed large cells, having high nuclearcytoplasmic (N-C) ratio and conspicuous nucleoli (one to multiple). The cells were arranged diffusely with occasional loose aggregates of three to four cells. A cytologic impression of the poorly differentiated carcinoma was made, keeping the clinical suspicion in mind. Biopsy was suggested for histological confirmation and to rule out malignant lymphoma. Tru-cut biopsy (histopathological examination) revealed diffuse proliferation of uniform looking large lymphoid cells replacing the normal breast parenchyma. The cells have high N-C ratio with prominent one to multiple nucleoli. The tumour cells expressed CD45 and CD20 (Fig 1, Immunohistochemistry, x 400). They were non-reactive to cytokeratin, CD3, CD5 and CD30. The entrapped ductal epithelial cells expressed cytokeratin antigen, while the surrounding tumour cells were negative (Fig 2, Immunohistochemistry, x 100). No lymphoepithelial lesion was found (seen in mucosa associated lymphoid tissue type or marginal zone B-cell lymphoma or MALT lymphoma). Hence,

JUNE-2012

PRIMARY NON-HODGKIN'S LYMPHOMA OF BREAST WITH SCALP INVOLVEMENT IN FOLLOW-UP — MONDAL ET AL

the diagnosis of NHL of DLBCL was confirmed. Contrast enhanced computerised tomography (CECT) screening of neck, chest and abdomen did not reveal enlarged lymph node, organomegaly or lymphadenopathy. Bone marrow examination showed no tumour involvement. Thus, a diagnosis of primary NHL of DLBCL in the right breast (stage IE) was reached. Treatment — The patient was treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy for 4 cycles, followed by involved field radiation. Follow-up — The case showed remarkable improvement with disappearance of the mass and the patient remained symptom-free. But after one year she presented to medical oncology OPD with a scalp mass and later on proved to be DLBCL by tru-cut biopsy. This lesion was treated with DHAP (dexamethasone, high dose ara-C, cisplatin) for three cycles of 21 days' interval. The entire lesion resolved in three months. The patient is alive for last 2 years without any recurrence till now.

(53)

401

Fig 1 — Immunohistochemistry Showing Diffuse Membranous Pattern Staining of CD20 in the Tumour Cells

DISCUSSION PBLs are classified like the nodal lymphomas according to REAL classification. Most of the PBLs are B-cell lymphoma, of which DLBCL is the most common histologic subtype (40-70%) 2. According to Wiseman and Liao5, the criteria needed to diagnose PBL are (a) technically sufficient tissue, (b) close interaction between lymphoma infiltration and breast tissue, (c) no prior diagnosis of a non-breast lymphoma and (d) no evidence of wideFig 2 — Immunohistochemistry Showing Negative Expression of Cytokeratin Antigen by the Tumour Cells, while the Entrapped Ductal Epithelial Cells Are Positive for Cytokeratin spread disease at the time of diagnosis. In this case, the above criteria were met and diagnosed as PBL. Other histological subtypes of The prognosis of PBL is similar to that of nodal lymphoma, PBL are follicular centre lymphoma, marginal zone B-cell lymwhich has a similar histologic type and clinical stage. Although phoma (MALT lymphoma), lymphoplasmacytoid lymphoma, standard treatment protocol of PBL is yet to be established; a diaganaplastic large cell lymphoma, peripheral B-cell lymphoma, T-cell nostic / incisional biopsy or limited surgery followed by chemolymphoma and Burkitt’s lymphoma. therapy along with radiotherapy is usually recommended. Lyons et The differentiation of breast lymphomas from lobular carcinoal6, recommended some combination of surgery, radiation and chemas, poorly differentiated breast carcinomas and pseudolymphoma motherapy as treatment of PBL. In this case, the disease is under is necessary. In addition to the absence of in situ lobular carcinoma, control for two years, and no further local or systemic recurrence adjacent to infiltrative areas, leucocyte common antigen (LCA or had been observed. Hence it can be concluded that differentiating CD45) positivity and cytokeratin-negativity are helpful findings to PBL from breast carcinoma is important, to avoid an unnecessary diagnose breast lymphoma over lobular carcinoma. In the present mastectomy in PBL. case, LCA (CD45) and CD20 staining showed diffuse membranous REFERENCES positivity, while cytokeratin immunoreactivity was negative. Poorly 1 Aguilera NS, Tavassoli FA, Chu WS, Abbondanzo SLT — Bdifferentiated carcinomas are cytokeratin positive but CD45- and cell lymphoma presenting in the breast: a histologic, CD20-. In some cases, anaplastic large cell lymphoma (ALCL) can immunophenotypic and molecular genetic study of four cases. be confused with DLBCL. However, ALCLs are CD45±, Alk1+, Mod Pathol 2000; 13: 599-605. EMA+, CD30+ and CD20-, while DLBCLs are CD45+, CD20+ 2 Topalovski M, Crisan D, Mattson JC — Lymphoma of the but ALK1-, EMA-and CD30-. Besides, marked anaplasia seen in breast: a clinicopathological study of primary and secondary ALCL, is usually absent in DLBCL. (Continued on page 403)

JUNE-2012

(54)

Case Note Tuberculosis of the gall bladder clinically mimicking carcinoma — a case report Sangeeta Sharma1, Rani Bansal2, Nivesh Agrawal3, Anjali Khare4, V V Bharosay1 Gall bladder tuberculosis is very rare and curable but, sometimes can be confused with the clinical diagnosis like carcinoma. A 32-year-old male presented with acute pain in right abdomen for one month and fever off and on for two months. CT scan (whole abdomen) showed features suggestive of lymphadenopathy although peroperatively no significant lymph node could be identified but there were multiple white patches on gastrohepatic ligament and neck of gall bladder probably which were identified as lymph nodes on scanning. On the basis of peroperative findings clinician diagnosed it as a case of carcinoma gall bladder and was subjected to cholecystectomy. On histopathological examination it turned out to be tuberculosis gall bladder. Therefore tuberculosis of gall bladder can mimic carcinoma clinically. [J Indian Med Assoc 2012; 110: 402-3]

Key words : Gall bladder, tuberculosis.

A

bdominal tuberculosis is common in developing countries but tuberculosis of gall bladder is extremely rare. To the best of our knowledge till date approximately 50 cases have been reported1. The first case was reported by Lacereraux in 18712. Gall bladder tuberculosis is more common in females than males and it is commonly seen over 30 years of age3,4. Gall bladder is comparatively resistant to tuberculosis due to high concentration of bile acids in pure bile3,4. It becomes affected by contiguous spread of infection from adjacent caseating lymph nodes, peritoneum and haematogenous route3. The clinical presentation of tuberculosis of gall bladder is same as cholecystitis and is often associated with gall stones2,3. The diagnosis of gall bladder tuberculosis is often missed prior to surgery or biopsy. In the present case also clinical diagnosis of carcinoma gall bladder neck was made but histopathologically it turned out to be a case of tuberculosis of gall bladder. This case report is to highlight that completely curable disease like tuberculosis can be confused with such a grave clinical diagnosis like carcinoma5. CASE REPORT A 32-year-old male was admitted with the complaint of acute abdominal pain. He also complained off and on pain in right abdomen for one month and history of fever off and on for 2 months. There was no history of clay coloured stool, jaundice, itching, haematemesis or melaena. There was history of pulmonary tuberculosis about 10 years back for which he had taken full course of antituberculosis therapy (ATT) for 10 months. Family history was also suggestive of tuberculosis. Examination — Patient was of average built with no other significant findings. On per abdominal examination liver, spleen and Department of Pathology, Subharti Medical College, Meerut 250002 1 MD (Pathol), Assistant Professor 2 MD (Pathol), Professor and Head of the Department 3 MS (Surg), Assistant Professor of Surgery 4 MD (Pathol), Associate Professor; At present : Professor 402

gall bladder were not palpable. Investigations — Haematological and biochemical investigations were within normal limits. His x-ray chest revealed calcified spots in upper zone of both the lungs suggestive of old case of bilateral tuberculosis. CT scan (CECT-whole abdomen) showed multiple hypodense non-contrast enhancing areas in aortic, paraaortic and periportal region suggestive of lymphadenopathy. All the viscera including gall bladder were normal. No stones were identified on sonography or CT. Surgery — Exploratory laparotomy was planned with a clinical diagnosis of lymphoma or secondaries. Peroperatively no significant lymph node could be appreciated but there were multiple white patches on gastrohepatic ligament and on neck of gall bladder, probably which were identified as lymph nodes on scanning. Cholecystectomy was performed with the strong suspicion of carcinoma gall bladder neck and specimen was subjected to histopathology to rule out or confirm the malignancy. Pathology — Gall bladder measured 7x3x1.5cm. On cutting no stones seen. Wall of the gall bladder was focally thickened (1-1.2cm) at neck towards the body and showed gray-white nodular areas with necrosis, replacing normal appearance of neck wall (Fig 1). Rest of the gall bladder was normal. Sections from neck, body and fundus were taken and observed. Sections from nodular areas showed that gall bladder was studded with numerous epithelioid cell granulomas with area of caseous necrosis. Granulomas were seen in all the layers from mucosa to serosa and also in periserosal tissue. There was no evidence of malignancy. Ziehl-Neelsen stain revealed many acid-fast bacilli (AFB). Follow-up — After three months patient improved dramatically after putting on ATT. DISCUSSION According to National survey population, patients suffering from active disease of tuberculosis in India is 20.5 millions (2%), of

JUNE-2012

TUBERCULOSIS OF THE GALL BLADDER CLINICALLY MIMICKING CARCINOMA — SHARMA ET AL

Fig 1 — Opened up Gall Bladder Exhibiting Nodular Thickening of Neck Wall (Arrows)

which 4.1 millions (0.4%) are sputum positive and rest are sputum negative (1.6%) but radiologically active6. Despite this massive prevalence only about 50 cases of gall bladder tuberculosis have been reported to the best of our knowledge1. Pain and fever were the main clinical features in the present case. This was in accordance with the previous reports1,5. Presence of jaundice was infrequent finding, as reported previously7 and was absent in the present case also. Most cases of gall bladder tuberculosis are associated with underlying gall-stones or cystic duct obstruction1 . In this case there was no association with gall-stones, this was similar to the previous case reported8 in which no stone was visualised on sonography or CT. Imaging morphology of gall bladder tuberculosis has no pathognomonic diagnostic features. It can mimic acute cholecystitis3, chronic cholecystitis, gall bladder mass5 and multiloculated thick walled gall bladder8. However in this case gall bladder was normal on imaging. As our information goes the normal gall bladder on imaging has not been previously described. Presence of features like portal, mesenteric and reteroperitoneal adenopathy, mesenteric thickening and ascitis if present favour the diagnosis of tuberculosis3,5, although these were absent in the present case. Peroperatively multiple superficial patches were found on the gastrohepatic ligament. On histopathological examination there may be localised ulceration or there may

(55)

403

be typical tuberculous nodules of varying sizes and numbers in the wall of gall bladder. In the present case nodular thickening was present only at neck region and microscopically gall bladder was studded with tuberculous granulomas in all the layers. Four types of gall bladder tuberculosis have been described : (A) Miliary tuberculosis in children with ulcerating tubercles in the gall bladder, (B) gall bladder tuberculosis in association with severe generalised tuberculosis, (C) isolated gall bladder tuberculosis, (D) gall bladder involvement in association with tuberculosis in other intraperitoneal organ . The fourth group is said to be the commonest type1. In the present case it was not clear whether the gall bladder tuberculosis was primary or secondary to lung lesion, patient took full course of treatment and pulmonary lesions were found healed. In between he was asymptomatic. This case highlights the fact that the gall bladder tuberculosis can present without significant local findings on imaging and to emphasise the importance of histopathological examination after cholecystectomy to avoid missing this rare, but curable disease which was clinically misdiagnosed as malignancy. REFERENCES 1 Abasca J, Martin F, Abreu I — Atypical hepatic tuberculosis presenting as obstructive jaundice. Am J Gastroenterol 1985; 83: 1183-6. 2 Lancereaux E — Atlas d’anatomic pathologique. Paris: Victor Masson et Fils, 1871: 70. 3 Abu-Zidane FM, Zayat I — Gall bladder tuberculosis: a case report and review of the literature. Hepatogastroenterology 1999; 46: 2804-6. 4 Duan JG, Liu CL, Chen Y — One case of gall bladder tuberculosis. Chin J Radiol 1992; 26: 379. 5 Jain R, Sawhney S, Bhargava D, Berry M — Gall bladder tuberculosis: sonographic appearance. J Clin Ultrasound 1995; 23: 327-9. 6 Chakraborty AK — Expansion of the Tuberculosis Program in India : the Policy Evolution towards Decentralization and Integration. Pune: The Center for Health Research and Development (CHRD)-– a unit of the Maharashtra Association of Anthropological science, Pune, India, 2003. 7 Faria M, Wani J, Ravishankar R, Desai S, Kale CH — Acute tuberculous cholecystitis. BHJ 2003; 18: 12. 8 Gulati MS, Seith A, Paul SB — Gall bladder tuberculosis presenting as a multiloculated cystic mass on CT. Indian J Radiol Imaging 2002; 12: 237-8.

(Continued from page 401) cases. Arch Pathol Lab Med 1999; 123: 1208-18. 3 Talwalkar SS, Miranda RN, Valbuena JR, Routbort MJ, Martin AW, Medeiros LJ — Lymphomas involving the breast: a study of 106 cases comparing localized and disseminated neoplasms. Am J Surg Pathol 2008; 32: 1299-309. 4 Vardar E, Ozkok G, Cetinel M, Postaci H — Primary breast lymphoma cytologic diagnosis. Arch Pathol Lab Med 2005; 129: 694-6.

5 Wiseman C, Liao KT — Primary lymphoma of the breast. Cancer 1972; 29: 1705-12. 6 Lyons JA,Myles J,Pohlman B, Macklis RM, Crowe J, Crownover RL —Treatment of prognosis of primary breast lymphoma: a review of 13 cases. Am J Clin Oncol 2000; 23: 334-6.

JUNE-2012

(56)

Case Note Gastro-intestinal stromal tumour — a case report S R Agashe1, P P Patil2, M A Phansopkar3, Aslam Shivani4, S H Kulkarni5 Gastro-intestinal stromal tumours are rare tumours of the gastro-intestinal tract. Among nonepithelial tumours of gastro-intestinal tract, gastro-intestinal stromal tumours are the commonest but as they are not extensively documented, they are underestimated, poorly understood and inadequately treated for various reasons, particularly at peripheral centres in India. The gravity of the problem increases further as these tumours respond poorly to conventional cytotoxic chemotherapy and radiation therapy. Here a case of gastro-intestinal stromal tumour is reported. The patient was a 35-year-old male who was admitted with evidence of subacute intestinal obstruction. The haematological and biochemical tests showed moderate anaemia, raised serum aminotransferase aspartate (AST, SGOT) and mild hypoproteinaemia. Laparatomy revealed a jejunal tumour which was resected. The routine histopathological examination revealed a spindle cell tumour suggestive of gastro-intestinal stromal tumour – intermediate risk group. Immunohistochemical study showed strong positivity for c- kit confirming the diagnosis of gastro-intestinal stromal tumour. The patient was then referred to oncology centre for further management. [J Indian Med Assoc 2012; 110: 404-5]

G

Key words : Gastro-intestinal stromal tumour, c-kit.

astro-intestinal stromal tumour (GIST) is the commonest mesenchymal tumour of gastro-intestinal (GI) tract. It is also reported to arise from mesentery, omentum, retroperitoneum and pelvis1. Previously they were classified as smooth muscle tumours, nerve sheath tumours and tumours with no differentiation. The term stromal tumour was introduced in 1983, after Mazur and Clark failed to find ultrastructural evidence of smooth muscle or nerve sheath differentiation in several gastric tumours. GISTs are now thought to arise from stem cells related to interstitial cells of Cajal which are the pacemaker cells of the gut, associated with Auerbach’s plexus. The clinicopathologic findings of a case of GIST is reported here. CASE REPORT A 35-year-old male was admitted for abdominal pain, nausea and vomiting of 24 hours' duration. Investigations — The haematological investigations revealed moderate anaemia, mild neutrophilia, hypoalbuminaemia and slightly raised AST, SGOT. Surgery — With a pre-operative diagnosis of subacute intestinal obstruction, exploratory laparotomy was performed. On opening the abdomen a cystic mass of 7 cm diameter was seen arising from jejunum. The resection specimen was that of small intestine with a mass arising from it and measuring 7.5 x 6.5 x 5.0 cm. Department of Pathology, Bharati Vidyapeeth University Medical College and Hospital, Sangli 416416 1 MD, Professor 2 MD, Professor and Head of the Department 3 MD, Ex-Professor 4 MS, Lecturer of Surgery 5 MS, Professor of Surgery 404

Pathology — Cut section of the mass had granular grey white appearance. Microscopic examination revealed a spindle cell tumour which showed minimal nuclear atypia and less than 5 mitoses per 50 high power field (Fig 1, H&E, x40). Both surgical margins of the intestine were free of tumour. The biopsy was reported as GIST – intermediate risk group. Immunohistochemistry revealed strong positivity for c-kit. The patient was then referred to oncology centre for further management. DISCUSSION Although less common than epithelial neoplasms, mesenchymal tumours of GI tract are not rare. The main bulk of these mesenchymal tumours is formed by GISTs. Recent immunohistochemical and molecular evidence has prompted the concept of GIST as an umbrella term for all spindle cell tumours of the GI tract. A majority of GISTs (68-90%) express c-kit, a tyrosine kinase receptor of the immunoglobulin supergene family, which is also expressed by the gut pace maker cells – the interstitial cells of Cajal2. So as to develop a consensus approach to the diagnosis and prognostication on the basis of morphologic features, GIST workshop held by NIH in April 2001 has recommended classification of GIST in very low risk, low risk, intermediate risk and high risk categories depending upon the size of tumour and mitotic count per 50 high power field (Table 1)3. It has been modified to include the anatomic site by Rubin et al1 because small bowel GISTs carry a higher risk of progression than gastric tumours of similar size and mitotic activity. Although small intestinal GISTs are less common than gastric GISTs (36% and 51% respectively)4 they follow a more aggressive course. Miettinen5 analysed 906 cases of GIST arising from small intestine. Presence of diffuse nuclear atypia, epithelioid cytology, coagulative necrosis, ulceration and mucosal invasion were adverse

JUNE-2012

GASTRO-INTESTINAL STROMAL TUMOUR — A CASE REPORT — AGASHE ET AL

(57)

405

prognostic factors while small size, low mitotic activity and skeinoid fibres were favourable prognostic factors. The clinical symptoms depend upon the site of involvement, size of tumour and the precise portion of gut wall in which the tumour is located. The most common symptom is abdominal pain. GI bleeding, nausea, vomiting, weight loss and abdominal lump are other presenting symptoms. Clinical examination and imaging studies are contributory, however a definite diagnosis is obtained only by histopathologic study. FNAC and endoscopic biopsy or frozen section may not be useful in distinguishing between benign and malignant GISTs3. Aggressive GISTs commonly matastasise to the liver or throughFig 1 — Microphotograph Showing Minimal Nuclear Atypia out the abdomen. cal laboratory and most importantly unawareness on part of surThese tumours Table 1 — Riskwise Classification of GIST in geons as well as pathologists. It is necessary to (1) put the tumour rarely metastasise Terms of Size of Tumour and Mitotic Count Size Mitotic count in proper risk category, (2) plan proper margin-free surgical resecto lymph nodes. Risk (per 50 high tion, (3) give adjuvant therapy with tyrosine kinase inhibitors like Extra-abdominal power field) imatinib mesylate, especially for intermediate and high risk group spread is mainly