ISSN - 0971 - 9903

THE
JOURNAL OF
MAHATMA GANDHI INSTITUTE
OF MEDICAL SCIENCES
Volume 14, Number (i) March 2009

EDITORIAL 45 GENETIC STUDY - A HELPING HAND FOR

I Redesigning Self ! CLINICAL DIAGNOSIS
OP Gupta AM Tarnekar, JE Waghmare, P Bokariya,
IV Ingole, AK Pal
WORLD HEALTH DAY THEME, 2009 49 I Want My Father Back - Child’s Destiny.
v “ Save Lives - Make Hospitals Safe In Emergencies” BH Tripude, PN Murkey, VG Pawar,
S Anwar & B S Garg S Shende, A Keche, KS Singh

REVIEW ARTICLE 52 Dislocation Of First Metatarsal

Phalangeal Joint : A Case Report
1 Migraine : A Review
A Kumar, C Rathod, CM Badole, KR Patond
A Saxena, OP Gupta
7 Evaluation And Management Of The Patient DRUG UPDATE
With Esophageal Varices.
54 RENIN BLOCKERS - A Newer Therapy In
J Jain
Regulating Hypertension
12 Gastroesophageal Reflux In Children B Taksande, S Yelwatkar, UN Jajoo
A Taksande, KY Vilhekar
17 Face To Face With Nontuberculous BOOK REVIEW
Mycobacteria At Sevagram 57 Utopia Is Now Promised By Science!
DK Mendiratta, P Narang, R Narang Book - Future Human Evolution : Eugenics
In Twenty First Century
ORIGINAL ARTICLE Anupama G.
22 Effect Of Physiological Factors On Soleus
H-Refles In Normal Human Subjects OBITUARY
B Ghugare, R Singh, AP Jain
61 Dr Michael Ellis Debakey
26 Assessment Of Functional Capacity In
Elderly Population By Elderly Mobility Scale In NOBEL PRIZE IN PHYSIOLOGY OR MEDICINE
Wardha (District) Maharashtra India
25 Year 2008
SD Ganvir, SS Ganvir
62 Year 1909
38 Suicides In Elderly Age-Group In Wardha Region
Of Maharashtra In A Period Of Five Years,
POEM
From 1st January 2001 To 31st December 2005.
PN Murkey, BH Tirpude, VG Pawar, KS Singh. 63 The Liberation
Dr OP Gupta
CASE REPORT
64 Abstracts of The Papers Presented in The
43 Inability To Start Hemodialysis After National and International Conferences
A Smooth Dual Lumen Hemodialysis Held During The Year 2008
Catheter Insertion Procedure : A Case Report
S Kumar, AP Jain 91 Instruction To Authors
 THE JOURNAL OF
MAHATMA GANDHI INSTITUTE
OF MEDICAL SCIENCES
Vol. 14, No. 1, 2009

CHIEF PATRON
SHRI DHIRU S MEHTA
EDITOR IN CHIEF
Dr O P Gupta
PATRON
Dr P NARANG
Dr S CHHABRA

ASSOCIATE EDITORS
Dr A P Jain Dr P Chaturvedi
Dr B S Garg Dr S P Kalantri
Dr D K Mendiratta Dr M V R Reddy

ASSISTANT EDITOR MGIMS FACULTY

Dr R Joshi Dr S Pande Dr K V Desikan
Dr R Narang Dr B C Harinath
EDITORIAL ADVISORY BOARD Dr R K Gupta Dr N Gangane
Dr B S Chaubey, (Nagpur) Dr G M Taori, (Nagpur)
Dr B H Tirpude Dr P B Behere
Dr M Kothari, (Mumbai) Dr A B Vaidya, (Mumbai)
Dr A K Shukla Dr Ramji Singh
Dr N N Wig,(Chandigarh ) Dr J L Gupta, (New Delhi)
Dr A T Tayade Dr V Vyas
Dr K K Aggarwal,(New Delhi) Dr Robert A Ollar, (U.S.A.) Dr P S Nagpure Dr R S Naik
Dr Madhukar Pai, (U.S.A.) Dr Sunil Gupta, (Nagpur) Dr K R Patond Dr Dilip Gupta
Dr Anil Narang (Chandigarh) Dr P S Shankar (Gulbarg) Dr K Vilhekar Dr S Kar
Dr J Anbalagan (Pondichery) Dr M G Pillai (Bombay) Dr I Ingole

EDITORIAL CORRESPONDENCE
The Editor,
JOURNAL OF MGIMS
Department of Medicine,
M.G.Institute of Medical Sciences, SEVAGRAM 442102 (MS)
Tel : (07152) 284341 to 55 Extn : 327 - Ext. : 23, Fax : (07152) 284333
E-mail : jmgims@gmail.com Web Site : www.mgims.ac.in
Printed published & distributed by Dr OP Gupta for Mahatma Gandhi Institute of Medical Sciences, Sevagram 442102.
 Editorial

REDESIGNING SELF!

We celebrated bicentenary of Charles Robert Darwin (1809-1882) on 12th Feb 2009. Darwin’s
“On the Origin of Species by Means of Natural Selection” in late 19th century revolutionized the
whole concept of the origin of life. The theory of evolution put forth by him convinced people at that
time. Most people thought Drawinian science is a universal solvent that can sort out most recalcitrant
problems of the society, consciousness, politics, literature and more, they mislead them, writes Steve Jones
in an essay.

According to Darwin’s concepts, initially there was spontaneous generation of life by chance
from inanimate matter into unicellular form and through adaptation, conflict and environmental
influences it evolved in different species, including the present day man. Though in his own time
other scientist criticized and refuted his theories. Darwin himself acknowledged that only by making
a supreme effort of imagination to think about the vast stretches of time in which tiny changes in form
can take place. In moral terms, he accepted that ‘ homosapiens was something more—“of all the differences
between man and animals, the moral sense or conscience is by far the most important” (Steve Jones)

‘ Dr Hargovind Khorana and colleagues were awarded Noble prize for discovering the genetic
code-the DNA which is regarded as master molecule of life. The genes containing DNA molecules have
the growth plan and are capable of replicating and sustaining the growth of a creature. So are we
our genes? Or the proteins generated from DNA via RNA? Life is a mystery and for time immemorial
search is on to find the final answer.

Thus the ‘genes’ promote their self replication.Genes use individuals to make more genes.
When genes adopt the bodies it becomes their principal mode of transport. Every part of us is either
an adaptation or by-product of adaptation. Why we live, suffer or die is basic question! Answer is provided
again in the genetic concept—we live because by working together, the genes can build bigger and
better adaptation then they can by going alone. We suffer because our adaptations are designed to
promote not health or happiness but gene replication. And we die because we are built not to last but

J MGIMS, March 2009, Vol 14, No (i), i - iii

Editorial

to be replaced by new gene-replicating machines. Thus the genes are potentially immortal, while the
vehicle they create—us—are not. (Helena Cronin, Oliver Curry)

It reminds me of shloka from Shrimadbhagvatgeeta —-

Oklkafl th.kkZfu ;Fkk fogk;]uokfu xzz.gkfr ujksijkf.k
rFkk ‘kjhjkf.k fogk; th.kkZU;U;kfula;kfr uokfu nsgh ¼2%22½
uSua fNUnfUr ‘kL+=kf.k uSua ngfr ikod%
u pSua Dysn;UT;kiks u ‘kks”k;fr ekjqr% ¼2%23½

The embodied soul casts away old and takes up new bodies as a man changes worn out
raiment for new, thus it uses the body as vechicle for its own transport The soul is indestructible,
and immortal. However it remains debatable whether the genes per say can be equated with that of
thesoul.

The completion of human genome project by Francis Collins and Craig Venter in 1995 has
given rise to new ideology, and new thinking —Eugenics- “liberal vision for the improvement in the state of
all humankind”. In view of Dr glad, it is opening up new opportunities for the enhancement of both
the physical and mental conditions of human species. Here is an attempt to examine Darwinism
critically. Hansen NE et al write,”Common understanding of the naturalness of natural selection
appears to be fundamentally disconnected from the daily lived experience of the human species.
Impairment and disability are not commonly understood as natural variations in human biology but
as biology having gone wrong”.

The eugenic practices are on going since long. Sir Francis Galton (1883), Darwin’s cousin
coined the word eugenic in his book “Inquiries into Human faculties”. Individual efforts are already
in full swing, like sterilization or vasectomies for population control, permitted selective abortions on
health ground, one child norms of China.“How can we best protect the interest of still unborn generation?”
is the recent thinking. A close ended question is asked ‘do people have the right to give birth to babies
who in all probability will grow up feeble minded or who are likely to suffer from devastating genetic
illnesses? Or Do we not want our next generation to be genius and physically fit. And here is the crux of
the matter that is the ‘use and abuse of the eugenics. The eugenicists then ask that forced sterilization

ii

J MGIMS, March 2009, Vol 14, No (i), i - iii

 Editorial

of persons with genetically predetermined low IQ and major genetic illnesses should be reinstituted.
And many more such radical suggestions are put forth by them like, curbing reproductive rights of
criminals, insane, feeble minded & paupars, not to discourage female feticide, reducing age of
pregnancy, allowing polygynae, asexual in-vitro fertilization etc which are likely to be unpopular, and
unacceptable socially and morally (please read the book review’ on ‘Future Human Evolution’ in this
issue). This is so called the overall efforts to ‘redesign self’. It may be labeled as barbaric, inhumane, mad
idea or materialistic reductionism etc by the moralists. The society and the moralists react strongly to
oppose such proposals at the initial stages, but a time comes when their slogans lose the sharpness and
they themselves become insensitive to such issue, and the things like euthanasia are legalized and
latermisused.

“We know what we are, but not what we may be”

HAMLET

Darwin wrote “man in distant future will be far more creative than he now is”. Life is
developed by primarily natural and sexual selection. Life was material and consciousness an
epiphenomenon. (Athar Yawar) The modern science has provided an apparently secure way for human
being to excel themselves. Though essence of excellence is material and not spiritual. All the human
behaviors, emotions, and morality could be explained by ultimately self-centered urge to survive and
reproduce. The era of evolution of species, or specifically homosapiens by genetic (artificial) selection
rather than natural selection is on the anvil.

Dr. O P GUPTA

1. Lancet, Darwin’s gifts, December ‘2008

2. Future of Human Evolution, John Glad (2006)

Hermitage publishers

iii

J MGIMS, March 2009, Vol 14, No (i), i - iii

" SAVE LIVES - MAKE HOSPITALS SAFE IN EMERGENCIES "
World Health Day Theme, 2009
SANAM ANWAR* & B S GARG**
The World Health Day is one of WHO's
most visible opportunities to raise awareness in
global health priorities. On 7 April 2009, the
World Health Organization will mark World
Health Day (WHD), the theme of which being
"SAVE LIVES - MAKE HOSPITALS SAFE IN
EMERGENCIES." This theme underscores the
critical importance of ensuring health facilities
are built safely, possess the resilience to withstand
various crises and can deliver services in any
emergency scenario.
The health centres, staff and other health
care providers in the area are critical life-lines
for vulnerable people in disasters - treating
injuries, preventing illnesses and caring for
people's health needs. They are cornerstones for
primary health care in communities - meeting
everyday needs, such as safe childbirth services,
immunizations and chronic disease care that must
continue in emergencies. Often, already fragile
health systems are unable to keep functioning
through a disaster, with immediate and future
public health consequences. Many people are left
even without emergency care during and after
disasters when hospitals and health facilities fail
to perform.
Global Context
Globally, natural hazards and disasters
are set to increase. Increased frequency of hazards
such as floods, droughts and cyclones, are
* Associate Professor, ** Professor and Head,
Address for correspondence : Dr. Sanam Anwar, Dept. of
Community Medicine, MGIMS, Sevagram, Wardha,
MH-442102. Email : sanamanwar@gmail.com
worsening the impacts on lives and livelihoods.
Hundreds of hospitals and health facilities are
destroyed or damaged every year by disasters. The
number of people at risk has been growing by
70-80 million per year. According to global
statistics, Asia is the continent exposed to the
most hazards, and has the highest numbers
of people vulnerable to hazards, due to both
physical and socio-economic factors. The World
Disaster Report 2006 highlighted the discouraging
fact that around 58% of the total number of
people killed in natural disasters during the
decade 1996-2005 was from the Asia region.
In December 2004, the Tsunami in the
Indian Ocean destroyed 61% of the health facilities
in Banda Aceh, Indonesia. In August, 2007
within two minutes, the city of Pisco, Peru lost
97% of its hospital beds to an 8.0 magnitude
earthquake. In the October 2005 earthquake in
Pakistan, 50% of the health facilities in affected
areas were completely destroyed.
In this context, the importance of disaster
risk reduction and preparedness requires great
emphasis. The trend towards a focus on this area
began with the International Decade for Natural
Disaster Reduction (IDNDR) in 1990. At the
closure of the decade, the International Strategy
for Disaster Reduction (ISDR) was approved by
the United Nations General Assembly (UNGA)
in 1999 to coordinate action for disaster risk
reduction worldwide.
Hyogo Framework for Action 2005-2015 (HFA)
Less than one month after the tsunami,
at the January 2005 World conference on Disaster
J MGIMS, March 2009, Vol 14, No (i), v - x
“ Save Lives - Make Hospitals Safe In Emergencies “ World Health Day Theme, 2009
Reduction, 168 nations endorsed the Hyogo
Framework for Action 2005-2015 (HFA). Among
other challenges, the HFA calls on countries to
"Integrate disaster risk reduction planning into
the health sector; promote the goal of HOSPITALS
SAFE FROM DISASTERS by ensuring that all
new hospitals are built with a level of resilience
that strengthens their capacity to remain func-
tional in disaster situations and implement
mitigation measures to reinforce existing health
facilities, particularly those providing primary
health care.
Later in 2005, disaster health professionals
primarily from SEAR countries took initial steps
towards filling the identified gaps and improving
the level of disaster preparedness region-wise by
developing benchmarks against which to measure
progress. One benchmark (Benchmark 11) calls
for health facilities to be built or modified to
withstand expected risks posed by natural
hazards. Issues to be ensured are :
Š multi-sectorality : there is a need for the
health system to include and engage
lawmakers and regulation enforcers,
especially for building codes, engineers
and architects ;
Š expansion beyond hospitals to include other
critical facilities such as blood banks and
laboratories is imperative; and,
Š hazards and risk assessment-based planning
for hospitals is essential so that plans remain
appropriate and stay within available
resources
Regional Context
The 11 member countries of WHO's
South-East Asia Region are highly vulnerable to
disasters. The diagram shows the situation in the
region.
vi
Figure I
(Source: The World Disasters Report 2006)
There are countless examples of health infra-
structure-from sophisticated hospitals to small
but vital health centres-that have suffered this
fate. A few are below:
Š 2001, Gujarat (India) Earthquake
3812 health facilities were destroyed during
the earthquake. There was total collapse of
the health infrastructure in Kutch district,
which was the worst affected. Most difficulties
encountered during the response phase in
the Kutch district were due to the collapse
of the health infrastructure. The cost of
reconstruction for the health sector alone
was estimated at US$ 60 million.
Š Earthquakes and Tsunami of 26 December
2004
The earthquake and tsunami of 26 December
2004 was a watershed event for countries in
WHO's South-East Asia Region. Never before
had one single event affected such a large
number of countries so severely.
z Aceh province (Indonesia) Indian Ocean
Tsunami
It damaged 61% of health facilities and
killed nearly a third of the area's midwives,
a major loss for women's health.
J MGIMS, March 2009, Vol 14, No (i), v - x

z Maldives
One regular hospital and 20 health
centers were destroyed. As many as 5000
people had to be evacuated from 13 is-
lands.
z Sri Lanka
92 health facilities were destroyed. This
included 35 hospitals.
z India
7 district hospitals, 13 primary health
centers and 80 sub-centers were damaged
in the southern Indian States of Tamil
Nadu, Andhra Pradesh, Kerala, the
Union Territory of Pondicherry and the
Andaman and Nicobar Islands.
Š 2005 December, Jammu & Kashmir (India)
Earthquake
38 health facilities in the Kashmir were
completely damaged and 14 were partially
damaged. One such case is the Uri Hospital
in the Baramulla district, which serves a
population of 130,000 was totally destroyed.
Patients were shifted to buildings which
were under construction and those who were
in a position to be carried, were taken to the
temporary health care outlets set up by the
Directorate of Health Services.
Š 2006 March, Bantul district (Indonesia)
Earthquake
One of the six hospitals in the district was
destroyed. This led to overcrowding in the
surrounding hospitals. Bantul was worst hit
by the earthquake.
Š 2007 February, Indonesia Floods
49 health facilities were damaged by the flood
waters.
vii
S Anwar & B S Garg
Š 2008 May, China earthquake
More than 11 000 medical institutions were
damaged in China's Wenchuan earthquake
in May 2008, forcing tens of thousands of
people to seek treatment elsewhere.
Š Current conflicts in Ethiopia and Gaza are
interrupting primary health services, such
as immunizations.
Why focus on health facilities safe from
disasters?
Health facilities and health services are
the community's lifeline in normal times, but
especially so in times of crisis. It is the main
location for providing care for the injured and,
in many cases, a point for delivery of relief goods.
It is also the point where information on missing
people can be collected. Damage to the health
system can include the loss of services, human
resources and damage to health-related infra-
structure. This can create gaps in service
provision following the disaster and lead to
secondary disasters. Public health infrastructure
losses include damaged hospitals, drug stores,
cold rooms, preventive health care offices, health
staff accommodation facilities, district health
offices, vehicles, and medical equipment in
hospitals, stores, clinics. Disasters create an
intensive demand for health services. In addition
to treating disaster victims, hospitals must
quickly resume treatment of everyday emergencies
and routine care.
Hospitals provide a great social value to
communities and an essential sense of security.
Hospitals represent an enormous investment for
any country. In some regions of the world, the cost
of running hospitals consumes approximately
70% of the budget of the ministries of health; in
J MGIMS, March 2009, Vol 14, No (i), v - x
“ Save Lives - Make Hospitals Safe In Emergencies “ World Health Day Theme, 2009
remote areas and in small island nations,
frequently there is only one facility of this type;
losing this hospital represents a 100% loss.
Destruction or loss of functionality poses a major
economic burden. Direct economic losses involve
more than the structure; the value of non-structural
elements can be higher than the structure itself.
USD 350 million was the estimated amount for
projects and programmes to rebuild health
facilities in Aceh post tsunami; USD 60 million
to rebuild health facilities after the Gujarat
earthquake of 2001.
Certain factors put hospitals and health
facilities at risk during disaster :
Š Buildings: The location, design specifications
and resilience of the material used, all
contribute to a hospital's ability to withstand
natural hazards.
Š Patients : Damage to hospitals multiplies
patient vulnerability and increase in numbers.
Š Hospital beds : Increase in demands for
emergency care.
Š Health Workforce : The loss or unavailability
at the time of disaster, hiring outside personnel
to sustain response capacity - add to the over-
all economic burden.
Š Equipments : Damage to non-structural
elements can cost 80% of the total costs.
Š Basic lifelines and services : Electrical power,
water and sanitation, waste management and
disposal can affect the entire health facility.
Civil conflicts have also made it difficult for
health facilities to cope with a sudden influx of
injured people. In these situations, the problem
is usually not the physical or structural integrity
of a hospital or clinic, but understaffing, the lack
viii
of access to supplies and essential utilities.
During mass demonstrations in Nepal in 2006,
WHO-led hospital assessments revealed that the
main problem was understaffing and the lack of
access to "lifelines" (eg. power, gas).
Several initiatives have been started to
reduce a health facility's risk of destruction in
an emergency. However, it is important to know
what we mean by safe health facilities.
Safe health facilities
The term 'safe health facilities' encom-
passes all health facilities - large or small, urban
or rural, complex or primary care centres. A
health facility can be classified as safe when three
aspects are in place :
Š Physical integrity - in accordance with the
hazards in its environment, allowing the
facility to remain intact and not collapse in
disasters, killing or injuring patients and staff;
Š Continued functionality - Installed capacities,
so that it will continue to function, providing
critical services and absorb extra needs when
there is an emergency
Š Contingency plans and a well-trained health
workforce that is ready and able to deal with
the health consequences of emergencies.
How to keep safe health facilities
The processes leading to the HFA represent
a significant change from the way disasters have
been dealt with in the past. Whereas previous
strategies were focused on emergency management,
humanitarian response and relief measures,
today there is strong recognition that risk and
vulnerability reduction are key in reducing the
negative impacts of hazards, and thus essential
to the achievement of sustainable development.
J MGIMS, March 2009, Vol 14, No (i), v - x

Š Well-built or retrofitted hospitals have
remained functioning following disasters.
The health sector has excellent examples of
and substantial accumulated experience
contributing to in safe health facilities.
Š The knowledge exists to assess vulnerability
and reduce risk in health facilities. The cost
of protection is much less when included in
the design stage. Vulnerability assessments
for structural and non-structural aspects of
hospitals in Nepal was done with the goal to
keep hospitals in the Kathmandu Valley
physically intact and functioning in the
scenario of an earthquake. The work to keep
health facilities safe also entails training and
planning. The key technical issues that must
be addressed are hazard assessment, site
evaluation, appropriate conceptual design,
competent analysis, complete pre-construction
detailing, quality control during construction
and planned maintenance. Several countries
are working to keep hospitals safe, improving
preparedness to protect lives.
z In Mexico, trained evaluators have
diagnosed the safety of 200 health
facilities, identifying which facilities
need improvements.
z Multi-functional facilities for health,
education and agriculture were built in
Bangladesh to aid relief after cyclones
and floods - which saved thousands of
lives after Cyclone Sidr in 2007.
z In Japan, Pakistan and Peru, health facilities
are now built to withstand earthquakes.
z After the Gujarat earthquake in 2001, all
health facilities were rebuilt to interna-
tional standards to make this critical
infrastructure disaster resilient.
ix
S Anwar & B S Garg
Activities to address the problem
The UN International Strategy for
Disaster Reduction (UN/ISDR) and the World
Health Organization (WHO) are partnering with
governments, international and regional organi-
zations, non-governmental organizations and
individuals worldwide to raise awareness about
how and why we must redouble efforts to protect
health facilities and ensure they can function
during and in the aftermath of disasters. The
theme of the World Disaster Reduction Campaign
2008-09 is HOSPITALS SAFE FROM DISAS-
TERS: REDUCE RISK, PROTECT HEALTH
FACILITIES, SAVE LIVES. The campaign is
implemented with support from the Global
Facility for Disaster Reduction and Recovery
(GFDRR) of the World Bank. The campaign's
objectives are :
z Contribute to structural resilience of health
facilities.
z Help hospital services continue to function
in the aftermath of emergencies and disasters
z Assist health institutions to improve risk and
emergency management capability
z Involve health professionals in identifying
and reducing risk.
z Take steps to incorporate these priorities into
national development plans.
The campaign urges all those responsible
such as decision makers, politicians, architects,
engineers, public health professionals, development
banks and donors to come forward with required
policies, legislation, technical guidance and
public awareness to make hospitals and health
facilities safe from disasters.
A regional Consultation on keeping
Health Facilities Safe from Disasters was held
in New Delhi in April 2008. It recommended
the following key action points :
J MGIMS, March 2009, Vol 14, No (i), v - x
“ Save Lives - Make Hospitals Safe In Emergencies “ World Health Day Theme, 2009
z Establish safe hospitals committees
z Ensure new health facilities are safe at
planning and design stage
z Conduct contingency planning and training
for existing health facilities
z Obtain political and donor commitment
through advocacy.
The theme of World Health Day, 2009
"SAVE LIVES. MAKE HOSPITALS SAFE
IN EMERGENCIES" is an opportunity for
advocacy. This year on World Health Day WHO
and international partners will underscore the
importance of investing in health infrastructure
that can withstand hazards and serve people in
immediate need. They will also urge health
facilities to implement systems to respond to
internal emergencies, such as fires, and ensure
the continuity of care. Events around the world
will highlight successes, advocate for safe facility
design and construction, and build momentum
for widespread emergency preparedness - to save
lives and improve global health. In summary with
current knowledge, existing resources, and a
strong political commitment, it is possible to
stop disasters and reduce risk in the health
sector. Everyday problems in providing routine
health services can be looked for. However, in
large-scale emergencies, the backbone of lifesaving
health services must be preserved.
References :
1. Hospitals safe from disasters. World Disaster
Reduction Campaign, 2008-2009 (ISDR, WHO).
2008.[Online]. [Cited 2009 February 20].
Available from: http://www.unisdr.org/eng/
public aware/world camp/2008-2009/pdf/
wdrc-2008-2009-information-kit.pdf
2. Emergency and Humanitarian Action: FOCUS
(WHO) 2008. [Online]. [Cited 2009 February 20].
Available from: http://www.searo.who.int/
LinkFiles/Hospitals_Safe_from_Disasters_
EHAFOCUSnew30.pdf
3. Safe hospitals, a collective responsibility, a Global
measure of Disaster Reduction (PAHO, WHO)
2005. [Online]. [Cited 2009 February 20].
Available from: http://www.paho.org/english/dd/
ped/SafeHospitalsBooklet.pdf
4. World Health Day 2009: Save lives, make hospitals
safe in emergencies. [Online]. [Cited 2009
February 20]. Available from: http://
www.searo.who.int/worldhealthday2009/
World_Health_day.htm
5. Hospitals safe from disasters. World health day
2009. [Online]. [Cited 2009 February 20].
Available from: http://www.safehospitals.info/
J MGIMS, March 2009, Vol 14, No (i), v - x
 Review Article

MIGRAINE : A REVIEW

A SAXENA*, OP GUPTA**

Headache is the commonest problem, Migraine Historical timeline :

men have been enduring since the time immemorial. Date Event
Migraine, one of the more troubling cause of 400 BC Hippocrates states that headaches
headache, afflicts approximately 15% of women are derived from “humors” (fluids
and 6% of men, No age is immune but it generally or vapors) circulating in the body,
starts in younger generation. illness resulted from imbalances of
natural elements.
Migraine is a markedly disabling condition,
and exerts a significant burden on the sufferer 200 AD Galen introduces the term
“migraine”, which is derived from
in terms of pain, suffering and imparied quality
the Greek world hemicrania.
of life. This results in a large economic burden
1598 Charles Le Pois described premonitory
on society, both in therms of direct medical costs
symptoms and migraine with aura
of care and indirect costs due to lost work time
for the first time.
and working at reduced productivity. It is a
1938 Graham and Wolff demonstrate the
common clinincal disorder that continues to
efficacy of ergotamine in aborting
be underrecognised, underdiagnosed and migraine by constricting cerebral
undertreated. blood vessels.
Migraine is a heterogeneous condition, 1943 Stoll and Hoffman synthesize DHE
with headache attacks varying in frequency, (dihydroergotamine).
duration, symptomatology and associated 1945 Horton, Peters, and Blumenthal use
disability, both between sufferers and between DHE to treat acute migraine at the
attacks in the same individual. It can be defined Mayo clinic.
as a benign and recurring syndrome of headache, 1976 Propranolol is reported to be
nausea, vomiting, tenderness around the face efficacious in migraine prevention.
and scalp and/or symptoms of neurologic 1991 Pat Humphrey reports the efficacy
dysfunction in varying admixtures. It is a of Sumatriptan in aborting acute
neurovascular event the occurs in people with a migraine in human volunteers.
genetically susceptible sensitive nervous system. 1993 Sumatriptan is first triptan to be
Migraine is a complex disorder with polygenic FDA approved and marketed.
inheritance and a strong environmental 2002 Valproic acid is FDA approved for
component. migraine prevention.
**Professor, *Sr. Lecturer, Add. for correspondence : 2004 Topiramate is FDA approved for
Dr Amrish Saxena, Deptt. of Medicine, MGIMS, migraine prevention.
Sewagram. Email : dramrishsaxena@rediffmail.com

J MGIMS, March 2009, Vol 14, No (i), 1 - 6

Migraine : A review
Pathogenesis :
It was widely held for many years that
the headache phase of migrainous attacks was
caused by extracranial vasodilatation and that
the neurologic symptoms were produced by
intracranial vasoconstriction (i.e., the “vascular”
hypothesis of migraine).
Migraine is now considered to be a
neurovascualr disorder because its pathology
involves important interactions between the
cerebral nerves and blood vessels. A simple
clinical definition of migraine is “a referred
pain from duramater and blood vessels” It is a
clinical syndrome of self-limited neurogenic
inflammation. The concept of neurogenic
inflammation(NI), referring to both vasodilatation
and increased vascular permeability is mediated
by the peripheral release of neuropeptides such
as substance P(SP), neurokinin A(NKA),
endothelin-3 (ET-3), and calcitonin gene-related
peptide (CGRP).
The release of tachykinins and endothelin
-3(ET-3) from trigeminal neurons induces
dural vascular permeability and vasodilatation
via activation of tachykinin receptor (1 (Tacr 1)
and endothelin receptor type B (Ednrb) on
endothelial cells. Endothelial cell receptor
stimulation results in cellular contraction, leading
to plasma protein extravasation (PPE), which is
the most recognized physiological hallmark of
neurologic inflammation (NI), and NO-induced
vasodilatation. By contrast, the release of calcitonin
gene-related peptide (CGRP) from trigeminal
neurons- also a key physiological commponent
of NI- does not affect vascular permeability but
does induce neurogenic vasodilatation (NV) via
the direct, (Endothelium independent) relaxation
of vascular smooth muscle.
Fig - Mechanism of migrain. Migraine is probably
triggered through hypothalamic or cortical mechanisms.
Trigeminal innervation of pain sensitive intracranial
structures, dura mater, and blood vessels provides pain
input through trigeminal ganglion to trigeminal nucleus.
The nucleus extends from medulla to C2 (accounting for
commonly reported neck pain with migraine) and sends
fibres to thalamus. 5-Hydroxytryptamine receptors on
blood vessel (5-HT 1B) and neurone (5-HT1D) mediate
vasoconstriction and presynaptic inhibition, thus
antagonising vasodilator effects of calcitonin gene
related peptide. Peripheral transmission in blocked by
sumatriptan and ergotamine, while central transmission
is also blocked by zolmitriptan7.
Current theories propose that
(1) In genetically predisposed individuals
migraine-specific triggers promote
meningeal nociceptor activation, dilation of
meningial blood vessels and the activation
of trigeminovascular system.
(2) Sensitization of cells in the trigeminal nucleus
caudalis in the medulla (a pain-processing
center for the head and face region) results
in the release of vasoactive neuropeptides,
including substnace P and calcitonin gene-
related peptide,
(3) These peptide neurotransmitters induce a
J MGIMS, March 2009, Vol 14, No (i), 1 - 6

neurogenic inflammation that is characterized
by vasodilation, vessel leakage, and mast cell
degranulation causing peripheral nociceptor
sensitization.
(4) In addition, neuropeptides relay nociceptive
impulses to the CNS, leading to severe
migraine pain; to central sensitization, which
lowers the pain-responsive threshold. This is
responsible for cataneous allodynia11. The
non-nociceptive stimuli become painful.
Simple activities like brushing the hairs,
wearing the hat, even resting head on pillow
induces severe pain.
TREATMENT :
Nonpharmacologic Approaches :
Migraine can often be managed to some
degree by a variety of nonpharmacologic
approaches -
(1) Lessening one’s response to stress by various
techniques - yoga, transcendental meditation,
hypnosis, and conditioning techniques such
as biofeedback, behavioral therapy. However
for most patients, this approach is, at best,
an adjunct to pharmacotherapy.
Behavioral and psychological interventions
used for prevention include relaxation training,
thermal biofeedback combined with relaxation
training, electromyography (EMG) biofeedback,
and cognitive-behavioral treatment. Behavioral
approaches are particularly recommended for
patients who prefer nondrug interventions, who
tolerate drugs poorly, who have medical
contraindications to drug therapy, who have
insufficient response to specific drug treatments,
good options for patients who are pregnant,
nursing, or planning to become pregnant8.
(2) Avoidance of migraine trigger factors-provide
significant prophylactic benefit.
Saxena A, Gupta OP
Natural remidies for Migraine :
Recently, some good studies have
demonstrated the effectiveness of the herb
Butterbur (Petasites hybridus) in preventing
migraines. Another herb, Feverfew (Tanacetum
Parthenium), is also wodely used and some
studies have shown it to be safe and possibly
effective for migraine prevention.
A variety of other CAM (complimentary
& alternative medicine) techniques are not bolstered
by solid scientific data, but they may be perceived
to be of benefit to patients. A few techniques
commonly practiced for headache relief include
body work (eg, chiropractic, massage), creative arts
(eg, dance, music), nutritional/herbal supplements
(eg, vitamins, herbs), Eastern medicine (eg, yoga),
acupressure and acupuncture, and Ayurveda.
Pharmacologic Treatment of Acute Migraine :
The mainstay of pharmacologic therapy
is the judicious use of one or more of the many
drugs that are effective in migraine. Treat early.
This will not only reduce the total duration of
treatment but also the recurrence and redosing
of the drugs. Chances of treatment failure are
also reduced, since it has been observed that once
allodynia sets in triptans are not more effective.
The selection of the optimal regimen for
a given patient depends on a number of factors,
the most important of which are the severity of
the attacks co-morbid illness and emotional
background. Most drugs effective in the treatment
of migraine are members of one of three major a
pharmacologic classes : (1) anti-inflammatory
agents, (2) 5-HT1 agonists, and (3) dopamine
antagonists.
Migraine therapy must be individualized
for each patient; a standard approach for all
patients is not possible.
J MGIMS, March 2009, Vol 14, No (i), 1 - 6
Migraine : A review
Non Steroidal Anti-Inflammatory Agents :
Both the severity and duration of a migraine
attack can be reduced significantly by anti-inflam-
matory agents. NSAIDs are most effective when
taken early in the migraine attack. The combination
of acetaminophen, aspirin, and caffeine, or
indomethacin have been found to be effective for
the treatment of mild to moderate migraine. The
combination of aspirin and metoclopramide has
been shown to be equivalent to a single dose of
sumatriptan10.
5-HT1 Agonists :
Stimulation of 5-HT1 receptors can stop
an acute migraine attack. (a) Ergotamine and
dihydroergotamine are nonselective receptor
agonists, while the (b) series of drugs known as
triptans are selective 5-HT1 receptor agonists.
A variety of triptans (e.q., naratriptan, rizatriptan,
sumatriptan, zolmitriptan, almotriptan,
frovatriptan) are now available for the treatment
of migraine. Rizatriptan and almotriptan are
the fastest acting and most efficacious of the
triptans currently available. Sumatriptan and
zolmitriptan have similar rates of efficacy as
well as time to onset,
Unfortunately, monotherapy with a selective
oral 5-HT1 agonist does not result in rapid,
consistent, and complete relief of migraine in
all patients. In recent studies, a single-tablet
combination of sumatriptan and naproxen
sodium relieved migraine symptoms more
effectively than did either individual medication.
Triptans are not effective in migraiine with
aura unless given after the aura is completed and
the headache initiated. Similarly they are not
effective in patients having allodynia. Side effects,
although often mild and transient, occur in up
to 89% of patients. Moreover, 5-HT1 agonists are
contraindicated in individuals with a history of
cardiovascular disease.
Dopamine antagonists :
Copamine antagonists (eq. Metoclopramide,
chlorpromazine, prochlorperazine) should be
considered as adjunctive therapy in migraine.
Drug absorption is impaired during migrainous
attacks because of reduced gastrointestianl
motility. Therefore, when oral NSAIDs and/or
triptan agents fail, the addition of a dopamine
antagonist such as metoclopramide, 10 mg,
should be considered to enhance gastric
absorption. In addition, dopamine antagonists
decrease nausea/vomiting and restore normal
gastric motility.
Butalbital combinations :
Medications that combine the sedative
butalbital with aspirin or acetaminophen are
sometimes used to treat migraine attacks. Some
combinations also include caffeine or codeine.
These medications, however, have a high risk of
rebound headaches and withdrawal symptoms
and accordingly should be used infrequently.
Opioids :
Medications containing narcotics, particularly
codeine, are sometimes used to treat migraine
pain when people can’t take triptans or ergots.
These drugs are habit-forming and are usually
used only as a least resort.
CGRP antagonist BIBN 4096 SB :
A highly specific and potent neuropeptide
CGRP-receptor antagonist, is effective in treating
acute attacks of migrains. It blocks trigeminocervical-
induced vascular dilatation6. Telcagepant (oral
CGRP receptor antagonist) is effective and
J MGIMS, March 2009, Vol 14, No (i), 1 - 6

generally well tolerated for actue migraine
treatment2.
Fixed drug combinations (FDCs) combine
standardized doses of two or more drugs in a
single tablet, injection, nasal spray or suppository.
FDCs may improve treatment compliance, efficacy
and /or tolerability through a variety of mecha-
nisms. Improved understanding of migraine
pathophysiology might now allow the development
of rational combination approaches to treatment,
based on manipulation of the three major
biological processes involved in migraine
pathophysiology: dopaminergic hypersensitivity,
neurogenic inflammation and serotonergic
disturbances.
In particular, the following combinations
are identified as being praticularly promising,
based on current beliefs about the biological
systems involved in migraine9.
(1) a dopamine antagonist + an anti-inflammatory
agent
(2) an anti-inflammatory agent + serotonin agonist
(3) a dopamine antagonist + serotonin agonist;
and
(4) a dopamine antagonist + an anti-inflammatory
agent + serotonin agonist.
The most consistent and impressive
evidence of benefit is for NSAID-containing
FDCs. Evidence suggests that NSAID-containing
FDSs perform as well or better than single agent
triptan comparators.
Other nonspecific therapies that have
been used to abort acute migraine attacks include
intranasal lidocaine (Xylocaine) and systemic
steroids. While limited studies report lidocaine
to be superior to placebo, the reported incidence
of recurrent headaches has been inconsistent.
Because the evidence is insufficient, a defined
Saxena A, Gupta OP
role for intranasal lidocaiine as abortive migraine
therapy has yet to be established. Steroid therapy
may be the treatment of choice for patients with
status migrainosus (a severe, continuous migraine
that may last up to one week), but there are no
good studies documenting its efficacy int he
treatment of the acute migraine attack.
Prophylactic treatment of migraine :
The occurrence of at least three attacks
per month could be an indication for this
approach. Drugs must be taken daily, and there
is usually a lag of at least 2 to 6 weeks before an
effect is seen. The 3 classes of medications that
are effective for migraine prevention are (1)
antiepileptics, (2) antidepressants, and (3)
antihypertensives. The drugs that have been
approved by the FDA for the prophylactic
treatment of migraine include propranolol,
timolol, sodium valproate, and methysergide,
topiramater4,5. In addition, a number of other
drugs appear to display prophylactic efficacy.
This group of drugs includes amitriptyline,
nortriptyline, verapamil, phenelzine, gabapentin,
and cyproheptadine. Phenelzine and methysergide
are usually reserved for recalcitrant cases because
of their seriosu potential side effects. Other drugs
recently approved for preventive treatment are -
Tiagabine, Levetiracitam, Zonisamide.
Botulinum toxin A (BOTOX(R)) may be
beneficial in patients with intractable migraine
headaches that fail to respond to conventional
preventive medication. The injections are
administered to the scalp and temple. They may
reduce the frequency and severity of migraine
attacks after 2-3 months of injections. The injections
are expensive and must be administered every
2-3 months to maintain their effectiveness. The
most appropriate duration of prophylactic
J MGIMS, March 2009, Vol 14, No (i), 1 - 6
Migraine : A review
therapy has not been determined. In most patients
who are receiving prophylaxis, therapy must be
continued for at least 3-6 months. The mechanism
by shich Botox might prevent migraines is
unclear, although the drug may cause changes
in nervous system that modify the tendency to
develop migraines.
By understanding the pathophysiology of
migraine, the clinician can optimize therapeutic
options and therapeutic strategies for their
patients.
References :
1. Goadsby PJ. Recent advances in the diagnosis and
management of migraine. BMJ. 2006 Jan 7; 332
(7532): 25-9.
2. Silberstein SD. Recent developments in migraine.
Lancet 2008; 372: 1369-71.
3. Bahra A, Matharu MS, Buchel C, Fracknowiak RSJ,
Goadsby PJ. Brainstem activation specific to
migraine headache. Lancet 2001;357:1016-7.
4. Brandes JL, Saper JR, Diamond M, Couch JR,
Lewis DW, Schmitt J, et al. topiramate for migraine
prevention: a randomized controlled trial. JAMA
2004; 291: 965-73.
5. Silberstein SD, Neto W, Schmitt J, Jacobs D.
Topiramate in migraine prevention: results of a
large controlled trial. Arch Neurol 2004;61:490-5.
6. Olesen J, Diener H-C, Husstedt I-W, Goadsby PJ,
Hall D, Meier U, et al. Calcitonin gene-related
peptide (CGRP) receptor antagonist BIBN4096BS
is effective in the treatment of migraine attacks. N
Engl J Med 2004;350:1104-10.
7. Goadsby PJ, Oleson J. Fortnightly Review:Diagnosis
and management of migraine. BMJ 1996 ; 312 :
1279-1283.
8. Campbell JK, Penzien D, Wall EM.Evidenced-based
guidelines for migraine headache: behavioral and
physical treatments. http://www.neurology.org,
2000.
9. Loder E. Fixed drug combinations for the acute
treatment of migraine: Review article. CNS Drugs
2005; 19(9): 769-784.
10. Tfelt-Hansen P, Venry P, Mulder LJ, et al. The
effectiveness of combined oral lysine acetylsalicylate
and metoclopramide compared with oral
sumatriptan for migraine. Lancet 1995;346:923-6.
11. Freitag, f, Saper, J., Silbersstein, SD., Diagnostic
and therapeutic challenges of acute migrain,
Medscape neurology 26th Dec. 2008.
J MGIMS, March 2009, Vol 14, No (i), 1 - 6
 Review Article

EVALUATION AND MANAGEMENT OF THE PATIENT

WITH ESOPHAGEAL VARICES.
J JAIN

ABSTRACT

Esophageal varices are enlarged or swollen veins on the lining of esophagus which are
prone to bleeding and fatal in upto 50% of patients. Until recently, management of esophageal
varices is generally ineffective in alleviating symptoms or improving survival. However, past decade
has witnessed remarkable advances in under standing of the pathogenesis, development of
disease-specific treatments. Despite these achievements, esophageal varices remain a challenging
condition to manage. This article reviews recent developments in the diagnosis and highlight the
key management points of esophageal varices.

Esophageal Varices is a common disorder Clinical & Endoscopic Finding

that may complicate patients with Portal
hypertension (PHT). PHT is an elevation in
portal venous pressure (>10 mm Hg) that caused by
obstruction of portal venous flow. The anastomoses
connecting the portal and systemic circulation
may enlarge to allow blood to bypass the obstruction
and pass directly into the systemic circulation.
High portal pressure is the main cause of the
development of portosystemic collaterals. The
most important portosystemic anastomoses are
the gastroesophageal collaterals. Draining into the
azygos vein, these collaterals include esophageal
varices.
Recent studies have demonstrated the
role of endothelin-1 (ET-1) and nitric oxide (NO)
in the pathogenesis of PHT and esophageal
varices. ET-1 (vasoconstrictor) has been implicated
in the increased hepatic vascular resistance and
development of liver fibrosis. In the cirrhotic
liver, the production of NO (vasodilator) is
decreased, and endothelial nitric oxide synthase
(eNOS) activity and nitrite production are reduced.
* Assc. Prof., Dept. of Medicine, MGIMS, Sevagram
Although esophageal varices may be
asymptomatic, symptoms of anemia and sudden
massive bleeding with shock are the most
frequently encountered symptoms. Accordingly,
varices should be suspected in chronic liver
disease, family history of hereditary liver disease
such as Wilson disease, Alpha 1 antitrypsin
deficiency. Patients may have a history of
previous jaundice, alcohol abuse, blood
transfusion, administration of various blood
products or intravenous drug abuse(1).
Endoscopy is required at an early stage
to confirm the diagnosis. If active variceal
bleeding or an adherent clot is observed, variceal
hemorrhage can be diagnosed confidently.
Causes of PHT usually are classified as prehepatic,
intrahepatic, and posthepatic. (Table 1). To
establish a cause detailed history, clinical
examination, various laboratory tests (viral
markers, serum ceruloplasmin, alpha 1
antitrypsin) and radiological investigation
(ultrasonography, CT abdomen) are needed.

J MGIMS, March 2009, Vol 14, No (i), 7 - 11

Evaluation And Management Of The Patient with Esophageal Varices.

Table 1 : Causes of Portal Thrombosis

Prehepatic Intrahepatic Posthepatic
Splenic vein Congenital hepatic fibrosis, Idiopathic Budd-Chiari
thrombosis portal hypertension syndrome
Portal vein thrombosis Sclerosing cholangitis, Schistosomiasis Thrombosis of the
inferior vena cava
Extrinsic Primary biliary cirrhosis,Alcoholic cirrhosis
Hepatitis Band C virus-related cirrhosis, Chronic Constrictive
compression active hepatitis & Fulminant hepatitis pericarditis
of the portal vein Wilson disease & Hemachromatosis Venoocclusive
Alpha-1 antitrypsin deficiency disease of the liver

Risk Factors For Variceal Hemorrhage Š Establish airway protection in patients

Š Variceal size: larger the varix, the higher the
risk of bleeding.
Š Presence of endoscopic red color signs (eg,
red whale markings, cherry red spots)
Š Child classification-especially the presence
of ascites increases the risk.
Š Active alcohol intake in patients with chronic
alcohol-related liver diseases
Treatments
The objective of therapy is to stop
acute bleeding and manage persistent varices.
Approaches include pharmacotherapy, endoscopic
intervention, surgical therapy and, more recently,
radiologic shunting. All of these treatments are
limited by their inability to prevent or arrest
hemorrhage in a universal manner, extensive side-
effect profiles, and failure to improve long-term
survival rates. Availability of resources and expertise
is an important consideration in determining the
best approach.
Managment of Bleeding Esophageal Varices?
I. Emergency treatment
Š Assess the rate, volume and severity of
bleeding (by inserting a nasogastric tube).
with massive upper GI tract bleeding.
Š Measure the platelet count (Platelet
transfusions are reserved for counts <
50,000/mL), hematocrit (maintained in
the low 30% range), prothrombin time
and obtain a type.
Š Measure renal, liver function tests and
serum electrolytes.
Š Correct clotting factor deficiencies with
fresh frozen plasma, blood, & vitaminK-1.
Š Nephrotoxins should be avoided to prevent
renal failure as patients are volume-
depleted.
II. Pharmacologic Therapy
Currently, therapeutic endoscopy is the
definitive treatment for active variceal
hemorrhage. But on its non availability
somatostatin, or octreotide play an important
role. The advantages of vasoactive agents
include the ability to treat variceal bleeding
in emergency department, and offering
endoscopist a clearer view of varices(2).
a. Vasopressin : Vasopressin controls 60%
to 75% of variceal bleeding but increase

J MGIMS, March 2009, Vol 14, No (i), 7 - 11


the mortality rate because of vasoconstriction
in splanchnic, portal, coronary, cerebral,
and intrahepatic vessels. A meta-analysis
of three controlled trials has shown that
combination with Nitroglycerin is better
than vasopressin alone(3).
b. Terlipressin : Synthetic analog of vasopressin
and only pharmacologic agent shown to
reduce mortality. It has longer biological
activity, advantage of preserving renal
functions, beneficial when combined
with EST.
IV. Surgical Therapies - Approximately 5-10% of
c. Somatostatin : Naturally occurring
tetradecapeptide which has similar effects
as vasopressin but does not cause coronary
vasoconstriction.
d. Octreotide acetate : Synthetic, long-acting
analogue of Somatostatin. Several studies
found octreotide to be more effective than
either placebo or vasopressin and soma-
tostatin in controlling both initial and
sustained bleeding. Because it has fewer
side effects than vasopressin, it has become
the drug of choice in acute variceal bleeding.
Unfortunately, like vasopressin, it does
not increase the survival rate.
III.Interventional therapies
a. Endoscopic Sclerotherapy (EST) - EST
remains first-line therapy. Obliteration of
varices by repeated injections arrests
acute bleeding. Injections may be directed
under direct vision into the veins
(intravariceal) or into the esophageal
wall (paravariceal). Several different
sclerosants are available-5% sodium
morrhuate,1% to 3% sodium tetradecyl
sulfate,5% ethanolamine oleate, Absolute
alcohol,N-butyl-2- cyanoacrylates (tissue
glue). Typically 1 to 2 mL and total of 10
to 15 mL of sclerosant is injected.
Jain J
b. Endoscopic Variceal Ligation (EVL) - EVL
or variceal banding is an alternative to
EST, mainly because of fewer complications
and similar efficacy. Elastic O bands are
placed around varices by ensnaring
esophageal mucosa and the submucosa
using endoscope. Ischemic necrosis,
thrombosis, and fibrosis ensue, eradicating
the varix. Rebleeding occurs less frequently
with EVL than with EST (26% vs 45%)(4).
patients with variceal bleed have conditions
that cannot be controlled by endoscopic
and/or pharmacologic treatment. Balloon
tamponade (eg, Minnesota tube, Sengstaken-
Blakemore tube,) may be used as a temporary
option. Definitive salvage options may include
the following :
1
. Transjugular Intrahepatic Portosystemic
Shunt - TIPS is an angiographically created
shunt (expandable, implantable metallic)
between hepatic and portal veins first
conceived in the late 1960s.The potential
advantages include avoidance of general
anesthesia and surgery (nonsurgical
shunt), decreased morbidity and mortality
rates,lessinvasive.Itcontrolsactivevariceal
bleeding over 90% and achieving a
mortality rate of less than 10%, even in
critically ill patients(5).
Contraindications to TIPS are
polycystic liver disease, cholangiohepatitis,
primary pulmonary hypertension, biliary
obstruction, active intrahepatic or systemic
infection, severe hepatic encephalopathy,
portal vein thrombosis. Thus, it should
be considered as a bridge to subsequent
liver transplantation.
J MGIMS, March 2009, Vol 14, No (i), 7 - 11
Evaluation And Management Of The Patient with Esophageal Varices.
2. Shunt Operations (Portosystemic shunt) -
Shunt operations traditionally have been
classified on the basis of their intended
impact on portal blood flow. Both shunts
were 100% effective in controlling
hemorrhage. However, the partial shunts
preserved hepatopetal flow in 90% of patients
and were associated with a significantly
lower frequency of encephalopathy.
a. Total shunts divert all portal blood
flow into the inferior vena cava. The
end-to-side portacaval shunt an
anastomosis between the end of the
portal vein and the side of the inferior
vena cava.
b. Partial shunts-A side-to-side anastomosis
is created between the portal vein and
inferior vena cava to divert only part
of the portal stream into the vena cava;
the remainder, would continue to
perfuse the liver.
c. Selective shunt (Distal splenorenal) -
Selectively decompresses variceal flow,
while preserving portal blood flow
thus avoid the high rate of encephal-
opathy. The varices are decompressed
by anastomosis of the splenic vein, to
the distal left renal vein.
3. Esophageal Devascularization - Direct
surgical devascularization of the lower 5
cm esophagus and upper two third of
stomach with staple gun. It may have a
role in patients with portal and splenic
vein thrombosis who are not suitable
candidates for shunt procedures.
4. Simple surgical variceal ligation with
esophageal transection is an effective
means of controlling acute variceal bleeding,
10
but bleeding frequently recurs. Improved
long-term control of bleeding has been
reported with the Sugiura operation, a
more extensive procedure consisting of
transthoracic paraesophageal devasculariza-
tion, esophageal transection, splenectomy,
esophagogastric devascularization,
pyloroplasty, and vagotomy.
5. Orthotopic liver transplantation - Treatment
of choice in patients with end-stage liver
disease. The selection of candidates is
dictated by the patient's clinical status,
etiology of cirrhosis, abstinence from
alcohol, and availability of a donor organ.
6. Percutaneous transhepatic embolization
(PTE) of gastroesophageal varices involves
catheterization of the gastric collaterals
that supply blood to varices via the
transhepatic route. This procedure is less
effective. Thus, it should be reserved for
situations in which other therapies has
failed or contraindicated.
Prognosis of Esophageal Varices ?
Š Rebleeding has poor prognosis
Š Occurrence of complications (eg, bacteremia
and/or endotoxemia, SBP, portosystemic
encephalopathy, hepatorenal syndrome)
Š Severity of portal hypertension
Š The location & number of the bleeding varices
Š The functional status of the liver and the
severity of liver disease.
Š Active alcohol intake in patients with chronic
alcohol-related liver diseases
References :
1. Luketic VA, Sanyal AJ. Esophageal varices. I.
Clinical presentation, medical therapy and
endoscopic therapy. GI Clin North Am 2000; 29(2):
337-85.
J MGIMS, March 2009, Vol 14, No (i), 7 - 11

2. Sanyal AJ, Shiffman ML. Pharmacologic treatment
of portal hypertension. In: Lewis JH, Dubois A,
eds. Current clinical topics in gastrointestinal
pharmacology. London : Blackwell Scientific,
1997:242-75
3. Angelico M, Carli L, Piat C, et al. Effects of
isosorbide-5-mononitrate compared with
propranolol on first bleeding and long-term
survival in cirrhosis. Gastroenterology 1997; 113(5) :
1632-9
11
Jain J
4. Laine L, Cook D. Endoscopic ligation compared
with sclerotherapy for treatment of esophageal
variceal bleeding: a meta-analysis. Ann Intern Med
1995;123(4):280-7
5. Luketic VA, Sanyal AJ. Esophageal varices. II.
Transjugular intrahepatic portosystemic shunt
and surgical therapy. GI Clin North Am 2000; 29(2):
387-421.
J MGIMS, March 2009, Vol 14, No (i), 7 - 11
 Short Review
GASTROESOPHAGEAL REFLUX IN
A TAKSANDE*, KY VILHEKAR**
Introductions :
Gastroesophageal reflux (GER) is the
common esophageal disorder and occurs when
stomach contents reflux into the esophagus
during a meal. Lower esophageal sphincter (LES)
at the bottom of the esophagus opens and closes
to allow food to enter the stomach. Reflux can
occur when the LES opens, allowing stomach
contents and acid to come back up into the
esophagus1. Transient LES relaxation (TLESR)
is the major primary mechanism allowing refluxe
to occur. A vagovagal reflux, composed of afferent
mechanoreceptor in the proximal stomach, a
brainstem pattern generators, and efferent in
the LES, regulates TLESR. Gastric distension
is the main stimulus for TLESR. There is a high
prevalence of GER in children with chronic
cough and asthma2.
GER is classified as follows :
Functional GER : patients have no underyling
predisposing factors. Growth and development
are normal, and treatment is typically not
necessary.
Pathogenic GER or Gastroesophageal reflux
disease(GERD) : Patients frequently experience
complications, including strictures, malnu-
trition, respiratory disorders, esophagitis,
bleeding, and changes in the normal epithelial
* Senior Lecturer, ** Professor,
Address for Correspondence : Dr. Amar M Taksande, Dept.
of Pediatrics, MGIMS, Sevagram, Wardha, MS-442102
E mail : amar_bharti2000@yahoo.co.uk
CHILDREN
lining of the lower esophagus. Patients
require careful evaluation and treatment2,3.
Secondary GER : A case in which an underlying
condition predisposes to GER. Examples
include hiatal hernia and gastric outlet
obstruction.
Risk Factors: 4,5.
y Anatomic factors that predispose to GER
include.
ΠThe angle of His (made by the esophagus
and the axis of the stomach) is obtuse
in newborns but decreases as infants
develop. This ensures a more effective
barrier against GER.
ΠThe presence of a hiatal hernia displaces
the LES into the thoracic cavity. The lower
intrathoracic presure may facilitate GER.
ΠResistance to gastric outflow raises
intragastric pressure and leads to reflux
and vomiting. Examples: gastroparesis,
gastric outlet obstruction, and pyloric
stenosis.
y Other factors that predispose individuals to
GER include :
ΠMedications 9eg. Valium Theophylline)
ΠSmoking
ΠPoor dietary habits (eg. overeating, eating
late at night, assuming a supine position
shortly after eating)
ΠFood allergies
ΠCertain foods (eg. greasy, highly acidic)
12
J MGIMS, March 2009, Vol 14, No (i), 12 - 15

ΠDisorders of motility (postulated to
potentially cause reflux)
y Antral dysmotility
y Delayed gastric emptying
ΠTLESR, accounting for 94% of reflux
episodes in children and adults.
y Physiologic factors : Reflux is also facilitated
when an increase in intra-abdominal pressure
exists, but, the presence of a chronically lax
sphincter and a functional decrease in
sphincter tone determine the occurrence
of GER2.
Clinical Manifestation :
Infant reflux become symptomatic
during the first few month of life, peaking at
about 4 month and resolving in most by 12
month and nearly all by 24 months. Symptoms
in older children tend to be chronic, waxing
and waning, but completely resolving in more
than half, resembling adult pattern6.
When refluxed material rapidly returns
to the stomach, it does not harm the esophagus.
However, in some children, the stomach contents
remain in the esophagus and damage the
esophageal lining. In other children, the stomach
contents go up to the mouth and are swallowed
again. When the refluxed material passes into
the back of the mouth or enters the airways, the
child may have a raspy voice, or a chronic cough.
Other symptoms include7,8.
ΠRecurrent pneumonia
ΠWheezing
ΠDifficult or painful swallowing
ΠVomiting
ΠSore throat
ΠWeight loss
ΠHeartburn (in older children)
13
Taksande A, Vilhekar KY
Investigation9,10,11.
Upper endoscopy, which involves the
direct visulization of the esophagus, stomach,
and a portion of the small intestines. Biopsies
can be obtained at the time of endoscopy to
determine whether there is inflammation due
to GERD or whether there are other problems
such as allergic esophagitis that are causing the
symptoms.
Contrast (usually barium) radiographic study of
the esophagus and upper GIT.
Esophageal pH probe monitoring : A thin, light
wire with an acid sensor at its tip is inserted
through the nose into the lower part of the
esophagus. This probe detects and records the
amount of stomach acid coming back up into
the esophagus and indicates whether acid is in
the esophagus when the child has symptoms such
as crying, coughing, or arching her back.
Radionucleotide scintography using technetium
may demonstrate aspiration and delayed gastric
emptying when these are suspected.
Esophageal manometry permits evaluation for
dysmotility.
Esophagography : In more seven cases, diagnosis
is made by barium esophagography under
fluoroscopic control. Strictures can be
demonstrated by esophagography.
MANGEMENT :
Medical Care11,12.
y Functional GER - Reassurance is the only
treatment needed
y Conservative measures:
ΠSleeping on the left side has been shown
to drastically reduce nighttime reflux
episodes in patients
J MGIMS, March 2009, Vol 14, No (i), 12 - 15
Gastroesophageal reflux in children
ΠUpright positioning after feeding
ΠMild, uncomplicated cases: the prone
position with thickening of feeds with
cereal and burping after feeds is beneficial.
ΠMore severe cases : prone position in
addition to elevating the head of the bed
to 300 is recommended.
ΠProviding small, frequent feeds thickened
with cereal.
y Older children benefit from bland diet,
small, frequent feeds, and proper eating
habits.
The goals of medical therapy are to
decrease acid secretion and to increase gastric
emptying2,12.
y Antacids :
- Rapid & transient relief of symptoms
- Acid neutralisation
y Histamine 2 receptor antagonists:
- First line drugs for mild to moderate GER
- Ranitidine, Cimetidine, Famotidine
y Proton Pump Inhibitors (PPIs): A second
class of medications often used to reduce
stomach acid is PPI, which block the production
of stomach acid. This class of drugs block
the hydrogen-potassium ATPase channels in
gastric acid secretion.
- Omeprazole & Lansoprazole
y Prokinetic agents : These agents make the
LES close tighter so stomach acid cannot
reflux into the esophagus.
- Metoclopramide (dopamine 2 & 5HT 3
antagonist)
- Bethanecol (cholinergic agonist)
- erythromycin (motilin receptor agonist)
- Indcrease LES pressure, improve gastric
emptying & esophageal clearance
14
Surgery13:
y Goal : Re-establish the antireflux barrier
without creating obstruction to the food
bolus.
y Nissen Fundoplication : The stomach is
wrapped and sutured 3600 around the distal
esophagus.
y Disadvantage : More episodes of dysphagia
and gas bloat than a partial wrap.
Complications of GERD2 :
y Strictures occur in mid to distal esophagus.
Patients present with dysphagia to solid meals
and vomiting of nondigested foods.
y Barrett esophagus occurs when goblet cell
metaplasia occurs.
y Risk of adenocarcinoma is increased 30-40
times.
y Failure to thrive because of caloric deficit.
Key Points :
y GER disease includes all consequences of
reflux of acid or other irritants from the
stomach into the esophagus.
y GER is common in infants, but most
children grow out of it.
y GER may cause vomiting, coughing, hoarseness,
or painful swallowing.
y Treatment depends on the child’s symptoms
and age and may incoude changes in eating
habits and taking medications. Surgery may
be an option.
References :
1. Monnier P, Ollyo JB, Fontolliet C. Epidemiology
and Natural History of Reflux esophagitis. Semin
Laparosc Surg. 1995, 2: 2-9.
J MGIMS, March 2009, Vol 14, No (i), 12 - 15

2. Orenstein S, Peters J, Khan S, Youssef N, Hussain
SZ. Gastroesophageal Reflex disease. In: Behrman
RE, Kliegman RM, Jenson HB, editors. Nelson
Texibook of Pediatrics. 17th ed. Philadelphia: WB
Saunders, 2000; p. 1222-25.
3. Spechler SJ. Epidemiology and natural history
of gastro-esophageal reflux disease. Digestion.
1992; 51 Suppl 1: 24-9.
4. DeVault KR, Castell DO. Updated guidelines
for the diagnosis and treatment of gastrosophageal
reflux disease. The Practice Parameters Commit-
tee of the American College of Gastroenterolog.
Am J Gastroenterol. 1999: 94 (6): 1434-42.
5. Orenstein SR. Esophageal disorder in infant
and children. Current opinion in Pediatrics 1993;
5: 580-89.
6. Fernando HC, Schauer PR, Rosenblatt M, et al.
Quality of life after antireflux surgery compared
with nonoperative management for servere
gastroesophageal reflux disease. J Am Coll Surg.
Jan 2002; 194(1): 23-7.
7. Bremner RM, Bremner CG, DeMeester TR.
Gastroesophageal reflux: the use of pH monitoring.
Curr Probl Surg. Jun 1995; 32(6): 429-558.
15
Taksande A, Vilhekar KY
8. Harding SM, Richter JE, Guzzo MR, et al Asthma
and Gastroesophageal reflux: acid suppressive
therapy improves asthma outcome. Am J Med. Apr
1996; 100(4): 395-405.
9. McCallum RW, Berkowitz DM, Lerner E. Gastric
emptying in patinets with Gastroesophageal reflux.
Gastroenterology. Feb 1981; 80(2): 285-91.
10. Vigneri S, Termini R, Leandro G, et al. A
comparison of five maintenance therapies for
reflux esophagitis. N Engl J Med. Oct 26 1995;
333(17): 1106-10.
11. Porro GB, Pace F, Peracchia A, et al. Short-term
treatment of refractory reflux esophagitis with
different doses of omeprazole or ranitidine. J
Clin Gastroenterol. Oct 1992; 15(3): 192-8.
12. Patti MG, Arcerito M, Feo CV, et al. An analysis
of operations for gastroesophageal reflux disease:
identifying the important technical elements. Arch
Surg. Jun 1998; 133(6): 600-6; discussion 606-7.
13. Abbas A, Deschamps C, Cassivi SD, et al. (2004).
“The role of laparoscopic fundoplication in
Barrett’s esophagus”. Annals of Thoracic Surgery
77(2): 393-396.
J MGIMS, March 2009, Vol 14, No (i), 12 - 15
 Review Article
FACE TO FACE WITH NONTUBERCULOUS
MYCOBACTERIA AT SEVAGRAM
DK MENDIRATTA *, P NARANG **, R NARANG ***
The non-tuberculous mycobacteria
(NTM), also known as atypical mycobacteria or
mycobacteria other than M. tuberculosis (MOTT)
have been recognized since Koch's time but being
opportunists they did not gain as much importance
as M. tuberculosis. Today, however, the recovery of
NTM from patient's specimens, where they can
cause infections called "other mycobacteriosis" 1
and from environmental sources is of concern
to microbiologists, epidemiologists and physicians.
There is a gradually shift in the focus from AFB
with rough, tough and buff colonies to AFB with
smooth and pigmented colonies , some of which
may be rapid growers. NTM infections are more
common in developed countries but have also
been documented in developing countries of
Latin America, Africa, and Asia2,3,4,5,6. Many a
times the NTM are found circulating in blood
(mycobacteremia) and this has lead to disseminated
infections. Among disseminated NTM infections,
most are caused by mycobacteria belonging to
Mycobacterium avium complex (MAC) and are
known as Disseminated MAC (DMAC). DMAC
infection decreases survival and worsens the
quality of life. DMAC was rare before the advent
of acquired immunodeficiency syndrome (AIDS)
and a steady rise has been observed after increase
in cases with AIDS. Between 1985 and 1990
*Professor & Head., ** Director Professor & Secretary
KHS, *** Professor, Deptt. of Microbiology, MGIMS,
Sevagram. Corresponding author : Dr Deepak K
Mendiratta, Prof & Head , Dept of Microbiology,
MGIMS, Sevagram. Email:dkmendiratta@rediffmail.com
16
DMAC occurred in 16% of AIDS patients at
Grady Memorial Hospital, Atlanta7. It was estimated
that most AIDS patients would develop DMAC
infection if they survive long enough to become
severely immunocompromised8. However, highly
active anti retro viral therapy (HAART) changed
the scenario and among patients in John
Hopkins cohort with advanced HIV disease, the
proportion developing DMAC had fallen from
16% before 1996 to 4% after 1996, and the rate
observed in 2004 was less than 1%9.
Clinically in AIDS patients it is not possible
to differentiate between M tuberculosis and other
mycobacteriosis. M tuberculosis causes majority of
pulmonary infections and the risk is largely
increased if the CD4 count falls below 300cell/
cumm10. In some cases disseminated infections
are also found11,12. NTM, on the other hand, may
colonize the gut or respiratory tract of HIV patients
but once the CD4 counts fall <100 cells/cumm,
they start multiplying rapidly, enter the blood
stream and cause disseminated infections. Patient
may succumb to these infections if not treated
in time. Horsburg in 1994 stated that persons
with HIV infection are like open culture plates
and AIDS related immunosuppression is the
single most important risk factor associated with
disseminated NTM infection especially MAC.
Laboratory support is a must to diagnose
these conditions and the clinical samples for
detection of various NTM species are blood,
J MGIMS, March 2009, Vol 14, No (i), 16 - 21

sputum, stool and other extra-pulmonary specimens.
Smear examination and isolation of Mycobacteria
are two important steps in laboratory diagnosis
of such infections. Only smear examination, as
recommended by RNTCP, may not be sufficient
in such conditions, especially in HIV/AIDS
patients, as NTM which are important organisms
causing disease in such cases need to be
differentiated from M. tuberculosis by culture,
since the treatment of the two differs.
Isolation of Mycobacteria from clinical
specimens other than blood is performed
routinely in many of the laboratories these days
using Egg based media, BACTEC media &
system, MGIT 960, BACTEC 9000MB system and
BacT/ALERT MB. Blood samples which need
special treatment and media are not routinely
cultured. However, since NTM cause bacteremia,
blood may be the only sample from where we can
isolate such organisms. Likewise, in some of the
TB patients with advanced HIV disease blood
may be the only sample yielding M. tuberculosis13.
The radiometric BACTEC 13A blood culture
bottle (Bectec Dickinson Diagnostic Instrument
System) or Isolator lysis centrifugation system
(E.I. Du Pont, de Nemours, Wilmington, Del) is
recommended for blood culture.
Lowenstein Jenson medium routinely
used for isolation of M. tuberculosis supports
growth of NTM from specimens other than blood,
but utilization of paraffin wax as sole carbon
source for growth by NTM and the inability of
Mycobacterium tuberculosis to do so, in a basal salt
media is a useful and often forgotten fact. The
paraffin system is a biphasic system which consists
of a liquid (Czapek Broth) phase and solid
(paraffin wax coated slide) phase. Non-motile
organisms such as Nocardia and NTM are carried
by Brownian movement to the paraffin wax, sole
17
Mendiratta DK, Narang P, Narang R
carbon source. When these organisms attach to
the paraffin wax acting as sole carbon source
they begin to grow, since they now have all the
essential components for their growth cycle. When
positive, in situ growth is seen on the paraffin
slide and it appears as distinct points or spots
on the paraffin wax surface. One can also often
see the presence of a heavy growth at the meniscus
of the broth/slide. In some instances the heavy
growth can even display pigmentation. The
beauty of this system is that few pathogens
(NTM, Nocardia, Psuedomonas & C.tropicalis) can
grow in such a system and the growth of NTM
can not only be confirmed by Z N stain and
observed under the microscope in situ but also
used for molecular studies. Moreover, even the
least experienced member of a laboratory can
obtain quality results with this method. The system
could be made selective for NTM by adding
a cocktail of antibiotics like Polymyxin B,
Amphotericin B, Naladixic acid, Trimethoprim
and Azlocillin to the medium. This system has
been standardized and successfully used for
isolation of NTM from stool, sputum, blood
and environment as also speciation and drug
susceptibility testing in our laboratory14,15,16,17.
Identification of NTM species is important
as, not only does the treatment variy between the
species but geographical location may also be a
risk factor for certain species. Speciation is usually
done using conventional phenotypic and newer
genotypic methods. By conventional methods ie
rate & temperature of growth, pigmentation,
niacin & catalase (quantitative and qualitative)
production, tellurite and nitrate reduction,
tween-80, arylsulphatase & urea hydrolysis, TCH
sensitivity, growth on MacConkey agar, sodium
chloride tolerance etc, the identification of
mycobacterial strain requires 2 to 4 weeks for
J MGIMS, March 2009, Vol 14, No (i), 16 - 21
Face To Face With Nontuberculous Mycobacteria At Sevagram
morphological and biochemical tests, in addition
to 4-6 weeks required for primary isolation.
Newer methods which include analysis of fatty
acids by chromatography, hybridization with gene
probe, gene amplification followed by restriction
analysis ( hsp65: heat shock protein, 16S rDNA,
ITS : internal transcribed spacer 16S-23S rDNA,
RNA polymerase beta sub unit: rpoB), LiPA
Mycobacteria( line probe assay) and gene
amplification analysis by sequencing are very
rapid and reduce the turn around time remarkably.
Kox et al18 for the first time used 16s rDNA based
gene amplification assay directly on clinical
samples containing mycobacteria. These new
alternative methods have limited the role of
conventional identification methods.
Speciation of mycobacteria using phenotypic
methods is still widely used in many of the
laboratories in the developing countries19 since
the genotypic methods are costly and not easily
available. The reference laboratories such as
Central JALMA Institute for Leprosy and other
Mycobacterial Diseases, Agra; Tuberculosis
Research Centre, Chennai (TRC); Centers for
Disease Control and Prevention, Atlanta, USA
(CDC) and National Mycobacteria Research
Laboratory, Bilthoven, The Netherlands are some
of the reference centers which help in identifying
the mycobacterial isolates by genotypic methods
to species level and beyond.
The mechanism of resistance in NTM
are quite distinct from M. tuberculosis and
mechanisms like permeability at cell wall and
efflux pumps appear to be more important than
targets like rpoB in M tuberculosis. Usual mutations
seen in M. tuberculosis are not frequently seen in
resistant NTM. Generally NTM are resistant to
low concentrations of various anti-tuberculous
drugs. The drugs to which NTM usually respond
18
and are modestly effective in controlling bacteremia
are macrolides (clarithromycin, azithromycin),
ethambutol, clofazimine and rifamycins (especially
rifabutin). However, the only antimicrobial agents
for which correlation between in-vitro susceptibility
test and clinical response has been demonstrated
in controlled clinical trials are macrolides
(Azithromycin & Clarithromycin) and that too
in MAC only. Drug susceptibility testing of the
mycobacterial isolate is an important aspect for
guiding the treatment. However, till recently
there were no approved guidelines for drug
susceptibility testing of mycobacteria, especially
NTM. In the year 2003, Clinical and Laboratory
Standards Institute (CLSI)20 published approved
standards for Mycobacteria, Nocardiae and other
aerobic Actinomycetes.
NTM are ubiquitous and majority are
present in the environment surrounding the
patient. AIDS patients may acquire infection
with multiple NTM species or multiple strains
of the same species21. It is thus important to type
mycobacterial strains if we wish to find the
relatedness of multiple isolates from a single patient.
If environmental samples from surroundings of
the patient suffering from NTM disease are
screened for NTM and the same species are
isolated from clinical and environmental samples,
typing of these isolates helps us to know if the
same strain has caused infection in such
patients22. A number of phenotypic techniques
viz. biotyping, antibiogram typing, serotyping,
multilocus enzyme electrophoresis (MEE) have
been used in the past. However, since in all these
methods measurement relies upon gene expression
which can be influenced by cultural conditions
their typeability, reproducibility and discrimination
may vary. Newer typing methods are based on
the analysis of DNA (and thus are unaffected by
J MGIMS, March 2009, Vol 14, No (i), 16 - 21

environmental conditions) and include plasmid
typing, restriction fragment length polymorphism
(RFLP), analysis of chromosomal DNA of rRNA
genes, rRNA spacer sequencing and large restriction
fragment (LRF) involving pulsed field gel
electrophoresis (PFGE).
In the department of Microbiology at
Mahatma Gandhi Institute of Medical Sciences,
Sevagram studies on NTM were initiated way
back in 1988 , when an ICMR sponsored project
to estimate the prevalence of pulmonary TB in
Wardha was underway in the early eighties.
Lowenstein Jensen medium was used for isolation
of mycobacteria and species were identified using
phenotypic methods - morphology and biochemical
reactions. A total 14 tests were performed and
150 NTM belonging to 16 species were recovered,
in addition to the principal pathogen , MTB.
HIV testing was not performed during this field
house to house survey14.
Later, during 1997-1998, we standardized
the paraffin slide culture (PSC) technique for
isolation, identification and drug susceptibility
testing of NTM15. Fifteen known species of NTM
along with Nocardia asteroides (positive control)
and M. tuberculosis H37Rv (negative control) were
used for this standardization. This PSC technique
was later used to isolate NTM from stool and
sputum samples of HIV seropositive subjects. Six
NTM species (4 MAC and 2 M. fortuitum) were
isolated from 80 stool samples and three NTM
species (2 MAC and one unspeciated) were isolated
from 42 sputum samples. Biochemical reactions
using PSC technique was used to speciate the
NTM. Drug susceptibility testing was performed
by MIC using PSC, LJ and Microtitre plates.
PSC results were comparable with that done on
LJ & Microtitre plates. The MAC isolates were
uniformly sensitive to Azithromycin and variably
19
Mendiratta DK, Narang P, Narang R
sensitive to first line anti-TB drugs16. In another
study blood samples from 77 HIV seropositive
subjects were subjected to culture for mycobacteria
using BACTEC 13A medium followed by
subcultures on PSC and LJ medium. A total of 6
NTM isolates were recovered including 3 MAC
and 3 M. simiae6. In our initial studies on NTM
and HIV, CD4 counts were not performed and
thus the information of patients' HIV disease
status was not known and also that all the clinical
samples were not processed for the recruited
subjects.
A comprehensive study was undertaken
in 2005-0717 where in all the possible clinical
samples viz. blood, stool, sputum and other
extrapulmonary specimens were processed for
mycobacteria. CD4 counts were performed as
part of the protocol. A number of mycobacterial
species viz. M. tuberculosis, M. avium, M. simiae,
M. vaccae and M. wolinskyi were isolated. In two
patients, same species of NTM, M. avium in one
case and M. simiae in another, was isolated from
both blood and stool samples. In this study,
environmental viz. soil and water were also
processed for NTM using PSC technique. These
samples were collected from the environment of
patients with NTM disease. A large number of
species of NTM viz. MAC, M. fortuitum, M.
chelonae, M. abscessus, M. flavescens, M. phlei, and
M. thermoresistibile were isolated from such
samples. Drug susceptibility testing was performed
using MIC in microtitre plates and BACTEC
460TB system. Variable patterns of susceptibility
were obtained, the clinical isolates being more
resistant as compared to environmental isolates.
The clinical and environmental isolates of M.
avium were typed using PCR designed to amplify
DNA segments located between the insertion
sequences IS1245 and IS1311. Only two clinical
J MGIMS, March 2009, Vol 14, No (i), 16 - 21
Face To Face With Nontuberculous Mycobacteria At Sevagram
isolates from the same patient matched.
The NTM isolates obtained during
2005-07 were speciated using morphology and
biochemical reactions in our laboratory and
further confirmed using advanced techniques in
reference laboratories, by HPLC in CDC Atlanta,
InnoLiPA in Bilthoven the Netherlands, and
PCR-PRA & Gene Sequencing in National
JALMA Institute for Leprosy and other
Mycobacterial Diseases in Agra. The main
problematic NTM species showing discrepant
results was the M. simiae.
To conclude, NTM have started appearing
as important pathogens along with M. tuberculosis,
at least in AIDS patients. Paraffin slide culture
technique can be used as a selective medium for
NTM along with the routine LJ medium. The
laboratories can use phenotypic speciation
methods, which are available in most Medical
College laboratories and significant isolates from
important clinical samples may be sent to NRL
for confirmation. As per CLSI, MIC using
microtitre plate is acceptable method for drug
susceptibility testing of NTM.
Acknowledgement : The exhaustive work on NTM
has been possible due to contributions by Dr
Rahul Narang, Dr G M S Siddique, Dr Sangeeta
Dey, Dr Debashish Roy, Dr S Bhatacharya, Mr D
U Ingle, Mr Sunil Tiwari, Mr Sandeep Taksande
and Mr Siddharth Mendiratta)
References :
1. Anon (1989) Editor's note. Am Rev Respir Dis
140: 561
2. Grant AD, Djomand G, De Cock KM (1997)
Natural history and spectrum of disease in adults
with HIV/AIDS in Africa. AIDS 11(suppl B):
S43-S54.
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3. McDonald LC, Archibald LK, Rheanpumikankit
S, et al (1999) Unrecognised Mycobacterium
tuberculosis bacteraemia among hospital inpatients
in less developed countries. Lancet 354:1159-1163.
4. Mohar A, Romo J, Salido F, et al (1992) The
spectrum of clinical and pathological manifesta-
tions of AIDS in a consecutive series of autopsied
patients in Mexico. AIDS 6:467-473.
5. Murillo J and Castro KG (1994) HIV infection
and AIDS in Latin America. Epidemiologic
features and clinical manifestations. Infect Dis Clin
North Am. 8(1):1-11.
6. Narang P, Narang R, Mendiratta DK, Roy D,
Deotale V, M. A. Yakrus, Sean T, and Kale V (2005)
Isolation of Mycobacterium avium complex and M.
simiae from blood of AIDS patients from Sevagram,
Maharashtra. Indian J Tuberc 52:21-26.
7. Joseph O, Falkinham,III (1996) Epidemiology of
Infection by Nontuberculous Mycobacteria Clin
Microbiol Rev 9(2);177-215
8. Bucher HC, Griffith LE, Guyatt GH, et al (1999)
Isoniazid prophylaxis for tuberculosis in HIV
infection: a meta-analysis of randomized controlled
trials. AIDS 13:501-507
9. Karakousis P C, Moore R D and Chasson R (2004)
Mycobacterium avium complex in patients with HIV
infection disease. Lancet 14:557-65.
10. Kumarswamy N,.Snigdha V, Timothy P (2005)
Clinical profile of HIV in India.Ind J Med Res
121: 377-394
11. David ST, Mukundan U, Brahmadathan KN and
John TJ (2004) Detecting mycobacteraemia for
diagnosing tuberculosis. Indian J Med Res
119(6):259-66.
12. Deodhar L (1999) Mycobacteraemia in AIDS
patients report of 2 cases. Ind J. Med. Microbiol
17 (4): 196-197.
13. Shafer RW, Goldberg R, Sierra M, Glatt AE (1989)
Frequency of Mycobacterium tuberculosis
bacteremia in patients with tuberculosis in an
Area endemic for AIDS. Am Rev Respir Dis 140;
I51I-1513.
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14. Siddiqi GMS (1989) Prevalence & characterization 16S rRNA for detection and identification of
of NTM among the symptomatics screned for mycobacteria in clinical samples. Journal of
pulmonary tuberculosis in the community. A Clinical Microbiology 33 (12): 3225-3233.
thesis submitted to the RTN Nagpur University,
19. Paramasivan CN, Govindan D, Prabhakar R,
Nagpur for the degree of M.D. Microbiology. Somasundaram PR, Subbammal S and Tripathy
15. Narang P, Dey S and Mendiratta DK (2000) SP (1985) Species level identification of non-
Paraffin slide culture technique for 'Baiting tuberculous mycobacteria from South Indian
Non-tuberculous Mycobacteria". Indian J Tuberc. BCG trial area during 1981. Tubercle 66 : 9 - 15.
47:219-220.
20. NCCLS. Suceptibility testing of Mycobacteria,
16. Narang P, Narang Rahul, Bhattacharya S and Nocardiae and other aerobic Actinomycetes :
Mendiratta DK (2004) Paraffin slide culture approved standards. NCCLS document M24-A,
technique for isolating non tuberculous mycobacteria Wayne (PA): NCCLS ; 2003.
from clinical specimens of stool and sputum of
21. Arbeit, R.A., A. Slutsky, T.W. Barber, J.N. Maslow,
HIV seropositive patients. Indian J Tuberc 51 :
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23-26. and C. F. von Reyn (1993) Genetic diversity
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Wankhade A, Joshi R, Soolingen D van, van monoclonal and polyclonal bacteremia in patients
Der Laan, Ollar RA. Isolation and speciation of with AIDS. J. Infect. Dis. 167:1384-1390.
mycobacteria isolated from AIDS patients in a
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rural teaching hospital in central India. Falkinham III, and R. D. Arbeit (1994) Persistent
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AH (1995) PCR assay based on DNA coding for

21

J MGIMS, March 2009, Vol 14, No (i), 16 - 21

 Original Article

EFFECT OF PHYSIOLOGICAL FACTORS ON SOLEUS

H-REFLES IN NORMAL HUMAN SUBJECTS

B GHUGARE *, R SINGH **, AP JAIN ***

ABSTRACT

Background : H reflex is a monosynaptic reflex elicited by percutaneous submaximal stimulation

of tibial nerve and recorded from the gastroe-soleus muscle. H reflex is affected by age, sex,
height, position of patient, sleep, vibration and Jendressik’s maneuver. With above background
current study was designed to collect the normative data of Soleus H reflex study and to evaluate
influence of age, height, weight on H reflex parameters.

Material and Methods : Following standard history taking, neurological examination and brief
electrophysiological examination 50 subjects, further divided age wise in two group from 21 to 35
and above 35 yrs, were enrolled, which underwent H reflex study on RMS-EMG-EP mark-II
machine in Clinical Neurophysiology Laboratory in Department of Physiology.

Results : Mean and SD were obtained for age, height, weight, H threshold, H latency and H amplitude. A
positive correlation was observed between H latency and age (r=0.41). Difference in H latency was
found to be statistically significant between two groups (p value<0.05).

Conclusion : Study concluded with the observation that age of the subjects and H latency shows
positive correlation i.e. as age advances latency also increases. Also our data is in accordance with
normative data of previous normative H reflex studies.

Key words : Soleus H reflex, Stretch reflex.

Background : include muscle spindle activation but rest of the

The H reflex is perhaps the most exten- arc is similar to stretch reflex; therefore there is
sively studies reflex in clinical neurophysiology. a high correlation between Achilles reflex and
The H reflex derives its name from Hoffman, Soleus H reflex7.
who first evoked the response on 1918. H reflex is
H reflex is affected by various intrinsic
a monosynaptic reflex elicited by percutaneous
and extrinsic factors. Extrinsic factors like
submaximal stimulation of tibial nerve and recorded
temperature, electrical artifacts and poor recording
from the gastroe-soleus muscle.It is a true reflex
techniques and intrinsic factors like age, sex,
with Group Ia large sensory afferent, a synapse
height, position of patients, sleep, vibration and
with alpha motor neuron and a motor efferent
Jendressik’s maneuver. H reflex has the advantage of
segment supplying muscle1. H reflex does not
evaluating proximal sensory and motor pathways.
* Tutor ; **Professor and Head Department of
It is helpful in the evaluation of plexopathies and
Physiology. ***Director-Professor and Head Dept.
of Medicine. MGIMS, Sevagram, Wardha- 442102 radiculopathies. It may be absent or delayed in

22

J MGIMS, March 2009, Vol 14, No (i), 22 - 25

 Ghugare B, Singh R, Jain AP

Figure : Mechanism of It refees in nerve co____chin velocity

GBS, absent in S1 radiculopathy. Flexor carpi CMAPs, Sural SNAPs, conduction velocity and
radialis H reflex may be absent in C6-C7 prolonged F wave latencies (For comparison,
radiculopathy3. normative laboratory vlues were used). Age in years,
If the extrinsic factors i.e. temperature, Height in centimeters and weight in kilograms
electrical artifacts and poor recording techniques were noted prior study. All the included subjects
are taken care of, effect of the physiological were further subdivided into two groups on the
factors on Soleus H reflex can be studied. With basis of age - Group I: 21-35 yrs and Group II:>35
above background current study was designed yrs. Temperature of laboratory was maintained
to collect the normative data of Soleus H reflex at 32 degree centigrade throughout study.
study and to evaluate influence of age, height, For obtaining Soleus H reflex study data
weight on H reflex parameters. we used RMS-EMG-EP mark -II machine, the
sensitivity, sweep speed and duration were kept
Material and Methods : at 0.2- 1mV/div, 5ms/div
We enrolled 50 volunteers to this study We completed our study with 50 subjects.
after obtaining an informed consent. Following The group consisted of 47 males (94%) and 3
a standard history taking, all of them underwent females(6%). Findings of our study are summarized
physical examination and a brief electrophysiological in table 1 and H latency in two different age
evaluation which comprises of bilateral tibial and groups is summarized in table 2.
peroneal motor conduction, F wave and sural
Table No. 1
sensory nerve conduction to rule out asymptomatic
polyneuropathy. We defined our exclusion Variables Mean (SD)
criteria as history of radiculopathy or diabetes Age (Yrs) 33.02 (9.1)
mellitus or any other disease with potential Height (Cm) 166(4.83)
to cause neuropathy or any abnormality in Weight (Kg) 58.04 (8.6)
H-Th (mAmp) 3.98 (1.42)
neurological or musculoskeletal examination or
H-lat (msec) 28.15(2)
any of the abnormal electrophysiological findings
H - A m p (mV) 5.49(3.24)
i.e. prolonged distal motor latencies, reduced

23

J MGIMS, March 2009, Vol 14, No (i), 22 - 25

Effect of Physiological Factors on Soleus H-Refles in Normal Human Subjects

Table No. 2 H-amplitude; height and H reflex parameters;

H Latency weight and H reflex parameters.
Group I 27.68(1.74)
(21-35 yrs) n=14 Discussion :
In this study we found significant correlation
Group II 29.55 (2)*
between age and H-latency, but there was no
(Above 35 yrs) n=36
such a relation between any other parameter.
A positive correlation was observed Correlation between age and H latency as found
between age of the patient and H-latency (r=0.41) in our study was corroborative with the hypotheses
which can be tested in larger population for of neural structure remodeling, including
better statistical significance. drop-out of largest fibers, and a segmental
*Difference in H latency was found to demyelinisation and remyelinisation process with
be statistically significant between two groups a consequent reduction in internodal length4.
(p value <0.05).
A comparison between current study and
There was no significant correlation
previous studies is summarized in Table 3.
found between age and H-threshold, age and

Table No. 3
H threshold (mA) H latency (ms) H amplitude (mV)
Current study (n=50) 3.98 (1.42) 28.15 (1.42) 5.49 (3.24)
Riccardo M 2001 (n=40) 8.1 (3.0) 30.6 (3.9) ---
David Preston 2005 (n=100) --- </=34 ---
Misra and pandey 1994 (n= ) --- 30.3(1.7) 9.8 (6.1)

It is evident from the available data that variation in various parameters of H reflex
H latency and H amplitude values obtained by due to sex could not be assessed. Normal interleg
current study match with previous studies. H-latency difference was not determined as study
Larger difference in mean H threshold was conducted unilaterally.
in current and previous5 studies may be attrib-
uted to smaller sample size in both studies. Abbreviations :
C M A P :Compound Muscle Action Potential
Limitations : SNAP :Sensory Nerve action potential
In this study we focused on age, height H-Th :H wave threshold
and weight as potential contributing factors on H-Lat :H wave latency
H reflex study. We did not control randomize H - A m p :H wave amplitude.
or obsrve other possible confounding factors with GBS :Guillain - Barre syndrome
potential to affect H reflex study. As sample size
is very small other factors affecting H reflex References :
study could not be correlated well. Physiological 1. Braddom RI, Johnson EW. Standardization of H

24

J MGIMS, March 2009, Vol 14, No (i), 22 - 25

 Ghugare B, Singh R, Jain AP

reflex and diagnostic use in S1 radiculopathy.
Arch Phys Med Rehabil 1974; 55: 162.
2. David P, Barbara S. Electromyography and
Neuromuscular Disorders 2nd edition 2005. Late
responses; 47.
3. Fisher MA. AAEM minimonograph #13. H reflex
and F waves : physiology and clinical application.
Muscle Nerve 1992; 15: 1223.
4. Jacobs JM, Love S. Qualitative and quantitative
morphology of human sural nerve at different
ages. Brain 1985; 108: 897-924.
5. Riccardo M, Giovanni BS, Aldo Mariottni.
Recruitment curve of Soleus H reflex in chronic
low back pain and lumbosacral radiculopathy.
BMC Musculoskelet Disord. 2001; 2: 4.
6. UK Misra, J Kalita. Clinical Neurophysiology
2nd edition 2006. Late responses; 103.
7. Weintraub JR, Madalin K, yong M, et al. Achilles
tendon reflex and H response. Muscle Nerve 1988;
11: 972.

The Nobel Prize in Physiology or Medicine 2008

for his discovery of human human

papilloma viruses causing cer- for their discovery of immunodeficiency
vical cancer virus

Harald Zur Hausen Francoise Barre-Sinoussi Luc Montagnier

Germany France France

Born 1936 Born 1947 Born -1032

German Cancer Regulation of Retroviral World Foundation for

Research Centre Infections Unit, Virology AIDS Research and
Heidelberg, Germany Department, Institut Pasteur Prevention Paris,
Paris, France France

Source : Noble Prize.Org.

25

J MGIMS, March 2009, Vol 14, No (i), 22 - 25

 Original Article

ASSESSMENT OF FUNCTIONAL CAPACITY IN

ELDERLY POPULATION BY ELDERLY MOBILITY SCALE IN
WARDHA (DISTRICT) MAHARASHTRA INDIA

SD GANVIR* , SS GANVIR**

ABSTRACT

Background And Purpose : The rapid growth of the elderly population has resulted in a
corresponding rise in the number of elderly individuals who experience disability during their
lifetimes. The purpose of this study was to test the usefulness of (Tinniti scale-elderly mobility
scale ) four established clinical measures of balance, gait, and subjective perceptions of fear of
falling as screening methods for referring community-dwelling elderly individuals living in
residential care facilities for detailed physical therapy evaluation and possible intervention. The
number of persons over the age of 65 years has increased since the turn of the century, with the
most dramatic increase occurring in the number of persons 85 years of age and over. As the
number of elderly persons has grown, there has been a Corresponding rise in the number of
older persons with disability.

Subjects : The subjects were a convenience sample of 53 elderly individuals living in two
residential care facilities for the elderly.

Methods : Subjects were tested on each of four clinical measures of balance and mobility. Their
performance on these measures was compared with a physical therapist's brief evaluation of
disability and appropriateness for more detailed evaluation. The usefulness of these tools as
screening methods was determined by calculating sensitivity and specificity levels using the
physical therapist's evaluation as a standard.

Results : The sensitivity and specificity levels of the four clinical measures in their application as
screening tests for referral to physical therapy were as follows : Berg Balance Scale, 84% and 78%;
balance subscale of the Tinetti Performance-Oriented Mobility Assessment, 68% and 78%; gait
speed, 80% and 89%; and Tinetti Fall Efficacy Scale, 59% and 82%. The combination of two tests,
Berg Balance Scale and gait speed, yielded the highest sensitivity of 91% and the highest specificity of
70% when a subject tested positive on at least one test.
Conclusion And Discussion : These findings indicate the feasibility of developing screening methods
for referring community-dwelling elderly individuals for a detailed physical therapy evaluation
based on established clinical assessment measures, with a combination of tests measuring balance
and gait demonstrating the most promising results.

Introduction : with the most dramatic increase occurring in the

The number of persons over the age of 65 number of persons 85 years of age and over. As
years has increased since the turn of the century, the number of elderly persons has grown, there
* Professor, ** Assc. Professor, Ravi Nair Physiotherapy has been a corresponding rise in the number of
College Sawangi Meghe Wardha India older persons with disability. Based on data from

26

J MGIMS, March 2009, Vol 14, No (i), 26 - 37


the 1987 National Medical Expenditure Survey,
an estimated 9.5 million non institutionalized
individuals experience difficulty in the performance
of basic life activities such as walking, self-care,
and home management activities1. Out of this total
of 9.5 million people, approximately 5.6 million
individuals (55%) are over the age of 65 years.1
The likelihood of having difficulty in carrying
out basic life activities increases as an individual
ages. In the 65- to 74-year-old age group, one in
nine individuals has difficulty performing basic
activities.1 This ratio rises to 1 in 4 individuals in
the 75- to 84-year-old age group and to 3 in 5
individuals aged 85 years of age and over1. As the
number of individuals with disability rises, there
will be a subsequent rise in the demand for
rehabilitation services to assist these individuals
in maintaining the highest functional level
possible. Despite this increase in demand for
services, many elderly individuals may not receive
needed care because of inconsistent referral to
physical therapists by primary care physician.2
The inability of elderly individuals to gain access
to physical therapy on a routine basis, and the
shortage of physical therapists to meet the growing
demand for services by community dwelling
elders.3 To alleviate this growing problem, screening
methods can be used in the community to identify
elderly individuals who have gross limitation in
mobility and who may be in need of referral to a
physical therapist for more detailed evaluation
and possible intervention.
In epidemiology, screening methods are
often used to identify a group of individuals with
a higher probability of having disease than the
general population.4 General characteristics of a
screening test include cost, convenience, reliability,
and safety. The most useful characteristics of a
screening test, however, are its sensitivity and
27
Ganvir SD, Ganvir SS
specificity. Sensitivity is defined as the chance
that a test will be positive when applied to
someone known to have the disease or disability
under consideration. Specificity is defined as
the chance that the test will be negative when
applied to someone known to be disease- or
disability-free. Higher sensitivity and specificity
indicate a better screening test. These measures
can therefore be used to determine how well a test
performs in screening a group of individuals for
a certain disability.4 Clinically based methods that
have been developed to measure physical function
may act as screening tests to identify older
individuals with limitations in mobility who
may benefit from physical therapy. Clinical
assessment methods may be particularly suitable
for screening because they can detect specific
impairments, have established reliability and
validity, and can be administered by medical or
non medical personnel who are trained in their
application.5 If a clinical assessment method
is demonstrated to have high sensitivity and
specificity in detecting mobility impairment in
the elderly, it could be administered by other
medical or trained non-medical personnel to
determine whether more detailed evaluation
by a physical therapist is warranted 6. Several
clinical assessment methods have been developed
to assess mobility and balance function in the
elderly. These methods measure different
domains of function such as physical performance
on specific tasks,7-12 gait mechanics,13,14 or the
patient's subjective perceptions of his or her
ability to balance.15,16 The validity of these
methods has been tested by
1
. Determining the correlation between a
patient's performance and biomechanical
measures (such as measures of sway as
determined by force plates) 17, 18
J MGIMS, March 2009, Vol 14, No (i), 26 - 37
Assessment of Functional Capacity in Elderly Population by Elderly mobility scale In Wardha (MS)
2. Determining the assessment method's
ability to predict an event, such as whether a
patient will fall (predictive validity) l3
3. Determining the correlation of these
instruments with other established measures
of balance or mobility (concurrent validity).9
Further more, many of these instruments have
demonstrated test-retest and inter-rater
reliabilities on groups of elderly persons or
patients with specific medical conditions.
The aim of study is to test the ability
of four clinical assessment methods to act as
screening tests for detecting elderly individuals
with balance and mobility impairments who
should be referred for a detailed physical therapy
evaluation and possible intervention. These four
assessment methods were selected to correspond
to the three domains of mobility : Two of the
selected instruments measured functional
balance, one instrument measured gait, speed,
and one instrument measured subjective fear
of falling. The usefulness of each of these
assessment methods as a screening test for referral
to a physical therapist for detailed evaluation
and possible intervention was determined by
calculating sensitivity and specificity using a
physical therapist's brief evaluation of each
individual as the standard.
Method
Subjects
A convenience sample of elderly subjects
was obtained from residential care facilities
located in the Paloti ,wardha district Maharashtra
INDIA,. Prior to initiation of the study, the facility
administrator contacted conservators and
informed family members of the study. In addition,
the primary care physician of each potential
subject was contacted to determine whether there
28
were any medical problems that would preclude
participation in the study. Out of a total of 109
residents in two residential care facilities, 53 (40%)
consented to participate in the study. Subject
characteristics are presented in Table 1. The
mean age of the subjects was 83.3 years. The
majority (87%) of the subjects were female, with
an average length of stay in the facility of 2.3
years. Half of the sample required the use of
assistive devices for ambulation. There were
averages of 2.2 diagnoses per patient, with the
top five diagnostic categories being cardiovascular,
neurologic, psychiatric, musculoskeletal, and
endocrine. Specific diagnoses included hyperten-
sion, dementia, depression, stroke, arthritis, and
chronic obstructive pulmonary disease. The
mean score on the Folstein Mini Mental State
Examination was 21.2, indicating mild cognitive
impairment.
Clinical Measures
The clinical measures that were tested for
their feasibility as screening tests included the
following: (1) Berg Balance Scale,7,18-20 (2) balance
subscale of the Tinetti Performance-Oriented
Mobility Assessment (POMA),8,21-23 (3) gait
speed,l4 and (4) Tinetti Fall Efficacy Scale.15,16 24
The characteristics of each of these measures are
presented in Table 2. The Berg Balance Scale,
which measures "functional balance," has three
dimensions: maintenance of a position, postural
adjustment to voluntary movements, and reaction
to external disturbances.7,8, 20.Subject performance
on each of 14 activities is measured on a five-point
ordinal scale ranging from 0 to 4 (O=unable to
perform, 4=independent) so that the aggregate
score ranges from 0 to 56. Correlations between
the Berg Balance Scale and other measures of
balance have been determined to be moderate to
J MGIMS, March 2009, Vol 14, No (i), 26 - 37
 Ganvir SD, Ganvir SS

high. The correlations between the Berg Balance been associated with falling in elderly individual27.
Scale and laboratory tests of postural sway, Tinetti's Fall Efficacy Scale measures the degree
Tinetti balance subscale, Barthel mobility of confidence an individual has in performing
subscale, and timed "up and go" tests are -.55, certain activities.17,18, 24. Tinetti suggests that
.91, .67, and - .76, respectively.18 Berg et al have self efficacy may be an appropriate model to
found high inter-rater and intra-rater reliabilities investigate an individual's fear of falling. The
(inter-rater and intra-rater reliability intra-class total score on the Fall Efficacy Scale can range
correlation coefficients= .98 and .99, respectively) from 10 to 40, with lower scores indicating greater
and high internal consistency (Cronbach's alpha= confidence in walking. Test-retest reliability of
.%). The average time to administer the scale in this scale in a sample of community-dwelling
these studies was 10 to 15 minutes. Tinetti's elderly individuals was found to be.71(Pearson's
POMA balance subscale measures an individual's correlation)
position changes and ability to balance while
Sample Characteristics : TABLE 1
performing certain activities, and is usually used
N=53
in conjunction with a gait subscale to derive an
aggregate score of gait and balance.8, 12. The total Variable
score on the POMA balance subscale can range Age(y)
from 0 to 16, with a higher score indicating better X 83.3
balance. Tinetti has reported both inter-rater and SD 7.7
test-retest reliability of .95 for the aggregate score Range 62-96
on the gait and balance subscale24. The POMA Gender (%)
gait and balance subscales have been shown to be Male 13%(07)
highly predictive of falls and fall related injuries Female 87%(46)
in community-dwelling elderly individuals and Length of stay (y)
residents of intermediate care facilities.22,23,25 In X 2.3
addition, the POMA gait and balance subscales SD 2.2
have been shown to be predictive of nursing home Range 0-9
placement and mortality.26 The mean time to Diagnosis (%)
administer the gait and balance subscales is 15 Cardiovascular 36(41)
minutes. Gait speed was measured by an insole Neurologic 25(28)
footswitch system. This system measures gait Psychiatric 12(14)
characteristics such as speed, cadence, stride Musculoskeletal 12(13)
length, swing and stance times, single-limb support, Endocrine 8(9)
and double-limb support. As the subject walks a Respiratory 4(5)
specified distance, footswitches record foot-floor Digestive 2(2)
contact, and these gait characteristics are timed Ophthalmalgic 1(1)
and automatically calculated.14 Speed was the Folstein Mini Mental State
only gait characteristic to be considered as a Examination score
screening tool because decreased gait speed has X 21.2

29

J MGIMS, March 2009, Vol 14, No (i), 26 - 37

Assessment of Functional Capacity in Elderly Population by Elderly mobility scale In Wardha (MS)

SD 5.8 Tinetti Sitting balance 10

Range 29-May POMA Arise
Grip strength (kg) balance Attempt to arise
Right subscale Immediate standing balance
X 14.3 Standing balance
SD 5.6 Nudge
Left Standing, eyes closed
X 13.1 Turn 360"
SD 5.5 Sit down
ADL~(% ) Stride Gait speed 10
Medication 70(37) analyzer
Bathing 21(11) Fall Subject's 10
Dressing 4(2) Efficacy confidence in:
Feeding 2(1) Scale 1.Cleaning the house
Toileting 0(0) 2.Getting dressed/undressed
Walking aids (%) 3.Preparing simple meals
No aid 5(27) 4.Taking a bath/Shower
Canes 26(14) 5.Simple shopping
Walkers 23(12) 6.Getting in/out of a chair
7.Going up/down stairs
Table 2. Characteristics of Clinical Measures 8.Walking in neighborhood
Measure Item Approximate Time 9.Reaching into cabinets
to Completes (min)
10.Answering the telephone
Berg Sit to stand 15
Balance Standing unsupported Physical Patient interview 10

Scale Sitting unsupported therapist Observation of transfers;

Standing to sitting Assessment walking on indoor and

Transfers outdoor level surfaces,

Standing, eyes Closed ramps, stairs, and curbs

Standing, feet together Time to complete as determined in this study.

Reaching forward with POMA = Performance-Oriented Mobility Assessment
outstretched arm
The validity of the instrument is
Pick up object from floor
suggested by the finding that total scores increase
Turn to look over shoulders
progressively as subjects report an increase in fear
Turn 360"
of falling.28
Step touch stool
Standing unsupported with
Data Collection
one foot in front
A "health fair" day was scheduled at each
Standing on one leg
facility to collect baseline data. The "health fair"

30

J MGIMS, March 2009, Vol 14, No (i), 26 - 37


consisted of three stations at which residents
were interviewed and assessed on performance
based measures of gait and balance. Interested
residents could attend the health fair at any time
throughout the day. As each resident arrived, the
study was described, and, if informed consent
was obtained, the resident was entered into the
study. All subjects were initially tested for cogni-
tive impairment using the Folstein Mini Mental
State Examination. Those individuals who
achieved a score of 20 or higher were further
interviewed about their walking abilities and
administered the Fall Efficacy Scale to assess
their confidence in walking. A cutoff score of
20 was selected to allow individuals who were
moderately cognitively impaired to be evaluated
by the physical therapist. Following the interview,
each subject visited two measurement stations
to be evaluated on gait and balance/functional
activities.. The order of testing transfer was
variable. Three physical therapists assessed
balance and function by administering the Berg
Balance Scale and the Tinetti balance subscale
and by evaluating the subject's ability to transfer
and walk on level surfaces and ramps. These
therapists received prior training to standardize
their administration of these tests. Gait speed
was assessed by another physical and a research
assistant. Footswitches were inserted into the
subject's shoes, and a recorder was strapped onto
the subject's waist. Gait characteristics were
recorded as the subject walked a distance of 6.1
m (20 ft). The average time to prepare a subject
for testing and to test the subject on all activities
was 45 minutes. Two weeks following the initial
data collection, another physical therapist, who was
blinded to the results of the clinical measures,
visited each facility to briefly assess each subject's
functional level and the need for further evaluation
31
Ganvir SD, Ganvir SS
and possible intervention. The physical
therapist's assessment took between 5 to 10
minutes per subject and included an interview
followed by observation of the subject's ability to
transfer and walk on level surfaces, ramps, stairs,
and outdoors. The assessment was tailored to the
functional capacity of the subject. For example,
subjects who had difficulty walking a short
distance indoors were not assessed walking
outdoors. Subjects who exhibited difficulty while
performing any of these transfer and ambulation
activities were judged to be appropriate for
physical therapy intervention. To assess the degree
of agreement among physical therapists' judgments
of appropriateness for treatment, three of the
subjects were videotaped while performing the
transfer and ambulation activities. Ten physical
therapists, including the physical therapist
who performed the assessment on all patients,
subsequently rated each subject's appropriateness
for physical therapy based on their observation
of the videotaped performances. The level of
clinical experience of these physical therapists
ranged from 0.5 to 47 years, with a mean of 13
years. The physical therapists were asked to
Elaborate on their evaluation criteria by listing
each functional component included in their
assessment of subject performance.
Data Analysis
Distributions, frequencies, and measures
of central tendency were examined for each
clinical measure using the SAS statistical software
system. Next, the sensitivity and specificity levels
of each clinical measure of balance and mobility
were calculated using established methods.30,31.
In general, the number of subjects scoring above
and below a specified score (cutoff value) on each
measure were counted and categorized according
J MGIMS, March 2009, Vol 14, No (i), 26 - 37
Assessment of Functional Capacity in Elderly Population by Elderly mobility scale In Wardha (MS)
to whether they were true-positive, true negative,
false-positive, or false negative using the physical
therapist's brief assessment as the standard. The
selection of cutoff values by which to calculate
sensitivity and specificity is arbitrary; therefore,
optimal cutoff Values were determined by plotting
receiver operating characteristic (ROC) curves for
each assessment method to determine the point
that provided the best tradeoff between sensitivity
and specificity.32. The ROC curve plots sensitivity
on the y-axis and specificity (1-specificity) on the
x-axis for a range of score values. The point that
provides the best trade off between sensitivity and
specificity is determined by viewing the slope of
the ROC ~urve.3~ In this analysis, the optimal
point occurred where the slope of the curve was
theclosestto1.Finally,thesensitivityandspecificity
levels achieved by using two clinical assessment
measures, gait speed and the Berg Balance Scale,
were determined in a parallel testing situation in
which a subject was labeled positive if diagnosed
as positive on at least one test.33 These two measures
were selected because they demonstrated the best
sensitivity and specificity levels when determined
individually. To assess the degree of physical
therapist agreement of appropriateness for
treatment based on observation of the videotaped
patient performances, the kappa statistic was
calculated using STATA statistical software. Kappa
Table: 3 Subjects performance on clinical tests
Test
Berg Balance Scale (0-56)
Tinetti POMAe balance subscale (0-1 6)
Gait speed (m/min)
Fall Efficacy Scaleb (10-40)
“POMA = Performance-Oriented Mobility Assessment.
Fall Efficacy Scale score reported only for those with a Folstein Mini Mental State
Examination SCORE of >20
is a chance-corrected measure of agreement that
can yield values ranging from - 1 to 1, depending
on the strength of agreement.34 The frequency
of items assessed by the physical therapists during
their assessment was also examined. The accept-
ability of each clinical measure, as determined
by the subject's ability to complete the test, was
the highest for the evaluation by the physical
therapist, followed by both tests of balance, gait
speed, and fear of falling. All 53 subjects
completed the evaluation by the physical therapist.
Forty three subjects (81%) completed both balance
tests, 44 (83%) completed the gait speed test, and
28 (53%) completed the Fall Efficacy Scale. For
both tests of balance, the most common reason
for non completion was subject refusal. The
majority of the subjects who failed to complete
the gait speed tests did so secondary to decreased
cognition. For the Fall Efficacy Scale, almost
one half of the subjects could not complete the
measure because of cognitive impairment or
communication difficulties. Table 3 provides
performance results for each clinical test. Frequency
distributions on both the Berg Balance Scale and
the Tinetti POMA balance subscale tended to
be skewed to the right. In this study, the Berg
Balance Scale required 15 minutes to administer,
whereas the POMA balance
N x SD Median Range
43 42.7 12.4 47 0-55
43 13 2.9 14 1-16
44 33.6 15.6 33.3 9.1-68.5
28 18.3 9.9 12 10-40
32
J MGIMS, March 2009, Vol 14, No (i), 26 - 37
 Ganvir SD, Ganvir SS

Table 4: Best Sensitivity and Specificity for Each Screening Test

Measure Scale cut off score sensitivity specificity
Berg balance scale 48 84%(21/25) 78%(14/18)
Tinetti POMA balance subscale 14 68%(17/25) 78%(14/18)
Gait Speed 34 80%(20/25) 89%(17/19)
Fall Efficacy scale 16 59%(10/17) 82%(9/11)
Berg balance scale and Gait Speed 48&34 91%(21/23) 70%(12/17)
Based on physical therapist evaluation as the standard.
POMA=Performance-Oriented- Mobility- Assessment. Either testing positive.
Table 5. Item Included in a Brief Physical a severe stroke several years earlier. This subject
therapist Assessment was walking with an ankle-foot orthosis and a
Item Assessed No. of Physical quad cane, and had severe left-side weakness. In
Therapists
Assessing Item the 28 subjects who could be evaluated on the
Fall Efficacy Scale, the mean score was 18.3. Out
Difficulty with transfers 9
of 53 subjects,28 (53%) were judged by the
Difficulty with ambulation
physical therapist to be appropriate for inclusion
on levelsurfaces 9
in a physical therapy mobility training program
Difficulty with ambulation
based on the brief assessment described previously.
on stairs 9
The ROC curves for the Berg Balance Scale and
Difficulty with balance 9
gait speed are plotted in Figures 1 and 2. The
Difficulty with ambulation
optimal cutoff points, based on ROC curves for
on ramps 8
each clinical assessment instrument and measure,
Assistive device fit/use 7
are presented in Table 4. At a cutoff score of 48,
Posture 6
the Berg Balance Scale demonstrated an equal
Strength (functional) 6
specificity level of 78% and a better sensitivity
Gait deviations 6
level, 84% versus 68%, than the POMA balance
Range of motion 3
subscale at a cutoff score of 1.4. The measure of
Cognitive impairment 2
gait speed demonstrated good sensitivity and
.Ten physical therapists participated in the specificity levels (80% and 89%, respectively; at a
videotaped patient ratings cutoff score of 34. The sensitivity and specific-
. cognitive impairment could not be directly ity levels of the Fall efficacy Scale, using a cutoff
assessed on videotape although two physical score of 16 and administered to cognitively intact
therapists reported that they would assess this individuals, were 59% and 82%, respectively. Using
in person. a combination of the Berg Balance Scale and gait
Sub scale averaged 10 minutes. The gait speed yielded a sensitivity of 91% and a specificity
speed measurements were normally distributed, of 70% when a subject was positive on at least
with a mean of 33.6 m/min. The slowest speed one test. Analysis of the physical therapists' ratings
was recorded for a subject who had experienced of the videotaped patient performances yielded

33

J MGIMS, March 2009, Vol 14, No (i), 26 - 37

Assessment of Functional Capacity in Elderly Population by Elderly mobility scale In Wardha (MS)
moderate agreement beyond chance (K=.47,
P<.0001). The items assessed by the physical
therapists to arrive at their determination of
appropriateness for treatment are listed in Table
5. The most frequently reported items assessed
on videotape included difficulty with transfers,
difficulty with ability to balance, and difficulty
with ambulation on level surfaces and stairs
Figure 1. Berg Balance Scale receiver operating characteristic
curve. Asterisk P) indicates cut off point; double asterisk (")
indicates optimal cut off point.
Figure 2. Gait velocity receiver operating characteristic curve.
Asterisk (9 indicates Cutoff point ; double asterisk P) indicates
optimal cut off point.
Discussion
The results of this study show that clinical
assessment instruments that detect balance and
mobility impairments are useful for screening
elderly individuals who may be in need of a
detailed physical therapy evaluation and possibly
intervention. These screening methods demonstrated
good sensitivity and specificity for reproducing
34
a physical therapist's judgment. The two clinical
measures that showed the strongest potential for
use as screening methods were the Berg Balance
Scale and gait speed. Our results showed that
the Berg Balance Scale was more sensitive than
the Tinetti POMA balance subscale and had
comparable specificity. The Berg Balance Scale,
however, takes longer to administer than the
POMA balance subscale (15 minutes versus 10
minutes). The strength of the Berg Balance Scale
lies in its detailed grading scale, which appears
to be better at detecting balance impairment than
the POMA balance subscale. Topper et a135 also
describe this limitation of the POMA in identifying
individuals who are at risk for falling In developing
the screening methods, we included individual
measures of balance, gait, and subjective percep-
tions of fear of falling. The combination of two
clinical measures, balance (as measured by the
Berg Balance Scale) and gait speed, yielded the
highest sensitivity level of 91%, suggesting that
a combination of clinical tests most accurately
reflects the physical therapist's judgment and
thus might be the best for developing screening
methods. In a screening situation involving the
Berg Balance Scale and gait speed, a subject
would be administered the second test only if the
first test did not indicate the need for further
evaluation. In this study, physical therapists were
used to conduct screening tests to maximize efforts
of ensuring that these tests were performed
consistently. The use of non-physical therapists to
perform these tests could decrease the likelihood
that the tests were performed consistently
because physical therapists are specially trained
to assess function. In a screening situation, these
screening tests could be administered by health
care personnel who are in constant contact with
elderly people, such as primary care physicians
J MGIMS, March 2009, Vol 14, No (i), 26 - 37

during a routine office visit or facility personnel.
These individuals, however, would require in-depth
training to consistently administer the screening
tests. The next step is to have physical therapists,
or other individuals who are knowledgeable
about-these tests, educate other health care
personnel on how to conduct the tests for elderly
individuals. If physical therapists can teach
lower-level personnel to conduct these tests, the
screening procedure would be less costly. This
study showed that tests of balance and gait speed
had high sensitivity and specificity in screening
the older community dwelling population for
balance and mobility impairments. These specific
tests were selected because they have established
reliability and validity in the geriatric literature.
Other comparable, yet simpler, tests could be
used as screening methods for the detection of
balance and mobility deficits. For example, gait
speed could be measured by using a stopwatch
rather than the footswitch system, and balance
could be measured using the forward-reach
technique rather than the Berg Balance Scale.
The use of simpler tests would facilitate their
administration. Simpler methods, however,
would have to show acceptable sensitivity and
specificity to be able to identify appropriate
individuals. There are several limitations of this
study. First, the sample was relatively small and
drawn from the residential care facility population.
This study is therefore not generalize able to other
community-dwelling elderly individuals, such as
those living in their own homes. The residential
care facility population, however, represents a
sizable community-dwelling population with a
high prevalence of balance and mobility deficits
who often go undetected in their need for physical
therapy services. Second, there were only three
physical therapists to assess balance using the
35
Ganvir SD, Ganvir SS
Berg and Tinetti scales. These therapists, however,
received prior training to standardize the admin-
istration of these tests. Third, the standard for
identifying subjects with balance and mobility
deficits was limited to the assessment of one
licensed physical therapist, which was brief and
may not have been fully diagnostic. Subsequent
ratings of videotaped patient performances by
10-physical therapist including the rater, however,
yielded moderate agreement beyond chance,
indicating that therapists tend to evaluate patients
similarly. Finally, there was 2-week lag time
between testing and the physical therapists'
evaluations. There could have been some clinical
changes between the ratings, although such
changes should be minimal in a stable population.
Further studies be performed that incorporate
larger sample sizes and different sites in developing
screening methods to identify older persons with
balance and mobility deficits who may be in need
of more detailed physical therapy evaluation by a
skilled therapist. To facilitate the administration
of screening tests by clinicians or facility personnel,
further studies should be performed to identify
simpler and easier-to-administer methods with
comparable sensitivity and specificity in the
community based setting.
Conclusion
As the Indian population over the age of
65 years continues to grow, there will rise in the
level functional disability. Physical therapists can
.play. An important role in delaying the onset of
& ability and prolonging health into older ages,
it is there for imperative that appropriate screening
methods are developed to identify community-
dwelling elderly individual- with functional
impairment who should be referred for a detailed
physical therapy evaluation
J MGIMS, March 2009, Vol 14, No (i), 26 - 37
Assessment of Functional Capacity in Elderly Population by Elderly mobility scale In Wardha (MS)
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3. Koska MT. Rehabilitation growth fuels PT
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7. Berg K, wood-Dauphinee S, Williams JI,Measuring
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9. Weiner DK, Duncan PW, Chandler J, Studenski
SA. Functional reach: a marker of physical frailty.
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in elderly people who have and who have not fallen.
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responses and effector factors in persons with
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13. Feltner ME. MacRae PG. McNitt-Grav, J L
Quantitative gait assessment as a predictor of
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dwelling older women. Arch Phys Med Rehabil.
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14. Peny J. Gait Analysis: Normal and Pathological
function Thorofare, NJ: SLACK Inc; 1992:431.
15. Tinetti ME, Richman D, Powell L. Falls caw as a
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17. Lichtenstein MJ, Burger MC, Shields SL Shiavi
RG. Comparison of biomechanics platform
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1190-1193.
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 Original Article

"SUICIDES IN ELDERLY AGE-GROUP IN WARDHA REGION

OF MAHARASHTRA IN A PERIOD OF FIVE YEARS,
FROM 1ST JANUARY 2001 TO 31ST DECEMBER 2005."

PN MURKEY *, BH TIRPUDE **, VG PAWAR ***, KS SINGH ***.

ABSTRACT

The study was conducted at Mahatma Gandhi Institute of Medical Sciences (MGIMS),
Sevagram from 1st January 2001 upto 31st December 2005 i.e. 5 years on 99 cases of elderly suicide
which were received from in and around the district Wardha, Maharashtra. Cases included
victims greater than or equal to 50 years of age. Data was analyzed with regard to the age, sex,
methods of suicide, place of suicide, cause of suicide and time of the year components. There were
71 male (72%) and 28 female (28%) victims. The age range of the suicide victims was 50 to 85 years.
Commonest age group involved in our study was 50 - 59 years (n=47, 47.47%) in both sexes.
Poisoning (n= 62, 63%) was the most common method of suicide, followed by burning (n=27, 27 %)
and drowning (n=6, 6%). Maximum numbers of suicides were seen in the rainy and winter season
(n=54, 55%). Financial problem (n = 53, 53.5%) was the most common reason behind the suicide.

Key Words : Suicide, poisoning, burning, chronic illness.

INTRODUCTION : 7.2 percent of total population were above the

Aging is a natural phenomenon which is
inevitable to everyone. In the recent years, there
has been a considerable increase in the relative
or absolute numbers of the elderly people which
is due to decline in the fertility rates combined
with increase in life expectancy of people
achieved through medical interventions.1 In the
year 2002, there were an estimated 605 million
old persons in the world of which 400 millions
were living in the low income countries. It is
expected that by the year 2025, the number of
elderly people will rise to more than 1.2 billion,
with about 840 million of these living in low-income
countries. As per SRS estimates for the year 2003,
* Associate Professor, ** Professor & Head, *** Post
Graduate Students, Address for Correspondence :
Dr.P.N.Murkey, Associate Professor, Dept. of FMT,
MGIMS, Sevagram. E-mail : drpnmurkey@yahoo.com
age of 60 years.2
For most older people, their life is a time of
fulfillment, satisfaction with life's accomplishments.
For some older adults, however, later life is a time
of physical pain, psychological distress, and
dissatisfaction with present, and, perhaps, past
aspects of life. They feel hopeless about making
changes to improve their lives. Suicide is one of
the possible outcome. Life events commonly
associated with elderly suicide are: the death of
a loved one, physical illness, uncontrollable pain,
fear of dying a prolonged death that damages
family members emotionally and economically,
social isolation, lack of care from children and
loneliness and financial problems due to job
loss or retirement. The widowed, divorced, and
recently bereaved are at high risk. Others at high

38

J MGIMS, March 2009, Vol 14, No (i), 38 - 42


risk include depressed individuals and those
who abuse alcohol or drugs.3
In America, each year more than 6,300
older adults take their own lives, which means
nearly 18 older Americans kill themselves each
day. Although they comprise only 12 percent of
the U.S. population, people age 65 and older
accounted for 16 percent of suicide deaths in
2004.4 In India the rate of suicide among the
elderly in the year 2005 was 8.2 % (Male 5.8%, and
Female 2.4%) of the total suicides. According to
NCRB India report 2005, nearly 42.8% of the
elder age group committed suicide due to illness.5
In the present article, we have attempted
to study the incidences, patterns and modes of
suicides in the elderly persons brought for
medico-legal autopsy to MGIMS, Sevagram.
MATERIAL AND METHODS :
The Mahatma Gandhi Institute of Medical
Sciences (MGIMS), Sevagram, is one of the pioneer
rural based hospital in the country which was
established with the motive of providing the basic
medical needs to the rural population of India.
As in any other government medical hospitals,
here too the medico-legal autopsies are conducted
which covers the whole of Wardha district
(mainly) and also other nearby districts. We went
through all cases of elderly deaths on which
postmortems were done at MGIMS, Sevagram
(age of victim being 50 years and above, as
compared to 60 years and above in other studies)
over a period of 5 years, from 1st January 2001 to
31st December 2005. A total of 1306 autopsies were
done during this period, out of which 230 cases
were of elderly subjects (50 years and above). Out
of these 230 elderly autopsies, 99 cases were of
suicides, which constitutes about 7.58 % of all
the total autopsied cases which were done in the
39
Murkey PN, & et al.
above mentioned period of 5 years. The detailed
analysis of these cases was based on the medical
records and the evaluation of autopsy reports.
DISCUSSION :
In our study, out of total 1306 autopsy
cases, 312 cases were of suicides, which constitutes
about 23.89 % of all the autopsy cases. Out of
these 312 cases, 99 cases were in the elder age
group (50 years and above) which amounts to
31.73% of all the suicide cases.
In our study from 2001 to 2005, there
were almost an equal numbers of suicides in
each year with slight variation in the figures with
maximum incidence in 2002 (n=24) and minimum
incidence in 2004 (n=16). Kua et al, in a study
describing the trends of elderly suicide rates of
Chinese, Malays and Indians in Singapore from
1991 to 2000 reported that the suicide rates for
the elderly showed a decline, especially in elderly
Chinese.6
As for the pattern of age and sex wise dis-
tribution of suicide, Pritchard in a study of
changing patterns of suicide in the Western
World, examined changes in suicide rates between
1974 and 1992 in twenty-two countries. He found
a decrease in rate of suicide in 65-74 years olds of
both sexes in most countries and increases in
suicide rates in the population aged 75 years
and older, again in both sexes, but with a male
preponderance.7 But in our study, there is a
decrease in the rate of suicide with increasing
age with the commonest age group involved
was 50-59 years (n = 47, 47.47%) followed by the
age-group 60 - 69 years (n=31, 31.32%) and 70-79
years (n=15, 15.15%). Minimum cases of elderly
suicides were found in the age-group of 80-89
years (n=6, 6.06%). There is male preponderance
in all the age-groups except in the last one where
females are dominating. The highest rate of
J MGIMS, March 2009, Vol 14, No (i), 38 - 42
Suicides In Elderly Age-Group In Wardha Region Of MH In A Period Of Five Years, From 1st Jan. 2001 To 31st Dec. 2005.
elderly suicides in the age-group of 50-59 years
with male preponderance in our study may be
explained by the fact that there is high rate of
suicides among the farmers in the region of
Maharashtra.
Poisoning was the most common cause
of death (n=62, 62.6%) followed by burn injuries
(n=27, 27.3%). In cases of poisoning, the male :
female is 5.2 :1 whereas in cases of burns, females
predominated males with a male : female of 1:2.
Next to burn injuries the cause of death was
drowning which formed about 6.1% (n=6) with
male : female ratio of 1:5, followed by hanging
(n=2, M:F = 1:1)and railway cutting (n=2, both
males). Therefore, it was concluded that among
males poisoning was the most common cause of
death whereas among females burning was the
commonest mode of suicide. In a similar study
of 10 years (from 1996 - 2005) by C. Behera et al
at AIIMS, they found that hanging was the most
common cause of death which is quite different
from our study.1 This highlights the basic
difference of mode of suicide in rural and
urban areas where poisoning was most common
method in rural areas due to easy availability of
poisons (mostly pesticides and insecticides) in
each home of rural areas. Studies from most of
the western countries revealed firearms as the
most common method of suicide 8 which is quite
contradictory in our scenario where there was
not a single such case.
The highest number of suicides in the
elderly age groups was recorded in autumn and
winter (55%, n=54) followed by the rainy season
(28%, n=28) and spring and summer season (17%,
n=17) which is quite different from the findings
observed in the studies from eastern part of India
by S. Mohanty et al9 and from Northern India by
c.Behera et al1 where maximum cases were
40
recorded in the rainy season. Most of the suicides
occurred indoors (n=87, 88%), which is consistent
with the findings observed by S.Mohanty et al9
and c.Behera et al1.
The specific types of events most
pertinent to suicide in later life differ from
those of younger victims. Interpersonal discord,
financial and job problems, legal difficulties and
disputed romance etc. are more typical of suicides
in young and middle adulthood, whereas physical
illness and other losses including family
economical losses are the most common stressors
in older adults who end their own lives.
As per the findings of our study, financial
problem was the foremost reason behind the
high rates of suicide among the elders which
constituted 53.5 % (n=53) of the total cases. This
may be due to the below-poverty-line economy
of the poor rural populations combined with
high indebt from high-interest-money lenders.
This is followed by other family and personal
problems (n=26, 26.3 %) and chronic illness (n=11,
11.1%). This is quite contradictory to the findings
of most of the studies. Dorpat et al (1968)10 in a
study stated that physical illness directly contributed
to suicide in almost 70% of victims over 60 years
of age. Margda waern et al11in their study
mentioned that physical illness is a common
antecedent to suicide in elderly people, with
prevalent figures varying widely from 34% to
94% and higher risk factors in men than in
women. In 9.1% cases (n=9) the causes were unknown,
but here conditions like social isolation and
loneliness are important factors to be considered
(Barraclough 197112).
CONCLUSION :
Suicide is rarely, if ever, caused by any
single event or reason. Rather it results from
J MGIMS, March 2009, Vol 14, No (i), 38 - 42
 Murkey PN, & et al.

many factors working in combination which impulsive act and so we can have a window of
produce feelings of hopelessness and depression. opportunity to help the older persons get help
Elder suicide is usually associated with depression and we can prevent it by providing social welfare
and factors causing depression e.g. chronic illness, measures like national assistance, supplementary
physical impairment, unrelieved pain, financial pensions, adult care centres, home care agengies,
stress, loss and grief, social isolation and alcoholism hospices, assisted living facilities and nursing
etc. However, suicide for the older is not an homes etc.
FIGURES

Figure : 1 - showing age-wise distribution. Figure : 2 - showing sex-wise distribution.

Age-w
EPlace
Sex-wise Methods
ise
rlyof
ld ecut, su id eof
suicide
distribution
ic suicide
distribution
Reason s in of
fordsuiciden t suicide
ofreelderly
iffe seasons
Railway 2,
2% suicide casescases in elderly
60 53
Hanging, 2, 2%
50 47Outdoor,
of cases

4050
SDrowning,
p rin g a n d6,
12, 12%
No.cases

s u
40 6%26m m e r, A u tu m n Poisoning
a n d w in te r
30 17 , 1 7 % 31
30 Burn
Females,
20 15 R a in y s e a s 9o n
A u t u m n a n d 11
No. of

Burn,20 27, 27% Outdoor Drowning

R a in y
28, 28%
10 w in t e r, 5 4 ,
Poisoning, 62, Indoor Males 6
s e a 10
s on, 28, 55% S p rin g aHanging
nd
02 8 % 63%
0 s u m m e rRailway cut
Family problems Financial Chronic Illness Females
Causes not
Indoor, 87, 50 - 59 Males,
60 - 69 71,
Figure
problems :3 -70 - 79 methods
showing 80
knownandof suicide. Figure : 4 - showing season-wise distribution.
88% 72%
Reason above
Age -groups

Figure : 5 - showing place of suicide. Figure : 6 - showing reasons.

41

J MGIMS, March 2009, Vol 14, No (i), 38 - 42

Suicides In Elderly Age-Group In Wardha Region Of MH In A Period Of Five Years, From 1st Jan. 2001 To 31st Dec. 2005.

REFERENCES : 9) S. Sachindananda Mohanty Geeta Sahu Manoj

1) C. Behera, R. Rautji, R.K.Sharma, Suicide in Kumar Mohanty, Manju Patnaik, Suicide in India
elderly : A study in South Delhi (1996 - 2005) - A four year retrospective study, Journal of Forensic
and Legal Medicine 14 (2007) 185- 189.
2) Park's text book of Prevention and social Medicine
: 19th Edition Feb 2007, Banarasidas Bhanot 10) Dorpat TL, Anderson WF, Ripley HS (1968), The
Publishers,Page No. 476-477. relationship of physical illness to suicide. In:Resnik
HPL, editor, Suicidal behaviours : Diagnosis and
3) Suicide of older men and women - Elderly suicide
Management, boston : little, Brown, pp 209- 219.
www.healthyplace.com/Communities/depression/
related/suicide_3.asp - 25k) 11) Margda Waern, B runeson, K Wilhelson, Burden
of illness and suicide in elderly people : caee-
4) (Conwell Y, Brent D. Suicide and aging. I: patterns
control study, BMJ 2002; 324 : 1355 (8 June).
of psychiatric diagnosis. International
Psychogeriatrics, 1995; 7(2): 149-64.) 12) Barraclough BM (1971), Suicide in the elderly :
Recent developments in psychogeriatrics. Br J
5) Accidental deaths and Suicides deaths in India.
Psychiatry (suppl 6): 87 - 97.
National Crime Record Bureau. Ministry of Home
Affairs, Govt. of India, RK Puram, New Delhi,2005.
6) Kua EH, Ko SM, NgTP, Recent trends in elderly
suicide rates in a multi-ethnic Asian city, Int J
Geriatr Psychiatry, 2003 Jun; 18 (6): 533-6.
ERRATUM
7) Pritchard C.New patterns of suicide by age and
gender in the United Kingdom and the western JMGIMS Vol.13, No. ii, September 2008
World 1974-1992, an indicator of social change ?
Soc Psychiatry Psychiatr Epidemiol 1996, 31 :227-234.
The Title of the article may please be read as -
“ Genome Sequencing of HPV
8) Katalin Szanto, Holly G Prigerson, charles F. - A Hope to Overcome Cervical Cancer”
Reynolds III. Suicide in the elderly, Clinical
Neuroscience Research I (2001) 366-376. Editor

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J MGIMS, March 2009, Vol 14, No (i), 38 - 42

 Case Report

INABILITY TO START HEMODIALYSIS AFTER

A SMOOTH DUAL LUMEN HEMODIALYSIS CATHETER
INSERTION PROCEDURE : A CASE REPORT

S KUMAR *, AP JAIN **

ABSTRACT

Cannulation of the central vein for placement of the temporary dual-lumen catheter
for hemodialysis is usually safe and reliable even when performed blindly. Here, we report a case of
aberrant catheter entry into the external jugular vein during an apparently smooth procedure.

Case report - 20-mL syringe could be ascertained at the end

A 36-year-old man known case of CKD of the procedure. Hemodialysis, however, could
stage -5 who was on conservative management not be commenced due to a high negative ''arterial''
because of financial problems. His symtomps pressure. A post insertion chest X-ray was taken
became refractory and also developed pulmonary (fig-1). We did Doppler sonography of this patient
edema so planned for emergency hemodialysis. which showed catheter in vein beside internal
His laboratory investigation revealed blood urea jugular vein probably external jugular vein.
- 250 mg%, serum creatinine - 14 mg%, serum
sodium - 128 mEq/L. and serum potassium - 7.6
mEq/L. However his ECG did not showed any
changes of hyperkalemia. A temporary dual
lumen standard 12 F, 13 cm long, hemodialysis
catheter (arrow) was inserted into the right
Subclavian vein using the Seldinger technique.
The Seldinger technique means that a blunt
guidewire is passed through the needle, and the
needle is then removed. A dilating device then
passed over the guidewire to slightly enlarge the Fig - 1 : Double lumen catheter in upward direction
tract, and the catheter itself is then passed over probably in external jugular vein.
the guidewire, which is then removed. All the Discussion -
lumens of the line are aspirated (to ensure that In patients with end - stage renal disease,
they are all positioned inside the vein) and cannulation of the central venous system with
flushed.The procedure was uneventful, and free large- bore double lumen catheters is often necessary
flow of blood from both lumens using a standard until a functioning vascular access can be created.
* Sr Lecturer, **Director - Prof. and Head Dept. of
Medicine, MGIMS, Sewagram. Corresponding Author : Double - lumen catheters are widely used for
drsunilkr_med@rediffmail.com temporary access to the circulation in patients

43

J MGIMS, March 2009, Vol 14, No (i), 43 - 44

Inability to start hemodialysis after a smooth dual lumen hemodialysis catheter insertion procedure : a case report
who require acute hemodialysis. Since HD requires
rapid extracorporeal blood flow, femoral, subclavian
and internal jugular veins are the sites most
commonly chosen. While cannulating the internal
jugular vein or subclavian vein their surface
anatomical landmarks are known to be inconsistent
and unreliable. Anomalies of the central veins
occur in 25%-35% of uremic patients,1 which
commonly include anatomic variation of the internal
jugular vein in relation to the carotid artery,
stenosis, total occlusion, and nonocclusive thrombus
formation. The hemodialysis catheter had not
followed the expected course of the right subclavian
vein into the right jugular vein that crosses the
midline to join the right brachiocephalic vein
to form the superior vena cava. The catheter had
most likely entered a tributary of the right
subclavian vein i.e. right external jugular vein,
(fig-2) which explains why there was free flow
of blood by syringe aspiration during catheter
insertion, but not by the blood pump of the
hemodialysis machine that generated a suction
force to execute a flow rate of 200 mL/min. Such
complication may happen in patients who had
previous catheter insertions. The external
jugular vein varies in size, bearing an inverse
proportion to the other veins of the neck. It is
provided with two pairs of valves, the lower pair
being placed at its entrance into the subclavian
vein, the upper in most cases about 4 cm. above
the clavicle.
To circumvent these problems, direct
real-time ultrasound guidance for the insertion
of temporary hemodialysis catheter has greatly
enhanced the safety and success rates of this
procedure,3 which is commonly performed by
the practicing nephrologist, intensivist, and
radiologist in major hospitals worldwide. However
at this centre we are doing blindly because of lack
44
Fig-2 : Major vein and their tributries
(taken from internet)
of resources without any much complication and
inconvenience. Indeed, sonography does not
allow the operator to follow the course of the
guidewire and catheter beyond the subclavian
vein or internal jugular vein. So in addition to
an ultrasound survey, venography performed
during catheter insertion may detect unexpected,
clinically significant anatomical abnormalities or
variations of the central veins.
References -
1. Lin BS, Kong CW, Tarng DC, Huang TP, Tang
GJ. Anatomical variation of the internal jugular
vein and its impact on temporary haemodialysis
vascular access : An ultrasonographic survey in
uraemic patients. Nephrol Dial Transplant. 1998;
13:134-138.
2. M.Moini, M.R.Rasouli, M.M.Kenari, H.R.
Mahmoodi : Non-cuffed dual lumen catheters
in the external jugular veins versus other central
veins for hemodialysis patients. Saudi J Kidney
Dis Transpl 2009; 20:44-8.
3. Oguzkurt L, Tercan F, Kara G, Torun D, Kizilkilic
O, Yildirim T. US-guided placement of temporary
internal jugular vein catheters: Immediate
technical success and complications in normal and
high-risk patients. Eur J Radiol. 2005;55:125-129.
J MGIMS, March 2009, Vol 14, No (i), 43 - 44
 Case Report

GENETIC STUDY - A HELPING HAND FOR CLINICAL DIAGNOSIS

AM TARNEKAR *, JE WAGHMARE **, P BOKARIYA ***, IV INGOLE ****, AK PAL *****

ABSTRACT

Genetic disorders have diverse modes of presentation. Some present with obvious features
and have strong clinical suspicion in order to make a clinical diagnosis. Many other genetic disorders
remain masked till a specific genetic test such as karyotype analysis or molecular analysis (FISH,
PCR) is carried out. Some routinely encountered genetic disorders such as Klinefelter's syndrome,
Turner's syndrome and Down's syndrome may present in a variant form. In such cases there is very
little clinical suspicion for a genetic disorder and diagnosis is entirely based on karyotype analysis.
Importance of genetic study in conditions of poor reproductive outcome, bad obstetric history
(BOH) and inheritance of Down's syndrome is highlighted.
Key words : karyotype, mosaicism, genetic counseling.

INTRODUCTION However in many others a genetic test such as

With better control of infectious and
nutritional diseases more number of genetic
disorders are emerging1. People in general are
largely unaware of genetic disorders. Different
genetic disorders present in diverse manner and
manifest at different ages. Problems related to
fertility manifest much later than bodily deformities
(congenital anomalies) that manifest in neonatal
period. Many others manifest in adulthood or
may not reveal at all till a triggering signal is
received. Regardless of age of presentation, all
such conditions can however be identified at a
quite early age if specific genetic tests are applied
whenever clinically suspected.
Diagnosis of some of the genetic disorders
can be presumptively made on the basis of
presentation, signs and symptoms [e.g. Klinefelter's
syndrome, Down syndrome & Turner's syndrome].
*Associate Prof., ** Senior Lecturer, *** Lecturer,
**** Prof. & Head *****Prof. (Cytogenetics) &
corresponding author. Human cytogenetics unit, Dept.
of Anatomy, MGIMS, Sevagram.
Karyotype of peripheral blood lymphocytes or
molecular genetic tests such as PCR (polymerase
chain reaction) and FISH (fluorescent in situ
hybridization) are required to identify and
localise the abnormality. Most of the new world
diseases such as cancer, diabetes, hyperlipidaemia
etc have a genetic predisposition. This necessitates
carrying out a susceptibility test (e.g. human
leucocytic antigen 'HLA' typing) for the timely
diagnosis and proper management of such
conditions.
We have analysed some of the routinely
referred subjects to cytogenetics unit and categorized
some such cases where a clinical clue to point a
genetic abnormality was lacking. It reveals the
importance of carrying out Karyotype analysis
and subsequent genetic counseling for the
comprehensive management of such conditions.
Scenario 1 : An infertile married couple
is referred. No abnormality found in female
partner. Husband was azoospermic and found

45

J MGIMS, March 2009, Vol 14, No (i), 45 - 48

Genetic Study - A Helping Hand For Clinical Diagnosis
to have deletion of Y chromosome (46,XYq-); OR
mosaic of Klinefelter's syndrome (46,XY /
47,XXY) OR some other structural abnormalities
of 'Y' chromosome.
Fig 1 : Karyotype of an azoospermic individual :
karyotype 46,XYq-
Scenario 2 : Another infertile married
couple, male partner found normal, female
partner has mosaic pattern of Turner's syndrome
(45,X0 / 46,XX or 47,XXX / 45,X0) OR other
structural abnormalities of an 'X' chromosome.
Scenario 3 : A childless couple with history
of several pregnancy losses (bad obstetric history
'BOH'). Karyotype reveals autosomal structural
abnormality e.g. 46, XY, t(6;13) (p24; q21) in male
OR 46, XX, t(9;15)] in female partner.
Fig 2 : G banded Karyotype of male partner of
a couple with BOH: 46, XY, t(6;13)(p24;q21)
46
Fig 3 : Karyotype of the child with translocated
Down syndrome: Karyotype: 46,XY,t(14;21)
Scenario 4 : a couple presents with a child
who was born after series of pregnancy losses.
His parents want to rule out any genetic disorder
in child. Karyotype of the child reveals
traslocated type of Down's syndrome.
DISCUSSION :
The case scenarios suggest the modes
of presentation of some genetic disorders. The
existing myths about disease causation can be
removed by proper counseling and the scientific
background of such conditions be explained to
the family members in order to regain the peace
of the family.
In scenario 1, gentleman did not know
that he might have an abnormality till seminal
analysis and karyotype was performed. Mosaics
of Klinefelter's syndrome may not be azoospermic
and some sperms or round spermatids may be
obtained by MESA (micro epididymal sperm
aspiration) or TESA (Testicular sperm extraction)
for invitro fertilization (IVF) such as ICSI (intra
cytoplasmic sperm injection)2. Such persons have
chromosomally imbalanced gametes that may
lead to birth of an abnormal child. It is therefore
most undesirable for such couples to try their
J MGIMS, March 2009, Vol 14, No (i), 45 - 48

luck with assisted reproductive techniques
(ARTs), the ideal option is adoption. It is quite
unfortunate on part of lady when we here about
husband's second marriage, separation of the
couple or continued harassment of the lady3 by
family members in such circumstances.
In scenario 2, a lady in whom onset of
menses (menarche) occurs as usual, secondary
sex characters are developed, clinical examination
may not reveal any abnormality but the lady is
infertile due to a constitutional chromosomal
abnormality - 'X' chromosomal abnormality
[structural or numerical] such as mosaic
Turner's syndrome and fragile 'X' syndrome4. 'X'
mosaicisms cause premature ovarian failure
(POF) or polycystic ovary syndrome (PCOS) ren-
dering a lady primarily or secondarily infertile5.
In conditions of reciprocal balanced
autosomal translocations [scenario 3] phenotypic
abnormalities may not be there. However the
particular structural abnormality of autosomes
leads to improper segregation of chromosomes6
during gametogenesis rendering the gametes
chromosomally imbalanced and therefore
pregnancy either does not occur or results in
miscarriage (BOH)7.
The occurrence of abnormal karyotype
as 'translocated Down' in child [scenario 4] was
the result of inheritance of Robertsonian
translocation from one of the parents, which
happens in 3-4% cases of Down's syndrome8. In
such cases usual phenotypic features of Down's
syndrome are lacking so there is no clinical
suspicion. Though such children might lead an
apparently normal life as their parents do, but
their reproductive outcome will be poor. 'Trisomic'
Down's syndrome, which is the usual form of the
syndrome, occurs de novo and is never inherited.
47
Tarnekar AM & et al
Karyotype analysis is a basic investigative
tool for diagnosis of a genetic disorder. The
drastic features of genetic disorders are hereby
summarised for a proper and ethical approach
towards their management.
Genetic disorders may arise either de
novo or familial, so they are not always predictable;
only by genetic tools they can be identified; they
provide no option for treatment, any attempt of
treatment or further investigation will be
wastage of resources.
Pre marital counseling is must when a
genetic disorder is suspected in families of
marriageable candidates9. If already married,
child should be planned only after proper
genetic counseling. If an expert advice is seeked
when already pregnant, pre natal diagnosis is a
measure to rule out birth of baby with congenital
anomaly10.
On realizing that there is no treatment
option left, people might raise doubts about
feasibility of carrying out a genetic test. It can
clearly be stated that to have a safe future
generation genetic study should be carried out
today.
Acknowledgements : Authors gratefully acknowledge
the technical assistance of MR V P Kavinesan
and Mr. Satish Shingare.
REFERENCES :
1. Verma IC. The challenge of genetic disorders
in India : Molecular genetics and gene therapy.
The New Frontier. In Proceedings of First Annual
Ranbaxy Science Foundations Symposium, New
Delhi 1994: 11-20.
2. Lanfranco F, Kamischke A, Zitzmann M and
Nieschlag E. Klinefelter's syndrome. Lancet 2004;
364: 273-283.
J MGIMS, March 2009, Vol 14, No (i), 45 - 48
Genetic Study - A Helping Hand For Clinical Diagnosis
3. Phadke SR. and Agarwal SS. Adverse effects of
genetic counseling on women carriers of disease:
The Indian perspective. The National Medical
Journal of India 2001; 14, (1).
4. Pal A K, Waghmare JE, Tarnekar A, Rawlani S
and Ingole I. Genetic aspects of human infertility.
Perspectives in Cytology and Genetics (Eds. Giri
AK, Ghosh PD and Mukherjee A; AICCG
publication) 2007; 13: 106-114
5. Anasti JN. Premature ovarian failure: an update.
Fertility and Sterility 1998; 70: 1-15.
6. Sadler TW. Gametogenesis: conversion of germ
cells into male and female gametes. In Langman's
Medical Embryology (Lippincott Williams and
Wilkins Publ.), 10th Edition : 2008 : 11- 29.
48
7. Chandley AC, Edmond P, Christie S, Gowans L,
Fletcher J, Frackiewicz A and Newton M.
Cytogenetics and infertility in man. I. Karyotype
and seminal analysis. Results of a five year survey
of men attending a sub fertility clinic. Annals of
Human Genetics 1975; 39: 231-252.
8. Hamerton JL, Cowie VA, Gianneli F, Briggs SM,
Polani PE. Differential transmission of Down's
syndrome (Mongolism) through male and female
translocation carriers. The Lancet 1961 (ii): 956-958
9. Abdel MN, Zaki MS and Hammad SA. Premarital
genetic investigations: effect of genetic counseling.
East Mediterr. Health J. 2000; 6 (94):652-60.
10. Jackson LG. Prenatal genetic counseling. Primary
care Dec 1976; 3(4): 701-16.
J MGIMS, March 2009, Vol 14, No (i), 45 - 48
 Case Report

I WANT MY FATHER BACK - CHILD’S DESTINY.

BH TRIPUDE *, PN MURKEY **, VG PAWAR ***, S SHENDE ***, A KECHE ***, KS SINGH ***

ABSTRACT

A 50 years / male, rural farmer in Wardha district, Vidarbha region of Maharashtra,

cultivated cotton on his eight acres (3.2 heactares) of land, and the returns were good until a
couple of years ago. On August 11, 2007, he had consumed some unknown poison in his farm and
admitted in Kasturba Hospital, Sewagram and died during treatment. As the body comes to the
postmortem examination the children’s were crying agonizingly and shouting as “majhe baba mala
parat daya”. On postmortem examination, a visceral examination indicated the presence of a
pesticide. He had apparently taken the step as he is unable to face the local bankers and
moneylenders who had loaned him money. Two successive failed monsoons, coupled with the
non-payment of dues by an apathetic State Government, left him with barely enough to feed his
family and repay a debt of Rs. 50,000. It is a situation that thousands of farmers in the cotton belt
of Maharashtra are familiar with, and increasingly they are reaching for the pesticide can as a way
out of the misery. As this is one of the case filed as farmer suicide from the institute.

Key words - Poison, Pesticide, Cultivation.

Introduction - the insecticides; hence incidence of poisoning

Rig Veda mentions laws and regulations
regarding poisoning. Poisoning is prevalent in
all over the world since ancient times. Meera was
killed by giving “Charanamrit” by king Rana.
Cleopatra committed suicide by inducing snake
bite by her own. Nepolean Bonaparte of France
was killed by slow arsenic poisoning. Ala-Uddin
Khilagi and General Romel were also killed by
poison. Greece and Rome also practiced medical
laws and ethics regarding poisoning since 600
B.C.
Today the social scenario has changed the
face of poisoning. India being an agricultural
country, uses insecticides very commonly to pro-
tect the crops, fruits and vegetables from insects.
There is no check on the supply, sale and uses of
* Prof. & Head, ** Associate Professor, *** Post
Graduate Students, Dept. of Forensic Medicine &
Toxicology, MGIMS, Sevagram
cases is increasing rapidly. Instructions about the
use of the insecticides regarding concentration
and protective measures are not followed by the
users as the instructions written in very small
letters by manufacturers are Toxic substances are
mostly manufactured in developed countries and
banned in their own countries, but they are to
the developing countries.
Case Report :
The following information was brought
from the inquest made by the police, case paper
study and relatives.
A 50 yrs. old male, was brought by police
constable, in the casualty of KHS, Sevgram on
11/08/07 at night, with the history of consumption
of insecticides in his farm as he is unable to face
the local bankers and moneylenders who had
loaned him money.

49

J MGIMS, March 2009, Vol 14, No (i), 49 - 53

I want my Father Back - Child’s Destiny
Then he was referred to medicine ICU
for further treatment but he died during the
treatment. Postmortem was done on 12/08/07.
Postmortem Examination -
General Examination -
The body was averagely built and
nourished, height of 5”6’, was wrapped with
white cotton bed sheet.
On external examination, face was
congested, both eyes were open, pupils were
dilated, lips shows blusih purple colour, tongue
within the oral cavity, no bite marks on tongue,
subconjunctival hemorrhages present in both
eyes, no oozing from mouth, nostrils, ears
neigher any evidence of dribbling of saliva
present. Finger nails were bluish purple in colour.
No injuries to external genitalia seen but evidence
of purging of the stool as well as semen present.
No sign of decomposition seen postmortem
lividity was present and fixed on the back. Rigor
mortis well developed all over the body.
Internal Examiantion -
Head
The scalp was opened, no injuries under
the scalp were seen. The skull and meninges
appeared normal, brain matter edematous and
small petechial hemorrhages seen on cut section
of the brain. No pus or excessive cerebrospinal
fluid was noted, Circle of Willis and other vessels
were normal.
Respiratory system -
1) Walls, ribs, cartilages- No injuries fracture
of the ribs, cartilages, pleura were intact and
adherent to both sides of thoracic cavity.
2) Airway - The larynx appears normal, trachea
and major bronchi contained minute
50
haemorrhages, mucosa appears slightly
hyperemic.
3) Parenchyma and lungs- both lungs were
congested and collapsed, minute haemorrhages
were present on the surface. On cut section,
both lungs were congested and show minute
pin point petechial haemorrhages severaly
and kerosene like smell present.
Cardiovascular system -
1) Heart- The pericardium was empty and intact.
The heart was normal in size and shape and
weighs about 230 gms. both the chambers
were filled with fluid blood, no evidence of
infarction, no thickening of cusps of valves,
no hypertrophy seen. Coronary arteries were
patent.
2) Arteries - Aorta show mild atherosclerotic
changes.
Alimentary syswtem -
Esophagus was normal, mucosa congested, no ul-
cers seen. All organs in situ. No free fluid in the
peritoneal cavity.
Stomach contaiins greenish colour fluid about
700 cc. with kerosene like smell to the contents.
Mucosa shows multiple haemorrhagic spots.
Food particles like rice and dal were partially
digested.
Liver and gall bladder - was of normal appearance,
on cut section, pale and easily friable and weighted
1350 gms. no gall stones found.
Kidneys - congested, on cut section the right
kidney weight about 120gms. And left kidney
weights about 110gms. Kidneys Cortico medullary
ratio normal.
Urinary bladder - filled with about 20cc urine.
J MGIMS, March 2009, Vol 14, No (i), 49 - 53

Pancreas - appears normal and haemorrhages
seen. On cut section, soft in consistency.
Spleen - appears congested on cut section and
weighted 110gms.
Spine and spinal cord - Intact. No fracture of
the spine
As this is a case of poisoning, Blood and
viscera have been preserved and sent to RFSL,
Nagpur for chemical analysis.
Cause of death -
Taking the reference from the case
paper study, from treating doctor’s opinion and
postmortem examination we conclude that cause
of death was insectide poisoning.
Discussion -
Toxicology is a science which deals with
properties action, toxicity, fatal dose, detection,
estimation, treatment of poisons and medico
legal importance of poisons(1).
Poison is derived from the Latin word
pouts which means, poison is a substance which
when introduced in any form by any route in
to the body will produce by its local or and
constitutional effect or both any harmful effect
on the body leading to disease or death(2).
The highest rate of poisoning is in
Srilanka where death due to poisoning which
stands next to total number of death by war due
to LTTE. Unfortunately India is not lagging
much behind. About 50,000 deaths occur in
India due to poisoning every year(3).
Poisoning is the commonest method of
committing suicides in Vidarbha region of
Maharashtra. Organophosphorus, Organochlorus
compounds and zinc Phosphide are commonly
used poisons to commit suicide. Zinc Phosphide
due to its odorless and tasteless character is
commonly used for homicide (4).
51
Tripude BH & et al
People in the rural area are more prone
to poisoning due to occupational hazards, poverty,
illiteracy unemployment and easy availability.
August and November are the months
when suicidal poisoning was common due to
crop failure and repeated sowing process as a
result of scanty or heavy rain in most of the areas.
Hence the debt -ridden farmers, unable
to support their famili4es suffers from mental
stress and develop suicidal tendency very often.
Most commonly used poison is Organophosphorus
compound followed by ethyl alcohol and
combination of insecticides.
Organophosphorus is most commonly
responsible poisoning for accidental and suicidal.
Ethyl alcohol poisoning is mostly accidental
in nature due to its adulteration; it is prohibited
in as Wardha district.
Conclusions and Suggestions -
a. Suicidal and accidental poisoning can be
prevented to some extent by improving
social, economical, educational and moral
status of the people.
b. Prevention is better than cure hence the
farmer should be demonstrated and educated
regarding proper use of protective devices
while spraying insecticides through TV,
media and by the government agencies
working in the villages like gramsevak should
be provided.
c. Marital conflict is the most common cause
of suicidal poisoning so proper marriage
counseling should be provided at all levels
of society.
d. Government must ensure availability of
proper drugs needed for treatment of cases
of poisoning at affordable cost and at village
level dispensaries.
J MGIMS, March 2009, Vol 14, No (i), 49 - 53
 Case Report
DISLOCATION OF FIRST METATARSAL
PHALANGEAL JOINT : A CASE REPORT
A KUMAR *, C RATHOD **, CM BADOLE ***, KR PATOND ****
Introduction:
A rare injury consisting of an irreducible,
closed dorsal dislocation of the metatarsopha-
langeal joint of the great toe was encountered
in 25 year old man. An open reduction of the
metatarsophalangeal joint dislocation was
performed through midline medial approach
and fixed with K-wire
Case report :
A 25 years old man was involved in a road
traffic accident. He had Gr-IIIB compound
fracture Left Tibia and closed dorsal dislocation
of first metatarsal phalangeal joint on the same
side. He was taken to the operation theatre where
debridement of the wound and external fixator
was applied for fractured Tibia. Attempted
closed reduction of the metatarsophalangeal
joint dislocation was unsuccessful. Hence open
reduction of the metatarsophalangeal joint
dislocation was performed through midline
medial approach and fixed with K-wire. The
Patient postoperative course was uncomplicated.
At four weeks K-wire removed. There was full
range of movement and no evidence of metatar-
sophalangeal joint instability.
Discussion
Dislocations of first metatarsophalangeal
joint are rare and results from high energy
*Sr. Lecturer, **Registrar, ***Professor, ****Director
- Professor and Head. Address for Correspondence -
Dr. Ashok Kumar *, Dept. of Ortho. & Traumatology,
M.G.I.M.S., Sewagram – 442102, Wardha (M.S.)
52
trauma and are frequently associated with
multiple fractures of the lower extremity. Most
dislocations are dorsal through the plantar plate
and seasemoid complex with only occasional
reports of plantar , lateral or medial dislocations.
The mechanism of injury is hyperextension of
the proximal phalange on the first metatarsal
when the toes are forcibly dorsiflexed, results in
the metatarsal head being pushed through the
plantar capsule between the medial and lateral
tendons of the flexors hallucis brevis muscles.
The plantar capsule is disrupted at its proximal
attachment to the metatarsal. The proximal
phalange comes to lie dorsally with the metatarsal
head trapped between the one flexors hallucis
brevis tendon, the abductor hallucis tendon, the
adductor hallucis, and their associated sesamoid
laterally. The metatarsal head is fixed between
the plantar capsule and deep transverse metatarsal
ligaments dorsally and the longitudinal portion
of the plantar Aponeurosis on its plantar surface.
The tendon of the flexor hallucis longus is
displaced laterally to the dislocated metatarsal
head. Thus, the head of the metatarsal is locked
in the dislocated position, rendering closed
reduction impossible.
Jahss classified the First metatarsopha-
langeal dislocation into two types.
Type : I - In which the proximal phalange and
both sesamoids dislocate dorsally without
disruption of the sesamoid complex, are
invariably irreducible by closed manipulation
J MGIMS, March 2009, Vol 14, No (i), 49 - 53
 Kumar A & et al

Type : 2 - Dislocation in which the phalange
dislocates dorsally with disruption of the
sesamoid complex,. are usually reducible by
closed manipulation.
Pre-operation
There are different approaches for
open reduction of first metatarsophalangeal joint
dislocation like transverse plantar approach,
midline longitudinal approach but we chose the
midline medial approach for open reduction of
the joint.
The advantages of this approach is that
it does not lead to formation of painful scar on
the weight bearing aspect of metatarsal head and
at the same time avoids the damage to the planter
neurovascular bundle.

References :
1. Eric C. YU. Steven R: Closed dorsal dislocation
Post-operation of the metatarsophalangeal joint. On the great toe.
A surgical approach and case re open reduction
of the metatarsophalangeal joint dislocation
was performed through midline medial approach
and fixed with K-wire port. Clin. Orthop. 185:
237-240,1984.,
2. Jacques AB: Pathomechanics of complex
dislocation of the first metatarsophalangeal
joint. Clin. Orthop. 332:126-131,1996.
3. Peter B, Salamon MD, Richarts HG, James MH:
Dorsal dislocation of the metatarsophalangeal
joint of the great toe. J. bone and joint Surg 56.
No-5: 1073-1075, 1974"
4. Alans G, Lewis. Jesse C, Delee: Type I complex
dislocation of the first metatarsophalangeal
joint- open reduction through dorsal approach
a case report. J. bone and joint Surg 66A No-7:
1120-1123. 1984.
5. Osep E. Armagan , MD, and Michael J. Shereff,
MD : Injuries to the toes and metatarsals. The
Orthopaedic clinics of North America Volume
32 : 7-8 ; Jan 2001.

53

J MGIMS, March 2009, Vol 14, No (i), 49 - 53

 Drug Update

RENIN BLOCKERS - A NEWER THERAPY IN

REGULATING HYPERTENSION

B TAKSANDE *, S YELWATKAR *, UN JAJOO **

ABSTRACT

Though various drugs starting from beta blockers to the thaizides are used for regulating
hypertension, the ACE inhibitors are the widely used. Newer therapy for the control of hypertension
that is rennin blockers have come into picture. Only one drug of this group has come into the
market. Here is a review of the rennin blocker(aliskiren).
Key words : hypertension, reninblockers, drug.

HYPERTENSION antihypertensive drugs will lower the hypertension

Hypertension clinically is defined as that related morbidity and mortality(1).
level of blood presuure where the institution of
Blood Pressure Classification
Blood Pressure Classification Systolic, mmHg Diastolic, mmHg
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension 160 or 100
Isolated systolic hypertension 140 and <90

Hypertension is broadly classified into Three theories have been proposed to

2 categories primary(essential) and secondary.
The secondary causes for hypertension are fully
understood. However, those associated with
essential hypertension are far less understood.
What is known is that cardiac output (determined
by stroke volume and heart rate) is raised early in
the disease course, with total peripheral resistance
(determined by functional and anatomic changes
in small arteries and arterioles) is normal; over
time cardiac output drops to normal levels but
TPR is increased.
*Lecturer, **Professor. Address for Corresponence : Dr.
Bharti Taksande, Dept. of Medicine, MGIMS,
Sevagram, MH. Email : amar_bharti2000@yahoo.co.uk
explain this :
z Inability of the kidneys to excrete sodium,
resulting in natriuretic factors such as Atrial
Natriuretic Factor being secreted to promote
salt excretion with the side-effect of raising
total peripheral resistance.
z An overactive renin / angiotensin system leads
to vasoconstriction and retention of sodium
and water. The increase in blood volume
leads to hypertension.
z An overactive sympathetic nervous system,
leading to increased stress responses.

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J MGIMS, March 2009, Vol 14, No (i), 54 - 56


Role of Renin
Renin may play a critical role in the
pathogenesis of most hypertension, a view long
espoused by Laragh(2). The renin- angiotensin
system is the most important of the endocrine
systems that affect the control of blood pressure.
Renin is secreted from the juxtaglomerular
apparatus of the kidney in response to :
z Glomerular underperfusion
z Reduced salt intake.
It is also released in response to stimulation
from the sympathetic nervous system.
Renin is responsible for converting renin
substrate (angiotensinogen) to angiotensin I, a
physiologically inactive substance which is rapidly
converted to angiotensin II in the lungs by an-
giotensin converting enzyme (ACE). Angiotensin
II is a potent vasoconstrictor and thus causes a
rise in blood pressure. In addition it stimulates
the release of aldosterone from the zona
glomerulosa of the adrenal gland, which results
in a further rise in blood pressure related to
sodium and water retention. The circulating
renin-angiotensin system is not thought to be
directly responsible for the rise in blood pressure
in essential hypertension. In particular, many hy-
pertensive patients have low levels of renin and
angiotensin II (especially elderly and black
people), and drugs that block the renin-angiotensin
system are not particularly effective. There is,
however, increasing evidence that there are
important non-circulating "local" renin-angiotensin
epicrine or paracrine systems, which also control
blood pressure. Local renin systems have been
reported in the kidney, the heart, and the arterial
tree. They may have important roles in regulating
regional blood flow.
Action
Renin blockers works by inhibiting a
enzyme called renin which helps in regulating
55
Taksande B & et al
the blood pressure. Renin is the first step of a
complicated hormone system called the Renin-
Angiotensin-Aldosterone-System (RAAS). By
blocking the action of renin in the RAAS, these
drugs can decrease the production of angiotensin
and aldosterone, which are both potent agents
that raise blood pressure. Tetkurna inhibits the
renin release from the kidney and thereby is
powerful for controlling high blood pressure.
This Renin blockers have similar characteristics
as that of and ACE inhibitors and Angiotensin
receptor blockers(3).
Approved by FDA :
On 9 march 2008 FDA approved a new
drug called Tekturna, for the control of high blood
pressure the mechanism of which was completely
different from the rest of antihypertensives(4).
Indications
z At present available to treat only high blood
pressure in combination with other drugs
especially thaizides.(5)
z Certain clinical trials are going to find its
use in congestive heart failure and diabetic
neuropathy.
Dose :
The usual daily dose is 150 mg, to be
increased up to 300 mg if necessary
Renin Blockers
Currently, only one renin blocker is
available. The drug Tekturna (generic name
Aliskiren), manufactured by Novartis Pharma-
ceuticals. Three agents are currently in FDA
clinical trials which are thought to be renin
blockers and are to be released on to the market
soon Tekturna is available by prescription
throughout the United States and Canada.
J MGIMS, March 2009, Vol 14, No (i), 54 - 56
RENIN BLOCKERS - a newer therapy in regulating hypertension
Adverse Effects :
Some side effects of renin blockers
include :
z Gastrointestinal: Stomach Upset and Diarrhea
z Dermatology: Swelling of the Face and/or
Neck
z Respiratory system: Cough
z Metabolic: Rarely hyperkalemia
The effectiveness of frusemide is reduced
if used in combination with reninblocker(6).
Contraindications :
Pregnant women should not take renin
blockers.
Limitations :
z Expensive ,as they do not have any other
generic equivalent
z No data on long term effects on end organ
damage and cardiovascular outcomes
56
References :
1. Chobanian AV et al: The Seventh Report of the
Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High
Blood Pressure : The JNC 7 Report. JAMA 2003;
289:2560.
2. Laragh JH. The renin system and four lines of
hypertension research. Hypertension 1992 ; 20 :
267- 68.
3. Scheen AJ, Piérard L, Krzesinski JM. [Aliskiren
(Rasilez), direct renin inhibitor] Rev Med Liege.
2008 Sep;63(9):564-9.
4. Krop M, Garrelds IM, de Bruin RJ, van Gool JM,
Fisher ND, Hollenberg NK, et al. Aliskiren
accumulates in Renin secretory granules and binds
plasma prorenin. Hypertension 2008;52(6):1076-83.
5. Musini VM, Fortin PM, Bassett K, Wright JM.
Blood pressure lowering efficacy of renin
inhibitors for primary hypertension. Cochrane
Database Syst Rev. 2008 Oct 8;(4):CD007004
6. Vaidyanathan S, Bartlett M, Dieterich HA, Yeh
CM, Antunes A, Howard D, Dole WP. Pharmaco-
kinetic interaction of the direct Renin inhibitor
aliskiren with furosemide and extended-release
isosorbide-5-mononitrate in healthy subjects.
Cardiovasc Ther 2008 ;26(4):238-46.
J MGIMS, March 2009, Vol 14, No (i), 54 - 56
 Book Review
UTOPIA IS NOW PROMISED BY SCIENCE!
Book - Future Human Evolution : Eugenics in twenty first century
JOHN GLAD
No socio-political system in the history
of human race, it be emperors, feudal kings,
capitalists, communists, socialists, dictators or
democrats, have ever found the key to the much
dreamed and promised UTOPIA i.e. happiness
to every living creature and perfect harmony
between man and nature. John glad, an American
Jewish scholar in his recent book proclaims to
find solution to all social, political, cultural,
financial, moral human problems through
genetic engineering. The book is acclaimed
highly by academicians, researchers and readers
alike(downloaded more than1 million times from
the site till date) advocates a eugenic movement
towards creating a new human species Homo
autocatalyticus, and making a highly intelligent,
altruistic, nonpredatory and loving society which
will pursue the goal of intellectual enrichment
and not of materialistic gains. The flip side of
the coin is, to give the new much better man its
deserved place, the present Homo sapiens species
has to accept its selective disappearance from the
planet!
The book is a detailed account of history
and post- World War II Renaissance of eugenic
movement and insists that success of the movement
is the only hope of ever sustainable life on mother
planet. The Eugenics (Greek-eu 'well'+genes 'born')
is a branch of genetics dealing with improvement
of a population by controlled breeding to increase
Hermitage publishers, Schuylkill Haven, PA17972-0578,
www.whatwemaybe.org
57
the occurrence of desirable and inheritable
characteristics. All animal and plant breeders
know its utility very well, while practicing it in
human race suffered a near lethal blow by racial
killings and Nazi holocaust in early part of
twentieth century. Revival of interest in this
direction is evident from the number of books
written on the topic in recent years and worldwide
scientific deliberation going on. Out of total
3200 books listed on 'online computer library
center/OCLC/Worldcat', 473 are published
within last five years apart from innumerable
online discussions.
Author makes it clear in the beginning
itself that it is not the therapeutic eugenics he
is proposing, for eugenics to prevent genetic
diseases by pre- and post marital counseling,
antenatal diagnosis and selective abortion of
affected fetus is already more or less accepted by
most of us except few religious groups. It is the
new socio-political aspect of reproductive eugenic
movement which has been pondered over in the
book. Molecular biologists as prophets of this
new religion of genetics have following basic
concepts -
1
. In the role of a species on earth, we behaved
in utter indisciplined way, in fact just like a
malignant disease - freeing ourselves from
regulatory constraints of natural selection
and limitations of natural resources. Our
invasive development started to wreak havoc
not only on our fellow species and on the
J MGIMS, March 2009, Vol 14, No (i), 57 - 60
Utopia is now promised by science! Book - Future Human Evolution : Eugenics in twenty first century
host we parasitize- the planet but now also
endangering our own survival.
2. Evolutionary selection process which created
the human species on earth is almost stopped
by development of civilization, science in
general and Medicine in particular. Almost
everyone who is born, however genetically
weak he/she is, lives full life today thanks to
power of medical sciences. As a result, natural
selection by differential mortality is replaced
largely by differential fertility patterns of
communities.
3. Moreover fertility is decreasing fast in high
IQ individuals and groups (procreation is not
their ambition) while it is still high in low IQ
groups, world wide. This dysgenic phenomenon
is leading to deterioration of quality of human
life as a race. Not only we stopped evolution
on earth, we are going backwards in
evolutionary chain. This can be evidenced by
less and less numbers of masterminds and
geniuses with every passing generation.
4. Different ethnic populations on the earth are
not one Homo sapiens, the myth purposefully
woven by egalitarians, but are different species
with separate gene map of their own and so
their IQ, abilities and capabilities
5. Almost all physical, mental, behavioral, moral
and social characteristics are determined by
genes and are inheritable. 'Nurture' has trivial
role in defining the personality, unlike the
popular thinking. The author is troubled that
we continue to apply moral criteria of behavior
in spite of knowing that we are about to
decipher behavioral patterns scientifically,
after mapping of human genome.
6. Humanity is defined not as only the currently
living population, but as the total number of
58
people who will potentially ever live on earth.
Since the unborn constitute a vastly greater
potential population than do currently
living, their rights prevail (though in present
political - social sphere future generations
represent a zero political constituency).
Emboldened by recent mapping of human
genome, new breakthroughs in biotechnology,
animal cloning and stem cell research, Glad with
other proponents of eugenics predicts that areas
of health and behavior up till viewed through a
moral prism are going to be explained by genes
in a few years time. "The genie of enlightenment
can not be squeezed back into the bottle of
ignorance" whoever tries to do it now. They propose
that we should start working for artificial selection
of fertility by joining hands with genetics to make
human race evolving further and this time also
to save ecology of the mother planet. "Eugenics
views itself as the fourth leg of the chair of
civilization, the other three being a thrifty
expenditure of natural resources, mitigation of
environmental pollution and maintenance of a
human population not exceeding the planet's
carrying capacity." Eugenicists believe that "while
our social conduct, like that of all other animal
species, is necessarily centered around the mating
ritual, our perception of this process is governed
by a myriad of camouflaging taboos and fetishes.
The gap between reality and fantasy could not
be more crass." The goals advised by the author
for twenty first century are
A. to reduce fertility of low IQ groups from
each ethnic community by
1
. curbing their reproductive rights, along with
criminals, insane, feebleminded and paupers
2. removal of or severe constraints on help
provided to welfare mothers
J MGIMS, March 2009, Vol 14, No (i), 57 - 60

3. not to discourage female feticide in countries
with increasing population and thus
reducing number of reproducing females
B. to increase high IQ groups fertility in each
ethnic community by
1
. reducing the age of first pregnancy in the
females of these groups so they can bear more
children
2. polygynae /artificial insemination to make
best use of high quality sperms
3. asexual procreation by low IQ females using
high quality ova and sperms fertilized in vitro
4. asexual cloning of high IQ individuals
It is evident that the first and foremost
prerequisite to achieve these goals is to release
sex from its procreative duty and also from
number of myths encasing it. The speed at which
we are depleting the natural resources for our
mainly dysgenic and huge species, makes it very
clear that sooner or later we are bound to agree
to above proposals or accept our inevitable
extinction from the face of the earth.
But are we ready to consider the eugenic
movement our saviour? It is hard to accept the
following notions in the first place that :
1
. Different ethnic communities are separate
species. Few like Jews are genetically privi-
leged than others. Moreover gene mapping
can answer all our questions regarding
biodiversity in human race.
2. IQ can be the sole criteria to decide the
worth, progeny and fate of an individual on
the earth.
3. Not only physical but behavioral and social
negative traits as violent behavior, criminal
attitudes, cruelty, consumerism, addictions,
even marriage and divorce are not correctable
as determined by nature and not nurture.
59
John Glad
4. Success stories of breeding of health animals/
plants which did not take any socio-politico-
cultural issues in to consideration, suffice to
proceed for human breeding program
5. We have to surrender our beliefs in all other
socio-political movements if want to achieve
equality.
6. The basis of morals, emotions and relationships
can be entirely different in next era.
Even if we try to believe that the goal of
an advanced human species working in harmony
with nature is achievable through eugenics,
innumerable questions still remain -
1
. Advantages of eugenic practices will take at
least ten generations to surface if we start
action from the current reproducing popu-
lation (which is impossible as we just started
to explore genome, to use it we have to go a
long way) but abuse of eugenics is already very
well known to us in form of racial hatred,
Nazi holocaust and forced sterilizations. We
have to be absolutely ruthless and honest just
as nature, if we play god. Our history doesn't
assure us regarding this quality in us. How can
we trust the purity of intentions of eugenicists
and the politicians guiding them, this time?
2. Even if we trust them, who will decide which
characteristic is desirable up to what extent?
The world is not black and white; it has
innumerable shades of grey in between which
are angelic but intolerable to others.
3. According to Glad we must be dispassionate
(towards loss of reproductive freedom to
current population, morals) when talking
of scholarly discussion over eugenics! Perhaps
he forgot that being passionate must also
be a genetically determined trait in us which
can not be changed.
J MGIMS, March 2009, Vol 14, No (i), 57 - 60
Utopia is now promised by science! Book - Future Human Evolution : Eugenics in twenty first century
4. In an all highly intelligent society who will
do the manual labor, need for which will
always be there? It means the future
generations will have lord-slave system
again or else, have to live with robots.
5. If low IQ persons are more involved in crime
then what do we label all white collar scams
and scandals? Perhaps eugenics does not
count them in criminal activities.
6. Can we afford the total collapse of judiciary
in an already threatened world? The new
system would not lay responsibility on the
individuals for their own criminal acts and
crimes will no more be punishable. Concept
of Marriage will be irrelevant; and so also
the concept of adultery and incest as children
of same biological parents (who will be very
few selected individuals) but different legal
parents may make couples. Though all these
complications may look unreal or perverse in
present socio-cultural setting, this in fact is
the future being written for us by eugenic
movement
7
. It is the fact that people prefer their own
biological children at any cost. Reproductive
rights of a couple will no more be a personal
property in the new regime. Author himself
expressed fear of inability to pass this hurdle.
Moreover the love and natural bond formed
between a biological child and parents is
necessary for psychosocial development of
the child. Perhaps emotional security is also
considered here inherited! Which government
will risk its viability by this intrusion into
personal sphere when the promise of every
government is to give as much as freedom is
possible to its citizens?
60
8. Will concern over issues of reducing male :
female ratio and woman's rights to career and
development be absurd forever? The high IQ
females will be forced to enter the reproductive
pool at early age and thus the personal
freedom partially obtained just in last
century through a long feminist movement
to will be snatched away again.
9. Even if we are different genetically, we are
extremely intimately related species and if
reproductive rights of one community are
favored over other owing to genetic superiority,
will it not reflect into even more intense
intergroup conflicts than today?
Eugenics is proposing that there will be
no more stories of miracle from dust to sky; no
more families; no more interethnic marriages.
Or it is just another type of 'fantasies plucked
from the air' as J Bauer, a Viennese physician once
said about Nazi concept of race. Some of these
questions are addressed by Glad in the book very
intelligently but without satisfactory answers. A
book for rights of future generations and for that
of the earth is indeed a holy mission but as he
indicates, both of these clients have no say in the
matter and present population have to be forced
only, to act in such direction questioning its
feasibility.
If still you are ready to buy the idea, you
are welcome to dream once again of the Eugenic
Utopia.
By
DR. ANUPAMA G
Professor Dept., of Pathology
MGIMS, Sevagram
J MGIMS, March 2009, Vol 14, No (i), 57 - 60
 Obituary
DR MICHAEL ELLIS DEBAKEY
(Sept’ 1908-July 2008)
“Dr Debakey, a pioneering surgeon whose
carrier spanned 70 years, was one of the creator of
cardiovascular surgery. His death has brought to
an end almost a century of tireless work for
improvement of surgical treatment of major
cardiovascular disorders.” writes The Iris Medical
Times.
Dr Michael Debakey was born on 7th Sept
1908 at Lake Charles, Louisiana to Lebanese
immigrant parents. Interestingly, his father had a
Farmacy and his mother taught him to sew and knit
which resulted in his joining the medical school
and developing the surgical skills. He completed
his medical degree from Tulane University in
New Orleans. Later he continued his studies at the
University of Strassbourg in France and University
of Heidelberg in Germany.
In that era “there was virtually nothing you
could do to a patient of heart disease, If a patient
came with heart attack it was up to God” so said
Dr Debakey. He developed a roller pump which
subsequently became an important component of
heart-lung machine necessary today for any open-
heart surgery. The development of bypass surgery
for coronary heart disease made a medical history.
In 1953 for the first time he used a dacron graft for
blood vessel replacement allowing the repair of
Aortic Aneurysm. He with Dr Denton Cooley was
the first to introduced cardiac transplant in USA in
1968, after the very first transplant carried out by
Dr Christian bernard in South Africaq in 1967.
He developed the artifical heart for the patients
waiting for cardiac transplant. His innovations have
helped developing several newer surgical instru-
ments and surgical techniques Hundreds of heart
surgeons trained by him are working around the
world. He was totally dedicated to his work and his
61
patients without any
discrimication. He has been
tirelessly working almost 12
hours a day, performed
1000 operations per year
totalling about 60000. He continued to operate
till the age of 90 years. He remained active and
have been moving for delivering lectures and
attending conferences. He has over 1300 published
medical articles besides several chapters, and
books on surgery and medicine “The living heart”
is one of his best sellar publication.
He worked in army during second world
war initially as captain. Later he was made director
of surgical consultants division at Office of the
Surgeon General in Europe. His innovative mind
helped here also in developing ‘Mobile Surgical
Hospital. He has been medical advisor to five
presidents of United States of America. This
political support resulted in creation of Medicare
Health Insurance Scheme. In such a long carrier
he received innumerable awards. The few prominent
ones are President Medal for Freedom (1969 given
by President Lyndon Johnson), National Medal for
Science (1987, given by President Ronal Regan) and
the latest Cogressional Gold Medal (2008, given by
President George W Bush).
In leisure time he liked shooting and fishing.
He was Episcopalian by faith. In 2006 he had
himself undergone an aortic surgery. He passed
away at the age of 99 year on 11th July 2008. He has
improved the human conditions and touched the
life of generations to come. The medical world will
always remain indebted to him.
(Sources- Net reports of Irish medical times, the telegraph
and Houston Chronicle)
J MGIMS, March 2009, Vol 14, No (i), 61
THE NOBEL PRIZE IN PHYSIOLOGY OR MEDICINE 1909
EMIL THEODOR KOCHER
(August 25, 1841 - July 27, 1917)
Emil Theodor Kocher was a Swiss
physician, medical researcher, and Nobel laureate
for his work in the physiology, pathology and
surgery of the thyroid.
Theodor Kocher was born on August 25,
1841, at Berne Switzerland. His father, was a Chief-
Engineer. He studied in Zurich, Berlin, London and
Vienna, and obtained his medical doctorate in Berne
in 1865. His teachers of surgery were Demme, Lucke,
Billroth, and Langenbeck. In 1872, he succeeded
Georg Albert Lucke as Ordinary Professor of
Surgery and Director of the University Surgical
Clinic at the Inselspital in Berne.
In 1883 Kocher announced his discovery
of a cretinoid pattern in patients after total excision
of the thyroid gland, when a portion of the gland
was left intact, however, there were only transitory
signs of the pathological pattern.
When Kocher began his surgical activities
the transition from the septic to the antiseptic
treatment of wounds, works on the antiseptic
treatment of wounds with weak chlorine solutions,
Kocher was one of the first to go over to pure
asepsis processes he sought to advance.
He published works on a number of
subjects other than the thyroid gland including
hemostasis, antiseptic treatments, surgical infectious
diseases, on gunshot wounds, acute osteomyelitis,
the theory of strangulated hernia, and abdominal
surgery. His new ideas on the thyroid gland were
initially controversial but his successful treatment
of goiter with a steadily decreasing mortality rate
soon won him recognition and the Nobel prize. The
prize money he received, he donated to his University
the sum of 200,000 Swiss francs which helped him
to establish the ‘Kocher Institute’ in Berne.
His Chirugische Operationslehre (Theory
on surgical operations) reached six editions
and was translated into most modern languages. It
described many operations, mostly in abdominal
surgery and the surgery of joints. His book
Source - Noble prize.org
62
Erkrankungen der
Schilddruse ( Diseases
of the thyroid gland )
discussed the etiology,
symptology and treatment
of goitres.
Kocher was an honorary member of
numerous academies and medical scoeities, e.g. the
German Surgical Society. An Honorary Fellow of
the Royal College of Surgeons; Honorary Member of
the Royal Society of Sciences, Uppasala; Honorary
Member of the American Surgical Society; the
New York Academy of Medicine & the College of
Physicians, Philadelphia; the Imperial Military
Medical Academy, the Royal Medical Society of
Vienna; Royal Medico-Surgical Society, London;
He was a Corresponding member of the Surgical
Society of Paris, Brussels : Belgiam Academy of
Medicine; the German Society of Neurologists and
of the Hufeland Society of Berlin; Honorary M.D.
of the Free University of Brussels.
In 1902 he was President of the German
Society of Surgeons in Berlin and President of the
First International Surgical Congress, 1905, in Brussels.
A number of instruments and surgical
techniques (for example, the Kocher manoeuvre)
are named after him, as well as the Kocher-Debre-
Semelaigne syndrome, Kocher zonde Spoon-shaped
probe for goitre operations, Kocher’s arced incision
Oblique incision for opening the knee joint.,
Kocher’s incision II Tranverse incision over glandula
thyreoidea in the neck for thyroidectomies, Kocher’s
sign Eyelid phenomenon in hyperthyreosis and
Basedow’s disease, Kocher’s syndrome Splenomegaly
with or without lymphocytosis and lymphadenopathy
in thyrotoxicosis etc.
Kocher married Marie Witchi (1851-1921).
They had three sons, the eldest of whom, Albert
(1872-1941) became Assistant Professor of Surgery
and gave his father considerable help in his work.
Theodor Kocher died at Berne on July 27, 1917.
J MGIMS, March 2009, Vol 14, No (i), 62
 Poem

THE LIBERATION

Representative of the summit of creation,

The man,
Utopia remains his dreams, his imagination
Possessingconsciousness,thesupramentalability,
Prays and crave for immortality !!
About to slip in another world
Away from the wearying regimen of __
Pokes, prods, and pinches__
Endured since diagnosed as Acute leukemia
Curly haired
Cherub faced, reserved
Prone to one word answer
Behind his shy exterior
Lurked a creative spirit
Endowed with the capacity to endure
In the material universe, ever unsure
Eventide follow even the brightest day
Like the epilogue of life’s romance in a way
Plunging in to gloomy incertitude
‘Death’!Noterrorbutthelife’sprelude
Inevitably inseparable, intertwined
An evolutionary march for the new one, it reminds
No thanatophobia,
But a feeling of liberation from bondages
Carried on through the ages
Dr OP GUPTA

63

J MGIMS, March 2009, Vol 14, No (i), 63

 ABSTRACTS OF THE PAPERS PRESENTED IN THE NATIONAL AND
INTERNATIONAL CONFERENCES HELD DURING THE YEAR 2008
ANATOMY fact that both the partners be investigated simultaneously if
a couple is infertile. In India, especially, it is seen that women
1. EFFECT OF CELLPHONE ON DEVELOPING
have to undergo traumatic experiences of investigations
LENS OF CHICK EMBRYO. IV Ingole, JE Waghmare,
first. Unfortunately medical men too sometimes neglect
P Bokariya, BR Sonatakke, Tapti Das. 56 NATCON of
this issue and do not ask for examination of male subjects
ASI, BHU Varanasi, Dec 27-29, 2008.
simultaneously. Genetic counseling is essential at the very
Magnitude of the problem of exposure to
beginning of the management of infertility. Karyotype
Cellphone radiation is self evident from a vast number of
analysis is the most basic of the genetic tests and is usually
mobile phone users where the whole atmosphere gets
employed as a screening test in infertility. The best policy
charged with the radiation acting as an environmental
from our point of view is to have a pre marital counseling
pollutant. The radiation emitted by the Cellphone has been
done by a geneticist. Or else prenatal diagnosis be done if
incriminated to adversely affect the biological tissues. The
a couple wishes to got for assisted methods of reproduction.
embryonic tissues are the most sensitive as the processes of
Measures can also be taken to identify genetic abnormality
division and differentiation of the cells are crucial to its
in the foetus in order to prevent the birth of an abnormal
development and are most sensitive to any type of insult at
child if clinically suspected. When it is evident that a couple
this stage. Various effects on the developing visual system
can not conceive the best way out is to adopt a child.
have been reported as a result of exposure to cellphone
On interrogation with the infertile subjects
radiation case of congenital cataract have been frequently
referred for Karyotype analysis, some facts revealed pointing
reported as a result of prenatal exposure to certain teratogens.
to a possible gender bias in management of infertile couples.
None theless the reports of the adverse effects of radiation
Some scenario that we have identified as the most common
emitted by cellphone on the developing lens have been
prevaling situations in India, causing unnecessary delay in
contradictory. The present study is aimed at investigating
investigations, wastage of money & manpower and ultimately
direct effect if any on the developing lens. Fertile hen eggs
some untoward consequences to the extent of separation of
were incubated in 2 batches. Each batch comprised 18 eggs.
couple or remarriage, will be presented.
Out of 18 eggs, 9 eggs were incubated in a standard egg
incubator without giving any exposure to radiation and
3. NEED OF MORE CAPABLE TECHNICIANS TO
treated as control. Remaining 9 eggs were incubated in a
SUIT THE ANATOMY DEPARTMENT. Pradeep
special incubator exposing them to radiation from
Bokariya, Ruchi Kotheri, S Rawlani, AM Tarnekar, S
cellphone. Total exposure of 4 hours duration was given to
Kakde, IV Ingole. 56th NATCON of ASI, BHU
the experimental group of both the batches. One batch was
Varanasi, Dec 27-29, 2008.
sacrificed at the completion of 4 days and the other at the
completion of 6 days. Embryos were procesed for histological Most of the diploma courses after XII (like DMLT,
examination. 5 micron thick sections were cut and stained BMLT) make a candidate suitable for working in Pathology
with H & E. The lens epithelial cells from experimental labs but not in Anatomy Dept. These courses do not provide
groups showed increased number of mitotic figures in the the candidates with the appropriate knowledge of embalming,
form of metaphase and anaphase as compared to that of museum up keeping, organ identification. Most of them
controls. This points towards increased proliferation of are unaware with basic know how of Anatomy.
cells which may be compensatory phenomenon in response Considering paucity of suitable candidates for
to increased destruction of cells. Anatomy Department, there should be a provision of
Diploma course in Anatomy after XII.
2. NEED OF GENETIC COUNSELING IN Some recommendations for the same are as follows -
INFERTILE COUPLES. DOES A GENDER BIAS 1) Such a course should be conducted in a Medical College.
EXIST?. AM Tarnekar, JE Waghmare, IV Ingole & 2) It can be for duration of 9-12 months.
AK Pal. 56th NATCON of ASI, BHU Varanasi, Dec 3) Evaluation at the end of term should be more practical
27-29, 2008. based.
It is a social stigma to be carrier of a disorder and 4) The course can be named as “DALT - Diploma in
infertility is a lifelong suffering. It is a globally accepted Anatomy lab Technology”

64

J MGIMS, March 2009, Vol 14, No (i), 64 - 90

 Few bottlenecks are also there in implementing
such a course but they can be overlooked considering the
benefit of the department of Anatomy.
4. DERMATOGLYPHIC STUDY OF
SCHIZOPHRENIC PATIENTS - A CASE
CONTROL STUDY. BR Sontakke, IV Ingole, PB
Behere, SS Rawlani, AM Tarnekar, JE Waghmare.
56th NATCON of ASI, BHU Varanasi, Dec 27-29, 2008.
Dermatoglyphics is a scientific study of epidermal
ridges and their configuration on volar aspect of hands,
fingers, feet and toes. Eighty (80) clinically diagnosed
patients of schizophrenia (48 males & 32 females) were
selected from out patient department of Psychiatry and
compared them with 76 (44 males and 32 females) healthy
controls. Palm and finger prints were taken by ink method.
Both qualitative and quantitative analysis of finger tip,
palmar pattern and atd angle was done. We found statistically
significant increased total whorl composite, total arches
and tur palmar pattern at hypothenar area in male
schizophrenics as compared to male controls.
5. A HISTOLOGICAL STUDY OF THE EFFECT
OF MONOSODIUM GLUTAMATE IN LIVER OF
ALBINO MICE. T Das Bhattacharjee, AM Tarnekar,
IV Ingole. 56th NATCON of ASI, BHU Varanasi,
Dec 27-29, 2008.
Monosodium glutamate popularly known as
Azinomoto is used as flavouring agent in Chinese cuisines.
It is responsible for creating the fifth basic type of taste
sensation ‘Umami taste’ in brain. Receptors for Umami
taste sensation are found in Chorda tympani as well as
Glossopharyngeal nerve. It is powerful neurotransmitter -
both excitatory and inhibitory. MSG is reported to cause
damage in brain and reduced reproductive function in
adults. Present study was carried out with 25 albino mice
after exposing the animals to MSG (2mg/g body weight
subcutaneous injection) in neonatal period. Total 5 injections
were given at the interval of 48 hours starting 48 hours
after birth. Animals were sacrificed 75 days after birth and
liver was isolated and processed for histological study.
Histological findings were compared with same number
of control animals. The findings will be discussed.
6. VARIANT ARTERIAL PATTERN IN UPPER
LIMB WITH PERSISTANT MEDIAN ARTERY. AD
Kannamwar, AM Tarnekar, SJ Kakde, T Das, P
Bokariya, IV Ingole. 56th NATCON of ASI, BHU
65
Varanasi, Dec 27-29, 2008.
During the routine dissection of the right and left
upper limbs of a middle aged male cadaver, we encountered
mixed vascular pattern. We observed variant arterial
pattern in arm, forearm and hand which was present
bilaterally but not exactly similar.Most striking feature
was persistence of median artery which had significant
contribution in formation of superficial palmar arch
bilaterally. Details of this case along with its embryological
basis and clinical significance will be presented in conference.
POSTER PRESENTATIONS :
1. ANTHROPOMETRIC STUDY OF FEMUR IN
CENTRAL INDIAN POPULATION. Pradeep
Bokariya, S Rawlani, JE Waghmare, A Kannamwar,
IV Ingole. 56th NATCON of ASI, BHU Varanasi,
Dec 27-29.
Anthropometric provides scientific method and
technique for taking various measurements in different
geographic regions and races. The femur itself is a complex
anatomic unit so anthropometric study was devised on the
same. In the present study 106 (58 right and 48 left) intact
adult femora were obtained from the bone bank of Anatomy
department of MGIMS, Sevagram. For this purpose a sliding
caliper, osteometric board, tapeline and gonometer were
used.
The study was aimed at determining measurements
for obtaining platymeric index, robusticity index and
foraminal index for both right and left femur. The details
of data obtained with relevant review of literature will be
discussed.
2. EVALUATION OF SAFETY OF ASPARTAME
AS A FOOD ADDITIVE BY EXPERIMENTATION
OF NEONATAL SWISS - ALBINO MICE. SJ Kakde,
AM Tarnekr, A Kannamwar, SS Rawlani and IV Ingole.
56th NATCON of ASI, BHU Varanasi, Dec 27-29, 2008.
Aspartame is used in many baby products like baby
food, vitamin solutions etc. Present study was conducted
in Department of Anatomy at MGIMS, Sevagram with 30
control and 30 experimental neonatal Swiss-albino mice.
Aspartame was injected intra peritoneally at a strength of
100 microgm per gm body wt into experimental mice at an
interval of 48 hours for 6 doses starting from 72 hours of
life. Control group received same amount of normal saline
with same dose schedule. Animals were kept in cages and
were fed with standard rat feed free from aspartame with
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
cool drinking water ad libitum under ideal conditions. Body
weights were taken at birth and at 28 day of life. Body weights
th
were reduced in exposed group compared to controls.
Significant number of exposed animal had seizures during
experiment and subsequently death in few. Mortality rate
was significantly high in experimental group as compared
to control group. Details with be presented.
3. BILATERAL ABSENCE OF EXTENSOR
INDICIS MUSCLE - A CASE REPORT. SJ Kakde,
AM Tarnekar, A Kannamwar, JE Waghmare, P Bokariya,
IV Ingole. 56th NATCON of ASI, BHU Varanasi,
Dec 27-29, 2008.
During routine dissection in a middle aged male
cadaver we found absence of Extensor indicis muscle
bilaterally. There was no scar mark or external deformity
over forearm. Literature suggests it as a rare variation in
the form of congenital absence of extensors of forearm.
It is reported to be associated with polyneuropathy.
Reconstructive interventions of hand require knowledge
of such variations. Details of this case with its ontogeny
and clinical significance will be presented.
COMMUNITY MEDICINE
PAPER PRESENTED IN XVII WORLD CONGRESS
OF EPIDEMIOLOGY AT PORTO ALEGRE, RS Brazil :
20-24 September 2008
1. PERCEPTIONS AND HEALTH CARE SEEKING
ABOUT NEWBORN DANGER SIGNS AMONG
MOTHERS OF RURAL WARDHA. Dongre AR,
Deshmukh PR, Garg BS.
Abstract : Objectives : The objectives of the present study
were to know mothers' knowledge and explore their
perceptions about newborn danger signs and health care
seeking behaviors.
Material and Methods : In December 2003, a cross-sectional
study was undertaken in three of the 27 Primary Health
Centres of Wardha district; namely Anji, Gaul and Talegaon
with a population of 88187. Out of 1322 such mothers, 1160
mothers in the area were interviewed by house-to-house
visits. Data was entered and analyzed in SPSS 12.0.1. In
order to explore mothers' perception of danger signs and
actions taken, a triangulation of formative research methods
like chapatti diagram and Focus Group Discussion (FGD)
was undertaken. The analysis of free list and pile sort
66
data obtained was undertaken using Anthropac 4.98.1/X
software.
Results : About 67.2 % mothers knew at least one newborn
danger sign. Majority of mothers (87.4%) responded that
the sick child should be immediately taken to the doctor
but only 41.8% of such sick newborns got treatment either
from government hospital (21.8%) or from private hospital
(20%) and 46.1% of sick babies received no treatment. The
reasons for not taking actions even in presence of danger
signs/symptoms were ignorance of parents, lack of money,
faith in supernatural causes, non availability of transport,
home remedy, non availability of doctor and responsible
person not at home. For almost all the danger signs/
symptoms supernatural causes were suspected and remedy
was sought from traditional faith healer (vaidu) followed
by doctor of Primary Health Centre and private doctor.
Conclusions : The present study found gap between mothers'
knowledge and their health seeking behavior for sick newborn
and explored their deep perceptions, constraints and
various traditional treatments. Comprehensive intervention
strategies are required to change behaviour of caregivers
along with improvement in capacity of Government health
care services and National Health Programs to ensure
newborn survival in rural area.
2. EFFECT OF USE OF SOCIALLY MARKETED
FAUCET FITTED EARTHEN VESSEL / SODIUM
HYPOCHLORITE SOLUTION ON DIARRHEA
PREVENTION A T H O U S E H O L D L E V E L I N
RURAL INDIA. Dongre AR, Deshmukh PR, Garg BS.
Abstract : Objective : To evaluate the effect of socially
marketed faucet fitted to earthen vessel/sodium hypochlorite
solution on diarrhea prevention at rural household level
as a social intervention for diarrhea prevention under
'Community Led Initiatives for Child Survival (CLICS)
program.
Methods : Unmatched case-control study was carried out in
10 villages of Primary Health Centre, Anji, located in rural
central India. During the study period, 144 households used
either faucet fitted earthen vessel to store drinking water
or used sodium hypochlorite solution (SH) for keeping
drinking water safe. These served as case households for
the present study. 213 neighborhood control households
from same locality who used neither of the methods were
also selected.
Results : Odds ratio for households who used faucets fitted
to earthen vessel was 0.49 (95% CI= 0.25 - 0.95). Odds ratio
for households who used sodium hypochlorite solution
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
was 0.55 (95% CI= 0.31 - 0.98). Use of these methods by
the community, would prevent about 27 percent and 22
percent cases of the diarrhea (Population attributable risk
proportion = 0.25 by faucets fitted to earthen vessels and
0.22 by use of sodium hypochlorite solution) respectively.
Conclusion : To ensure safe drinking water at household
level, the effective and cheap methods like fitting faucet
to traditionally used earthen vessel and/or use of sodium
hypochlorite solution must be promoted through
community participation at household level for cost and
culture sensitive rural people in India.
PAPER PRESENTED IN INTERNATIONAL
CONFERENCE OF THE NETWORK - TOWARDS
UNITY FOR HEALTH AT BAGOTA: 27 th
September 2008
- 2nd October 2008
1. FORMATIVE EXPLORATION OF STUDENTS'
PERCEPTION ABOUT COMMUNITY MEDICINE
TEACHING AT MAHATMA GANDHI INSTITUTE
OF MEDICAL SCIENCES, SEWAGRAM, INDIA.
Garg BS, Dongre AR, Deshmukh PR.
Abstract: Objective : The objectives of the present formative
research were to explore medical undergraduates' study
problems and their perceived effective teaching approaches
in currently practiced teaching framework of Community
Medicine.
Methods : The present formative research was undertaken
at Dr. Sushila Nayar School of Public Health incorporating
Department of Community Medicine, MGIMS, Sewagram.
The respondents were 17 (26.5%) conveniently selected
final year exam appearing medical undergraduates from
2004 regular batch of 64 students. A triangulation of
qualitative research methods like structured free listing
and pile sort exercise and semi structured Focus Group
Discussion (FGD) were used. A two dimensional scaling
and hierarchical clustering analysis was completed with the
pile sort data. The data was analyzed by using software
Anthropac.
Results : The medical undergraduates could understand
the subject matter and learn skilled based topics like
IMNCI, PHC, Cold chain system, Immunization and Health
education, Dietary survey and Survey methods in community
based camp approaches. Students found it difficult to
comprehend the core of subject from scattered lecture
series over long time especially using lengthy OHP/LCD
presentations. The major problems encountered in studying
Community Medicine were difficulty in understanding con-
67
cepts of Biostatistics, confusions due to apparently similar
text in National Health Programs, concepts of Epidemiology,
difficult to recall subject, understanding Health planning
and Management and problems due to vast syllabus.
Conclusions : Students perceived community based camp
approach of teaching as a best method to understand the
subject, which is an integration of task oriented assignments,
integration of social sciences within medical domain and
active community involvement. The community based
camp approach can be scaled up as a best Community
Medicine teaching approach. Lectures and Clinics need
to be more interactive and problem based.
2. AN APPROACH TO MONITOR AND INITIATE
COMMUNITY LED ACTIONS FOR ANTENATAL
CARE IN RURAL INDIA - A PILOT STUDY. Garg
BS, Dongre AR, Deshmukh PR.
Abstract : Background & Objective : Utilization of antenatal
care in rural India is far from universal. It requires monitoring
and identification of specific needs at field levels for timely
corrective actions. To pilot test the triangulation of rapid
quantitative (Lot Quality Assurance Sampling) and qualitative
(Focus Group Discussion) monitoring tools for timely and
locally relevant information for decision making and
facilitating participatory community actions for ensuring
antenatal care in a community based program.
Methods : The present study was undertaken in surrounding
23 villages of Kasturba Rural Health Training Centre
(KRHTC), Anji, which is also a field practice area of
Mahatma Gandhi Institute of Medical Science (MGIMS),
Sewagram. The monthly monitoring and action system of
the study was based on the rapid quantitative monitoring
tool (Lot Quality Assurance Sampling, LQAS) to find out
poor performing supervision areas and overall antenatal
service coverage and the qualitative methods (Focus group
discussions (FGDs), and free listing) for exploring ongoing
operational constraints in the processes for timely decision
making at program and community level. A trained
program supervisor paid house visit to 95 randomly
selected pregnant women from 5 supervision areas by
using pre-designed and pre-tested questionnaire. For
poor performing indicators, semi structured FGDs and
free listing exercise were undertaken to identify unmet
service needs and reasons for its poor performance.
Results : Over three months period, the overall antenatal
registration improved from 253 (67%) to 327 (86.7%). The
proportion of pregnant mothers reporting farm work as
their current occupation, declined from 41.1% to 31.6%.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
Registration of pregnancy within 12 weeks improved from
24.2% to 29.5%. The consumption of 100 IFA tablets
during pregnancy also improved from 6.9% to 16.4%. There
was significant improvement in awareness regarding
pregnancy danger signs and symptoms.
Interpretation & Conclusion : To summarize, the present
field based monitoring and action approach constructively
identified the reasons for failures and directed specific
collective actions to achieve targets.
PAPER PRESENTED IN 9 TH
SOUTH EAST ASIA
REGIONAL SCIENTIFIC MEETING OF
INTERNATIONAL EPIDEMIOLOGICAL
ASSOCIATION AT DHAKA : 9-12 February 2008
1. CORRELATES OF OVERWEIGHT/OBESITY
AMONG SCHOOL GOING CHILDREN OF
WARDHA CITY. Bharati DR, Deshmukh PR, Garg BS.
Abstract: Background & objectives : Overweight and obesity
are important determinants of health leading to adverse
metabolic changes and increases risk of non-communicable
diseases. Following the increase in adult obesity, the
proportion of children and adolescents who are overweight
and obese has also been increasing. To halt the epidemic,
it is important to understand the epidemiology. Hence,
the present study was undertaken to study the magnitude
of overweight/obesity and its correlates among school
going children of Wardha city in central India.
Methods : The cross-sectional study was carried out in all
the 31 middle-schools (5th to 7th standard) and high-schools
(8th to 10th standard) of Wardha city. Probability proportionate
to size of population technique (PPS) was used to decide
the number of children to be studied from each school,
each class and then each section of the class. Systematic
random sampling technique was used to select the children
from each section. Pre-designed and pre-tested questionnaire
was used to elicit the information on family characteristics
and individual characteristics. Height and weight was
measured and BMI was calculated. Overweight and obesity
was assessed by BMI for age using CDC 2000 reference.
Student who had BMI for age =85th and < 95th percentile
of reference population were classified as overweight and
BMI for age = 95th percentile of reference population were
classified as obese. Data was analyzed by using epi_info
2002 v 3.3 and SPSS 12.0.1.
Results : In the present study, overweight and obesity was
found to be 3.1% (95% CI: 2.5%-3.8%) and 1.2% (95% CI:
0.8%-1.8%) respectively; together constitute 4.3% (95% CI:
3.6%-5.2%) for overweight/obesity. Final model of the
68
multivariate logistic regression showed that the important
correlated of overweight/obesity were urban residence, joint
family, father and/or mother involved in service/business,
English medium school and child playing outdoor games
for less than 30 minutes.
Interpretation & conclusion : The magnitude of overweight/
obesity among school going children of Wardha city was
found to be 4.3%. Family characteristics play important role
in predisposing the children to overweight/obesity and
hence the interventions need to be directed towards the
families.
2. THE EFFECT OF COMMUNITY BASED
HEALTH EDUCATION INTERVENTION ON
MANAGEMENT OF MENSTRUAL HYGIENE
AMONG RURAL INDIAN ADOLESCENT GIRLS.
Dongre AR, Deshmukh PR, Garg BS
Abstract : Objective : To study the effect of a community-based
health education intervention on awareness and behavior
change of rural adolescent girls regarding their management
of menstrual hygiene.
Material & Methods : A participatory-action study was
undertaken in Primary Health Centres in 23 villages in
Anji in Wardha district of Maharashtra state. Study
subjects were unmarried rural adolescent girls (12-19years).
We conducted a needs assessment for health messages with
this target audience, using a triangulated research design
of quantitative (survey) and qualitative (Focus Group
Discussion) methods. Program for Appropriate Technology
for Health (PATH) guidelines were used to develop a
pre-tested, hand made flip book containing need based
key messages about the management of menstrual
hygiene.The messages were delivered at monthly meetings
of village based groups of adolescent girls, called Kishori
Panchayat.After three years, the effect of messages was
assessed using a combination of quantitative (survey) and
qualitative(Trend Analysis) methods.
Results : After three years, significantly more adolescent
girls (55%) were aware of menstruation before its initiation
compared with base line(33%).The practice of using
readymade pads increased significantly from 5% to 25%
and re-use of cloth declined from 85% to57%. The trend
analysis showed that adolescent girls perceived a positive
change in their behavior and level of awareness.
Conclusion : The present community health education
intervention strategy could bring significant changes in the
awareness and behavior of rural adolescent girls regarding
management of their menstrual hygiene.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
PAPER PRESENTED IN 2 6 TH ANNUAL
CONFERENCE INDIAN SOCIETY FOR MEDICAL
STATISTICS AT NAINITAL : 7-9 Nov. 2008.
1. NEONATAL MORTALITY DIFFERENTIALS
IN RURAL AREAS IN CENTRAL INDIA,
DISTRICT WARDHA MAHARASHTRA. Bharambe
MS, Gupta SS, Deshmukh PR, Garg BS.
Abstract : Neonatal mortality is a very important component
of the Infant mortality, which contributes almost 50% of
the total infant mortality. The neonatal mortality is mostly
affected by endogenous causes and partly by the antenatal
care and the availability of obstetrics and neonatal care
services. These determinants of neonatal mortality are
largely depends upon national health policy and the
availability and utilization of the health care services. In
the present paper and attempt has been made to compare
the neonatal mortality as is achieved by the use of usual
health services and a specific model claimed to reduce
the neonatal mortality by around 25%.
The material used for the study has been taken
from the data about neonatal mortality collected from the
PHCs and the two large research projects supported by
USAID and Government of India in rural areas of districts
Wardha and Yeotmal of the Vidharbha region of
Maharashtra State. The study is based on 6207 neonates;
comprised of 3143 subjects from Government of India (ICMR)
project claiming 25% improvement in the neonatal mortality
and 3064 neonates from the CLICS study, the study period
is from July 2006 to June 2008, and the data has been
collected on the parameters of the child, mother, socio-
economic variables and the health services parted in the
two schemes. The neonates delivered outside the study
area have been excluded from the analysis.
The factor analysis has been done to study the
multi-collinearity in the maternal parameters viz. age,
parity, weight, education, caste/religion etc. Two principal
components comprising of i) age, parity and weight, and ii)
education, caste/religion etc. have been extracted, contributing
more than 70% of the variation of these variables.
The very young and mothers of age 30+ years,
and the primi-mothers and of parity more than 4 along
with no education were associated with the higher neonatal
mortality. The neonatal mortality decreased with increasing
baby weight, however, showing a reverse trend after the
birth weight more than 4 kg.
PAPER PRESENTED IN 5 2 ND NATIONAL
CONFERENCE OF INDIAN PUBLIC HEALTH
ASSOCIATION AT MAMC, New Delhi : 7-9 March 2008
69
1. EPIDEMIOLOGICAL CORRELATES OF
NUTRITIONAL ANEMIA AMONG CHILDREN
(6-36 MONTHS) IN RURAL WARDHA. Sinha N,
Deshmukh PR, Garg BS.
Abstract : Background and objectives : Nutritional anemia
is associated with impaired performance on a range of
mental and physical functions in children along with
increased morbidity. Iron supplementation at a later age
may not reverse the adverse effects. National Nutritional
Anemia Control Program was launched in India in 1970
failed to make any impact. The present study was undertaken
to find out prevalence of anemia and its correlates in rural
Wardha in children 6-35 months.
Methods : 772 children between 6-35 months were studied
for anemia by cluster sampling method. The hemoglobin
was estimated in the child by "Filter Paper Cyanmethemo-
globin method". Pre-designed and pre-tested questionnaire
was used to collect data on socio-demographic and other
variables. Data was analyzed by SPSS 12.0.1.
Results : Mean hemoglobin level was 98.5±12.9 gm/L.
Prevalence of anemia was 80.3%. Only 1.3% children had
severe anemia (hemoglobin < 70 gm/L). The univariate
analysis showed that anemia is significantly associated with
age of the child, education of mother and father, occupation
of father, socio-economic status, birth order and nutritional
status as measured by weight for age. The final model
suggested that only educational status of the mother,
occupation of the father, birth order and nutritional status
of the child were significantly associated with anemia.
Interpretation & conclusion : For short term impact,
appropriate nutritional interventions remain the only
operational intervention as only the nutritional status
(weight for age) is modifiable factor. But for long term
sustained impact, policy makers need to focus on improving
maternal education and reducing family size.
2. NUTRITIONAL STATUS AND AGE AT
MENARCHE IN ADOLESCENT GIRLS IN AN
URBAN SCHOOL OF WARDHA. D.G. Dambhare,
M.S. Bharambe, S.S. Gupta, B.S. Garg.
Research Question : What is the relationship between age at
menarche and nutritional status? Objectives : 1. To access
the nutritional status of adolescent girls. 2. To determine
the association between age at menarche and nutritional
status. Study Design : Cross sectional study. Setting : Kamla
Nehru School, Wardha. Participants : All 360 female students
in the age group 10-19 years studying in high school.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
Results : The mean age was 13.76 years (SD. 2.35). The mean
age at menarche in those who had attained menarche was
15.45 years (SD. 1.75). Menarche was attained by 51.94% of
the adolescents. A statistically significant relation between
menarcheal age and socioeconomic class is found
(P<0.0001). The overall level of malnutrition was very high
84.44%. However, in 10-14 years age group malnutrition
was significantly high 70.06% compared to 29.83% in 15-19
years age group (p <0.001). Among the adolescent of age
group 10-14 years, 28.94% attained menarche compared
to 95.2% adolescent of 15-19 years age (p <0.001). The
difference between the mean BMI of those girls who had
attained menarche 17.15 compared to those who had not
attained menarche 14.83 was statistically significant (p<
0.001). Conclusion : In this study, the adolescents from the
upper social class were attained menarche earlier than
those whose belong to lower social class. The rate of under
nutrition amongst adolescent girls was very high 84.44%.
The nutritional status was associated with age at menarche.
The higher the nutritional status, the lower is the age at
menarche.
3. MORBIDITY STATUS OF UNDER THREE
CHILDREN IN RURAL WARDHA. Thaware Preeti,
Deshmukh PR, Garg BS.
Background and Objective : Pre-school children, especially
under three children constitute the most vulnerable segment
of any community. Their morbidity status is a sensitive
indicator of community health.. Hence the present study
was undertaken with the following objective:
Objective : To assess the morbidity status of under three
children in villages under field practice area of Department
of Community-Medicine, M.G.I.M.S, Sewagram.
Materials & Methods : A cross-sectional study was conducted
in 3 PHC areas of Wardha District; namely Anji, Talegaon
and Gaul. 30-cluster sampling technique was used for
selection of study subjects. 33 respondents from each
cluster [11 from each of (0-11) months, (12-23) months, and
(24-35)month's age group] were selected for study purpose.
Thus, total 990 children were studied. Basic information
was collected by using a pre-designed and pre-tested
questionnaire. Data was entered and analyzed by using
epi_info 6.0
Results : In the study area; more then 50% children are in
the morbid condition. There is no difference in the morbid
status among male and female children in under three
children. According to the socioeconomic condition, the
70
children from low socioeconomic status are more morbid
then the children in high or middle socioeconomic status
family. There is considerable less morbidity in the children
in open group. Whereas almost no variation in morbidity
status in the children of other cast.i.e they are more morbid.
More morbidity is present in under weight and anemic
children (56%,54% respectively).The children with muac of
12.5 are more more morbid (55%) as compare to other
group The children with the parents of higher education
are less morbid.
Conclusion and Recommendation : Widespread prevalence
of morbidity among under three children and highlight a
need for a integrated approach towards improving the
child health by increasing the education,socio-economic
status of parents, at the same time nutritional status of
the children in this area.
4. ROLE OF VILLAGE COORDINATION
COMMITTEE (VCC) IN DECENTRALIZED
HEALTH CARE. Datta SS, Garg BS.
Research Question : To assess the effectiveness of Village
Coordination Committee (VCC) in decentralized health
care delivery in rural area. Objectives: 1. To develop and
test Institutional Maturity Index (IMI) for the VCC. 2. To
assess the effectiveness of VCC with emphasis on various
dimensions of health interventions. Study Design: Process
documentation vis. a vis. quasi experimental study. Setting:
Villages of three PHC areas: Anji, Gaul and Talegaon in
Wardha district of Maharashtra state. Participants: 64 VCCs
formed in these villages of atleast one year old. Results:
The IMI for the VCC was developed in a participatory man-
ner including various activities of VCC specially those
which are vital for sustainability. The IMI already devel-
oped by Aga Khan Rural Support Program (AKRSP) at
Gujarat was utilized as reference. Gradation of all VCCs
has been done using the IMI scoring mechanism and each
VCC promises of heading towards ownership of village
level activities. All VCC have village health plan in place
and majority has prepared their sustainability plan. The
average IMI score of the VCCs is 58 out of 100. Once any
VCC achieves score of 80 out of 100 and reaches a five star
VCC status, will also achieve ownership of health activities
at village level. Conclusions: The VCC has synergy with
'Village Health and Sanitation Committee' in NRHM and
the experience gained in the process will have long term
repercussion in the implementation of NRHM and at the
same time can guide into assessing maturity of these
committees in near future.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
PAPER PRESENTED IN 35 TH ANNUAL NATIONAL
CONFERENCE OF INDIAN ASSOCIATION OF
PREVENTIVE & SOCIAL MEDICINE AT JIPMER,
Puducherry : 23-25 January 2008
1. STUDY OF CHEST SYMPTOMATICS AT
TEACHING RURAL HOSPITAL. Nimbarte SB,
Mehendale AM*, Garg BS.
Abstract : Introduction : Pulmonary Tuberculosis contributes
to around 85% of total TB cases and these cases serve as
main reservoir of infection. So it is important to reduce the
transmission by diagnosing them and putting them on
treatment as early as possible. The present study was
planned in general out-patient department of Kasturba
Hospital, Sewagram with the following objective.
Objective : To study the sputum positivity of chest symptom-
atic with cough for diagnosis of pulmonary tuberculosis
Methodology : Cross-sectional study was carried out among
chest symptomatic who presented at General Hospital
out-patient department of Kasturba Hospital, Sewagram
with productive cough based on history. Three sputum
samples were collected from each of them and subjected
to sputum microscopy. Data thus collected was entered
and analyzed by EPI.Info.6 program me.
Results : Out of the 845 chest symptomatic, 104 had sputum
positive results with sputum positivity 12.3%. Sputum
positivity among females was more than males in the age
group 15-19 years. Sputum positivity was higher among
patients with chest pain and haemoptysis than those
without these symptoms.
Conclusion : The detection of smear- positive TB cases can
be substantially improved by actively eliciting history of
cough from all out-patients with related symptoms.
2. HOUSEHOLD & COMMUNITY IMNCI
THROUGH VILLAGE HEALTH WORKER.
Sanam Anwar, Garg BS
Abstract : Background : One of the MDG goal is reducing
child mortality by two third by 2015. In view of emphasis
on newborn illness and health, the child survival interventions
under CLICS Program are delivered using the Household/
Community IMNCI framework.
Objectives : To develop skills of Village Health Workers to
identify illnesses among children & communication skills
for guidance and counseling.
Materials and Methods : The study was conducted in 67
villages of 3 PHC areas of rural Wardha. 8 days skill
based IMNCI training through case demonstration in
hospital & community visits, Lecture and Group Discussion,
Video Demonstration, Role plays and case studies.
Results : 88 VHW trained on IMNCI. 16 key family
A practices for child health and nutrition targeted.
Implementation of Community Pharmacy using Essential
Drugs managed by VHW.
Conclusion : VHW act as effective tools for Household &
Community IMNCI.
3. A COMPARISON OF HIV/AIDS AWARENESS
BETWEEN SELF HELP GROUP LEADERS
AND OTHER WOMEN IN THE VILLAGES OF
PRIMARY HEALTH CENTRE, ANJI. Dongre AR,
Deshmukh PR, Garg BS, Boratne AV. Department of
Community Medicine, Mahatma Gandhi Institute of
Medical Sciences, Sewagram, Wardha (MS)
Abstract : Objective : To compare the level of awareness
about HIV/AIDS between women's self-help group leaders
and other women in the villages of primary health centre
area, Anji, Wardha District, Maharashtra.
Material & Methods : A cross sectional study was undertaken
in the month of May 2004 to compare the level of awareness
regarding HIV/AIDS between two group comprised of two
leaders (president and secretary) from each of 41 women's
SHGs promoted by Kasturba Rural Health Training Centre,
Anji in the area of PHC, Anji & second group comprised of
98 randomly selected women other than the leaders of
women's SHGs from the same villages. The women were
interviewed on per-designed and pre-tested questionnaire
by house to house visit. The data was analyzed by using the
software package epi_info 6.0.
Results : The level of awareness regarding the modes of
transmission of HIV/AIDS was higher among the leaders
of women's SHGs as compared with the other women. The
difference was statistically significant (p<0.05). Most of the
leaders of women's SHGs knew even at least one preventive
measure. 16% of women other than the leaders did not
know even a single preventive measure. The difference was
statistically significant (p<0.05). Most of the leaders of
women's SHGs had heard about HIV/AIDS. Majority (70%)
of them received information from television and most of
them (76%) had discussed about HIV/ AIDS with someone.
However 17 % of women other than leaders of women's
SHGs received information from health worker and only
24 % of them discussed about HIV/AIDS with someone.
(Table 1)
71
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
Conclusion : The leaders of women's SHGs can act as potential
resource persons for the delivery of the health education
about HIV/ AIDS to other women in the villages.
4. BEST PRACTICES IN INVOKING COMMUNITY
PARTICIPATION: LESSONS FROM CLICS
PROGRAM. Chetna Maliye, BS Garg.
Background : Community participation, a movement in the
public health field that respects the rights and responsibility
of community members to actively engage in designing,
implementing and evaluating strategies to address their
health problems.
The key strategy of CLICS (Community led
initiatives for Child Survival) is to build the capacity of the
target communities to develop, manage and ultimately
achieve 'ownership' of village based child survival and
health services.
Objectives : To study the best practices of community
participation in villages of rural Wardha.
Material and Methods : Study was conducted in 67 villages
of rural Wardha. The Village Coordination Committee
was trained in PLA techniques, planning, supervision,
monitoring and evaluation of community based activities.
Monthly one day training was conducted.
Results : Empower community to identify problems and
take decisions. Delegate responsibilities to make everyone
participate. Let community mobilize its own resources;
it gives them ownership. Train them in participatory
monitoring and self- evaluation.
Conclusion : Community organization is a prerequisite
for making community participate actively.
5. COST BENEFIT ANALYSIS OF "KIRAN
CLINICS" UNDER CLICS PROGRAM IN
RURAL WARDHA. Thaware Preeti, Deshmukh PR,
Garg BS.
Background and Objective : With increasing level of costs,
the health benefits are not increasing up to the mark.
Government of India spends 0.9 % total GDP on health, but
the result remain the same. For the best use of the scared
resources, analysis and accurate information is necessary,
to make health service efficient and effective, by using
alternate method of the health financing.
Objective : To find out cost recovery of Kiran clinics & to
study the expenditure pattern of Kiran clinics.
Methodology : Kiran clinics have been established so far
in 18 villages under CLICS program "Community Led
Initiatives for Child Survival (CLICS)" support from
72
Department of Community Medicine, MGIMS, and
Sewagram. Costing was for fixed assets at set up and
subsequently, training the manpower, personnel, drugs and
surgical, administration, Supplies, cost recovery it was from
user fees and drug sold. Information on monthly amount
was collected from the records.
Results : During the analysis period, total of 591 clinics
were held and the average attendance of patients was 21.3
per clinic. Out of this, 41.6% cost was incurred on personnel,
30.4% on administration, which mainly includes transport,
and 25.3% on drugs and surgicals. Average cost incurred
per patient served was Rs. 45.50. The variation in personnel
cost ranged from 29.4%-52.7%. Similarly, cost on transport
(administration) ranged from 15.5% -48.6%. Overall, the
cost recovery was 37.9%.
Conclusion and Recommendation : For more cost recovery,
sector-wise strategy needs to be evolved to cut down the
manpower cost and the transport cost. On the other hand,
user fees may be increased gradually in consultation with
Village Coordination Committee considering the above
cost distribution.
6. TO ASSESS THE EFFECTIVENESS OF VILLAGE
COORDINATION COMMITTEE (VCC) IN
DECENTRALIZED HEALTH CARE DELIVERY
IN RURAL AREA. Datta Shib Sekhar, Garg BS.
Background : Village Coordination Committees (VCCs)
are being promoted under the Community Led Initiatives
for Child Survival program (CLICS) at MGIMS, Sewagram.
The ultimate aim of the program is to achieve 'Community
Ownership', a stage where the VCC is able to independently
manage key health activities and sustain health gains at
village level.
Objectives : To develop and test Institutional Maturity
Index (IMI) for the VCC.
Materials and Methods : The present study was undertaken
in 64 VCCs from three PHC areas namely Anji, Gaul and
Talegaon in Wardha district of Maharashtra state. The IMI
for the VCC was developed in a participatory manner including
various activities of VCC specially those activities which
are vital for sustaining the VCC. The IMI already developed
by the Aga Khan Rural Support Program (AKRSP) at
Gujarat was utilized as reference.
Results : Gradation of all the VCCs has been done using the
IMI scoring mechanism and each VCC promises of heading
towards the ownership stage. The average IMI score of the
VCCs in the program area is 58 out of 100. Once any VCC
achieves a score of 80 out of 100 and reaches a five star
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
VCC status, it will be offered with the prize to sign the
ownership agreement of the program and interventions
related to program activities. The IMI is so far proving to
be acting as lever to motivate the VCC to strive forward in
order to achieve sufficient maturity to be the owner of the
program.
Conclusions : The program has synergy with NRHM and
the experience gained in the program will have long term
repercussion in the implementation of NRHM and at the
same time can guide into assessing maturity of 'Village
Health and Sanitation Committee' in near future.
FORENSIC MEDICINE & TOXICOLOGY
A) P A P E R S P R E S E N T E D I N X X I X A N N U A L
CONFERENCE OF INDIAN ACADEMY OF
FORENSIC MEDICINE, HELD ON 23RD TO 25TH
FEBRUARY 2008 AT MUMBAI.
1) EARLY CHEMICAL ANALYSIS OF POISONING
CASES ADMITTED TO THE HOSPITAL FOR
TREATMENT AND IMPORTANCE OF CLINICAL
TOXICOLOGY IN MEDICAL COLLEGE. AN
ASSET TO CLINICIAN, INVESTIGATING
AUTHORITY AND JUDICIARY. Presenting Author -
Dr.Bipinchandra Tirpude
Study was conducted at Mahatma Gandhi Institute
of Medical Sciences, Sewagram, Wardha in the year 2002
to 2006 in the department of Forensic Medicine and
Toxicology where clinical toxicology laboratory is available.
During this period, 1223 cases of poisoning were analyzed
by in Clinical Toxicology Laboratory. Out of this,1188 cases
were admitted with history of poisoning for treatment
and 35 cases were brought dead as medico-legal case for
postmortem examination. Present study was undertaken
with the purpose of determining how the toxicology
laboratory was contributing in clinical work, medico legal
work and research work. The toxicology laboratory has
provided a reliable data bank of poisoning cases, which can
be utilized for various purposes like diagnosing the cases
of poisoning, where the analysis report can be conveyed
within time to clinician so that they can start proper
treatment and fixing charges against the accused by
investigating authority and submit the case, for further
disposal to the judiciary. Judiciary is again known for
taking long time for giving final verdict in such cases, so
overall purpose is to help the clinician for proper diagnosis
and trement, investigating authority y visiting scene of
crime and judiciary for disposing the cases.
73
2) EUTHANASIA. Presenting Author : Dr.P.N.Murkey
The term euthanasia, also known as mercy killing,
was derived from the Greek words "eu" and "thanatos"which
means "good death". It literally means putting a person to
painless death especially in cases of incurable suffering or
when life haws become purposeless as a result of mental or
physical handicap. It is deliberately bringing about a gentle
and easy death making the last few days of the patient as
comfortable as possible. This is to be ensure a calm and
peaceful death, within the context of relieving incurable
suffering in terminal illness or disability. Euthanasia is
voluntary, when requested by the sufferer, involuntary or
compulsory if it is against the will of the patient, passive
when the death is hastened by deliberate withdrawal of
effective therapy of nourishment. Various ethical contra-
dictions exist regarding its practice in different religions
and in different societies. Laws around the world also
vary greatly with regard to its practice, and are constantly
subject to change as cultural values shift and better
palliative care, or treatments become available. It is legal
in some country and criminalized in others.
3) QUALITY OF POSTMORTEM EXAMINATION
IN INDIA. Presenting Author :-Dr.Indrajit Khandekar
In India any registered Medical practitioner
irrespective of his/her training or experience is allowed to
conduct medico-legal postmortems. The question that needs
answer is, on what basis government is allowing untrained
doctors to conduct medicolegal postmortem eaminations.
As per MCI norms any student after passing Final MBBS
examination and completion of one year rotatory internship
is allowed to do general practice. However, in the most of
universities there is no compulsory internship in the subject
of Forensic Medicine. WHO has said that in many countries,
where the allocation of scarce resouserces is at theissue,
it should be realized that it is unreasonable to expect
reliable & valid result from autopsies conducted by
medical practitioner without the benefit of further
substantial supervised post graduate training & experience
in pathology in general, forensic pathology in particular.
4) MODIFICATION OF FORMAT OF POSTMORTEM
REPORT: REQUIRED OR NOT ? Presenting Author
:- Dr.Indrajit Khandekar
Presently in Maharashtra we use a printed proforma
for writing postmortem report, as per the Govt of
Maharashtra, Bombay letter No.FRM/1462/19357, dated
4-7-62. Like government of Maharashtra various states
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
have their own format of postmortem report. This paper that this case may contribute to the establishment of actual
is presented by keeping in mind that there should be incidence of the above said condition.
uniform guidelines at national level regarding format of
post mortem report. 8) SUICIDES IN THE ELDERLY AGE GROUP
IN WARDHA DISTRICT OF MAHARASHTRA
5) NARCOANALYSIS. Presenting Author :- Dr. K. IN A FIVE YEARS PERIOD, FROM1ST
Suken Singh JANUARY 2001 TO 31 ST DECEMBER 2005.
Presenting Author - Dr.P.N. Murkey
Criminal investigation is one of the most challenging
issues of the present era with the number of crimes increasing Ageing is a natural phenomenon which is inevitable
day by day, and to know weather a person who is being to everyone. For most old people, their life is a time of
investigated on is speaking truth or not is most crucial fulfillment and satisfaction with life's accomplishment. For
areas of the criminal investigation. Forensic scientist have some older adults, however, later life is a time of physical
kept on developing newer techniques to fulfill this goals. pain, psychological distress & dissatisfaction with present.
The present article discuses the pros & cons of Narcoanalysis Suicide is one of the possible outcomes. The present study
& their validity in the court of law as per the law of the was conducted in Mahatma Gandhi institute of Medical
country. Sciences from 1st January 2001 to 31st December 2005 which
is one of the pioneer rural based hospitals in the country
6) PARENTAL NEGLIGENCE - A CASE REPORT.
Presenting Author-Dr.Atul Keche B) PAPERS PRESENTED IN XVI ANNUAL STATE
A 5 years old male child was brought to the CONFERENCE OF KARNATAKA MEDICOLEGAL
Kasturba Hospital, Sewagram with the history ingestion SOCIETY. 23RD & 24TH AUGUST 2008
of poison on 19/12/05 along with bottle containing some
1) UNDETERMINED DISEASE CAN CAUSE
poison which he was ingested. On asking relatives, it was
MYSTERY-A CASE REPORT. Presenting Author -
revealed that the child was operated for inguinal hernias
Dr.A.S. Keche
on 13/12/05 & was given regular medicine in the form of
syrupOn19/12/05 at around 11 AM, his grandmother gave 2) "CHIELOSCOPY" EVERYTHING IN NATURE
medicine to him but the child said that syrup was given IS UNIQUE. Presenting Author: - Dr.V.G.Pawar
in less quantity and demanded for more but grandmother
denied & kept the bottle on sajja.Unfortunately on same 3) "CONTRIBUTORY NEGLIGENCE" A CASE
sajja by the side of medicine bottle another bottle containing REPORT. Presenting Author- Dr.V.G.Pawar
poison was already present wrapped in piece of paper.
After grandmother left the room that child stood on the 4) SUICIDAL HANGING IN RURAL HOSPITAL
AROUND WARDHA. Presenting Author :-
stool & tried to get the bottle but rather than taking
bottle of medicine he had taken bottle containing poison Dr.V.G.Pawar

& ingested it & died on 21 December 2005.

5) HISTOPATHOLOGY REVEALS - HIDDEN
DISEASE. Presenting Author- Dr.A.S. Keche
7) PENTALOGY OF FALLOT WITH
NEUROFIBROMA OF HEART: AN AUTOPSY 6) CONCEPT OF MOMENT OF DEATH. Presenting
CASE AND REVIEW OF THE LITERATURE. Author -Dr.K Suken Singh
Presenting Author:-Dr.Sumeet Shende.
7) AN UNUSUAL WAY OF ASSAULT?. Presenting
The teratology of Fallot is a congenital heart
Author - Dr.S.T.Bhowate
defect which classically has four anatomical components. It
is most common cyanotic heart defect and a most common
8) IMPORTANCE OF FORENSIC MEDICINE
cause of blue baby syndrome. The four characteristics of EXPERT IN DEALING WITH MEDICOLEGAL
Fallot's teratology syndrome, plus a patent foramen ovale
CASES. Presenting Author - Dr.Aloke Mazumder
or atrial septal defect is known as pentalogy of Fallot. It
occurs rarely. we are reporting this case which is relatively 9) PRESENT: DOCTOR PATIENT RELATIONSHIP.
rare condition found on forensic autopsy, and considering Presenting Author - Dr.Aloke Mazumder

74

J MGIMS, March 2009, Vol 14, No (i), 64 - 90

C) P A P E R PRESENTED IN FIFTH ANNUAL
CONFERENCE OF SOUTH INDIA
MEDICOLEGAL A S S O C I A T I O N F R O M 3 1 ST
OCTOBER TO 2ND NOVEMBER 2008
1) CAUSE OF DEATH AND ITS RELATION
WITH TOTAL BODY SURFACE AREA (TBSA) IN
CASES OF BURNS. Presenting Author- Dr.P.R.Zopate
626 autopsies were performed in Kasturba Hospital
Sevagram during the period 1st July 2005 to 31st July 2007.
Out of these 626 cases 343(54.79) cases died because of
burn injuries. The study cohort was comprised of 68.80%
females and 31.19% males. The mortality in cases of burn is
directly related to TBSA.
MEDICINE
1. GERICON - 2008 - TO STUDY OF PREVALENCE
OF SLEEP APNEA IN ELDERLY PATIENTS
WITH CHRONIC OBSTRUCTIVE AIRWAY
DISEASE. AP JAIN***, A BHATT**, N PATIL*.
Introduction : Patients with chronic obstructive airway
diseases [COAD] are noted to have a high prevalence of
sleep disordered breathing including not only obstructive
sleep apnea syndrome but also episodes of hypoventilation
associated with oxygen desaturation. Pulse oximetry has
been proposed as useful diagnostic and screening tool for
obstructive sleep apnea syndrome. We investigated the
patients with chronic obstructive airway disease developing
sleep apnea syndrome and utility of pulse oximetry as a
screening tool for sleep apnea syndrome in a COAD patient.
Methods : The study was conducted in Kasturba Hospital
and Mahatma Gandhi Institute of Medical Sciences,
Sewagram. COAD was confirmed on basis of history, clinical
examination and pulmonary function tests. The total
number of patients that were taken for the study was 124
out which 62 patients had COAD and rest 62 were controls.
A detailed clinical history was obtained regarding age,
chronicity of symptoms, cough, sputum production, wheezing,
dyspnoea, smoking and number of admissions for acute
exacerbations. Assessment of severity was based on clinical
examination, chest radiograph and mainly spirometry
measurement of FEV1 [ forced expiratory volume in 1
second] and ratio of FEV1/FVC [forced vital capacity].
These patients were subjected to Epworth sleepiness scale
[ESS]. Pulse oximetry probe was attached to finger of the
patient and recording of Trans cutaneous SaO2 was
75
done manually during the night. These patients were
prospectively evaluated for episodes of oxygen desaturation,
apnea, hyperpnoea and arousals by overnight pulse
oximetry. The study was done to predict the prevalence
of sleep apnea syndrome in COAD patients.
Results : Prevalence of sleep apnea syndrome in COAD pa-
tients was 5% by pulse oximetry, 4% by Apnea Hyperpnoea
index - AHI [>10/hour] and 8% by Epworth sleepiness scale
[ESS]. We found that oxygen desaturation of >4% by pulse
oximetry is a cost effective screening tool for detection of
sleep apnea syndrome. Screening oximetry is most successful
in detecting patients with a high likelihood of having sleep
apnea syndrome, those with more severe disease and ESS
score>10. Excessive daytime sleepiness was found to have
56% sensitivity and 66% specificity for diagnosis of sleep
apnea syndrome. For pulse oximetry [O2 desaturation >4%],
there was 82% sensitivity and 69% specificity for diagnosis
of sleep apnea syndrome. Apnea Hyperpnoea index [AHI]
was 94% sensitive and 70% specific for diagnosis of sleep
apnea syndrome while ESS>10 was 96% sensitive and 82%
specific.
Conclusion : To conclude, the present study observes the
prevalence rate of 5% of sleep apnea syndrome in COAD
patients by overnight pulse oximetry. Oxygen desaturation
of >4% by pulse oximetry is a cost effective screening tool
for detection of sleep apnea syndrome. Screening oximetry
is most successful in detecting patients with a high
likelihood of having sleep apnea syndrome, those with
more severe disease and ESS score >10.
2. TITLE : THE DIAGNOSTIC SENSITIVITY
OF F-WAVE LATENCY IN DIABETIC
POLYNEUROPATHY. BHARTI TAKSANDE, AP
Jain, UN Jajoo (IMACON-DUBAI; OCT 2008).
Background & Aim : Diabetic patients have a 12 times higher
risk of amputations when compared with non-diabetic
subjects, due to diabetic neuropathy. Diabetic polyneuropathy
is characterized by a combined axonal loss and demyelinating
sensorimotor peripheral neuropathy. NCV- primarily CV
are considered one of the most sensitive indices of the
severity of neuropathy. To investigate this condition, NCV
with the determination of latency and velocity, are
commonly used as they are considered to be the most
sensitive, reliable, nonnoninvasive, and objective means.
Materials and Methods : This was a prospective study of 30
subjects of Type 2 DM admitted in medicine ward during
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
a period of 6 months. All patients underwent a detailed
neurological examination Nerve Conduction Velocity (NCV)
measurements were made using the standard RMS EMG
EP machine. Nerve conduction studies of the bilateral
median, ulnar, tibial and peronial nerves are performed.
DML, CMAP Amplitude, FWL were recorded. In total 240
motor nerves of 30 diabetic patient (60 limbs) were studied.
Statistical analysis was performed using SPSS, version 10
Results : The 30 diagnosed patients of type 2 DM were
taken. The minimum F wave latency had a larger Z score
than the MCV of the median, ulnar, peroneal or tibial nerves
and was larger than z score for the amplitude of the CMAP
in all the four motor nerve (Table 1). There was a significant
correlation between the minimum F wave latency and
MCV in all the four motor nerve. The bivariate correlation
coefficients were y = -0.41(p<0.05), y = -0.757 (p<0.05), y = -
0.759 (p<0.05) and y = - 0.74 (p<0.05), for the median, ulnar,
peroneal and tibial nerve, respectively.
Conclusion : Abnormal NCV is a common finding in NDD
subjects. Although F-response latency was considered a
sensitive indicator of peripheral neuropathy, amplitude and
duration in ulnar nerve F response were the other sensitive
parameters of the detection of mild diabetic neuropathy
in type 1 diabetes.
3. PULMONARY HYPERTENSION IN
HEMODIALYSIS PATIENTS – SEWAGRAM
STUDY. Sunil Kumar, AP Jain.
About half the death in dialysis patients is due
to cardiovascular disease, one of them is pulmonary
hypertension which usually develops secondary to
pulmonary artery calcification. Prevalence of pulmonary
hypertension ranges from 30-40 % as detected by Doppler
echocardiography in patient on chronic hemodialysis.
The aim of this study was to evaluate the prevalence
of primary pulmonary hypertension(PHT) among
hemodialysis patients and search for possible etiologic
factors. We studied 92 patients who were on long term
regular hemodialysis therapy by AV fistula 2 times per week
in Kasturba hospital of MGIMS, SEWAGRAM from
October 2007 to may 2008. The prevalence of PHT was
prospectively estimated by Doppler echocardiogram in 92
hemodialysis patients on the day post dialysis. PHT (> 35
mm Hg) was found in 32 (34.8%) patients with a mean
systolic pulmonary artery pressure of 39.6 ± 13.3 mmHg.
76
The hemoglobin and albumin levels were significantly
lower in the PHT subgroup (10.5 ± 1.86 vs 7.8 ± 1.97 g/dL
and 3.75 ± 0.44 vs 2.38 ± 0.32 g/dL, p = 0.01 and 0.02,
respectively). Our study demonstrates a surprisingly high
prevalence of PHT among patients receiving long-term
hemodialysis. Early detection is important in order to avoid
the serious consequences of the disease.
MICROBIOLOGY
1. MYCOTIC KERATITIS DUE TO
NODULISPORIUM GRISEOBRUNNEUM :
FIRST CASE REPORT : DK MENDIRATTA. DC
Thamke, P Narang : (Microcon-2008) 32nd National
Conference of Indian Association of Medical
Microbiologists. AFMC, Pune, 21st - 25th Oct. 2008.
Nodulisporium sp. occurs worldwide in nature often
as accompanying conidial anamorphs to wood decaying
fungi of family Xylariaceae. Human infections due to this
fungus are rare. Previously it has been reported from
patients of allergic fungal sinusitis (North Carolina), chronic
sinusitis (Brazil) and cerebral phaeohyphomycosis (India).
We here in report the first case of mycotic keratitis due to
Nodulisporium griseobrunneum from a female agricultural
worker of Vidarbha region, Maharashtra, Central India
following injury with vegetative matter. The fungus was
demonstrated on direct microscopy and grown on SDA
with Chloramphenicol after one week of incubation. It was
confirmed by Dr. Joseph Guarro, Professor of Microbiology,
University of Rovira i Virgili, Reus, Spain.
2. WORM IN THE EYE OF A CHILD - A CASE
REPORT : D K MENDIRATTA. Rahul Narang,
Vijayashri Deotale, A Shukla, N Gangane, Pratibha
Narang : (Microcon-2008) 32nd National conference
of Indian Association of Medical Microbiologists,
AFMC, Pune, 21st - 25th Oct., 2008.
A live 3.2mm x 0.8mm worm was extracted from
the anterior chamber of the eye of a 7 year old boy who
presented with history of repeated episodes of headache
and loss of vision since last 8 months. Son of a dairy farm
worker at Chandrapur, Maharashtra, the child did not
give any other significant history including that of travel
outside the district. The blood counts were within normal
limits, no microfilaria was observed in the blood and serology
(detection of Ag, Ab, Ag-Ab complex) for filaria was negative.
Repeated stool examination did not show presence of any
ova or larvae. The worm was extracted and the patient was
treated with DEC. After extraction, the headache was
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
relieved, however, loss of vision continued. The worm was
examined in great detail and photographs of the worm,
cut section and also a portion of the worm for molecular
identification was sent to Parasitology Division, CDC,
Atlanta and NIH, Bethesda. However no definite diagnosis
could be made by these Institutions. On the basis of absence
of cephalic papillae & irregular small bosses on cutile
(features of Loa loa) but presence of blunt anterior end
with spicule and copulatory bursa at the posterior end, we
strongly feel that it is a late stage larva of Angiostrongylus
cantonensis. The poster is being presented before the
August Scientific fraternity for their views and comments.
3. DETECTION OF AMP-C BETA LACTAMASES IN
KLEBSIELLA AND E.COLI ISOLATES FROM A
RURAL HOSPITAL, IN CENTRAL INDIA USING
THREE TEST METHODS: D Maraskolhe, VS Deotale,
P Narang, DK Mendiratta: (Microconf-2008),
XIV Maharashtra Chapter Conference of Indian
Association of Medical Microbiologists, GMC, Akola,
23rd-24th Aug. 2008.
The production of extended spectrum b lactamases
in gram negative organisms has evolved as a major mechanism
of drug resitance, Chromosomally encoded AmpC enzymes
i.e, Class C b lactamases also confer resistance to variety
of b lactams including Oxyamino cephalosporins,
Cephamycins, and Monobactams and have been reported
from some part of the country. However, there are no such
reports so far from ‘Central India. Klebsiella species and
E.coli are the commonest isolates from clinical specimens
in our hospital and therefore this study was undertaken
to detect the presence of AmpC b lactamases mediated
resistance in these organisms.
Method : A total of 1555 Klebsiella and 1378 E. coli isolates
from the clinical samples identified as per standard
methods were studied for 3rd GC resistance and production
of ESBL as per CLSI guidelines. The non ESBL isolates(165)
detected amongst the resistance strains further screened
for AmpC b lactamases production by using- Cefotoxin(Cn)
30 mg disc, Disc Potension Test(DPT), Double Disc Synergy
Test (DDST) and Modified Three Dimensional Test (M3DT).
Result : Presumptive screening by Cefoxitin revealed 135
out of 165 isolates (65 klebsiella and 70 E.coli) to be AmpC
producers. All these presumptive isolates were further tested
by 3 confirmatory tests. DPT detected 54(83.07%) Klebsiella
and 63(90%) E. coli, DDST detected 57(87.69%) Klebsiella
and 67(95.71%) E. coli and M3DT were positive for all the
135 isolates (100%). Cefoxitin resistance is considered to
77
be presumptive as strains negative for AmpC b lactamases
production may also show resistance to this drug due to
other mechanisms. CLSI gives no guidelines for AmpC
detection but according to other studies M3DT has been
taken as Gold Standard as it has 100% correlation with
isoelectric focusing and molecular methods. We observed
100% correlation between M3DT and Cefoxitin resistance
indicating thereby that in our 135 strains tested the
resistance was due to AmpC b lactamases and not due to
any other mechanisms. Thus in our hospital out of a total
1555 Klebsiellae and 1378 E. coli, 4.18% and 5.07% isolates
respectively were AmpC b lactamases producers.
4. INDUCIBLE CLINDAMYCIN RESISTANCE IN
STAPHYLOCOCCUS AUREUS ISOLATED FROM
CLINICAL SAMPLES : VS Deotale, DK Mendiratta,
UC Raut, SC Sharma, Prathibha Narang: (Microconf -
2008), XIV Maharashtra Chapter Conference of
Indian Association of Medical Microbiologists, GMC,
Akola, 23rd-24th Aug. 2008.
Introduction : Clindamycin is commonly used for treatment
of erythromycin resistant Staphylococcus aureus causing
skin and soft tissue infections. In vitro routine tests for
clindamycin susceptibility may fail to detect inducible
clindamycin resistance due to erm genes resulting in
treatment failure. Thus obviating the need to detect such
resistance by a simple D test on routine basis. The present
study used Erythromycin (15 mg) and clindamycin (2 mg)
discs to detect inducible (MLSBi phenotype), constitutive
resistance (MLSBi phenotype) and MS phenotype with
respect to clindamycin.
Methods : 247 Staphylococcus aureus isolates recovered from
various clinical specimens between February to May 2008
were subjected to routine antibiotic susceptibility testing
including that to Clindamycin (2 mg) by Kirby Bauer disc
diffusion method. Inducible Clindamycin resistance was
detected by disc approximation test (DAT) commonly
reffered as D test, as per CLSI guidelines. Isolates were also
screened for methicillin resistance using Oxacillin (1 mg)
disc.
Results : 80 (32.3%) isolates were erythromycin resistant.
Out of these 71 (28.7%) were sensitive to Clindamycin. 36
(50.7%) showed inducible clindamycin resistance (MLSBi
phenotype), 9(3.6%) constitutive resistance (MLSBi phenotype)
while remaining 35(49.3%) showed MS phenotype. Both
inducible as well as constitutive resistance was found to be
higher in MRSA (94.4% & 100%) as compared to MSSA
(5.6% & 0% respectively).
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
Conclusion : Study showed that D test should be used as an
auxillary method to routine disc diffusion testing in order
to detect inducible clindamycin resistance.
5. DETECTION OF AMP-C BETA LACTAMASES
IN KLEBSIELLA AND E.COLI FROM A RURAL
HOSPITAL IN CENTRAL INDIA. VS Deotale,
Deepashri Maraskolhe, P Narang, DK Mendiratta :
(Microcon-2008) 32nd National Conference of Indian
Association of Medical Microbiologists, AFMC, Pune,
21st-25th Oct. 2008.
Introduction : The production of extended spectrum b
lactamases in Gram negative organisms has evolved as a major
mechanism of drug resistance. Chromosomally encoded
AmpC enzymes i.e. Class C b lactamases also confer
resistance to variety of b lactams including oxyamino
cephalosporins, cephamycins and monobactums and have
been reported from some part of the country. CLSI gives
no guidelines for AmpC detection but many studies have
considered the M3DT test to be the gold standared as it
has shown 100% co-relation with isoelectric focusing and
molecular methods. Cefoxitin resistance has been used as
a screening test for AmpC production, but reports of
cefoxitin sensitive AmpC positive isolates have been
encountered. Detection of AmpC in ESBL producers by
phenotypic methods is difficult. Considering the paucity
of data on AmpC production, the present study was
conducted in klebsiellae sp and E. coli, the common
isolates in our rural hospital, where different phenotypic
methods were compared in both cefoxitin resistant and
sensitive non ESBL producers for AmpC detection.
Methods : A total of 1555 Klebsiella and 1378 E. coli isolates
from the clinical samples identified as per standard methods
were studied for 3rd GC resistance and production of ESBL
as per CLSI guidelines. The non ESBL isolates(165) detected
amongst the resistance strains further screened for AmpC
b lactamases production by using- Cefotoxin (Cn) 30 mgms
disc. Confirmation was done by Disc potentiation (DPT)
using boronic acid and closacillin in the concentration of
300 and 500 mgms, Double Disc Synergy (DDST) with
boronic acid and cloxacillin and Modified Three
dimensional Tests (M3DT).
Results : Amongst the 3rd GC resistant isolates 165 were
non ESBL producers. All these isolates were confirmed by
confirmatory tests. The sensitivity of DPT was 86.66%, for
DDST it was 91.85%. M3DT detected AmpC production in
both cefoxitin resistant and cefoxitin sensitive isolates where
as the other confirmatory tests detected only in cefoxitin
resistant isolates.
78
Conclusion : AmpC b lactamase production in Klebsiellae
and E. coli is prevalent in our area. Though cefoxitin
resistnace aws a good screening test, using M3DT a
confirmatory phenotypic test as M3DT detected AmpC even
in cefoxitin sensitive isolates in our set up.
ORTHOPAEDICS
1. ENDOSCOPIC LUMBAR DISCECTOMY BY
DESTANDU TECHNIQUE. Author : KR Patond,
Roshan Bhaisare. SICOT/SIROT Triennial
conference, HONGKONG. 22nd - 30th August.
Introduction : Traditionally lumbar prolapsed disc with
radicular symptoms in lower limb, not responding to
conservative management were treated with Laminectomy
and Discectomy. There is significant post operative morbidity
associated with these techniques, since there is a lot trauma
to the posterior elements.
Over last 10 yrs Endoscopic techniques develops
to accomplish a much smaller scar and early return to
activity. Foley and Smith (METRx system) and Destandu
(Karl Storz system) are among the most commonest of these
endoscopic techniques. We are presenting here the series
with Destandu’s Technique for Endoscopic Lumber
Discectomy.
Materials and Method : In this series 20 Endoscopic
Discectomy were performed using paraposterior technique
described by Dr. Destandu. There were 13 males and 7
females. Age averages from 20-55 yrs. L4-L5, L5-S1 disc
were the most common sites of disc herniation as assessed
on details neurological examination and MRI scans.
Patients were selected on the inclusion and exclusion
criteria. Only single level disc was operated. We use Prolo’s
criteria for out come assessment.
Results : Mean follow up period was 1 1/2 year. Excellent
and good results were found in 19 patients (95%), fair in 1
patient(5%). No poor result was seen. Discitis was developed
in one patient which was managed with antibiotics, no
further detoriation in neurological outcome. Most patients
were operated on day care basis, ambulated the next day
after surgery and discharge on 2nd or 3rd day post-op day.
Conclusion : Endoscopic discectomy by Destandu technique
for lumbar prolapsed intervertebral disc is a safe and
minimally invasive technique. Patients are mobilized early
and are very comfortable after surgery because of less pain.
Hospital stay is significantly reduced and they can go back
to work ealry.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
2. TITLE : ARTHROSCOPIC DEBRIDEMENT OF
THE ARTHRITIC KNEE. Authors : Ashok Kumar,
CM Badole , KR Patond. Annual Conference of
Indian Arthroscopic Society, Goa. 25th-28th September.
Introduction : Osteoathritis is present radiographically
in the weight bearing joint of 90% of the people over the
age group of 40 years and the commonly affected joint
is the knee. Arthroscopic debridement is the accepted
procedure for the treatment of symptomatic osteoartheritos
of knee.
Material and Method : 30 patients with symptomatic
osteoarthritis of knee joint underwent Arthroscopic
debridement of knee after failure of medical management
and physiotherapy. Radiographic findings were classified
as mild, moderate and severe. Patients with inflammatory
or traumatic type of osteoarthritis were excluded. Age
group was 40-70 yrs. Arthroscopic debridement includes
resection of unstable chondral flaps and meniscal tears.
Observations and Results : Out of 30 cases 17 were male and
13 were females. Age ranges from 40-70 yrs. Results of
surgery were graded on a nine point scale based on pain
reduction, functional improvement and overall patient
satisfaction. Patients were followed up at 6 months and
final follow up a 1 years, At 6 months the result were excellent
in 15 (50%) patients, good in 10(33%) patients, fair in 3(10%)
patients, failure in 2(7%). At the final follow up at 1 years
the results were excellent in 12 (40%) patients good in
10(33%) patients, fair in 6(20%) patients, failure in 2(7%).
Conclusion : Arthroscopic debridement can be used to
prolong the time for knee Arthroplasty since it is having
few contraindications, minimal risk, and low morbidity,
moreover it can be repeated and does not complicte future
Arthroplasty or realingement. to reach the final outcome,
long term follow up and large number of patients are
required since the disease is progressive.
3. ENDOSCOPIC LUMBAR DISCECTOMY BY
DESTANDU TEACHNIQUE. Author : Roshan
Bhaisare, KR Patond. Annual Spine Conference,
Rajkot. 25th - 28th September 08.
Introduction : Traditionally lumbar prolapsed disc with
radicular symptoms in lower limb, not responding to
conservative management were treated with Laminectomy
and Discectomy. There is significant post operative morbidity
associated with these techniques, since there is a lot trauma
to the posterior elements.
79
Over last 10 yrs Endoscopic techniques develops
to accomplish a much smallear scar and early return to
activity. Foley and Smith (METRx system) and Destandu
(Karl Storz system) are among the most commonest of these
endoscopic techniques. We are presenting here the series
with Destandu’s Technique for Endoscopic Lumber
Discectomy.
Materials and Method : In this series 20 Endoscopic
Discectomy were performed using paraposterior technique
described by Dr. Destandu. There were 13 males and 7 females.
Age averages from 20-55 yrs. L4-L5, L5-S1 disc were the
most common sites of disc herniation as assessed on
details neurological examination and MRI scans. Patients
were selected on the inclusion and exclusion criteria. Only
single level disc was operated. We use Prolo’s criteria for
out come assessment.
Results : Mean follow up period was 1 1/2 year. Excellent
and good results were found in 19 patients (95%), fair in 1
patient(5%). No poor result was seen. Discitis was developed
in one patient which was managed with antibiotics, no
further detoriation in neurological outcome. Most patients
were operated on day care basis, ambulated the next day
after surgery and discharge on 2nd or 3rd day post-op day.
Conclusion : Endoscopic discectomy by Destandu technique
for lumbar prolapsed intervertebral disc is a safe and
minimally invasive technique. Patients are mobilized early
and are very comfortable after surgery because of less pain.
Hospital stay is significantly reduced and they can go back
to work ealry.
4. CORRLATION OF CLINICAL FINDINGS AND
MRI FINDINGS IN LOW BACKACHE. Authors :
Ashok Kumar. CM Badole, KR Patond. VOSCON,
Akola. 9th - 10th Oct. 08.
Introduction : Low backache is a common complain and
a majro cause of work disability. MRI is the choice of
diagnosis in low backache.
Aim : To correlate the clinical findings and MRI in low
backache.
Material and Method : 100 patients with low backache with
radiculopathy underwent MRI lumbar spine to find out
correlation of clinical findings with MRI findings. Patient
between age group 20-45 yrs were selected for the study.
Detail clinical history comprising of type, onset, duration
of pain, sensory loss with or without motor loss, bladder
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
or/bowel disturbance was taken. Clinical examination in
the form of range of spine movements, gait, SLRT, sensory
or motor deficit, ankle and knee reflexes was recorded, AP
and lateral view of lumbar spine was taken. MRI lumbar
spine was done and findings were recorded as level and
type of disc prolapse like protrusion, extrusion, sequestration
and bulge with indentation. Bulge without indentation
was considered normal MRI fingings.
Observations and Results : There were 70 males and 30
females. In 38 patients there was bulge without indentation.
30 had extrusion disc, 18 had bulge with indentation, 8 had
protruded disc and 6 had sequestrated disc. L4-L5 level
was commonly involved. 70% of patients with positive
SLRT, 74% of patients with motor deficit, 80% with sensory
loss and 66% of patients with absent deep tendon reflex
had abnormal MRI Finding.
Conclusion : To diagnose intervertebral disc prolapse
detail clinical history and clinical examiantion should be
done. MRI must be correlated with clinical finding.
5. MANAGEMENT OF DISPLACED DIAPHYSEAL
FRACTURE OF FEMUR IN CHILDREN WITH
INTRAMEDULLARY KIRSCHNER WIRES.
Author : Ashok Kumar, CM Badole, KR Patond.
Conference : ARISCON, Sevagram. 15th-17th Nov. 08.
Introduction : Femoral shaft fractures account for 1.6% of
all pediatric bony injuries. Traction from non operative
(Plaster spica) to operative treatment (Intra medullary
osteosynthesis) in childhood has been accepted universally.
Complications such as malunion, rotational deformity, joint
stiffness, plaster sores & psychological problems can be
avoided
Methods : Study was conducted in the Kasturba Hospital
Sevagram Wardha, int he department of Orthopaedics, 25
childrens with a mean Age of 8-15 yrs (Range 4-14 yrs), 16
males and 9 females presented with closed displaced
diaphyseal fracture of femur were included in the study.
Closed reduction done under C-ARM control and K wires
fixation done using 3 point fixation principle. Follow up was
done monthly upto 6 months and Implant used was stainless
steel 316 L Kirschner 2.0, 2.5, 3.0, 3.5, 4.0mm X 30cm.
Results : Evaluation of Results was done using Flynn et al
(2001) criteria as Excellent, Satisfactory and Poor results.
Present study had 18 Excellent 7 Satisfactory results no poor
results.
Conclusion : Intramedullary fixation with K wires for
diaphyseal fracture femur gives predictably good results
80
with minimal infection rates. Complication of conventional
traction & spica are avoided. Early ambulation & decreased
hospital stay for the patients. No joint stiffness. Maintenance
of rotational & logitudinal stability.
6. DECOMPRESSION IN MULTILEVEL CERVICAL
SPONDYLOTIC RADICULOMYELOPATHY.
Author : CM Badole, KR Patond. Conference :
MOACON, Mahabaleshwar. 21st- 23rd Nov. 08.
Introduction : Various techniques and approaches have been
established for the surgical management of multilevel cervical
spondylotic radiculomyelopathies. Though there is an
increasing success of anterior decompression & laminoplasty,
however en block laminectomy is still the best and reliable
option for symptomatic multilevel cervical spondylotic
radiculomyelopathy not responding to non operative line
of management.
Method : The study was conducted in KHS, Sevagram
between Jan 2005 and May 2008 Patients having significant
neurological symptoms suggestive of cervical canal stenosis
were screened clinically and radiographically. Patients with
multilevel compression in the MRI were selected for the
study. Study group consisted of 27 patients, 24 males and 3
females with mean age of 61 years. Patients were admitted
and evaluated preoperatively and postoperatively using the
“Japanese Orthopaedic Association score.” Positioned in
prone with neck in neutral position. through posterior
midline approach, En block Laminectomy was done from
C3-C7. A fine, high speed burr was used to create troughs
at the facet-lamina junction on both sides. Laminas and
spinous processes are lifted off en block. Postoperatively
soft cervical collar given. Patients were discharged on 7th to
10th day and called for follow-up after 3 weeks.
Results : Results of surgery were decided based on the
comparison of preoperative and postoperative “Japanese
Orthopaedic Association score.” 23 patients had good results, 3
patients had fair result and 1 had post operative complication
but neurological improvement was significant.
Conclusion : Cervical en block laminectomy is safe, easy
and reliable technique. It is technically simpler than anterior
corpectomy as a means to address multiple levels of
pathology. This approach also avoids the increased
pseudoarthrosis rates of multiple level fusion procedures.
This technique also avoids incomplete decompression,
recurrent stenosis and neck restriction with are common in
laminoplasty procedure. No spinal instability or deformity
has been documented in the study so far.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
Key words : En block Laminectomy, spondylotic
radiculomyelopathy, cervical spine.
7. MANAGEMENT OF DISPLACED FRACTURE
SHAFT HUMERUS BY INTERLOCKING NAIL.
Author : CM Badole, R Chasnal, KR Patond.
Conference : MOACON, Mahabaleshwar. 21st - 23rd
Nov. 08.
Introduction : Various types of devices have been used
for fixation of fracture shaft of humerus. Rigid plate
osteosynthesis carries disadvantages including extensive
soft tissue trauma, significant blood loss and risk of intra
operative radial nerve injuries. Intramedullary stabilization
of humeral shaft fractures avoids some of these disadvantages,
but the nails are not without complications. However, locked
nails provide good rotational stability with good results.
Methods : Study was conducted in the Kasturba Hospital
Sevagram, Wardha May 2006 to May 2008. Patients presenting
with displaced diaphyseal fractures of shaft of humerus
5cm proximal to the distal metaphysis, Closed or Grade II
compound fractures were included in the study. Of the 31
patient treated with humerus Interlocking nail, 23 were
included in the study. Passive ROM movements were allowed
from third postoperative day. Assessment of shoulder
function was done by Constant - Murley Shoulder Score at
follow up visits.
Results : Assessment of shoulder function was done at
follow up in which 78.2% of the study has 81-100% score,
13% has 61-80% score and 8.6% has 41-60% score.
Complications like iatrogenic fracture, broken drill bit,
delayed union, shoulder stiffness and implant failure, were
encountered in 6 cases.
Conclusions : Intramedullary nailing offers the benefits
of anatomical alignment, rigid fixation, with limited soft
tissue dissection and early rehabilitation. Although shoulder
stiffness is a common problem it can be treated by making
entry point at correct site and with active physiotherapy.
8. NEURENTERIC CYST, A CASE REPORT.
Author : CM Badole, KR Patond. Conference :
IOACON, Bangalore. 4th-7th Dece., 2008.
Introduction : Benign epithelial lined cystic structures in
the Intraspinal - lower cervical or upper thoracic may be
Intradural and extramedullary along with spinal deformities,
resembling that of alimentary canal also known as
‘Enterogenous cyst’. We are reporting 2 such cases.
81
9. MINIMAL INVASIVE PERCUTANEOUS PLATE
OSTEOSYNTHESIS FOR PROXIMAL TIBIAL
FRACTURES. Author : Devashis R Barick, KR Patond.
Conference : IOACON, Bangalore. 5th December 08.
Introduction : Proximal tibial fractures pose many problems
in their treatment specially related to skin condition & tissue
equilibrium around the proximal tibia. Open reduction and
internal fixation may pose problems with wound healing
at the operative site with high chances of post-op infection.
Minimally Invasive Percutaneous Plate Osteosynthesis is
a safe, technically easy & equally effective in addition to
being cosmetically better.
Methods : 20 patients were treated with this modality
for closed fractures of the proximal tibia over a period
of 3 years at the department of Orthopaedics MGIMS,
Sevagram.
Results : The mean follow up was 2.8 yrs. All patients had
favourable results with no incidence of wound complications,
with minimal restriction of joint mobility.
Conclusion : Percutaneously introduced tibial condylar
plates in appropriately chosen cases give a good functional
outcome without additional procedures. Post-op. skin
necrosis is minimal with a significantly reduced infection
rate.
PATHOLOGY
1. ROLE OF OXIDATIVE STRESS AND
ANTIOXIDANT LEVELS IN TUBERCULAR,
REACTIVE AND METASTATIC
LYMPHADENOPATHY. P Magdum, S More, K Mehra,
NS Ingole, N Gangane. MAPCON 2008, Annual
Conference of Maharashtra Chapter of Indian
Association of Pathologists and Microbiologists,
Sawangi Meghe, 19-21 Sept. 2008.
Introduction : Oxidative stress is implicated in the
etiopathogenesis of a variety of human diseases including
tuberculosis and cancer. Mycobacteria can induce reactive
oxygen species (ROS) production by activating phagocytes
resulting into inflammation and tissue injury. ROS are
also involved in carcinogenesis. This study was carried out
to determine if there is difference in free radical and
antioxidant levels in patients of tubercular, reactive and
metastatic lymphadenopathies.
Aim : To evaluate the serum levels of malondialdehyde,
nitric oxide, ascorbic acid, reduced glutathione and
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
superoxide dismutase in patients with tubercular, reactive
and metastatic lymphadenopathy.
Methods : Fine needle aspiration cytology (FNAC) was
performed on 120 subjects presenting with lymphadenopathy.
The study included 40 cases each of tubercular lymphadenitis,
non specific reactive lymphadenopathy and metastatic
lymphadenopathy. Levels of malondialdehyde, nitric oxide,
superoxide dismutase, reduced glutathione (GSH) and
ascorbic acid were evaluated in all three categories and in
the control group comprising of 30 healthy controls.
Results : Levels of malondialdehyde and nitric oxide were
significantly raised in patients of tubercular and metastatic
lymphadenopathy as compared to controls. The antioxidant
levels (superoxide dismutase, glutathione reductase and
ascorbic acid) were significantly lower in tubercular and
metastatic lymphadenopathy when compared to patients
with reactive lymphadenopathy and controls.
Conclusions : We found rise in reactive oxygen species
and lipid peroxidation products in patients of tuberculosis
and malignancy. There was significant decrease in the
values of antioxidants in both metastatic and tubercular
groups. This study provides new insights on their role in
pathogenesis of various diseases and could have therapeutic
significance.
2. A HISTOMORPHOLOGICAL STUDY OF
BENIGN VASCULAR LESIONS WITH SPECIAL
REFERENCE TO ELASTING STAINING AND
MAST CELL DENSITY (SECOND PRIZE: BEST
PAPER AWARD). P Pawane, D Dhumal, R Gode,
Anshu, N Gangane. MAPCON 2008, Annual
Conference of Maharashtra Chapter of Indian
Association of Pathologists and Microbiologists,
Sawangi Meghe, 19-21 Sept. 2008.
Introduction : The diagnosis and management of benign
vascular lesions continue to present diagnostic and the
therapeutic challenges to surgeons, radiologists, and
histopathologists. This is in part due to lack of agreement
regarding the nosology and classification of these lesions.
In 1982, Mulliken and Glowacki introduced a new
classification based on the clinical and histological
characteristics of vascular lesions. They classified vascular
lesions into hemangiomas and vascular malformations.
Aim : This study was carried out of classify benign vascular
anomalies using Mulliken and Glowacki’s simple two-tier
classification. We also tried to see whether presence of
arteries and arterioles can be used as diagnostic criteria to
82
differentiate between hemangiomas and arterio-venous
malformations. We also sought to explore diagnostic clues
that may help in the diagnosis and differentiation of these
lesions. We studied mast cells using toluidine blue stain
in these lesions.
Materials and Methods : Cases reported as benign vascular
lesions were retrived from the Surgical Pathology records
of the Department of Pathology, MGIMS Sevagram. All
lesions were reclassified using Mulliken and Glowacki’s
classification into hemangiomas and arterio-venous
malformations. Sections were stained by routine haematoxylin
and eosin stain, Verhoeff’s method and 1.0% toluidine blue.
Lesions were also evaluated for presence or absence of
intralesional nerves.
Results : Lesions which showed presence of arteries and
arterioles on elastin stain were classified as arteriovenous
malformations. Intralesional nerves were found to be
significantly higher in arteriovenous malformations than
in hemangiomas. Mast cell density was high in proliferating
hemangiomas compared to involuting forms which showed
fibrosis.
3. CARDIAC PARAGANGLIOMA ASSOCIATED
WITH PENTALOGY OF FALLOT: A CASE REPORT.
S Deshmukh, R Sougaijam, R Sinha, SM Sharma, N
Gangane. MAPCON 2008, Annual Conference of
Maharashtra Chapter of Indian Association of
Pathologists and Microbiologists, Sawangi Meghe,
19-21 Sept. 2008.
Introduction : Primary cardiac tumors are rare. The majority
are benign and 75% are atrial myxomas. One of the more
unusual tumors affecting the heart is a cardiac paraganglioma.
We report an unusual case of cardiac paraganglioma which
was associated with Pentalogy of Fallot.
Case Report : A 22 year old woman succumbed to sudden
death within two hours of admission. Autopsy was conducted.
On examination the heart was enlarged. The heart showed
the presence of ASD, VSD, overriding of aorta, dilatation
and hypertrophy of the right ventricle, left ventricular
hypertrophy and origin of pulmonary trunk from left
ventricle. Pulmonary trunk was dilated. Apart from these
congenital defects, the heart also showed a nodular swelling
on posterior wall of the left ventricle just below the
atrio-ventricular groove.
Sections from the nodule showed the presence
the typical ‘Zellenballen pattern’ around an elaborate
vasculature. A diagnosis of paraganglioma was made.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
Conclusion : Tetrology of Fallot is one of the most common
congenital cardiac defects causing cyanosis. It is characterized
by biventricular origin of the aorta above a large VSD,
obstruction to pulmonary blood flow, and right ventricular
hypertrophy. Tetralogy when associated with ASD is called
Pentalogy of Fallot, and is not distinguishable clinically.
Pentalogy of Fallot and transposition of pulmonary trunk
to the left ventricle along with cardiac paraganglioma is a
very rare combination which was seen in the present case.
4. CYTODIAGNOSIS OF AMYLOIDOSIS OF LIVER
IN A PATIENT OF MULTIPLE MYELOMA : A
CASE REPORT. V Rao, C Nalinimohan, R Singh, VB
Shivkumar, N Gangane. MAPCON 2008, Annual
Conference of Maharashtra Chapter of Indian
Association of Pathologists and Microbiologists,
Sawangi Meghe, 19-21 Sept. 2008.
Introduction : Amyloidosis occurs in less than 15% of cases
of multiple myeloma. We report a case of amyloidosis of
the liver which was diagnosed on fine needle aspiration
cytology (FNAC). The cytological diagnosis of amyloidosis
prompted a search for the cause and multiple myeloma was
discovered.
Case Report : A 60 year woman presented with lump in
right hypochondrium of 4 years duration. The patient had
massive hepatomegaly which was progressive and painless.
Fine needle aspiration cytology was performed from the
liver. The smears showed thick deposits obscuring the
hepatocytes. These dense fragments were homogenous and
appeared reddish purple on the Giemsa stained smears and
pale green on the Pap smears. There was scalloping of the
margins of these deposits. The deposits were Caongophilic
and confirmed the presence of amyloid. A diagnosis of
amyloidosis of liver was made on cytology.
The cytologic diagnosis of amyloidosis prompted
a search for its cause. Radiographs from the skull showed
multiple punched out lesions. Serum electrophoresis was
done and showed the presence of M band. Bone marrow
aspiration was also performed. It showed mature and
immature plasma cells diagnostic of multiple myeloma.
Conclusion : Multiple myeloma can evolve into amyloidosis.
Primary amyloidosis occurs due to the tissue deposition
of AL protein which is derived from monoclonal light
chain fragments of the immunoglobulins. As our case
demonstrates, FNAC can be a useful minimally invasive
procedure in diagnosing amyloidosis. Further diangosis of
amyloidosis should prompt search for the cause.
83
5. EUMYCOTIC MYCETOMA - REPORT OF FOUR
CASES (SECOND PRIZE : BEST POSTER AWARD).
M Quadri, N Tatkare, S Gabhane, A Gupta, N Gangane.
MAPCON 2008, Annual Conference of Maharashtra
Chapter of Indian Association of Pathologists and
Microbiologists, Sawangi Meghe, 19-21 Sept. 2008
Introduction : Mycetoma is a late stage clinical manifestation
of a subcutaneous infection produced by either bacteria
(actinomycetoma) or fungi (eumycetoma). Only few articles
have described the morphological appearance of this
uncommon pathology on cytology. We report four cases
of Eumycotic mycetoma due to fungi where FNAC was
instrumental in diagnosis.
Case reports : Our cases include three men and women with
age range of 18 to 41 years and a history of a swelling with
discharging sinuses of six months to three years duration.
In three of them the foot was affected and one exceptional
case showed left side chest wall involvement. FNAC was in
all cases. Smears showed inflammatory infiltrate comprising
of mainly neutrophils, along with lymphocytes, plasma
cells, histiocytes and foreign body type of giant cells. A
prominent feature noted was presence of thick, septate,
branching fungal hyphae. Dark brown-black granules
were also seen in the macrophages and extracellularly in
smears. Hence the diagnosis of eumycotic mycetoma was
entertained.
Conclusion : Mycotic mycetoma can be accurately diagnosed
by FNAC, when there is high index of suspicion. Awareness
amongst cytopathologists for the possibility of eumycotic
or actinomycotic mycetoma in proper clinical context may
lead to rapid and economic diagnosis for the patient and
will be helpful in early treatment.
6. CYTOMORPHOLOGICAL FEATURES OF
MIXED INVASIVE PAPILLARY CARCINOMA
AND CRIBRIFORM CARCINOMA BREAST : A
CASE REPORT. S Chaukade, Y Bhiogade, Y
Zonunfawni, D Joshi, N Gangane. MAPCON 2008,
Annual Conference of Maharashtra Chapter of Indian
Association of Pathologists and Microbiologists,
Sawangi Meghe, 19-21 Sept. 2008.
Introduction : Special types of mammary carcinoma are
collectively responsible for about 25% of invasive breast
cancers, and their recognition may often be of prognostic
importance. Though Fine-needle aspiration (FNA) is a
reliable method for the diagnosis of breast carcinoma, but
difficulties exist for the cytopathologist to determine the
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
tumor subtypes. We hereby report the cytomorphological
features of a case of mixed invasive papillary carcinoma
and cribriform carcinoma breast.
Case - Report : A 62 years old female presented with a recurrent,
gradually progressive painless lump in right breast for six
months. Previous lumpectomy was done around the same
site one and half years back. FNA was performed and a
diagnosis of ductal carcinoma with degenerative change
was made and biopsy was advised for confirmation. Patient
then underwent modified radical mastectomy, histological
examination revealed presence of invasive papillary and
cribriform carcinoma breast extending upto the overyling
skin. Retrospective examination of the cytological smears
showed presence of papillary sheets, columnar cells,
vacuolated cells and macrophages more characteristic of
papillary carcinoma. Micro-acinar groupings denoting
areas of cribriform carcinoma were also noted. Presence of
micro-acinar groupings and background macrophages led
to the erroneous diagnosis of ductal carcinoma with
degenerative change.
Conclusion : Invasive papillary and cribriform carcinoma
are rare tumors of the breast and since their prognosis
differs from conventional ductal carcinomas, cytological
recognition of these entities is important. We have not only
described the specific cytological features of these rare
tumors but also the features which can cause diagnostic
confusion of these entities with ductal carcinoma.
7. DOES HPV TESTING HELP WHEN HIGH-GRADE
CYTOLOGY IS NOT CONFIRMED AT
COLPOSCOY? (BEST PAPER AWARD). Anshu,
Amanda Herbert, Gillian Holdsworth, Hilda
Dunsmore, Ali Kubba. CYTOCON 2008, Annual
Conference of Indian Academy of Cytologists,
Ahmedabad, 15-16 Nov 2008.
Introduction : At Guy’s and St Thomas’ NHS Foundation
Trust(GSTFT), high risk HPV(HRHPV) testing with Hybrid
Capture 2(HC2) is carried out during post-colposcopic
follow-up of women with high-grade dyskaryosis or
‘bordeline, high-grade not excluded’ cytology found not to
have at least CIN2. The aim of this study was to find out
whether HPV testing helped with the clinical management
of these non-concordant cases.
Material and Methods : Cases comprise 98 non-concordant
cases among 627 cases in which HC2 tests were conducted
at the Colposcopy Unit at Guy’s Hospital from September
2006 to September 2007. In these women, HC2 was carried
out because initial colposcopy did not confirm a high-grade
84
dyskaryosis or ‘borderline, high-grade not excluded’ cytology
report. The screening histories of these 98 women were
retrived and colposcopy, cytology, biopsies and HC2
results were recorded. These were analyzed according to
their final management protocols and outcomes and their
original slides were reviewed.
Results : Of the 98 cases, the index smear was high-grade
dyskaryosis in 94, “bordeline, high grade not excluded’ in
four. Of 94 high-grade reports, eight had been reported as
mildmoderate dyskaryosis, 20 as ‘ungraded dyskaryosis,
probably high-grade’, 42 as moderate dyskaryosis and 24
as severe dyskaryosis or?glandular neoplasia. 50 were
positive for HC2 and 48 were negative.
Slides from 93 cases were reviewed. These were
reviewed as benign (4-tubal metaplasia, tubo-endometrioid
metaplasia, squamous metaplasia and reactive), borderline
change in glandular cells(1), atypical immature metaplasia
(24), ‘borderline, high-grade not excluded’ (3), mild
dyskaryosis or borderline (13). High-grade dyskaryosis was
confirmed on review in 33.
At least CIN2 was found in subsequent biopsies
of 20 women. Eighteen were HC2 positive. In 35 cases, the
outcome was considered more likely to be potentially
reversible low-grade disease. Of these, 21 were HC2 positive
and 14 negative. Excisional treatment has been avoided in
all these women, at least in the short term, but 21 remain on
colposcopy follow-up, either because of persistent low-grade
changes or positive HC2, while 14 have been discharged to
cytological surveillance.
Conclusion : HC2 adds a useful parameter to cytology
review in management of these women but is rarely used
on its own to decide treatment. The whole process of slide
review and HC2 testing allows a high proportion of these
women to avoid ablative or excisional treatment. However,
clinical judgement is needed to decide management of
women with positive HC2 in whom no lesion is found,
especially when previous high-grade cytology is confirmed
on review. HC2 proved to be useful in detecting persistent
disease in women previously treated for high-grade CIN.
8. PREVALENCE, TREND AND CO-INFECTION
OF INFECTIOUS DISEASE MARKERS IN
BLOOD DONORS. NS Ingole, A Thakre, D Joshi,
N Gangane. Transcon, SGPGI Lucknow, 5-7 Dec 2008
Introduction : Transfusion trasmitted diseases (TTD) are a
major challenge to transfusion services all over the world.
The problem of TTD is directly proportional to the
prevalence of the infection in blood donor community.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
Aim : The aim of the study was to find out the prevalence,
trend and correlation between HIV, HBsAg, HCV and
VDRL positivity in the blood donor population in Wardha
district.
Materials and Methods : Study was undertaken at Kasturba
Hospital, Sevagram which is a tertiary care hospital catering
health services to the patients of central provinces of
Maharashtra. Data was obtained from blood bank registry
of TTD positive donors at MGIMS, Sevagram. All such
cases between the periof of 1st January 2001 to June 2007
were selected. The screening for anti HIV I and II, HBsAg,
and anti-HCV was done by ELISA. VDRL testing was done
by Rapid Plasma Reagin test marketed by Tulip diagnostics.
Results : The percent prevelence rate of HIV, HBsAg, HCV
and VDRL reactivity was found to be 1.1, 2.3, 0.87 and 0.84
respectively amongst total 26,603 donors held during this
period. The statistical analysis of co-occurrence of TTD
markers showed highly significant positive correllation of
HIV with VDRL but not with HBsAg and HCV. There was
significant decrease in the prevalence of HBsAg from 2001
to 2005 (3.06 to 1.7) but it again increased in the last two
years (2.14 and 2.94).
Conclusion : In spite of rigid donor selection criteria and
screening of TTD markers, there remains some risk of
post transfusion infection, hence transfusion of blood or
its products should be done when atmost indicated.
9. A PILOT OF HPV TESTING FOR TRIAGE OF
LOW-GRADE CYTOLOGY AND MANAGEMENT
OF DISCORDANCE IN A COLPOSCOPY CLINIC
SETTING. Eva Lysova1, Anshu2,4, Tamara Kubba3,
Ruhi Jawad1, Hilda Dunsmore2, Amanda Herbert2,
Gillian Holdsworth1, Aggie Jokhan2, Michael Kidd2,
Ali Kubba2. Annual Scientific meeting, Birmingham,
10-11 April 2008.
Aims : To use hybrid 2 (HC2) for HPV triage in colposcopy
(i)to allow more women with lowgrade cytology to be returned
to cytological surveillance and (ii) improve the management
of women with non-concordant cytology/colposcopy.
Methods : HC2 testing was carried out on residual material
in ThinPrep vials after obtaining consent for the tests to
be carried out. New referrals with-low grade cytological
abnormalities and cases in which high-grade cytology was
not confirmed.
Results : Results are currently available on 374 women
referred with mild dyskaryosis (most were referred on
second occurrence) and 131 with borderline change. Of 505
85
women, HC2 was negative in 38.2%. In women with negative
HC2, management was altered by the test result in 29%
(67 of 231 women) who were returned to cytological
surveillance. In the non-concordance group, CIN2 or worse
was not confirmed in 81 women originally referred for
investigation of high-grade cytology. Of these, 46.9% were
HC2 negative. HC2 was more likely to negative in women
referred for moderate or ungraded dyskaryosis (34.6%)
compared with severe dyskaryosis or worse (12.4%). HC2
results provided a useful parameter in these cases alongside
slide review at multidisciplinary meetings.
Conclusion : Repeat colposcopy could be avoided in women
with low-grade cytology if their HPV status is known. HC2
added a useful parameter to the management of women
with highgrade cytology when not confirmed at colposcopy.
10. AUDIT OF INVASIVE CERVICAL CANCER
DURING THE INTRODUCTION OF ORGANIZED
SCREENING : HOW INTERVAL CANCERS
BECAME RELATIVELY MORE FREQUENT
WHILE THEIR INCIDENCE DECLINED. A
Herbert1, Anshu1,2, S Gupta2, M Gregory3 and N
Singh3,1Guy’s & St Thomas’. 47th Annual Scientific
Meeting, Dublin, 7-10 Sep. 2008.
Introduction : A 12-year study of invasive cervical cancer
was analysed to investigate the significance of screen-detected
cancers defined in clinical terms, the reasons why screening
does not prevent all cancers and to provide a baseline for
current audits.
Methods : A database of 382 invasive cancers diagnosed
between 1985 and 1996 was re-examined to analyse screen-
detected cancers and interval cancers in terms of four
3-year periods, age band, histological type and stage of
cancer. Incidence was calculated for the local population
of total women and, for the more recent years in which the
data were available, for previously screened and unscreened
women eligible for screening.
Results : There was a significant fall in symptomatic
cancers per 100 000 total female population form 13.0 in
1985-1987 to 6.4 in 1994-1996 (P = 0.00005) while screen-
detected cancers, both fully invasive and microinvasive,
became relatively more frequent (P=0.002). Interval cancers
increased as a proportion of all cancers from 34.1% in 1985-
1987 to 48.6% in 1994-1996 and showed a peak during the
third period of the study (1991-1993). Incidence among
eligible women aged 25-64 years screened within 5 years
fell in 1994-1996, when the overall incidence in SSWH
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
was the same as for England as a whole (10.4/100 000),
and could provide a baseline for current audits. Interval
cancers were significantly more likely to be seen in younger
age bands and in screen-detected cancers, especially
when microinvasive. Factors other than or in addition to
previous negative smears were recorded in 52.8% of
interval cancers and showed the importance of accurate
cytology, appropriate follow-up, prompt investigation and
effective treatment.
Conclusion : Interval cancers should be considered in
relation to the number of eligible women screened during
that period of time and not as a proportion of all cancers.
They were more likely to be screen-detected early cancers
in young women.
11. A N A L Y S I S OF PREDICTIVE VALUE OF
CYTOLOGIC FEATURES IN DIAGNOSIS OF
PAPILLARY CARCINOMA OF THYROID. Anshu,
Yvonne Zonunfawni, Ranjeeta Sougijam, Nitin
Gangane. APCON 2008, Annual National Conference
of Indian Association of Pathologists & Microbiologists,
Kattankulathur, Chennai, 15-17 Dec 2008.
Introduction : Papillary carcinoma is routinely diagnosed
on the basis of its characteristic features on fine needle
aspiration cytology(FNAC). However these cytologic features
are not unique to papillary carcinoma and are also seen in
other thyroid lesions. Further compounding the diagnostic
dilemma is the variable cytologic picture seen in variants
of papillary carcinoma. We followed up cases of papillary
carcinoma on cytology and compared it with their histologic
outcome. Further, each cytologic feature was statistically
analyzed to see how useful it was in predicting the
diagnosis of papillary carcinoma of the thyroid.
Material and Methods : 75 consecutive cases diagnosed as
either definite or probable cases of papillary carcinoma on
FNAC were studied. Histologic follow-up was available in
36 cases. We reviewed the Papanicolaou and Giemsa stained
smears of all the cases. The smears were graded on the
basis of their architectural features (cellularity, presence of
papillary fragments, monolayered sheets, single cells,
microfollicles, cellular swirls), cytoplasmic features (presence
of oxyphilia, vacuoles, fireflares), neclear features (presence
of nuclear grooves, intranuclear cytoplasmic inclusions,
pleomorphism, dusty chromatin, micronucleoli, nuclear
overlapping) and background changes (presence of thick
colloid, psammoma bodies, metaplastic cells, giant cells,
elongated cells, tall cells, lymphocytes and cyst macrophages).
The usefulness of each feature in diagnosing papillary
carcinoma on FNAC was statistically analyzed.
86
Results : Of the 18 cases where a definite diagnosis of
papillary carcinoma was offered on FNAC, 13(72.2%) were
confirmed on histology. Of the 5 false positive cases, 3
were hashimoto’s thyroiditis and 2 were colloid goiter with
cystic change. Of the 18 cases where a probable diagnosis
of papillary carcinoma was given, only 8 (44.4%) were
confirmed on surgery. The 10 false positive cases were
Hashimoto’s thyroiditis (1), hyalinizing trabecular adenoma
(3) and multinodular goiter with hyperplasis (6). The features
which helped most in diagnosis of papillary carcinoma on
FNAC were the combined presence of papillary fragments,
intranuclear inclusions, metaplastic cells and thick colloid.
Cytology was not effective in correctly predicting variants
of papillary carcinoma including tall cell varient and
columnar variant.
12. L E U K O C Y T E ALKALINE PHOSPHATASE
ACTIVITY IN NON-HAEMATOLOGICAL
MALIGNANCIES AND ITS UTILITY AS A
PROBABLE PREDICTOR OF METASTASIS
WITH EMPHASIS ON BREAST AND COLON
CANCER. Ingole NS, Deshmukh S, Dhumal D,
Gangane N. APCON 2008, Annual National
Conference of Indian Association of Pathologists and
Microbiologists, Kattankulathur, Chennai,15-17 Dec 2008
Introduction : Human alkaline phosphatase has been
demonstrated in different tissues of the body like liver,
pancreas, thyroid, bone marrow and peripheral blood
leukocytes. Assessment of LAP activity has many clinical
applications. It is found to be altered in physiological as
well as pathological states including haematological and
non-haematological malignancies.
Aims and objectives :
1. To establish the normal range of LAP score in healthy
controls in our laboratory.
2. To find out the LAP score in patients of non
haematological malignancies at the time of diagnosis.
3. To evaluate the differences in LAP score between
non-metastatic and metastatic cancer patients at the
time of diagnosis.
Materials and Methods : The ‘study’ group included total
100 patients with histologically or cytologically proven
non-haematological malignancies of different sites and
organs with particular emphasis on breast and colon
cancer. The histochemical staining technique used for
LAP scoring was by Rutenberg et al, (1965).
Observations :
ΠLAP score in the patients with non-haematological
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
 malignancies is lowere than in the control group
irrespective of the organ or site.
ΠIrrespective of the mode of treatment, LAP score
gradually increased with treatment of malignancy.
ΠMetastatic cases showed higher LAP values than in
non-metastatic patients. With metastasis, there is
marked increase in LAP score as compared to regular
values for that patient.
13. I N C R E A S I N G THROMBOCYTOPENIA AS
A EARLY MARKER OF SEPTICEMIA IN BURN
CASES. A Gupta, V Rao, C Nalinimohan, N Gangane.
APCON 2008, Annual National Conference of Indian
Association of Pathologists and Microbiologists,
Kattankulathur, Chennai, 15-17 Dec 2008.
Introduction : Infection is the most common, as well as
serious complication of a major burn injury. Sepsis accounts
for 50-60% of all deaths in burn patients today, despite
improvements in antimicrobial therapies. Diagnosis of
sepsis in burn patients can be difficult because it needs to
be distinguished from usual hyperdynamic, hyperthermic,
hypermetabolic post burn state. Fever spikes are not
proportional to degree of infection in such cases. Again
cultures are reported to be negative in many cases.
Aim :
1. To study changes in platelet count and increasing
thrombocytopenia if any, in cases of burn cases
2. To study the relationship between increasing
thrombocytopenia and incidence of septicemia in
these patients.
Materials and Methods : The current observational study
was carried out in the Dept.of Pathology, MGIMS, Sevagram
after receiving approval from institutional ethical committee.
All burn patients (Total of 498 patients) admitted in burn
wards between Jan ‘06 - May’08 were the study cases. After
taking informed consent complete blood count and
peripheral smear examination of all cases was done at regular
intervals. If sepsis was suspected, relevant investigations
were carried out to ascertain the diagnosis including
criteria given by Astone et al.
Results : The analysis of finding confirms that increasing
thrombocytopenia is an early indication of septicemia in
burn patients. Other related findings and their significance
will be presented.
14. CLINICOPATHOLOGICAL CHARACTERISTICS
OF INFILTRATING DUCT CARCINOMA
OF BREAST WITH MICROPAPILLARY
87
CARCINOMA COMPONENT. S Chaukade, SM
Sharma, Y Bhiogade, N Gangane. APCON 2008,
Annual National Conference of Indian Association of
Pathologists and Microbiologists, Kattankulathur,
Chennai, 15-17 Dec 2008.
Introduction : Micropapillary carcinomas(MPC) are described
as carcinomas with predominant papillary clusters, devoid
of fibrovascular core, surrounded by empty lacunar speces.
They have been reported to be associated with high incidence
of axillary lymph node metastases and poor outcome.
This study was carried out to determine if
infiltrating duct carcinomas (IDC) with micropapillary
component are prognostically different from tumors
without micropapillary component.
Aims and Objectives : This study is being carried out
(a) to determine the percentage of cases of IDC which
have a micropapillary component and
(b) to compare clinicopathological features of IDC of
breast showing micropapillary component with cases
of IDC without micropapillary component
Materials and Methods : All cases of IDC reported between
2000-2007 were retrieved from Surgical Pathology files.
Clinical and gross findings were recorded. Slides of all
cases were reviewed. Tumors were classified into a) those
with micropapillary component and b) those without
micropapillary component. Tumors with MPC were also
assessed to percentage of this component. Both the groups
were compared using Chi square test and linear regression
analysis to investigate the possible relationship between
their clinicopathological parameters.
Results : Of the 361 cases of IDC diagnosed in 8 years, 43
(11.9%) showed a micropapillary component. 60.4% of MPC
tumours were larger than 5 cm in size. None of the MPC
tumours were grade 1 tumours. Tumours with MPC had a
significantly higher DCIS component, number of metastatic
lymph nodes and lymphovascular invasion compared to
non-MPC tumours. Significantly higher proportions of
MPC tumours were of higher stage compared to non-MPC
tumours.
15. MAMMARY FIBROMATOSIS AS A MIMIC OF
CARCINOMA ON FINE NEEDLE ASPIRATION
CYTOLOGY. Anshu, N Shende, Y Bhiogade, N
Gangane. APCON 2008, Annual National Conference
of Indian Association of Pathologists and
Microbiologists, Kattankulathur, Chennai, 15-17 Dec
2008.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
Introduction : Smears obtained from aspiration of
mammary fibromatosis have classically been described as
cellular. They have shown presence of numerous stromal
cells without atypia in a background of granular amorphous
material, with presence of collagen fragments
Case Report : We encountered a case of fibromatosis of the
breast in a 33 year old female where the cytologic aspirates
were dominated by ductal cells with mild atypia. This led
to an erroneous diagnosis of low grade malignancy.
Conclusions : Careful sampling and multiple aspirations may
help in reaching a correct diagnosis in cases of fibromatosis
where stromal cells predominate. However in the absence of
these characteristic findings; and a presence of predominance
of epithelial elements, it may be wise to recommend tissue
confirmation, to avoid mutilating surgery.
PAEDIATRICS
1. Amar Taksande, STUDY OF RISK FACTOR FOR
CONGENITAL HEART DISEASES IN CHILDREN
AT RURAL HOSPITAL OF CENTRAL INDIA.
(International Saudi Heart Association Conference
SHA, RIYADH 11-14 Feb. 2008).
Objectives : To determine the risk factor for the development
of congenital heart disease (CHD)in children at Rural
hospital of Central India.
Settings : Study was conducted in the Department of
Pediatric, MGIMS, Sevagram, Maharashtra, India.
Design : Hospital based case control study conducted from
March 2004 to April 2007.
Methods : The children up to twelve year of age with clinical
suspicion of congenital heart disease were subjected to
chest x-ray and electrocardiography, and final diagnosis
was confirmed by echocardiography (n=209) as cases. The
control group (n=418) were randomly selected from children
without congenital heart disease who were admitted during
the same period. The etiological factors like environmental,
tertogens, infections, drugs, and maternal factors were
analyzed by using EPI 6 version.
Results : In cases group, 56% were male and 44% female
children, 82% cases presented at age of less than 5 years
and 18% after 5 year of age. Exposure to smoking
(OR=10.45, 95% CI 2.13; 69.71), tobacco intake by mother
(OR=8.28, 95% CI 1.62; 56.93) and family history of
congenital heart disease (OR=7.21, 95% cI 1.48; 35.01) were
the significant risk factor present in cases.
88
Conclusion : The risk factors which are present in congenital
heart disease child are exposure to smoking and tobacco
intake by mother, family history of congenital heart disease,
antenatal infection in 1st trimester and history of diabetic
mother.
2. Amar Taksande. PREVALENCE OF HYPERTENSION
IN SCHOOL GOING CHILDREN IN RURAL
AREA OF WARDHA DISTRICT, MS (Annual
conference of International Medical Science Academy,
12-13 Oct. 2008, DUBAI).
Objectives : To study the blood pressure level in the children
at rural area and its relationship with the anthropometric
indices. Also to know the prevalence of hypertension in
the school children in rural areas of Wardha Districts of
Central India.
Material and Methods : A prospective, cross-sectional study
was carried out from November 2006 to December 2007
on school children between the ages of 6-17 years, drawn
from 8 different schools in the rural areas of Wardha District.
The height, weight, systolic and diastolic blood pressure
were recorded for both sexes followed by complete clinical
examination with special stress on cardiovascular system.
Hypertension was defined as the arterial BP above the 95th
percentile with reference to age, sex and height. Coefficient
correlation tests were employed to see the relation between
blood pressure (BP) and anthropometric variables.
Result : Of 2643 school children, 1416 were girls and 1227
boys with a male to female ratio of 1:1.16. In boys, SBP &
DBP increased with age groups except at a) 17 year of age,
slight declination in SBP i.e. -0.09 and b) -1.29 declinations
in DBP at 16 year. In girls, SBP and DBP also increases with
age groups except at a) 11 year of age, slight declination in
SBP i.e. -0.09 and b) -0.24 declinations in DBP at 11 year
age. Correlation coefficient analysis showed positive and
significant correlation of age, height, weight, and body
mass index with each SBP and DBP. The prevalence of
hypertension was 6.73% (i.e. 3.90% for systolic HT and
2.83% for diastolic HT).
Conclusion : We recommend that the need for regular
check up of BP in the children to find out the hidden
cases of hypertension in children.
PHARMACOLOGY
1. PAPERS PRESENTED IN 41ST ANNUAL
CONFERENCE OF INDIAN PHARMACOLOGICAL
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
 SOCIETY & INTERNATIONAL CONFERENCE
ON TRANSLATIONAL PHARMACOLOGY 2008
AIIMS ANSARI NAGAR, NEW DELHI. Comparative
study of chlorpromazine and resperidone on positive
and negative symptoms of schizophrenia. RK Gupta,
AP Singam.
Introduction : Schizophrenia is a devastating mental
disease that affecting human population worldwide with
prevalence of about 1%. Typical and atypical antipsychotics
are mainly used to treat schizophrenia. The typical
antipsychotic have autonomic side effects and EPS but
the drugs are cheaper and was found to more effective in
treating positive symptoms. Atypical antipsychotic takes
care of both positive and negative symptoms. Still there is
need for research in pharmacological intervention to treat
symptoms of the disease both positive and negative. Therefore
it was decided to conduct the study to assess the efficacy of
typical (chlorpromazine) I and atypical antipsychotic
(Resperidone).
Material and Method : It was a longitudinal single blind
prospective study 100 patients attending Psychiatry OPD
at KHS Sevagram, with Schizophrenia were selected (50
receiving Chlorpromazine and 50 receiving Risperidone).
They were interviewed and were administered test drug &
were followed up every 3 monthly for 1 year. Scoring was
done according to PANSS (Positive and Negative Symptom
Scale for Schizophrenia).
Results : Typical antipsychotics are better to treat positive
symptoms but not much effective in treating negative
symptoms of Schizophrenia. Atypical antipsychotics take
care of both positive and negative symptoms. Compliance
is better with atypicals
Discussion and Conclusion : After assessing the patient,
whether he has predominant positive or negative symptoms
the psychiatrist can decide either of typical or atypical
antipsychotic and this might be helpful for the better
treatment of the patient.
2. EFFECTS OF PANCHAGAVYA GHRITA (PG) ON
PARACETAMOL INDUCED HEPATOTOXICITY
IN ALBINO RATS. DD Gosavi1, J Premendran1,
D Sachdev1.
Introduction : Sushtrut Samhita mentions use of
Panchagavya Ghrita (PG) in the treatment of mania,
epilepsy, fever and hepatitis. In an effort to correlate the
ancient knowledge with the modern concepts of reasearch
int he Pharmacology, we decided to study the effects of PG
on paracetamol induced hepatotoxicity in rats.
89
Material and methods : The animals were divided into four
groups of 6 rats each. First two groups received PG in the
dose of 1 (PG1), 2(PG2),) ml per Kg of body weight for
thirty day. Third group received normal saline 2 ml per Kg
orally. The fourth group acted as a standard control and
received LIV 52 2ml/Kg body weight daily. Hepatotoxicity
was induced with Paracetamol 1gm/Kg body weight orally
once. Blood samples were collected and analyzed for liver
enzymes and bilirubin. Liver was separated and estimated
for Anti-oxidants (AO) in the liver tissue.
Results : PG prevented the increase in the liver enzymes
like AST, ALT and alkaline phosphatase produced by the
paracetamol. There was no significant effect on bilirubin.
It also has AO activity in vivo as shown by the changes in the
MDA, GSH and Catalase leveis.
Conclusion : Hepatoprotective action of PG can be due to
AO activity of PG. PG is a mixture of cow milk, ghee, urine,
dung, and curd milk. Cow milk contains minerals and vita-
mins. Cow urine contains minerals, urea, vitamins, enzymes,
and a large amount of free volatile acids with AO activity.
Of these which component is responsible for AO action is
difficult to comment.
3. EFFECT OF PANCHAGAVYA GHRUTA ON SOME
PARAMATERS IN ALBINO RATS. DD Gosavi, D
Sachdev, J Premendran.
Introduction : Sushrut samhita an authentic ayurvedic
text mentions the use of Panchagavya Ghruta (PG) in the
treatment of mania, epilepsy, fever and hepatitis. In an
effort to correlate the ancient knowledge with the moder
concepts of research in the pharmacology, we decided
to study the effects of Panchagavya Ghruta on some
parameters including anticonvulsant activity in rats.
Material and methods : For all the experiments the animals
were divided into three groups of 10 rats each. First three
groups received Panchagavya Ghruta in the dose of 1(PG1),
2(PG2), ml per Kg of body weight respectively and the fourth
group received normal saline 2ml per Kg orally twice daily
(9am-9pm) for 30 days. 1. Maximal electroshock induced
convulsions : After screening convulsions were induced by
maximal electroshock method. A current of 150mA was
delivered for 0.2sec using Techno convulsiometer. 2.
Spontaneous motor activity (SMA) : animals were screened
for SMA using Actophotometer. Animals were allowed to
adjust to the test chamber of the instrument for 30 minutes
and then activity was counted using the digital counter
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
for 5 minutes. 3. Pentobarbitone induced sleep time : Test
and control animals both were injected with injection
Pentobarbitone in the dose of 40-mg/Kg body weight. The
animals were observed for loss and recovery of righting
reflex for the calculation of duration of sleep. 4.
Haloperiodol induced catalepsy : Catalepsy was induced
by inj. Haloperiodol 1mg/kg i.p. and animal assessed with
catalepsy scale.
Results : In our study to study the effect of Panchagavya
Ghruta (PG) on some neurological parameters in rats we
found that, 1) PG protected rats from maximal electroshock
induced convulsions 2) had no effect on spontaneous motor
activity as measured by actophotometer. 3) Inhibited the
pentobarbitone induced sleep time in rats while 4) there
was no effect on the general behavior of the rats 5) PG
significantly potentiated the Haloperidol induced catalepsy.
Conclusions : To conclude it can be said that PG offers
protections against the MES induced convulsions without
producing any sedation in rats and also does not effect
the normal behavior of the animals. Potentiation of
catalepsy is an indicator of anti-psycotic action and
further studies are planned in this direction.
The animals were observed for loss and recovery
of righting reflex for the calculation of duration of sleeep
4. haloperidol induced catalepsy: catalepsy was induced
by inj. Haloperidol 1mg/kg i.p. and animal assessed with
catalepsy scale.
Results : In our study to study the effect of Panchagavya
Ghruta (PG) on some neurological parameters in rats we
found that, 1) PG protected rats from maximal electroshock
induced convulsions 2) had no effect on spontaneous motor
activity as measured by actophotometer. 3) Inhibited the
pentobarbitone induced sleep time in rats while 4) there
was no effect on the general behavior of the rats 5) PG
significantly potentiated the Haloperidol induced catalepsy.
Concludions : To conclude it can be said that PG offers
protections against the MES induced convulsions without
producing any sedation in rats and also does not effect the
normal behavior of the animals. Potentiation of catalepsy
is an indicator of anti-psycotic action and further studies
are planned in this direction.
90
4. TITLE : STUDY OF COMBINED EFFECT OF
CALCIUM CHANNEL BLOCKERS WITH
ANTIEPILEPTIC DRUGS IN MAXIMAL ELECTRIC
SHOCK AND PENTYLENETETRAZOL INDUCED
CONVULSIONS. R Brahmane, S Dahat.
Introduction : Present antiepileptic drugs unable to control
seizures effectively. Limitations highlighted need for
developing newer agents for epilepsy.
Materials and Methods : Effect of Phenytoin sodium
15mg/kg, sodium valproate 300mg/kg and carbamazepine
8mg/kg alone and in combination with cinnarizine
30mg/kg, Nimodipine 21mg/kg and Nifedipine 5mg/
kg studied in albinomice i.e. 12 mice in each group.
Seizures were induced by maximal electric shocks (MES)
by using electroconvulsionmeter and by Pentylenetetrazol
(PTZ) induced seizures. Abolition of hind limb tonic
extension was an index of anticonvulsant activity in MES.
Failure to observe even a single episode of tonic spasm for
5 second duration for 1 hour was an index of PTZ seizures.
With this percentage protection calculated. Combined
drugs are compared with antiepileptic drug alone to which
they are combined. For analysis formula of critical ratio
applied.
Results : In MES Seizures augmented effects obtained when
Cinnarizine and Nifedipine added to phenytoin sodium i.e.
66.66%; Nimodipine added to Carbamazepine i.e. 66.66%;
Cinnarizine and Nimodipine are combined with sodium
valproate i.e. 100%. In PTZ induced seizures augmented effects
obtained when Nimodipine combined with phenytoin
sodium i.e. 66.66%; Cinnarizine and Nifedipine combined
with carbamazepine i.e. 66.66%; Nifedipine and
Nimodipine combined with sodium valproate i.e. 100%.
Discussion and Conclusion : Cinnarizine given concurrently
with sodium valproate produces significant protection
against MES seizures. Nimodipine along with sodium
valproate produces significant protection against both MES
and PTZ induced seizures. Nifedipine along with sodium
valproate produces significant protection against PTZ
induced seizures. The results provide potential benefit
of combining calcium channel blockers with sodium
valproate in refractory epilepsy.
J MGIMS, March 2009, Vol 14, No (i), 64 - 90
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