Vol. 4 July 1997

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.i- / Vol. 4 1\O. I July 1997 1I JULY T997

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MARINE MEDICAL SOCIETY :

(RegdF-3611) a tlt" President SurgVADM JC SHARMA VSM t;, I DGMS(NAVY) ,tr Vice Presidents I Surg RADM VK PAHWA SurgRADM HPMUKHERJEEVSM t. CMO WesternNaval Command CommandingOfficer,INHS Asvini I ExecutiveCommittee Surg Cmde NR RAHA VSM Surg Cmde SP MALHOTRA Director INM DMS (P & M) Naval Headquarters

Surg Cmde WP THERGAONKAR Surg Cmde BPS RAWAT VSM CMO EasternNaval Command CMO SouthernNaval Command

Surg Cmde ML GUPTA EXO INHS Asvini Dental Advisor (Navy)

DMS (H&S) Surg Cdr S NANGPAL Naval Headquarters Officer-in-Charge, Schoolof Naval Medicine Surg Cdr AM JOGLEKAR BMO INS Vajrabahu

Secretary Surg Cdr MJ JOHN

Treasurer Surg Cdr KKDUTTA GUPTA -J

Address for Correspondence Secretary MARINE MEDICAL SOCIETY Instituteof Naval Medicine,INHS Asvini Campus, Colaba,Mumbai 400 005. India.

Printed,published and owned by Director GeneralMedical Services(Navy). SenaBhavan, New Delhi I l0 0ll. Printedon his behalfat Typo Graphics,Mumbai 400 103. Editor Surg Cdr S Nangpal,Institute of Naval Medicine, Mumbai 400 005. JOURNAL OF MARINE MEDICAL SOCIETY

VOLUME 4 NUMBER1 tuLY 1997

PublishedBiannually

Chief Editor Surg RADM VK PAHWA

Editor Surg Cdr S NANGPAL

Co-Editors Surg Cdr AC PRAVEEN KUMAR Surg Cdr GIRISH GUPTA

Sub Editors Naval Headquarters Surg Cdr A AHUJA NM Western Naval Command Surg Lt Cdr VRG PATNAIK EasternNaval Command Surg Cdr D D'COSTA Southern Naval Command Surg Cdr(Mrs) N KANAN VSM

Editorial Advisory Board Surg Cmde (D) ML GUPTA Brig DINESH PRASAD Surg Capt RAMESH KUMAR Surg Capt RT AWASTHI i -r Surg Cdr MJ JOHN I Surg Cdr KK DUTTA GUPTA

Addressfor Correspondence Editor JOURNAL OF MARINE MEDICAL SOCIETY Instituteof Naval Medicine,INHS Asvini Campus, Colaba.Mumbai 400 005. JOURNAL OF MARINE MEDICAL SOCIETY

CONTENTS

President's Message

From the Editor's Desk Surg Cdr S Nangpal REVIEWARTICLE Drugs and Therapy in Hyperbaric Environment Surg Cdr S NANGPAL, Surg Cdr MJ JOHN, Surg Cdr KK DUTTA GUPTA a n UPDATE ARTICLE s HumanImmuno Deficiency Virus (HIV) andTubercular Infection - A SeriousChallenge to HealthCare System 9 il Surg CmdeNR RAHA, VSM,Surg Cdr KK DUTTA GUPTA tl ORIGINAL ARTICLES n Evaluationof HyperbaricOxygen as Adjunctive Therapy in DiabeticFoot 12 p Surg Lt Cdr VRGPATNAIK, Surg Cdr PSLAMBA, Surg Cdr S IIIANGPAL,Surg Cdr MJ JOHN, Surg 1 CdTKK DUTTA GUPTA I lr Developmentof IndigenousCompressor Driven Atomizer for CockroachControl on BoardShips l6 ir Surg Lt J SNDHAR, SurgLt Cdr A CHATTEMEE,Surg Cdr KK DUTTA GUPTA tl MicrocoolingSystem for NavalApplication 20 r DT KRISHNAS HEGDE, HANSH S RAO,KOTRESH RM, DTI-IIZAR MATHEW S u ProblemWounds and Hyperbaric Oxygen (HBO) Therapy 26 F Dr SURESHPUROHIT, Surg Lt Cdr GD BHANOT,Surg Lt HBSCHAUDHRY, Surg Lt G KRISHNAN p PsychologicalAspects of UnderwaterEndeavors 29 li Surg Cdr MJ JOHN, Surg Cdr S NANGPAL,Surg Cdr VSSRRYALI, Surg Cdr KK DUTTA GUPTA v CarcinomaProstate : Profilesof Presentationand Modalities of Management 32 n Surg Cdr B FANTHOME,Surg Lt Cdr S MNJAN, Surg Cdr YK SAXENA,VSM h AccidentalPoisonings in Children 35 t( SSMATHAI, KS BAWA,G GUPTA,SR DAS, RN MEHNSHI tI tl EMERGING TRENDS n, Newer Prognostic Indicators in Breast Carcinoma 38 Lt Col S BHATTACHARYA (1 Emerging Trends in Alcohol RelatedDisorders and the Navy ' 40 p Surg Cdr VSSRRYALI, Surg Cdr MJ JOHN, Surg Lcdr A TNPATHI, Surg Lcdr KK MISHRA 'v t Recent Developnents in the Managementof Benign ProstaticHyperplasia 43 Surg Cdr VK SAXENA, VSM,Lt Col D BAWRq Current recommendation for prcventive ther- NGOs' assistancein achievingbetter drug compli- apy .' In USA, theCenter for DiseaseControl (CDC) ance and drug distribution through establishing a recommendsthat persons with HIV infectionshould propermachinery of co-operationand collaboration be given a fuberculinskin test with five tuberculin amongthe Govemmentand NGOs, as most of the units of purified protein derivative.In absenceof casesof tuberculosiswith HIV infection will have activetubercular infection, Isoniazid for 12 months to be treatedas outdoorpatients [8]. duration was recommendedfor all HIV infected person showing more than five mm induration. CONCLUSION WHO and IntemationalUnion againstTuberculosis There is a rapidly increasingincidence of TB- and Lung Disease(IUATLD) issuedsimilar guide- HIV co-infection. With the spread of HIV, the line for resourcepoor countries[6]. epidemiologicalsituation of tuberculosiswill dete- Management of cases riorate.With nearly halfof Indian population having focii oftubercular infection on one hand and a rapid Regimenscontaining Thiacetazoneare associ- rise in the incidenceof HIV infection on the other, ated with high rates of side effects, increasedtreat- complicatedby varioussocio economic factors such and relapse rate in HIV infected per- ment failure as poor quality of life, over crowding, illiteracy, sons.Similarly streptomycinshould be avoidedbe- largefamilies, lack of awareness,inadequate health cause of risk of transmission of blood bome 9 care facilities etc., the picture is gloomy unless infection. HIV positive patientswith tuberculosis adequatemeasures are taken at the earliest[9]. treatedwith Rifampicin containingshort course che- motherapyhave similar responseto HIV negative In a climate of economicrestraint and rampant t2 patientsand have similarly low early relapserate. HIV infection,intersectoral co-ordination, innova- The simplest regimen will be three times weekly tive ideas and further researchare essentialfor the Isoniazid,Rifampicin, Pyrazinamide and Ethambu- future developmentof Tuberculosiscontrol pro- lol. In USA, HIV infectedpatients taking supervised gramme. t6 intermittenttherapy had more favourablesurvival REFERENCES than those on daily self administeredmedication. Hencedirectly observed therapy (DOT) hasbeen the L World Health Organisation.Ninth General Programmeof 20 work covering the period 1996-2001. Geneva I 994 9. single most effective interventionand has contrib- ; uted to better tuberculosiscontrol in recentyears. 2. Kevin M Decock,David Wilkinson. Tuberculosiscontrol in resourcepoor countries. Altemative approaches in the eraof 26 Peripheralhealth functionariessuch as multipur- HIV. Lancet 1995:364 : 6'/5-77. M poseworkers, anganwadi worker, traineddais, vil- 3. Cofram SR, Vinay Kumar, Stanley L Robbers.Robbins lage healthguide etc.,could be usedfor DOT 29 [7,8]. PathologicBasis of disease5'n edition. WB SaundersCom- Integration of services at district level .' Patients pany,USA lS94 I 325-30. with HIV associatedtuberculosis may requiretreat- 4. Philip C Hopewell.Pulmonary manifestations of HIV infec- ment for other complicationsof HIV diseasethat tion in Cecil text book ofmedicine ed. BennettCJ and PIum tuberculosis control programmes are not accus- F, WB SaundersCornpany, Philadelphia 1996; 1859-65. J) tomed to dealingwith. Thereforetuberculosis con- 5. Kevin M Decock. Screeningfor tuberculosisand HIV in trol programme will have to integrate activities at resourcepoor countdes.Lancet I 995 ;345 : 873. the district level into other servicescatering to the 6. Kevin M Decock,Alison Grant,John DH, Porter.Preventive needofthe population[8]. therapy for tuberculosisin HIV infected persons;intema- 38 tional recommendationsresearch and practice. Lancet I 995; Information, Education and Communication 345 : 833-35. (IEC) : IEC activities should be augmentedso that 7. Dale I Morse. Directly observedtherapy lbr Tuberculosis '40 proper messagesreach the targetgroups and to those BMJ 1996;312:719-20. who are put on treatmentso that they continue their 8. Rohit S, Dey LBS. IndianNational tuberculosis programme treatmentfor entireduration. 43 - Revisedstrategy Ind J Tub 1995;42 : 95-100. Co-operation of Non Governmental Organisa- 9. MukherjeeAK. Tuberculosiscontrol programmein India - tion (NGO) .' Effort should be made to harness Progressand prospects.Ind J Tub 1995;42 :75-85.

Jour.Marine Medical Society, July 1997,Vol.4, No. I I] hasbe Original Articles such i EVALUATION OF HYPERBARICOXYGEN AS depen ADJUNCTIVETHERAPY IN DIABETIC HBO'I FOOT NOITNE healin SurgLt CdR VRG PATNAIK *, SurgCdr PSLAMBA**, level SurgCdr S NANGPAL***, SurgCdr MJ JOHN+, forma SurgCdr KKDUTTAGUPTA# bettet MAT ABSTRACT TT groul Diabetic foot is one of the most devastatinglong term complicationof diabetesmellitus. Hyperbaric oxygen therapy ([IBOT) is used in its treatment basedon physico-chemicaland haemodynamicconsiderations. To assessits role total a study was conducted at the Institute of Naval Medicine in an age matched group.30 patients were evaluated in the p a randomized study. Study group consistedof 13 males and two females(Mean age 63.1 + 8.74) . Control group TI consistedof three femalesand 12 males (mean age 67 + 9.81). Both groups were given standard antibiotic and fema surgical care. Diabetic foot was graded as per Wagener's classification.Study group was pressurisedto 2.8 ATA using 1007o oxygen for one hour. Controls were pressurisedto the samedepth but using 7.57ooxygen and 92.5 5l-7. 7o nitrogen asthe breathing mixture . The overall outcomewas significantly better in the study group as compared groul to controls (p < 0.01).86.67oin the study group either healedor improved comparedto 46.7Toin controls. 53.97o age! of Wagener's grade I-III in the control group either healedor improved. In comparison, significantly more (p to fe < 0.05) (92,3o/onumber of grade I-III caseseither healedor improved in the study group. In this study no patient 87: experiencedany complication of HBOT . the I KEY WORDS : HBO, Diabetic Foot. stud' recol

INTRODUCTION plicatesthe diabeticfoot. T presl The rationaleof employing HBOT in diabetic T\ iabetes mellitus is accompaniedby long 92.5 term micro-vascular, neurological foot is basedon physico-chemicaland haemody- I I and of0. L, macro-vascularcomplications . Long term namic considerations.When administeredat pression including diabetic foot have caused sures greater than one atmosphere(ATA), oxygen complications ing t the most morbidity and mortality sincethe introduc- acts as a therapeuticagent. HBOT improves blood tion of Insulin therapy.The preventionand amelio- supply,can reduce ischaemic damage to nervesand T ration of thesecomplications have been major goals can reduceoedema by upto 50%oin post ischaemic 2.8, med of recentresearch[1]. muscle and thus acts as a medical fasciotomy. It reducesplatelet adhesionto capillary walls after Dlabetrctoot ls oelrneoas a compromlseoloot .. _,._ _ .. B l- ischaemicor traumatic insult' mitigating the "no duetoneuropathy,macro-vasculardiseas.orinf. stud' RBCflexibilitv is doubled tion occuringsingly or in combination.tt i, on. li [2]' woul f:1",1, l$iTenonrreatments Leucocvtekilling of themost devastating complications of diabetesthai [3]' 11 1Tl' ]: tungiis greatlyenhanced It R leadstosuffering,disabiliry,lossoftimefro-*o;k, [4]' !T]tli,il9.,some raising02 tensionsin infected tient hospitalisationandagreatexpensetothepatientani ::::]l*:tly^by the andl to rhecommunity. These foot lesionsr"rutt rrorn :li,:|":::.t:Tal'whenthereisreturntonormalis enhancedas their intra cel- pre I peripherarvascular disease leading to rnua"quui" Illltl,t,ll-!:t^"^?tes arepartlv oxvgen depend- €xan blood supply,and from neuropathyresuttlng in re-- file, enti:t:l}*Tf3:*anisms [5-9.|.HBOT improves antibiotic efficiency. It ducedsensltrvltv oI tneloot. lnrectron runner com- bioti isms rGraded Specialist in Marine Medicine, Institute of Naval Medicine, Mumbai. +tEndocrinologist and Classified Specialist in Medicine, INHS Asvini, Colaba,Mumbai. **iClassified Specialistin Marine Medicine and Officer-in-chargeSchool of Naval Medicine, INM T Mumbai. +ClassifiedSpecialist in Marine Medicine,Institute of Naval Medicine,Mumbai. ++ClassifiedSpecialist in Preventive and or n( SocialMedicine, Instituteof Naval Medicine,Mumbai. Jour t2 Jour. Marine Medical Society,July 1997, Vol. 4, No. I has been shown that the transportof anti microbials Healed into such as aminoglycosides bacteria is oxygen If complete epidermal closure was achieved at dependent.Extremely important is stimulation by the end of the treatmentor soon afterwords. HBOT of new capillary and collagen formation. normalising tissueoxygen tensionto permit surgery, Improved healing and even bone grafting . It increasestissue If ulcersresponded but did not heal completely. level of superoxide dismutase which counters the These included patients who chose to discontinue formation of free radicalsafter injury, resultingin treatrnent or whose condition became static , yet bettertissue survival [0]. allowednormal activitiesto be resumed. MATERHL AND METHODS No Effect The study was conducted in an age matched If the ulcer made little progress or deteriorated while receiving treatment. erapy group in a randomised prospective procedure. A s role total of 30 volunteer patients rvere included during If after five HBO sittings patients in the srudy ledin the period 1995to 1997. group showed "no effect" the procedure was abon- Foup group doned. c and The study consistedof 13 males and two ATA females.Average age was 63.1 t 8.74 years (range Any controls showing deterioration during treat- t92.5 5l-75 yrs). Fifteen patients comprised the control ment were switched to HBOT so as ethically not to lered group with three females and12 males.The average deny them the adjunctive benefit of this modality. 3.9o/o agewas 67 t 9.81 years(range 45 to 85 years).Male RESULTS re (p to female proportion was 80 : 20 in the control and rtient 87 : l3 in the study group. The facilities available in The resultsofthis study are presentedbelow in a the hyperbaric centre at INM were used for this tabular forum. study which included a monoplaceand a multiplace recompressionchamber. TABLEI Age groups included in the study The control group was subjected to 2.8 ATA pressureand were made to breath 7.5 o/o Age Srudy betic oxygen and 92.5% nitrogen. This ensuredan partial pressre < | ?< ody- 02 Range 45-85 lres- of0.2l ATA atbottom . To avoidhypoxia,compres- Average 67r 9.81 6J.l!8.74 sion and surfacingwere doneusing air asthe breath- Fgen ing medium. lood TABLE2 i group and The study were also subjectedto the same Sexwise distribution of cases :mic 2.8 ATA but used 100% oxygen as the breathing y. It medium. Study after Feinale 3 2 ttno Both groups had a bottom time of one hour. The study and control groups were given standard Male 12 IJ bled wound care, antibiotic cover and insulin. Male : Female proportion 80:20 87:13 gof tl.rt Rigid acceptancecriteria were adopted and pa- cted tients were thoroughly examinedfor HBOT fitness TABLE3 I the and lesionsclassified as per Wagener'scriteria . The Showingresponse to HBOT pre HBO therapy work up included complete ENT cel- Study x2 gnd- examination,chest skiagram, ECG, blood sugarpro- y.It file, pulse oximetry, wound swab culture and anti- Healed 5(33.3%) t0(66.6%) 3.33 NSr biotic sensitivity testing ofthe detectedmicro organ- Improved 2(13.4%) 3 (20%) 0.24 NSt isms. No cffect 8(53.3%) 2(t3.4%) 5.4 .01r+ ctne, INM The outcome was adjudgedas healed,improved *Not signifi cant; **Signifi canl and or no effect.

Jour. MarineMedical Society, July 1997,Yol. 4, No. I t? Io. I

E-- Declining Trendsin Casesof SexuallyTransmitted Diseases Among Armed ForcesPersonnel : The INHS Asvini Experience Surg Cdr PLKDESYLYA, SurgCapt ICM SHAH CASE REPORTS DelayedTherapeutic Recompression in TypeII DecompressionSickness Sz surg Lt cdr GSRJAYAWARDANA BowenoidPapulosis : A CaseReport 54 Surg Cdr R DHIR, Surg Capt KM SHAH,Col AK HUKOO Migration of UnthreadedPin into PoplitealFossa : A CaseReport 55 Lt Col SM BHATNAGAR,Surg Cdr P SARN Tubercubsisof Patella: A CaseReport 57 Lt Col SM BHAft'IAGAR"Swg Cdr P SARN MucosaAssociated Lymphoid TissueLlmphomas - RareType of Non Hodgkin Llmphoma 59 SurgLt Cdr S MNJAN, Lt Col W SNGH, Surg Cdr B FATHOME,Dr SH ADVANI, Brig D PMSAD RTJMINATIONS ForensicOdontology 61 SurgCmde(D) MLGUPTA Bleachingof Teeth 62 SurgSLt(D) S PAHWA ECG Quiz 64 SPOT TIIE DIAGNOSIS 65 BOOK REVIEWS 67 JOURNAL WATCH 69 NEWS FROM TIIE DEEP 70 LETTERS TO THE EDITOR 72

GUIDELIITES FOR AUTHORS IJ ACCEPIEDBYflIORE NAIIOIIA1DENTA1 ASSoCIAiloNSI THA}TA]IY OIHER

@ ilEWomDUADER lll omrcmE vdqerqqwfr

MESSAGE

With the pr:blication of this issue the Journal of Marine Medical Society has stepped into i-ts fourth year. Although the Marine Medical Society lilas forured in L976, the first issue of the journal was brought out only in 1994. The credit for the success and popularity of the journal must go to the various authors who have been contributing ; f--:..e1 scientific articles on various medical and {i related problems with special ernphasis on problems related to Naval Medicine. I will particularly like the younger members of the medical fraternity to imbibe a scientific temperament and actively contribute papers for the journal.

I am quite confident that with every new issue, the journal will continue to show progress and improvement, particularly in its scientific content. It gives me great pleasure in felicitating the past editorial office bearers who have always strived hard to maintain the high standard of the journal. I also take this opportunity to convey my thanks to members of the Erecutive Committee and various organising comrnittees involved in the past with the Marine Medical Society. Active participation of the members of various comnittees wiII no dor;bt be instrunental in making the forthcoming National Conference a success.

(,lc Sha::ma) Surgr Vice Admiral Director General Medical Services (Navy) QUt[,Qest Cornp0tr*ents

Stor*

Bhrlrni MeJi"rl Bool. Ho'se

Opp.KEM Hospital Parel,Mumbai 400 012.

Phone: 4137650

Fax : 9,1-22-4138041 FROM THE EDITOR'SDESK

Four years is not a very long time in the life of a medical journal, but the outgoing editorial board have done a commendablejob in this shortperiod and have strived hard to improve the quality of the joumal since its inception. We take this opportunity to thank them for the commendablejob done.

That the joumal is gaining wider recognition and acceptanceis evident from the diverse sourcesfrom which articles are being received. The present issue contains articles from Sri Lankan Navyl Defence Researchand Development Organisationand civilian institutions.

According to estimates,the annual number of casesof tuberculosisand HIV will exceed l0 million and 30 million respectively by the turn of the century. HIV and drug rbsistanttuberculosis co-existing will pose iminense strain on the resourcesof any country. An update on HIV and Tuberculosis by Surg Cmde NR Raha VSM e/ c/ focuseson the enormity of the problem in the current issue.

High environmentaltemperature and humidity on.boardships requires installation of huge airconditioning plants which themselvesproduce heat and consume large amount of energy. A possible solution to this problem in the form of " micro cooling system" for Naval applicationshas been analytically discussedby Dr. Hegde et al from DEBEL , Bangalore in this issue.The problem of alcoholism in the Navy is as old as the Navy , but some solutions have been candidly discussedby Surgeon Commander Ryali et al in their article "Emerging trends in alcohol related disordersand the Navy ".

Perhapsno other malignancy has undergoneas intensea microscopic scrutiny by the scientistsas cancer breast and understandablyso. Some of the newer prognostic indicators in the diagnosis of this diseaseare discussedby Lt Col Bhattacharyain this issueofthe journal. It is hopedthat thesearticles will make interesting reading both for the enlightenedand the uninitiated.

We expect that an original article "Development of a compressordriven atomiser for cockroach control on board ships" by Surg Lt J Sridhar et ql ar'd another article, "Psychological aspects of under water endeavors"by Surg Cdr MJ Johnet al will elicit someresponse and reaction from the readersin the form of letters to editor.

A section on book review and joumal watch/scanand a quiz is included in this issue and more changes will be incorporated in forth coming issues.

There is no doubt that the major part of the credit for the successof this joumal goes to various authors who have been contributing scientific publications regularly. It is hoped that they will continue to do so in future also.

On our part, we at the editorial offic'e look forward to comments,suggestions and constructive criticism from not only the authorsofvarious articles but also from our esteemedreaders and subscribers.

S Nangpal ' SurgCdr Editor

Jour. Marine Medical Society, July 1997, Vol. 4, No. I Review Article DRUGSAND THERAPYIN HYPERBARICENVIRONMENT

Surg Cdr S NANGPAL *, Surg Cdr MJ JOHN*, Surg Cdr KKDUTTA GUPTA#

KEY WORDS : Drugs,Hyperbaric environment,HBO.

INTRODUCTION endotheliumand in pericapillary structures, indicating thatHBO increases permeability 1-nvestigation of drugs and their activity in the the of BBB [2]. hyperbaric Similar results have been reported I and hyperoxic environment is a by Chambi et al r multifaceted study area of researchwithin the t3l. context of hyperbaric medicine. Drugs are being These results are considered to have important investigated for various reasons[ 1]. clinical implicationsand have lead to the investiga- a. To examinephysiological process. tioir of HBO as enhancerofpenetratio- .f someanti bioticsacross b. To unlock the mystery of anaesthesia. BBB. Phagocytic c. As variable to be manipulated in an attempt to leucocytespresent the first and most important under stand certain phenomenaseen in hyper- line of defenceagainst micro-organisms. The capacity baric environment' e.g. nitrogen narcosis and ofleucocytes to kill, largely depends high pressureneryous syndrome(HPNS). on amountsof oxygen available to them [4]. Growth of Mycobacterium tuberculosis is greatly retarded d. In addition, clinical researchersare investisat- undersuitable HBO conditions[5,6]. ing drugs to determinetheir safety and efficicy in hyperbaric/hyperoxicenvironment. Thom et al (1985) testedthe effectsof intermittent HBO in experimentally induced faecal perito- When oxygen is inhaled in concentrationhigher nitis in rats. The mortality in control group (100% than that found in the ambient air it is consideredto without HBO) was reduced to 8% in HBO group be a therapeutic agent. Many patients who need [7].Similar results have been reported from the In- treatment in hyperbaric chamber require not only stituteof Naval Medicine hyperoxia but various other drugs . Therefore it is [8]. important to be aware of the fact that drugs may Sulphonamides interact with oxygen whereby the effect of these Oxygen at higher pressure drugs ,may be either potentiated or attenuated.In has been shown to enhance the effects of PABA-Folic addition these drugs may either enhanceor reduce acid antagonist.The effectiveness the effect of hyperbaric oxygen therapy (HBO). of sulphazoxazolecan be in- creasedfive to ten folds at 2.8 ATA. Drug resistant Antimicrobials M tuberculosiswas found to be susceptibleto oxygen HBO increasesthe permeability of blood brain induced synergy by the same authors [9]. barrier (BBB). When animals were treated with Oxygen at2.2 ATA decreasesthe minimum in- HBO for 90 minutes per day at two ATA for five hibitory concentration (MIC) of Sodium Sul- days and then injected intra venously with cadmuim phisoxazole five folds and Trimethoprin two folds free ferritin and sections of brain examined under in various strainsofpathogenic bacteria.This could electron microscope,perivascular oedematous zone be further enhancedto 25 folds and l0 folds respec- and ferritin particles were seen outside capillary tively at 3.2 ATA [0].

*Classified Specialist in Marine and Hyperbaric Medicine, # Classified Specialist in Preventive and Social Medicine, Institute ofNaval Medicine,Mumbai 400 005.

Jour. Marine Medical Society,July 1997, Vol. 4, No. I Mafenide acetate(Sulphamylon) an anti bacte- nomena as indicated by the fact that Helium at 68 rial agent used in burns patient is a carbonic anhy- ATA enhancestransport of iron in Staph aureus, drase inhibitor which tends to promote CO2 reten- reducesthe binding of Penicillinby the sameorgan- tion and vasodilation.The use of this drug should ism and may repress the growth of Streptococus therefore be avoidedin burnspatients undergoing faecalis by interfering with uptake of Folic acid . HBO therapy. This mechanismmay explain the altered sensitivity of microbial agents.In addition mutagenic property Aminoglycosides of oxygenmay also effect the microbial sensitivity HBO does not effect the transfer of aminogly- [3,17- 1 9]. cosidesacross the blood brain barrier. In a study the CSF transfer of Tobramycin was not found to be Drugs effecting the central nervous system effected by HBO. Similarly pharmaco-kineticsof Anaesthetics Gentamycin did not change in healthy volunteers The use of general exposedto HBO at2.4 ATA for 90 minutesafter a anaestheticsin hyperbaric single dose but patientswith systemicinfections, environment was first described by Paul Bert in 1878. septicaemiaor other fulminant infection are likely Anaestheticcare may be requiredat increased pressurefor following to be pyrexic and subjectto severalothers systemic indications:- responseswhich interact with hyperoxic environ- a. Treatment of conditions that produce transient ment. Considerationshould be then given not only anoxaemiasuch as whole lung lavageat two to to interactionof antibioticswith HBO environment four ATA. but changes in susceptibility of the micro- organ- b. Emergencysurgical procedures required on a isms to HBO environment and also to the fact that patientinvolved in a diving accidentwhich may thesepatients may be more susceptibleto oxygen occur while at pressureup to 35 ATA (350 inducedseizures I l,l2]. meterssea water depth)which is the maximum Synergism between Oxygen and Streptomycin, depthofsaturation diving [20]. INH or PAS has been reported even with drug Although very limited literatureis available on resistantM. tuberculosrs[9]. Similarly increased the pharmakokineticsof IV anaesthesiasuch as oxygen tensionalso causessensitivity to the respi- Meperidineand Pentobarbitol, no significantaltera- ratory inhibitor Mericidin-A in Candidautilis [3]. tion in half life, volume of distribution or plasma clearanceofthe drugsoccurs between 2.8 to 6 ATA Effects of Pressureper-se indicating perhapsthat IV anaestheticagents commonly usedat one ATA can be judiciously usedat The possibleeffects ofpressure per-se (not nec- 2 to 6 ATA. essaryof oxygen) on altering the drug sensitivity of microbes must also not be underestimated.Pressure Due to problemsof anaestheticgas pollution of the ambient environmentwhile delivering anaes- may enhancethe bactericidaleffect of oxygen[4]. The effect of pressureon in-vivo action of drugs, theticgases, use of IV anaesthesiais recommended (not necessarilyonly anti microbials) assumes l2rl. greater significancein view of prolonged diving Successfuluse of Ketamine anaestheticsin 48 schedulesin the offshore industry. Increasein drug patientsundergoing open heart surgery while having sensitivity was noted in M. tuberculosisisolated oxygen administeredat 3 ATA was describedin from patients undergoing HBO therapy. Increased 1987 [22]. Similarly 20 patientsundergoing thera- resistant to penicillin, Vancomycin, Cephalothin peutic lung lavagewere successfullyadministered and Tetracyclinand increasedsensitivity to Sodium Ketamineand Benzodiazepine with musclerelaxant Colistimethatehas been reported for Staph.aureus underHBO conditions[23]. grown in hyperbarichelium at 68 ATA. However Amongst gaseous anaesthetics, Halothane re- susceptibilityof Streptococcuspyogenes was unal- mainsthe gas most usedclinically under HBO, as teredby Heliumat 68 ATA [5,16]. Halothanevaporising equipment functioning is not Helium effects the membraneassociated phe- affectedby pressure[24].

Jour.Marine MedicalSociety, July 1997,Vol. 4, No. I Certain practical aspectsneed to be considered pressure,indicating that amphetaminesmay be me- while administering anaesthesiain hyperbaric tabolized faster at seven ATA or perhaps the de- chamber. During compression or decompression, pressantactivity of pressuredominates. the noise lewl in the chamberis significantlyhigh Ethanol which can interfere with auscultationand audibility of alarms of various equipments.These periods of There is no evidencethat HBO acceleratesme- compressionand decompressionare preciselythe tabolismof alcohol.Although antagonismbetween periods when the anaesthetistmust be especially HBO and alcohol has been demonstrated,there is alert,as most complicationsin anaestheticmanage- synergismbetween high pressureair and alcohol as ment in HBO conditionsoccur at that time. indicatedby increasein sleepingtime in mice.How- ever in the practice of hyperbaricmedicine espe- and their batteries are not ad- Laryngoscopes cially that involved with diversthere is almostunt- versely by pressurebut endotrachealtubes effected versal consensusthat alcohol alters the responseof patient should be oflargest size appropriateto the as the individual and is therefore to be avoided. with rise of pressureturbulent flow increases.Tra- cheal tubesshorild be filled with salineand not air. Narcotic analgesics There is ample evidence that drug effects are It is important to reducethe number of electrical modifiedat pressure.The safe effectiveuse of these equipmentsto minimum. Air driven ventilatorsare drugsunder hyperbaric(hyperoxic) conditions, re- ideal, though under hyperbaricconditions they ex- quires knowledge of the behavioural and pharmo- hibit some what lower peak flow rates.Oxygen cologicaleffects, which is singularlylacking at pre- leakage from the ventilators must be kept to the sent. However , narcotic drugs generally depress minimum. Arterial oxygen measurementsare diffi- respiration by reducing the reactivity of medullary cult becausewhen the sampleis passedout of the centresto carbondixoide. This combinedwith de- chamber,gas bubbles out of blood. Most gasanalys- pressingeffect of HBO on respirationcan lead to ers are not calibrated for very high concentrationof rise in PaCO2which causesvasodilatation and may oxygen likely to be encounteredin hyperbaricenvi- leadto enhancedoxygen toxicity. ronment. Pulse oxymetry may be carried out by Anti neoplasticdrugs splicing cables throughthe chamberwalls. Exposureof Burkitt lymphoma cell culture to In a paralysedpatient EEG may be the only way HBO at threeATA for two hours producesinhibi- to identifu oxygen inducedseizures. Defibrilation tion of DNA synthesisand mitosis. Simultaneous is possibleby takingthe defibrilatingpaddles inside exposureto HBO andAdriamycin resultsin reduced and having the equipmentoutside. cytotoxicity.However exposureto Adriamycin two to eighthours before or afterHBO enhancesthe drug CNS stimulants effeqt.Similarly, cytotoxicity increaseswhen cells Excessive coffee drinking may predisposeto areexposed to HBO before,during or afterNitrogen oxygentoxicity. At pressuresbetween I to 6.5ATA Mustardadministration [25]. caffeine causesdecrement in leaming processas HBO reducesthe rate of Misonidazolemetabo- manifested by increase in error rate and a 20o/oto lism, therebyincreasing its bio-availabilityand con- 50o%increase in time to completethe tasksin vol- centrationin tumorswhich enhancesradio sensitiv- unteersubjects. These effects also vary with indi- ity. vidual susceptibility.Amphetamines have been studiedunder hyperbaric conditions in mice.Expo- Radiation sensitisationof tumours by HBO sure to high pressuremarkedly reducesthe lethality Oxygen tension inside the tumor may be as low and frequency ofconvulsionsin doseswhich under as eight mm of Hg and it may fall to near zero in the normobaric conditions could causeconvulsions in necrotic centre of the tumor. With oxygen tension 100% animals.By studyingthe effect of ampheta- insideat zero,the amountof radiationrequired to be mines on stereotype behaviour in the sameanimals effective is three times that reouired with normal it was seen that the effect was reduced bv hieh oxygentensions [20].

6 Jour.Marine Medical Society, July 1997,Vol. 4, No. I Reproductiveintegrity ofhypoxic tumors cells is MiscellaneousDrugs. more resistantto damageby radiation than the tumor The hypotensiveeffect ofalpha and beta block- cells oxygenatedto normal physiological levels. ers, ganglionblockers and beta adrenomimeticsis Therefore largerthe numberof tumor cells that loose considerablyreduced in HBO environment. The their reproductive capability the greaterthe chances pressoreffect of alpha adrenomimeticsis potenti- of cure or palliation 120,251. ated.Therefore it is recommendedthat the drugs be A study sponsoredby British medical research given afterbut not beforeHBO session[20]. council on randomizedclinical trials of HBO in Digitalis : Thereis someevidence that HBO may radiotherapyof advancedcancer cervix (total 320 reduce the toxic effects of digitalis. HBO also is cases)showed that benefitwas greatestin agegroup reported to decreasethe effectiveness of cardiac below 55 with stage II disease.Theuse of HBO glycosides[20]. resulted in improved local control of tumor and Heparin : Though no studieshave been reported extendedsurvival. Although there was a slight in- in human beings, heparin treated animals develop creasein radiation morbidity but it seemedthat the pulmonaryhemorrhages as a resultof interactionof benefit of HBO out weighedthis factor Other [26]. anticoagulanteffect ofheparin and oxygen induced studies have however failed to find any advantage pulmonarylesions. Although pressure and exposure by addingHBO to radio therapy. time in thesereports were much longer than those Addition of HBO with radiotherapymay be use- used in clinical practice,the possibility of pulmo- ful for the following reasons125,26]. nary damage in patients receiving heparin during a. It improvesa more uniform kill by improving HBO therapymust be kept in mind [20]. oxygenation. Insulin : The hypoglycemiceffects of HBO are b. It is usefulas an adjunctto surgicalrepair after well known. The dosesof insulin required in dia- radiation. betic are decreasedduring HBO therapy and should be readjusted.The possibility ofhypoglycaemic epi- c. It reducesthe period ofpreoperativeradiation sodein diabeticpatients undergoing HBO must be and interval between its discontinuation and kept in mind. The incidenceof significanthypogly- surgicaloperation. caemia requiring intervention in patients undergo- d. It increasethe rate of primary wound healing. ing HBO therapyis 0.73 eventsper 100 total treat- e. There is lessimpairment of lymphocytefunc- ments and 1.3 events per 100 diabetic patients tion. treated[28]. In a controlled trial on the effect of HBO and CONCLUSIONS AND radiotherapyin casesof squamouscell carcinomaof RECOMMENDATIONS lungs,the survival ratesin HBO group was 24.8Yo Inspite of frequent use of drugs in hyperbaric as compared to l2.4Vo in controls. In malignant environment, literature about the action of drugs is melanomaalso radiotherapyin combinationwith very limited. There are certain drugs which are HBO gaveenc6uraging results . Treatmentof cancer known to interact with hyperoxic environment in of the bladderwith radiotherapyand HBO however man.The interactionof otherdrugs though demon- yielded contradictoryresults [27]. stratedin animal experimentsis at best speculative In view of the fact that HBO is a usefultherapy in human beings. There are other drugs and espe- for radiationinduced necrosis ofnormal tissuesand cially newer and emerging drugs which have not survival of patients with at least head and neck beentested in the aboveenvironment. The actionof canceris higher than in the non-HBO group,HBO certain chemotherapeutic drugs, anaesthetics, is consideredto be a suitableagent for enhancing cardiorelated drugs etc. in man under HBO condi- the effects of radio therapy.HBO is however not tions is well established.Since HBO effectscardiac very useful in metastasis.HBO is also contraindi- functions, this makes any cardio effective pharma- catedin acuteradiation sickness. cologicalagent suspect. The drugsof abuseare also

Jour. MarineMedical Society, July 1997,Vol. 4, No.I strong candidates for interesting intractions with 99. HBO environment. In view of the increasing fre- 15. Schlamm NA, Coykendall AL, Mayer CE. Effect of penicil- quency of use of HBO in clinical practice, there is lin on.Srapft.aureus cultivated in high atmospheric pressure. need to investigatevarious drugs in details. J Bact 1969;98:327-28. REFERENCES 16. Schlamm NA. Effects of elevated atmospheric pressure on antibiotic susceptibility of Staph. aureus and Str pyogenes l. Michael J Walsh. Editor. Twenty first Under Sea Medical Antimicro AgentsChemo 1972; | :512-13. Society Workshop on interaction ofdrug in the hyperbaric 17. Schlamm NA, Perry JE, Wild JR. gas environment. l3 - l4 Nov I 979, BathesdaMaryland USA. Effects of Helium at elevated pressure on iron transport of E. coli. J Bacteriol perme- 2. Lanse SB, Lee JC, JacobsEA, er a/. Changesin the 19'14:ll7 : 170-74. ability ofblood brain barrier underhyperbaricconditions. lv Space Environment Medicine 1978;49 : 890-94. 18. Schlamm NA, Dolly DP. Effects of elevated pressure on penicillin binding by Staph. aureus and Steptococus pyo- 3. Chambi IP , Caverh MD, Hart GB, et al. Effect of HBO on genes.Anti micro Agent Chemo 1972; 3 : 147-51. permeability of blood brain barrier. Eighth International Congress on Hyperbaric Medicine. Long beach, Califomia 19. Fraltali, Robertson R. Effect ofhyperbaric helium on vita- t984. min uptake and utilisation by micro organisms. Av Space Environ Med 1975: 46: 898-901. 4. Beaman L, Beaman BL. Role of oxygen and its derivatives in microbial pathogenesisand host defence.Ann Rev Micro- 20. Camporesi EM. Anaesthesiain the hyperbaric environment biol 1984;38:27-28. .. In : Text book of hyperbaric medicine. Jain KK. Editor. Hogrife and Huber publisher : Toronto, 19961.457-63. 5. Gottlieb SE. Effect of HBO on microorganism. An Rev Microbiol l97l: 25 : I I l-52. 2l Ross JF, Manson HJ, Shearer A, et al. Some aspects of 6. Nangpal S, John MJ. Effect of HBO in tuberculosis and in anaesthesiain high pressure environment.Proc. Int. Con- gress, experimental infection. AFMRC project 1986; 1597/86. Hyperbaric Medicine. Aberdeen University press 197'l;449-452. 7. Thom SR, Lauermann MW, Hart GB. The effects of HBO on experimental intra abdominal sepis. Under Sea Biomed 22. Li W& Zhen Z,Chang-Xian. Open heart Surgery with extra Res1985: 12 :25. corporeal circulation under HBO at 3 ATA. Proc 8th Int Cong Hyperbaric Med. Kindwall ER. Editor. 1987:,l7'7-80. 8-.Nangpal S, John MJ. Effects of HBO in experimental an- aerobic non-sporing bacterial infection. AFMRC project 23. Camporesi EM, Moon RE. HBO as adjunct to therapeutic t479/84. lung lavage in pulmonary alveolar proteinosis. In 9th Int Symposium on Under Water and Hyperbaric Physiology. 9. Gottlieb SF, Solosky JA, Aubrey R. Synergistic action of Bathesda.198'l : 449-52. bacteria. In : Trapp WG, Bannistar FW, Devidson AJ, et a/ (Editors) Fifth Intemational Hyperbaric Conference pro- 24. Bennett PB. Anaesthesiaat high pressurein 2 lst Under Sea ceeding,Simon Fraser,University Press, 1974;557-83. Medical Society workshop on intraction ofdrugs in hyperbaric environment.Walsh JM (Ed.) Under Sea Medical 10. Keck PE , Cottleib SF, Conley J. Interaction of increased pressure of oxygen and sulfonamides on the in-vitro and SocietyBathesda t979; 55-60. in-vivo growth ofpathogenic bacteria. Under Sea Biomed 25. Wheeler RH, Dirks JE, Lunardt I, NemiroffMJ. Effects of Res1980;7 :95-196. hyperbaricoxygen on cytotoxicity ofAdriamycin and Nitro- I l. Kent TA. SheftelTG. SuttonTE. Effect ofHBO on blood gen Mustard in cultured Burkitt's lymphoma cells. Cancer CSF transfer of Tobramycin. Av Space Environ Medicine Res 1979;39 :3'70-'75. 1986;57 :664-66. 26. Watson ER, Halnam KE, Dische S. Hyperbaric Oxygen and 12. Merritt GD, SladeJB. Influence of HBO on pharmacokinet radio therapy Medical ResearchCouncil Report. .BrJ Radiol ics of single dose gentamycin in healthy valunteers.Pftar- 1978;51:879-8'1. macotherapy1993; l3 :382-85. 27. Cade IS, McEwen JB. Clinical trials of radiotherapy with 13. Katz R . Oxygen induced sensitivity to Piericidin in Candida HBO at Portsmouth. 1964-76. Clinical Radiol 19'18:.29 : utilis. Fed Pro 19701'29:892. 338. | 4. Gottleib SF. Oxygen under pressureand microorganism. In 28. John MJ, Nangpal S, Ruparel VJ, et a/. Transient hemiplegia : Davis JC,TK Hunt, Editors. Hyperbaric Oxygen Therapy. following a single clinical HBO exposure at 2.5 ATA. J Under Sea Medical Society. Bethesda.Maryland 1977;'19- Marine Med Socien 1996:.3 : 54-55.

Jour. Marine Medical Society,July 1997, Vol. 4, No. I Update Article HUMAN IMMUNO DEFICIENCYVIRUS (HIV) AND TUBERCULARINFECTION. A SERIOUSCHALLENGE TO HEALTH CARESYSTEM

SurgCmde NR RAHA, VSM *, SurgCdr KK DUTTA GUPTA**.

ABSTRACT There has been a rapid increasein the number ofcases ofHIV and tuberculosis co-infection. The incidence of multidrug resistant (DIDR) tuberculosis in HfV casesis also rising especially in Asia and Africa which is a major dilemma faced by these resource poor countries. Moreover, diagnosis of tubercular infection in HIV infected patients with standard diagnostic tools can be dillicult due to several reasons. In the ensuing article various recommendations to manage these problems are discussed. KEY WORES : HIV associatedtuberculosis: Tubercular infection.

INTRODUCTION diseasethan people infected with only M tuberculosis[3,4]. f T Torld Health Organisation(WHO) has es- l7|/ timated that annual number of tuberculo- 2. Primary infection.'New M tuberculosisinfec- Y Y sis cases world wide will reach 10.2 tion in people with HIV can progress to active million by the year 2000. Similar projections by diseasevery quickly. In USA, active tubercular WHO estimate a cumulative total of 3040 million diseasein two-thirds of people with HIV is due HIV casesby the year 2000. Although several fac- to recentrather than reactivation oflatent infec- tors contribute to the increaseoftuberculosis cases, tion. Peoplewith HIV are at risk ofbeing newly HIV infection plays a dominantrole in resourcepoor infected ifthey are exposedto M tuberculosis countries. In some African countries heavily af- becausetheirweakened immune systemmakes fected by HIV epidemic, the number oftuberculosis them more vulnerable [3,4]. cases annually has more than doubled. In Europe 3. Recuning infection ; people with HIV who and North America, the rise in TB casessince mid havebeen cured of tuberculosismay be more at 1980's is partly due to HIV. Similarly, incidenceof risk of developing tuberculosis again. How- HlV-associated tuberculosis is beginning to in- ever, it is not clear at present whether this is creasein many partsof Asia [1,2]. becauseofre-infection or relapse[3,4]. Appearanceof MDR tubercularinfection among Mechanism of interaction between M tuberculo- AIDS patients poses a threat to close contacts and sis and HIV infection : health care workers. Whereas the fatality rate of As HIV infects both helper T cells and macro- untreatedimmuno competentpatients is 50 percent, . the fatality rate in MbR tubercular infection in phages,.defectsin the host immune responseto M. tuberculosis may be secondary to the failure of AIDS is reported to be g0 percent [3]. ' helper T cells to secretelymphokines that activate Reasonfor increasedincidencett"tsence oftuberculosisor tuoerculosls ln macrophagesor the failure of HIV infected macro- HIV infection , phagesto respondto lymphokines. The relative in- L Reactivation of latent infection .' People who creasein the number of CD8 cytotoxic T cells may are infected with M tuberculosis and HIV are also causemacrophage destruction in the tubercular 25-30 times more likely to develop tubercular lesions [4].

*Director; **Classified Specialist (PSM); Institute of Naval Medicine, Mumbai-400 005.

Jour. Marine Medical Society, July 1997, VoL 4, No. I Histopathologicallydepending on the degreeof losis may have a higher frequencyof negative immuno-suppression,mycobacterial infection can sputum smears.Diagnosis may require sputum take three forms : culture. 1. HIV infected individuals haveprimary and sec- 2. Mantoux test often fails to work in people who ondary tubercular infection with the usual well are HIV positive. As the immune system is formed granuloma composedof central areaof damagedby HIV, it may not respond even caseationsurrounded by epitheloid cells, Lang- thougha personis infectedby M tuberculosis. han's giant cells, fibroblastsand lymphocytes. 3. Chestradiography may be lessuseful in people In these casesacid fast organismsare few and with HIV becausethey have less cavitation. often difficult to find. Cavities usually develop becauseof immune 2. When HIV positive patients develop AIDS response to tubercular bacilli leading to de- (with less than 200 CD4 helper T lymphocytes struction of lung tissue. per cubic mm), tubercular infection is fre- 4. Casesof extra pulmonary tuberculosisseems to quently causedby reactivation or exposureto be more common in peoplewho are co-infected new mycobacteria. In these cases,granulomas 13,41. are lesswell defined and contain abundantacid fast organisms Options for preventing ensuing catastrophy: 3. When CD4 helper T lymphocyte counts be- From the abovediscussion, it is apparentthat the come less than 60 per cubic mm, opportunistic biggest challengeto health care system of poor infection with M avium-intracellulareoccurs. countriesof Asia and Africa will be unmanageable Most infectionswith theseorganisms originate number of tuberculosispatients in near future with in gastro-intestinaltract [4]. increase in HIV infection. Existing programmes, availablefunds and trained Clinical featuresof tuberculosisin patientswith manpowerwill be hope- lessly inadequateto tackle this gigantic problem. HIV infection vary with degreeofimmuno suppres- The sion as follows : only silver lining in this dismal scenariois the fact that tuberculosisin HIV infected people is treat- able with standard anti-tubercular regimen. But Clinical course HIV infection HIV disease(AIDS) when tuberculosisstrikes a patient of AIDS, situ- More indolent More active ation is hopelessbecause Fewer systemic systemic of higher frequency of Symptomsand symptoms and signs MDR tuberculosis,hence early diagnosisand treat- Signs more predominant. ment of tuberculosisat the stageof HIV infection Site ofdisease Predominantly Predominantly extra can offer somesolution to this problem.Following Pulmonary pulmonary and actiohsmay be consideredfor implementation, spe- Disseminated. cially by developingcountries. Chest radiograph Upperlobe Diffuse or lower lobe Cavitary lesions Infiltration Screening: Tuberculintest Usually positive Usually negative l. Screeningof HIV infectedpersons for tubercu- Sputum culture Usually positive Usuallypositive in Patientswith pulmonary lar infectionand disease. Disease. 2. VoluntaryHIV testingof patientswith tubercu- lnfectiousness Infectious Infectious when lungs losis. are involved. Responseto Excellent Excellent but MDR 3. Preventionof transmissionwith help of health Therapy Tuberculosismost carefacilities where HIV infectionis prevalent. Common. A priority for tuberculosis control programme in developing countries is identification and However, diagnosisof tuberculosisin HIV in- treatmentof smearpositive cases. Passive case fectedpeople using standard diagnostic tools can be finding among patients presenting to health more difficult due to following reasons: care facilities rather than active casefinding is l. HIV positive peoplewith pulmonarytubercu- the most effective approach[5].

I0 Jour.Marine Medical Society, July 1997,Vol. 4, No. I Current recommendation for preventive ther- NGOs' assistancein achievingbetter drug compli- apy : ln USA, theCenter for DiseaseControl (CDC) ance and drug distribution through establishing a recommendsthatpersons with HIV infectionshould propermachinery of co-operationand collaboration be given a tuberculin skin test with five tuberculin among the Governmentand NGOs, as most of the units of purified protein derivative.In absenceof casesof tuberculosiswith HIV infection will have activetubercular infection, Isoniazid for l2 months to be treatedas outdoorpatients [8]. duration was recommendedfor all HIV infected person showing more than five mm induration. CONCLUSION WHO and IntemationalUnion againstTuberculosis There is a rapidly increasingincidence of TB- and Lung Disease(IUATLD) issuedsimilar guide- HIV co-infection. With the spread of HIV, the line for resourcepoor countries[6]. epidemiologicalsituation of tuberculosiswill dete- Management of cases riorate. With nearly half of Indian population having focii oftubercular infection on one hand and a rapid Regimens containing Thiacetazoneare associ- rise in the incidenceof HIV infection on the other. ated with high rates of side effects, increasedtreat- complicatedby various socio economic factors such ment failure and relapse rate in HIV infected per- as poor quality of life, over crowding, illiteracy, sons.Similarly streptomycinshould be avoidedbe- large families, lack of awareness,inadequate health cause of risk of transmission of blood bome o care facilities etc., the picture is gloomy unless infection. HIV positive patients with tuberculosis adequatemeasures are taken at the earliest[9]. treatedwith Rifampicin containingshort course che- motherapyhave similar responseto HIV negative In a climate of economic restraint and rampant tz patientsand have similarly low early relapserate. HIV infection,intersectoral co-ordination, innova- The simplest regimen will be three times weekly tive ideas and further researchare essential for the Isoniazid,Rifampicin, Pyrazinamide and Ethambu- future developmentof Tuberculosiscontrol pro- lol. In USA, HIV infectedpatients taking supervised gramme. to had favourable intermittent therapy more survival REFERENCES than those on daily self administeredmedication. Hencedirectly observedtherapy (DOT) hasbeen the l. World Health Organisation.Ninth General Programmeof 20 work covering the period 1996-2001. Geneva I 994 9. single most effective interventionand has contrib- ; uted to better tuberculosiscontrol in recentyears. 2. I(evin M Decock,David Wilkinson. Tuberculosiscontrol in resourcepoor countries. Altemative approaches in the eraof 26 Peripheral health functionaries such as multipur- HIV. Lancet 1995:364 : 6'15-77. \I pose workers, anganwadi worker, trained dais, vil- 3. Cofram SR, Vinay Kumar, Stanley L Robbers. Robbins lagehealth guide etc.,could be usedfor DOT 29 [7,8]. PathologicBasis of disease5tn edition. WB SaundersCom- Integration of sewices at district level.'Patients pany.USA lS94:325-30. with HIV associatedtuberculosis may requiretreat- 4. Philip C Hopewell.Pulmonary manifestations of HIV infec- ment for other complicationsof HIV diseasethat tion in Cecil text book of rredicineed. BennettCJ and Plum tuberculosis control programmes are not accus- F, WB SaundersCornpany, Philadelphia 1996; 1859-65. 35 tomed to dealingwith. Thereforetuberculosis con- 5. Kevin M Decock. Screeningfor tuberculosisand HIV in trol programme will have to integrate activities at resourcepoor countries. Lancet I 995 ; 345 : 873. the district level into other servicescatering to the 6. Kevin M Decock,Alison Grant.John DH, Porter.Preventive needofthe population[8]. therapy for tuberculosis in HIV infected persons; intema- 38 tional recommendationsresearch and practice. Lancet I 995; Information, Educstion and Communication 345 : 833-35. (IEC) : IEC activities should be augmentedso that 7. Dale I Morse. Directly observedtherapy fbr Tuberculosrs 40 proper messagesreach the targetgroups and to those BMJ 1996;312 :719-20. who are put on treatmentso that they continue their 8. Rohit S, Dey LBS. IndianNational ruberculosis programme treatmentfor entireduration. - +J Revisedstrategy Ind J Tub 1995; 42 : 95-100. Co-operation of Non Governmental Organisa- 9. MukherjeeAK. Tuberculosiscontrol programmein India - tion (NGO) .. Effort should be made to hamess Progressand prospects.Ind J Tub 1995; 42 : 75-85.

Jour.Marine Medical Society, July 1997,Vol. 4, No.I I] hasbt Original Articles such EVALUATION OF HYPERBARICOXYGEN AS depet ADJUNCTIVETHERAPY IN DIABETIC HBO FOOT norm heali: SurgLt CdR VRG PATNAIK *, SurgCdr PSLAMBA**, level Surg Cdr S NANGPAL***, SurgCdr MJ JOHN+, form Surg Cdr KK DUTTA GUPTAT-I bette MA'I ABSTRACT T] grou Diabetic foot is one of the most devastating long term complication of diabetes mellitus. Hyperbaric oxygen therapy (IIBOT) is used in its treatment basedon physico-chemicaland haemodynamicconsiderations. To asiessits role total a study was conducted at the Institute of Naval Medicine in an age matched group. 30 patients were evaluated in thep a randomized group study. Study consistedof 13 males and two females(Mean age 63.1 + 8.74) . Control group T consistedof three females and 12 males (mean age 67 t 9.81). Both groups were given standard antibiotic and surgical care. Diabetic foot was graded as per Wagener's classification. Study group was pressurised to 2.8 ATA femt using 100%ooxygen for one hour. Controls were pressurisedto the samedepth but using 7.57o oxygen and 92.5 )l-l 7o nitrogen as the breathing mixture . The overall outcome was significantly better in the study group as compared grou to controls (p < 0.01) . 86.6% in the study group either healed or improved compared to 46.7ohin controls. 53.92o ager of Wagener's grade I-III in the control group either healedor improved. In comparison, significantly more (p to fe < 0.05) (92.3% number of grade I-IU caseseither healedor improved in the study group. In this study no patienl 87: experiencedany complication of HBOT. the KEY WORDS : HBO, Diabetic Foot. stud rec0

INTRODUCTION plicatesthe diabeticfoot. 1 pres iabetes mellitus is accompanied The rationale of employing 1.\ by long HBOT in diabetic 92.: term micro-vascular, neurological and foot is based on physico-chemical and haemody- I ! of0 namic considerations.When administered at pression complicationsincluding diabeticfoot have sures greater than one atmosphere(ATA), caused oxygen ing acts the most morbidity and mortality sincethe inhoduc- as a therapeuticagent. HBOT improves blood 'l tion of Insulin therapy.The preventionand amelio- supply, can reduceischaemic damage to nervesand ration of thesecomplications have been major goals can reduce oedemaby upto 50o/oin post ischaemic 2.8 of recentresearch I I ]. muscle and thus acts as a medical fasciotomy. It mec reduces platelet adhesion to capillary walls Diabetic foot is defined as a compromised foot after I ischaemic or traumatic insult, mitigating the "no due to neuropathy, macro-vasculardisease or infec- stuc reflow" phenomenon RBC flexibility is doubled " tion occuring singly or in combination. It is one of [2]. wot in about 15 treatments[3]. Leucocyte killing of the most devastatingcomplications of diabetesthat I bacteriaand somefungi is greatly enhanced It leadsto suffering , disability, lossoftime from work, [4]. acts indirectly by raising 02 tensionsin infected , tien hospitalisationand a greatexpense to the patient and tissuesto normal. When there is return to normal the and to the community . These foot lesions result from killing by leucocytesis enhancedas their intra pre peripheral vascular disease leading to inadequate cellular killing mechanismsare partly oxygen depend- exa blood supply, and from neuropathyresulting in re- file ent [5-9]. HBOT improvesantibiotic effrciency.It duced sensitivity of the foot. Infection further com- bio isn *Graded Specialist in Marine Medicine, Institute ofNaval Medicine, Mumbai. *+Endocrinologist and Classified Specialist in Medicine, ***Classified INHS Asvini, Colaba, Mumbai. Specialist in Marine Medicine and Officer-in-charge School of Naval Medicine, INM Mumbai. +Classified Specialist in Marine Medicine, Institute of Naval Medicine, Mumbai. ++Classified Specialist in Preventive and Social Medicine,Institute of Naval Medicine,Mumbai. Jot t2 Jour. Marine Medical Society,July 1997, VoL 4, No. I has been shown that the transportof anti microbials Healed such as aminoglycosides into bacteria is oxygen If completeepidermal closure was achievedat important dependent.Extremely is stimulation by the end of the treatment or soon afterwords. HBOT of new capillary and collagen formation. normalising tissueoxygen tensionto permit surgery, Improved healing and evenbone grafting. It increasestissue If ulcersresponded but did not heal completely. level of superoxidedismutase which countersthe These included patients who chose to discontinue fonnation of free radicalsafter injury, resultingin treatment or whose condition became static , yet bettertissue survival [10]. allowed normal activities to be resumed. MATERIAL AND METHODS No Effect The study was conducted in an age matched If the ulcer made little progress or deteriorated r therapy group in a randomised prospective procedure. A while receiving treatment. ssits role total of30 volunteer patients rvere included during If after five HBO sittings patients in the study ,luatedin the period 1995to 1997. group showed "no effect" the procedure was abon- :ol group doned. ioticand The study group consistedof 13 males and two 2.8ATA females.Average age was 63.1 L 8.74 years (range Any controls showing deterioration during treat- end92.5 5l-75 yrs). Fifteen patientscomprised the control ment were switched to HBOT so as ethically not to ompared group with threefemales and12 males.The average deny them the adjunctive benefit of this modality. Is.53.9% agewas 67 + 9.81years (range 45 to 85 years).Male more (p RESULTS to female proportion was 80 : 20 in the control and o patient 87 : I 3 in the study group. The facilities availablein The resultsofthis study are presentedbelow in a the hyperbaric centre at INM were used for this tabular forum. study which included a monoplaceand a multiplace recompressionchamber. TABLEI Age groups included in the study The control group was subjected to 2.8 ATA oZ Age Study diabetic pressureand were made to breath7.5 oxygen and emody- 92.5%onitrogen. This ensuredan 02 partial pressre Range 45-85 5l-75 at pres- of 0.2 I ATA at bottom . To avoid hypoxia, compres- Average 67x9.81 63.1!8.74 oxygen sion and surfacingwere doneusing air asthe breath- s blood ing medium. TABLE 2 vesand group The study were also subjectedto the same Sexwise distribution of cases haemic 2.8 ATA but used 100% oxygen as the breathing rmy. It medium. Control Study ls after Both groups had a bottom time of one hour. The Feinale J 2 he "no study and control groups were given standard Male t2 IJ loubled wound care, antibiotic cover and insulin. Male : Female proportion 80:20 87:13 ling of l{41.It Rigid acceptancecriteria were adopted and pa- rfected tients were thoroughly examinedfor HBOT fitness TABLE3 nal the andlesions classified as per Wagener'scriteria . The Showingresponse to HBOT pre HBO therapy work up included complete ENT fa cel- Study x2 epend- examination,chest skiagram, ECG, blood sugarpro- ,ncy.It file, pulse oximetry, wound swab culture and anti- Healed 5(33.3%) 10(66.60/0) 3.33 NSr biotic sensitivity testing ofthe detectedmicro organ- Improved 2(13.4o/o) 3 (20%) 0.24 NS+ isms. No cffect 8(53.3%) 2(13.4%) 5.4 .01** :.dt"t*, re, INM The outcome was adjudgedas healed,improved *Not significant;**Significant jve and or no effect.

Jour.Marine Medical Society, July 1997,Vol. 4, No. I I3 t, No. I TABLE 4 Comparisonofgrading and response

Control Study --- No% No % (n= l3) (n= 13)

Grlrle I, II, III

Healed f 38.5 l0 76.9 X2=3.94 p < 0.05* ') Improved 2 15.4 15.4 X2=0 p > 0.05** ' No effect 6 46.1 I 7.7 X2=12 p < 0.001+ Grade IV, V# (n=2) (n=2) Improved I 50 No effect z 100 I 50

* Significant, ** Not significant, + Highly significant, # No statistical analysiswas performed as the sample size was inadequate.

DISCUSSION nine casesin the study group healed. In grade III, one oftwo cases'healed' in the group The averageage of both groups was compatible study with the other having 'no effect'. In grade (control 67 t 9.81 years, range 45 to 85 years and V, there was one caseeach in both groups and both ofthem had 'no study group 63.1 ! 8.74 years,range 5 I to 75 years). effect'. Statisticalanalysis ofthe (Table The male : female ratio for the control group was above data 4) revealsthat only 53.9% ofthe total casesofgrades 80:20 and for the study group was 87: 13.This study I-III in the controls either'healed' or 'improved'. In ilid not reflect any sex bias in the responseto HBOT comparison, more (p < (92.3%) for diabetic foot. significantly 0.05) numberof caseseither'healed' or'improved' in the The overall outcome was significantly better in study group. For grades IV and V in both groups, the study group as comparedto the control group (p statistical analysis was not done due to inadequate < 0.01) (Table 3). Thus, 86.6%in the study group samplesize. The outcome of a caseof diabetic foot either healed or improved. In the controls 46.7% was relatedto Wagner grade.Grade I lesions faring either healed or improved. 13.4Yo of the casesin the better than grade five lesions. 92.3% of gradesI-III study group had "no effect" as comparedto 53.3Yo in the study group healed/improved, whilst in the in the control group. Smith et a/ noted partial or case of grades IV and V only 50% of cases im- complete healing with HBO in 640/oof casesof the proved. 36 patientswith diabeticfoot [11]. Many non healing wounds are hypoxic and the Barr et al reportedcomplete healing in 670locases tissue Oz tensionsmay be in the range of 0-15 mm of the 24 diabetic foot ulcers , improvement in 4 Yo Hg. Although hypoxia may seryeas an initial stimu- and no effect in 29 Yoof the casesI I 2]. Leg ulcers lus to the healing process, tissue Oz tensions of did the best with 86% healing.6l% of foot ulcers 30-40 mm of Hg are neccessarysubsequently for healed. They further concluded that amptutation enhancementof leucocytekilling ofbacteria and for could be avoided in 60% of patients who were angiogenesisand collagen formation and the tran- otherwiseat risk. In anotherstudy of 30 patientswith sient vasoconskiction causedby HBO helps in re- foot lesions treated with routine care or with care duction of oedemain the neuropathic foot causing plus four45 minutes HBOT sessions,fewerpatients ameliorationof symptoms[3,14] in the HBOT group required above ankle amputa- REFERENCES tion and the hospital stay was also reduced [3]. l. The diabetic control and complications trial researchgroup. Wagener's Grade I foot healed in both control The eflect ofintensive treatmentofdiabetes on the develop- and study group with two casesin eachgroup. Five ment and progressionof long term complications in insulin of the nine patients of Grade II in the control group dependentdiabetes mellitus..ly'ElM 1993;329 : 14. 'no had effect' with treatment. whilst seven of the 2. Zanboni WA, et al. Morphological analysis of the micro

14 Jour. Marine Medical Society, July 1997, Vol. 4, No. I circulation during reperfusion of ischaemic skeletal muscle flaps in rats. lrcl Surg 1990; 125:.607-9 and the effect ofhyperbaric oxygen.Plast ReconstSurgery I L Smith VC, Murphy BP, Crammer FS. Hyperbaric Medicine 1993:91:100-23. proceedingsofthe Eigth IntemationalCongress. Ed: Eric P. 3. Mathiou D, et al. Red blood cell deformability and hyper- Kindwall, Milwaukee, Wisconsin. Best publication 1984; baric oxygen. Med SubaquatiqueHyperbar 1984;32:100-4. 2M-6 4. Mader lT, et al. A mechanism for the amelioration by 12. Ban PO, PeninsDJD. HyperbaricMedicine. proceedings of hyperbaric oxygen of experimental staphylococcal the Eigth Intemational Congress.Ed:Eric P Kindwall, Mil- osteomyelitisin rubbits.J Infecl Dn 1980; 142(6):915-22. waukee, Wisconsin. Best publication 1984:219.

5. Babior BM. Oxygen dependentkilling by phagocytes.N 13. Doctor N, Pandya S, Supe A. Hyperbaric Oxygen Therapy Engl J Med 1978;298: 659-68. in diabetic foot- J Post Grad Med 1992; 38 (3) : I l2-4 . 6. Baldridge JD, Genard RW The extra respiration ofphago- , I 4. Committee on hyperbaric oxygenation. The compressedgas cytosis. Am J Physiol 1993;'103:225-26. atmosphere . In : fundamentals of hyperbaric medicine . 7. Klebanoff SJ. Oxygen metabolism and toxic properties of NationalAcademy ofSciences - National ResearchCouncil' phagocytes.lnn Int Med 1980;93: 480-89. 1966;3-ll. 8. Mader JT. Phagocytic killing and hyperbaric oxygen : Anti 15. Committee on Hyperbaric Oxygenation: the physiological bacterial mechanisms.HBO Rev l98l: 2 : 37-49. basis ofhyperbaric therapy In: fundamentals ofhyperbaric 9. StosselTP. Phagocytes.N Engl J Med 19741'71'7-23. . medicine . National Academy of Sciences - National Re- 10. Kachin CM, et al. The effects of hyperbaric oxygen on free searchCouncil 1966:33-35.

54TH BOMBAY MEDICAL CONGRESS

The 54th Annual Conferenceof Bombay Medical Congresswill be held at SP Jain Memorial Hall Bombay Hospital, Mumbai on 7th and 8th March 98. Unique features of Conference a. IntermedicalCollege Symposium Competition b. Prizc Papers i. By GeneralPractitioners/FamilyPhysicians ii. ByArmed ForcesGeneral duty Medical Offrcers iii. By Young PostGraduates c. Oration and key note addresses

Authors desirousofparticipating in prize papersmay forward the abstractof articles in triplicate in 250 wards to Hon Secretary54th Bombay Medical Congress,C/o INHS Asvini ColabaMumbai - bv 07 Feb 98.

Jour. Marine Medical Society,July 1997, Vol. 4, No. I I5 DEVELOPMENTOF INDIGENOUS COMPRESSORDRIVEN ATOMISER FOR COCKROACHCONTROL ON BOARD SHIPS

SurgLt J SRIDHAR*,Surg Lt Cdr A CHATTERJEE+, SurgCdr KKDUTTA GUPTA#

ABSTRACT The medical importance ofcockroachesis very much greater than is generally realised.They harbour pathogenic bacteria, serveas intermediate hostsfor helminths,viruses, protozoa and fungi afTecting'manand other vertebrate animals.

Ships are a natural habitat for cockroachesbecause oftheir enclosedspaces, false panellings and easily accessible sourcesoffood and water. Thus, cockroach control posesa tough challenge,both for the ship's medical setup as well as for the local Station Health Organisation.

Such a challenge on board a Coast Guard Ship led to the development of an insecticide atomiser, designedto penetrate hitherto inaccessiblecockroach infestedspaces in the ship. The device was made from inputs that are commonly available in a ship's medical storesand was driven by the ships air compressor. A trial was carried out to determine the eflicacy of the device as against conventional hand-operated spraying techniquesin use on board ships.

It was found that the devicenot only improves the efficecyofcockroach control on board but will also reduce the dependenceon SHO's for routine decockroachingoperations.

INTRODUCTION roaches excrete compounds which are mutagenic ockroachesare an ancientand highly suc- and carcinogenic[4]. cessfulform of insect life. They harbour Ships are a natural habital for cockroachesbe- pathogenicbacteria, serve as intermediate causeoftheir enclosedspaces, false panellings and host for pathogenic helminths and carry helminth easily availablesources of food and water. Their eggs,viruses, protozoa and fungi, affecting man and uncheckedproliferation hasan adverseimpact upbn other vertebrateanimals []. the ships habitability as well as the morale and Many people are unaware of the extent to which health of the ship's company. Cockroach numbers cockroaches contaminate food. Perhaps the most areoften a tell-tale indicator ofa ships sanitarystate. disgusting and partially digested food and poten- Cockroach control thus occupies a special position tially dangerousfeature of cockrsach behaviour is in the health agendaof any ship's Medical Depart- their habit ofregurgitating. Their habit offeeding on ment. both human faecesand human food is suggestiveof Light hand-operated conventional insecticide their potential health hazard,to man. Further, they sprayershave been the mainstay ofcockroach con- give off secretions which impart a persistent and trol measureson board ships. However, they are characteristicodour to areasvisited by them [2]. often time consuming and offer only local control Cockroachescan causedermatitis of the skin and with limited effrcacy. Thus, ships have beenlargely oedemaof the eyelids[3]. Certainspecies of cock- dependenton periodic spraying routines undertaken tMedical Officer, Coast Cuard Ship Vijaya, C/o FIeet Mail Officer, Mumbai-400 001, +Regional Medical Officer, HeadquartersCoast Guard Region (West), Worli and Post -GraduateTrainee (PSM), Institute ofNaval Medicine, Mumbai4OO 005. #Classified Specialist (Preventive and Social Medicine). Institute of Naval Medicine. Mumbai4OO 005. l6 Jour. Marine Medical Society,July 1997, Vol. 4, No. I by the local StationHealth Organisations (SHOs) for cockroachcontrol on board.While sailingcom- mitmentspose hurdles for shipsin adheringto prescribed dates for such routines, the SHOs thern- selvesare often constrainedby shortagesofman- power andtransport for smoothconduct of spraying operations. Further, cockroach infested comparhents in shipshave false pannelingwhich compoundsthe cockroachnuisance. Routine insecticidespraying merelydrives the cockroachesbehind the panelling, only to bring them out into the open, once the residualeffect wearsoff. In order to penebatehitherto inaccessiblecock- Fig. I : Cross-sectionof the compressordriven atomiser. roachinfested panelling spaces in the ship,as well as reduce an operationalship's dependenceon SHOs,an atomiserdevice driven by the ship'sair compressorwas assembled on board. MATERIAL AND METHODS The atomiserdevice is primarily madeup of a systemof interlockingsyringes. Following itemsare made use of : (i) l0 cc disposablesyringe - one (ii) 5 cc disposablesyringe - one - (iii) 2 cc disposablesyringe one Fig. 2 : Photogra.phof the CompressorDriven Atomiser. (iv) Ryle'sTube - one25cm length The banel of eachof the abovesyringes is iso- latedand its endsare cut to get a hollow, cylindrical piece,open at bothends. The cylindricalpieces are then serially interlockedusing adhesiveplaster to get a gradually tapering noz.zle.The interlocking joints are fixed by piercing syringeneedles through them (Fig 1 and2). Projectingends ofthe needles are then brokenoffon eitherside. A small hole is madejust before the nozzle tip arada25cm lengthof Ryle'stube is T-jointedwith it (Fig l). Theend of theRyle's tube is immersedin a cancontaining ready-to-spray insecticide solution. Fig. 3 : Insecticidesprayrng in progressin thegalley ofthe ship. Compressedair from an air compressoris fed through the atomiserdevice using a long hosenor- atomiser(10 cc sy-ringeend). This allows com- mally availableon boardfor deckwashing. The high pressedair to preferentiallyescape through the hole velocity air leaving thenozzle tip createsa venturi (insteadof throughthe atomiserdevice), thus stop- suctioneffect on the insecticideliquid, thusspraying ping deliveryofthe insecticide.Delivery of insecti- it as a fine mist @ig 3). cide can be restartedby obliterating the hole with the operatorsthumb A stop-startmechanism is incorporatedby making a button-sizedhole in the broad end of the Theinsecticide mist is deliveredbehind the pan-

Jour.Marine Medical Society, July 1997, Yol.4, No. I t7 elling in variouscompartments of the ship by drill- Tables I and 2. On analysis it is evident that the ing holes of about 0.5 cm diameter,each five feet atomiser device used in the test ship proved more apart. The narrow end of the atomiser is directed at effective in controlling the cockroachpopulation for theseholes and the insecticideis sprayedbehind the a period of more than l4 days after spraying. panelling into the hidden and inaccessiblespaces. This techniqueof sprayingis employedin addition TABLEI to conventional spraying of the ship's compart- Pre spray density ofcockraoch infestation in various places in ments. ships A preliminary trial was carried out in the se- Ship Average of 5 days lected, cockroach infested compartmentson board Galley Pantry Toilet two Coast Guard ships in order to determine the Test 18.6 24.6 D-Z 49.4 efficacyofthe deviceas against conventional hand- Control 17.8 22.8 7.2 47.8 operatedspraying technique in use.Both shipswere X2= 0.02632 P>0.05 of similar configurationand in addition,the decockroaching routines ofthe ships had not been carried It canbe noted that there is no significantdifference in thc pre spraydensities ofthe two ships. out by SHO for a period of three monthsprior to the date of commencementof trial. Observationswere TABLE2 carried out over a period of one month. One of these Postspray density ofcockraoch infestation in ships ships acted as control. Ship Visual count on differentdays in Pre-spray assessmentof cockroach density: Galley, Pantryand Toilet Pre-spray assessmentwas done using visual Day I Day 3 Day 7 Day 14 Day 30* count on both ships.The visual count ofcockroaches Test Nit Nil f 8 l9 was done in the night after cooking hours in the Control 2 8 7 32 4'7 galley (vegetable cutting table), pantry (food serv- ing table)and toilet (WC cubicle)of both shipsfor tVisual count discontinued as it ahnost reachedpre spray den- five days. At a fixed time, the lights were switched sity in control. on and the cockroacheswere counted as they ran about over a period of five minutes. Light from a DISCUSSION torch was thrown into dark comers to drive out The atomiser device and the spraying technique cockroachesfrom their hiding places.This method offer some distinct advantagesover conventional hasbeen used by most of the earlierworkers [2]. hand spraying methods in use so far in warships. Post-spray assessmentofcockroach density : As air compressorunits are available for routine Spraying was carried out on the sixth day in the requirementon boafd all ships,decockroaching rou- compartments of the control ship using a conven- tines become a self-sufficient exercise with ability tional hand sprayerand external spraying technique to conduct spraying operations even at sea. This while the atomiser device was used in the compart- obviates the need for ships having busy sailing ments of the test ship with a combination of internal schedules to depend upon shore-based Station and extemal sprayingof panellingspaces. The in- Health Organisation,which are constantly overbur- secticidechosen was combinationof 0.05 percent denedwith decockroachingappointments. Pyrethrum and one percent Malathion. Quantity of In addition, the device addressesthe problem of insecticideused was five litersin both cases.Cock- inaccessible cockroach infested panelling spaces roach density on both ships was measuredusing which are unique to ships. Moreover, by this tech- visual countson days1,3,7,10,14 and 30 afterspray- nique, the insecticide mist remains restricted to the ing was carried out. spacebehind the panelling.Thus, the ship's airconditioning neednot be shut off and sprayingcan be RESULTS carriedout with very little intemrption to normal life Data collectedfrom the two shipsis recordedin on board.

18 Jour.Marine Medical Society, July 1997,Vol. 4, No. l The equipmentis powerful and fully mechanised not only knockdown effect but also flushing effect and as such, one untrained person is sufficient to and Malathion has residual effect. However there is carry out spraying operation. Further, the equipment no reasonwhy other insecticides should not be ef- is durable and cost effective. To achieve adequate fective in similar conditions. A large scale study pest control, spraying should be caried out once in with other available insecticideswill be desirable. a fortnight. With a 0.5 HP compressorrun at mini- Being mechanisedand easyto operate,the device mum rpm, the device can deliver approximately can be adoptedfor coverageoflarger areasand for three litres of insecticideper houflThe delivery rate useas a powerful, cost effective tool for independent can be enhanceby increasingthe compressorrpm. insect control on board ships. CONCLUSION REFERENCES Soundsanitation is an integral part ofpest control l. Cochran DG. Cockroaches: Biology and control. In : Vector in any environmental setting. However, insecticide Biology and Control.WHO 1982;856 : l-10. spray remains the most effective method of cock- 2. Dutta Gupta KK, Grewal GS, Srivastava R, Urmil AC. roach control on board ships. Though Rust and Rclative eflicacy ofeasily available insecticides in the con- Rierson (1978) found that residual insecticide de- trol ofcockroaches. MJAFI I 991; 43 : 195-8. posit ofmore then five days duration does not pro- 3. Roth LM, Willis ER. The Biotic Association of Cock- vide significant changes in mortality, post-spray . roaches.Smithsonian Miscell. Coll, London 1960; l4l : l-70. density assessmenton board test ship revealed effective control for well over 14 days,when spraying 4. WHO Insecticide Resistanceand Vector Control 1970:Tech rep ser no 443; l-7. was done inside the false panelling [5]. 5. Rust MK, fuerson DA. Comparison of Laboratory and Field Combination of Pyrethrum and Malathion was Efficacy oflnsecticides for German Cockroach Control. JE chosenfor the trial as it is known that Pwethrum has Con Entomol 1978:.71:704-8.

Qliith Qest Comp0rments

Sr,orn

,t,M,aAXl E C0.

Regd.Office 16,Bank Street Fort,Bombay 400 001.

Jour. Marine Medical Society, July 1997, Vol. 4, No. I I9 MICROCOOLINGSYSTEM FOR NAVAL APPLICATION

DT KRISHNA S HEGDE+, HARISH S RAO#, KOTRESH TM+{-+, Dr LAZAR MATHEW*

ABSTRACT

Prolonged exposureto very high hot humid conditions prevailing in living and working spacesof ships leads to physical discomfort and lossof working elliciency, Air conditioning of the entire environment using the conventional methods may not be viable, We have examined the micro climatic cooling which aims at providing a comfortable environment immediately next to the skin on exposureto hot and humid conditions using an assembly of vortex tube and air ventilated suit, air ventilated vest and mask developedin our laboratory. The miniaturized vortex tube when supplied with compressedair givesout two streamsof air - cold and hot. The cold air generated was distributed over the body through air ventilated suit, air ventilated face mask and vest. Six subjects were exposedto simulated hot and humid environment CIar-SOoC,RH - 507o and wind velocity l7m/min). Subjects wore air ventilated suit and vest immediately next to the skin. They were subjectcd to heat exposurefor one hour wearing different combinations of air cooled garment with vortex tube on dilTerent days. ln o:re of the heat exposuressubjects were not provided with micro cooling,while cool air at 15+ loC with 450 L pm were supplied to them wearing difl'erent combinations of ventilated garments. Heat strain indices such as heat accumulation, heart rate and sweatloss were measured.The resultsindicate a significant reduction in heart rate (p < 0.001),heat accumulation (p < 0.001)and sweat loss (p < 0.01) when subjectedto micro cooling. Micro cooling produced by vertex tube, air ventilated clothing assemblyin alleviating heat induced physiologicalstrain was lbund to be very effective. KEY WORDS : Micro cooling, Vortex tube, Air ventilated suit, Mask, Vest.

INTRODUCTION providing a comfortable environmentnext to the skin of the personassumes a great significancein fnh. warmth and humidity prevailing in the shipsand heat"produced this context.We have developeda micro cooling I "wild by the excess I- of horse power required of the ships heat systemwhich consistsof a compact miniaturized enginesin order to work the extra machineryleads vortex tube, face mask and air ventilatedclothing to substantialloss ofworking efficiencyboth mental ensemble.An attempthas been made to developan and physical. Extremes of temperatures should efficientsystem in providing thermalcomfort to the therefore be avoided in the living and working personnelworking in an adversethermal environ- spacesofships, especiallyby thosepersonnel who ment. are required to maintain high pitch of efficiency. METHODS AND MATERJALS Therefore, there is a dire needto provide a compact, The studies were conducted on six male volun- efficient air conditioningor cooling systemfor Na- teersdrawn at random in the age group of26 to 35 val personnelworking in hot and humid environ- years.They were clinically normal and free from ments.Conventional air conditionersare normally any history of illness. The subjectswere briefed very bulky and occupy large area.The refrigeration about the experimental procedure and heart stress providedby thesedepend on heatexchanger which prior to the commencementof the experiment. in tum depend upon ambient temperatures and henceare not practicable. Subjectswere instrumentedfor measurementof oral temperature(Tor), skin temperaturefrom four Micro environmentalprotection which aims at different sites viz, chest, upper arm, mid thigh and

+Mcdical Physiologist;++Mechanical Engineer; +++Textile Technologist;+Director; Defence Bio Engineeringand Electromedical Laboratory (DEBEL). CV Raman Nagar, Bangalore - 560093

20 Jour. Marine Medical Society,July 1997, Vol. 4, No. I calf. Temperature measurementswere made using The vortex tube - air ventilated assemblyconsists digital multi channel temperature recorder with of a light weight vortex tube, ventilated suit, venti- platinum resistant thermistor. The mean skin tem- latedvest and face mask (Figs 1,2,2A,3,3A, and perature (T5p)was then computedas recommended 3B) by Ramanathan []. The mean body temperature Vortex cooling tube was obtained by the formula [2], Tu:0.35 Tst+0.65Tor It is a small device which converts compressed air at ambienttemperature into two streams,the cold Heart rate (HR) was determinedfrom ECG trac- and the hot. The two streamscome out simultane- ings on a BPL INDIA Cardiacelectrocardiograph. ously from the oppositeends of the tube. The vortex Heat accumulation (HAI) was computed from tube consists of a generator, diaphragm, throttle changesin body temperature(Tu) at 60 minutes of valve, hot and cold tubes (Fig l). Compressedair at heat exposure. The sweat loss for the duration of 100 psi and at 450 L pm is fed to the vortex tube heat exposurewas calculated was calculated from through quick releasecoupling. The vortex tube at differential body weight taken before and after heat its hot end has a throttle valve which regulates the exposure.Heat accumulation in thebody wascalcu- amount of cold air at the desired temperature. latedusing the formula, : Heataccumulation (Kcal/m"/hr) Air ventilated suit Bodyweight (kg) x specifrcheat ofbody x ATb It is a two layered overall which consists of an Body surfacea.ea 1m2) inner and outer overalls (Fig2,2A). The inner overall is made of light weight permeableabsorbent Initial data were recorded after 30 minutes of 100% cotton fabric while the outer overall is made restingin an air conditionedroom (Tau250C),and at of medium weight nylon/cotton fabric which has a every l5 minutesinterval on exposureto simulated lower permeability. The ventilation system is hot environment(Tau-500C), Ru - 50 % and air stitchedto the inner side of the inner overall. The movement l7mlmin) in a thermal chamberfor a ventilationsystem consists of a manifold with five period of 60 minutes. All the subjectsunderwent brancheswhich is fed by the vortex tube. The center heat exposurefor one hour duration wearing differ- outlet catersfor the cooling of the headportion while ent combinationsof ventilatedclothing assembly two each cater for the cooling of front and back with face mask. In one of the exposuressubjects portions of the body. The transparentPVC tubes are were not provided with mic^rocooling (control) provided with one mm diameter holes at regular whereascooledairat l5'C + l'C with 450Lpm was intervals through entire length of the tubes. supplied to them while they were wearing different Vest clothing systemswith face mask. Each subjectwas clothed with cotton brief, vortex tube-air ventilated It is fabricatedout of light weight permeableand suit and air ventilatedvests with face mask. absorbentpolyester/cotton blended fabric. lt is pro-

INLET ,1,

THROITLEVALVE c0L0 HOT AIR - AIR

hOT ENO Fig. l: Votextubc

Jour. Marine Medical Society, July 1997, Vol. 4, No. I 2I vided with a detachabletype ventilation systemas againstthe fixed tlpe provided in the two layered overall.The vestconsist of highly permeablepads whichhelp in obtaininglaminar flow of air. A total of eightpads were fitted on to the vest.Four on the front andfour on theback (Fig 3a,3b and3c). FaceMask It is fitted with a mini vortex tube. It is madeup ofrubberand essentially consists ofa full visor inlet andexpiratory valve. Cold end of the vortex tube is connectedto the inlet while hot endis connectedto a PVC transparenttube which runs along the lower edgeof thevisor (Fig 3). Theresults were analysed using student's t-test. RESULTS The thermal strain assessmentin terms of HR, heataccumulation and sweatloss at 60 minutesof heat exposurein control and different air cooled groupsare shown (Fig4,6,7). The terminal HR decreasedsigrrificantly in dif- Fig.2a& b : Ventilationsystem ofsuit (innerlayer) a. Frontview b. Rearview ferentcategories ofair cooledgroups compared to controlgroups. The meanvalues of HR at 60 min-

Front view Rear view

Fig. 3a, b& c : a. Vest with ventilation mask; b & c. Detachableventilation system of vest, Front view, Rear view.

22 Jour. Marine Medical Society,July 1997, Vol. 4, No. I 10 !.5

!.9 ta

!.1 fio qt

9.7 it- v5

373 I

37.1 &

D t5o o rs 5 _1 Th(d) +cd +cdryk +cd!&+vd.d +cdEk+vd +@ +CdEb +Cdg8+Vd.d +CdlEavd

Fig. 4 : Effect of microcooling ensembleon heart rate (mean 1 Fig. 5 : Effect of microcooling ensemble'on oral temperature SD).n=6 (meanaSD),n=6.

80 [zo {80 $so Ioo i30 I20 Iro 0

Fig. 6 : Effect of cooling ensembleon body heat lead (mean a SD), n = 6

600

c5@ { E40o I g 300 o '5i zoo r 1oo

Fig. 7 : Effect of microcooling ensembleon fluid loss n = 6.

Jour. Marine Medical Society, July 1997, Vol. 4, No. I 23 utes of heat exposure in control and air cooled thermal stress using different combination of arr groups were 123.16! 12.04 bpm, 109.3 t 8.73 ventilated assemblywith vortex tube. (cooling mask,P<0.05), 100.3 t 8.52bpm (cooling The resultsofour study indicate that vortex tube mask+suit, P<0.01) and 91.5 t 5.96 bpm (cool- air ventilatedsuit combinationhas sufficient cooling ing+v951,P<0.001). power to maintain personnelexposed to high hot and Themean skin temperatureTstvaried from 33.64 humid environment to near comfortable tempera- + 0.54oCb 37.65+ 0.2oC(cooling mask), 33.65 t nre. + * 0.49oC to 37.45 0.27oC (cooling mask 5ui1), It may be recalled from the Figs. 5 and 6 that the + + 33.6oC 0.48 to 36.7t 0.67 (cooling mask vest) physiological thermo regulatory variables such as + + as against33.65 0.60oCto 38.06 0.l7oc in Tor and sweatrate were reducedin the group which control group. The terminal Tsk values in all the air wore ventilated face mask. It is well documented cooled groupswere significantlyless (p<0.001) as that evaporation from the respiratory surface is an compared to control group. important mechanismfor body heat loss.The reduc- Oral temperature(To') presentedsimilar pattem tion in thermal strain indices in the group which asthat ofTst. The terminal valuesofTor in air cooled wore face mask could be attributed to evaporative groups showed a significant decrease (p<0.001) heat loss through respiratory passages. mainly in subjectswith the combination ofthe cool- Results of our study indicate significant reducing mask and suit and cooling mask with vest. The tion in HR, HAI and sweat loss in the groups which highest decreasein Tor was observed in cooling wore ventilated suit and face mask combination. In mask with vest combination (Fig 5). The mean val- this caseevaporative cooling ofthe sweat as well as ues at the end of 60 minutes of heat exposureswere convective heat hansfer aided the mechanism for 38.42! 0.I 9oCin controlas against37 .95 t 0.05oC heatloss. (cooling mask), 37.66 t 0.06oC (cooling mask + The group which had the combination of face suit) 37.42+ 0.04oC(cooling mask + vest). mask and vest, showed much higher reduction in The HAI (Fig 6) as computedfrom Tor and mean thermal strain indices. The permeablepads used in body temperature at 60 minutes of heat exposure the vest aid in obtaining the laminar flow of cold air was found to be sigaificantly lower (< 0.01) in all therebyhelping in betterdissipation ofheat from the the air cooled groups especially so in the group body. The humanbody is not uniformally insulated, which wore cooling mask and vest combination. some areashave a higher thermal conductivity and The mean values of HAI were 64.12 ! 8.54 allow a greaterloss than someother arcns.It could kcal/ m2/hr (cooI ing mask), 54.82 t 5 .23 kcalI m2 lhr be due to the fact that the numbcr of areaswhich (cooling mask * suit) and 43.79t l0.8kcal/m'lhr havea higherthernral contluci,vity may be distrib- (cooling mask * vest) as against 78.28 ! 4.69 uted on and around the chest leading to greaterheat kcaVm"lhr in control group. loss from theseareas. Sweating rate presentedin Fig 7 showsa signifi- We have not studied tolerancetime on exposure cant decrease(p<0.001) in two air cooled groups to hot and humid environment with micro climatic wearing combination of cooling mask with suit and cooling. The extension of tolerance time is attrib- cooling mask with vest. The sweat loss at the end of uted to lowering ofbody heat storage level caused the experimentin all the groupswas 541.83+94.87 by exposureto cold rinvironment[3]. Heat dissipa- gmlhr (control) as against4 86.67!7 6.59 gmlhr (face tion by evaporative sweat loss is expected to slow mask), 405.83159.56(cooling mask + suit) and down the buildup of heat accumulation and thus 425!60.58 gmlhr (cooling mask+vest)respectively. extend the tolerancetime[4]. The marked reduction in buildup of heat accumulation with micro cooling DISCUSSION as has been seen in this study may indicate the We employedthe natural heatdissipating mecha- extensionof tolerancetime with micro coolinq. nism of the body i.e. evaporatingcooling of the sweat as well as enhancingconvecting heat transfer CONCLUSION by the flow of cool air in providing relief from Micro cooling by vortex tube-air ventilated sys-

24 Jour. Marine Medical Society,July 1997, Vol. 4, No. I tem was found to be effective in reducing physi- REFERENCES ological strain of individuals working in hot and l. Ramanathan NLA. New waiting system for mean surface humid environmentswhen studiedin ahot temperature physiol chamber. of human body. "/ Appl 1964 19 : It can be a very effective system especially for 531 -534. personnel working in engine and boiler rooms of 2. Denin G. Aviation Medicine-physiology and human factors, ships and hence has a potential Naval application. Tri-Med Bookls, London, 1978' 343-36j. However, actual experiments in the ships will be 3. Veghte JH, P Webb. Body cooling response toheat. J Appl required before introducing Physiol -ships. this systemin tle naval 1964; 16 :235-238. 4. Sinha KC, CA Verghese. Effect of pre cooling on heat toleranceand estimation of pre cooling requirements./lero Med Soc India. 1969: 12 :25-28.

JOURNAL OF MARINE MEDICAL SOCIETY FORM NO rV (SECTTON RULE 8 )

Statementabout ownership and other particulars about newspapers(Journal of Marine Medical Society) to be published in the first issue every year after last day of February.

l. Placeof publication: Institute of Naval Medicine C/o INHS Asvini,Mumbai 400 005. 2. Periodicity of its Publication Halfyearly 3. Printer's Name DirectorGeneralMedicalServices(Navy). 4. Whether citizen of India Yes Ifforeigner, state the country of origin Address SenaBhavan, New Delhi I l0 0l I . 5. Editor's Name : Surg Cdr S Nangpal Whether citizen of India Yes Ifforeigner,state the country oforigin Address Institute of Naval Medicine C/o INHS Asvini, Mumbai 400 005. 6. Name and addressof individuals Marine Medical Society who own the newspaperand partners Reg.No F -3611 or shareholdersholdinng more than Institute of Naval Medicine one percent of total capital Mumbai 400 005.

I Director General Medical Services (N) hereby declare the particular given are true to the best of my knowledge and belief.

Date:2 September1997 sd/- DGMS CN)

Jour. Marine Medical Society, July 1997, Vot. 4, No. I 25 PROBLEMWOLINDS AND HYPERBARICOXYGEN (HBO) THERAPY

Dr. SURESHPUROHIT *, SurgLt Cdr cD BHANOT *, SurgLt HBS CHAUDHRY*, SurgLt G KRISHNAN+

ABSTRACT

Problem wounds are so calledbecause they fail to healas expected after adequatesurgery and antibiotic treatment. Hyperbaric oxygen (HBO) as a therapeutic tool has come to be acceptedas an important part of the overall armamentarium for managementof such conditions.

In the last ten years a total of 129 patientswith problem wounds such as diabetic foot , chronic non healing ulcers, synergisticgangrene , non clostridial myonecrosisetc., were treated at our Institute . All patientswere administercd HBO when conventional therapy failed. A uniformly successfuloutcome was achieved . In diabetic foot, either complete healing was achievedor where amputation was carried out, the level of amputation was lowered as a result of HBO. All casesof synergisticgangrene and venous ulcers showed complete heating. KEY WORDS : Problem wounds, HBO, Diabetic foot, Wound healing.

INTRODUCTION a ten yearperiod. Patientswere both service personnel and their dependentsas well as some civilians I-fyperUaric oxygen as a therapeutictool in referred by various local hospitals. l{ various diseaseshas gained wide accep- The age group I-Ltance. Besidesdiving relatedaccidents and was two yrs to 83 years. Pre HBO evaluation in- illness,use of HBO asa primarymodality or adjunc- cludedECG, X-ray Chest,middle ear function and tive modality in clinical conditionshas sound basis exclusionof any pulmonarypathology. [1,2]. However,as for any otherdrug, the therapeu- Each patient was treated on individual merit. tic advantagesmust be carefullyweighed against the HBO was given for 60 - 120 min duration at 1.8 - potentialtoxic or adverseeffects of HBO in a given 2.8 ATA pressure.A total of 1844HBO exposr.rres situation[2]. were given to 129patients. Perhapsone clinical settingin which HBO has Patientswere compressedin a multi place cham- beenused very successfullyas an adjunct with grati- ber or a monoplacechamber and on reachingthe fuing resultsis the areaof problem wounds.They assigned depth, made to breath 100% oxygen at are so called becausethey fail to heal as expected ambient pressure. after adequatesurgery and antibiotic mauagement. Number of HBO sittingsgiven varied from l0 - The problem arises from systemic or local host 39 to eachpatient dependingon responseand patient factors or environmental insults. compliance. Regardlessof the etiology'(diabetic,rheumatic, vasculitis,severe trauma, electrical or thermalbums RESULTS or irradiation) a common denominator of problem Variousproblems for which HBO was exhibited wound is tissuehypoxia and it is for this reasonthat are shown in Table I HBO hasbeen extensively used in the management of problemwounds. Diabetic Foot A total of 72 casesof diabetic foot were given MATERIAL AND METHODS HBO . All caseshad ulcers and gangreneof varying This studywas conductedwith 129patients over extent on lower limbs. All thesecase were referred

+Post Graduate Trainee Marine Medicine, +Submarine MO, Institute of Naval Medicine, Mumbai.

26 Jour. Marine Medical Society,July 1997, Vot. 4. No. I TABLE I Variouscategories of problemwounds treated with HBO

Indication No. of No. of Pressure Remarks Pts sitting

Diabeticfoot 72 1060 2.8ATA 57 complete healing, two pts opted out, I I pts had lower level of amputation .05* Chronic non healingulcer l7 269 2.5ATA I 5 casescomplete healing, two casesdropped out r* .05 Micro vascularreimplantation o 52 2.2 Four completehealing, Two partial healing .001+ fol lowing traumatic amputation Surgical wound infection 22 280 2.8 Completehealing in all Synergistic gangrene 48 2.5 Complete healing in all Necrotisingfascitis 3 60 2.5 Partial healing Non clostridialmyonecrosis 2 )l 2.5 Partialhealing Venousulcer 3 54 2.5 Completehealing in all t29 t844 ,deIII, 'ith the for HBO when adequateglycaemic control and ther- One caseof traumaticavulsion of the upper limb as one apy failed to arrestthe progressofthe lesion. One of was referred after microvascular repairs following ad'no thecases had large extensive necrosis ofupperthigh. onsetof ischaemicchanges in the distal part. A 20 (Table All caseswere on irisulin, with adequateglycaemic daysregime at 2.8 ATA helpedin completesalvage. grades and metabolic control. Two patients were referred Howeverneurological deficit persisted. ed'.In after amputation for non healing wound. ,2.3%) A two year old girl with traumatic amputation ' - in the Applicationof HBO at2.5 2.8 ATA for l0-21 thumb was taken up for HBO after surgical reim- days showed progressivewound healing with grad- plantation.l5 sittingsover l0 day period roups, resultedin equate ual disappearanceofpurulent dischargeand appear- completehealing. Four other casesshowed com- ic foot anceofhealthy granulationtissue. 57 casesshowed pleteto partialhealing. completehealing of the ulcer. Amputationwas re- faring Problem Surgical Wounds and Soft Tissue sorted to in two casesand in I I casesthe level of ESI.III Infections in the amputationwas loweredas a resultof HBO therapy. A total of 3l casesof soft tissueinfection were es im- HBO was seento be helpful in casesof diabeticfoot and hasnot only resultedin high numberof salvage treated with HBO. Surgical wound infections of the limbs which would otherwise have required formed a majority of these cases,although there nd the amputationsbut also in lowering of the cost of were casesofsynergistic gangrene, necrotising fas- t5 mm medical treatment. citis and non clostridial myonecrosis.The salient stimu- common featureof all thesecases was that they Bacterial culture was done in all the cases Onsof were subjectedto HBO when conventionalthera- tly for Negative peutic modalities such as debridment,antibiotics md for etc. had failed to elicit satisfactoryresponse. There a) Pre HBO Culture 9.0% t0% e traR- was rapid healing of the wounds which became b) Post HBO Culture 20% 80% in re- sterilein sevento ten days. ausing Chronic Non Healing Ulcers Wound infection was adequatelycontrolled by HBO alone as evident from above data. A total of20 casesofchronic non healingulcers including three casesof venous stasisulcers were ngoup. Reimplantation of Limbs Following levelop- Traumatic referred for HBO therapy when conventional ther- r insulin Avulsion apy did not show any improvement. A total of six caseswith microvascularreim- Administrationof 15 to l8 HBO sittings of 60 e mlcro plantsof limbs/digitswere treatedwith HBO. minuteseach at 2.5 ATA resultedin completeheal- t. No. l Jour.Marine Medical Society, July 1997,Vol. 4, No. I 27 ing of the ulcer in all the casesexcept in two cases hamperingwound healing and tissue repair [3,6]. who could not continue the therapy. HBO may further augment blood circulation in a diabeticby increasingthe flexibility of red blood DISCUSSION cells.The RBC's in a diabeticare often more rigid Wound healing is a complex processinvolving making it difficult for them to pass through small interaction of multiple cell types and various bio- capillaries. It has been shown that the flexibility of chemicalmediators. Following tissueinjury, plate- RBC's is almostdoubled after l5 HBO treatments. lets and fibrin are attractedto the site. Macrophages, as measuredby forcing them through a 3 micron follow and these cells undergo or- fibroblasts etc. filter []. ganisation. Production of cytokines stimulate cell The present study has clearly established the growth followed by angiogenesisand collagen for- efficacy of HBO in management of problem mation. Macrophagephagocytosis of deadtissue wounds. debris and contaminantsis followed by formation of healthygranulation tissue. REFERENCES Oxygen is perhapsthe most critical nutrientof l. Kindwall EP. Clinical hyperbaric oxygen therapy. In : Physi- ology and medicineofdiving. BennetP and Elliot D (edi- the wound and plays an important role in wound tors).4th Edition,WB SaundersCo : London, 1993;543. repair.Non healingin a wound is mostly relatedto 2. LambertsenCJ, Kough RIl, et al. Oxygen toxicity : effects hypoxia and ischaemiawhich hampersangiogenesis in man ofoxygen inhalationat 1.0and 3.5 atmosphereupon and collagen formation [3-5]. Wounds in hypoxic blood gas transport, cerebral circulation and cerebral meta- state become highly susceptibleto infection which bolism. J Appl Physiologt 1983; 5 : 4'l l-86. further contributesto tissuehypoxia, thus settingup 3. Hunt TK. The physiology ofwound,healing. Ann Emerg Med a visciouscycle [3,6]. 1988:17 :1265-'13. By increasing tissue oxygen level, HBO can at- 4. Prockop DJ, Kivirikko KI, Tuderman L, Giuz man NA. The tack the deleterious effects of hypoxia on wound biosynthesisofcollagen and it's disorders.NEIM I 994;301 healing.The exactmechanism by which this is ac- : 13-23. complished is not yet fully understood.However, 5. Hunt TK, Pai MP. The effect of varying ambient oxygen there is evidencethat suggeststhat HBO stimulates tensionon wound metabolismand collagensynthesis. &rrg GynaecolObstet 19721'135 :561-7. angiogenesis 11,3,4f. In fact various studies have KnightonDR, clearly shown a slow improvement in blood flow in 6. Halliday B, Hunt TK. Oxygen as antibiotic,a comparison ofthe effects ofinspired oxygen concentration affected limbs after a few sittings ofHBO, asevident and antibiotic administration on in-vivo bacterial clearance. from raisedtissue oxygen tensions [5]. ArchSurg1986; l2l: l9l-5. Local hypoxia also predisposesto wound infec- 7. Hill GB, Ostbr Hout S. Experimental effects of hyperbanc tion becausethe neutrophil mediatedkilling of bac- oxygen on selected clostridial species.ln-vitro studies. J teria by free radicals is decreased.HBO restoresthis InfectDis 19'12;125:l7-25. defence against infection and increasesthe rate of 8. Boehm DE, Vincent K, Brown OR, oxygen and toxicity killing of somebacteria by phagocytes.In addition, inhibition of amino acid biosvnthesis.Nature 1976:.262 : HBO alone is bactericidalto certainanaerobes, in- 4t8-20. cluding Cl. perfringens and is bacteriostatic for 9. Brown OR, Reversible inhibition of respirationof E. Coli by hyperoxia. Microbios 19721,5 : 7-16. some speciesof Escherichiaand Pseudomonas[7- l0l. 10. Park MK, Muhvich KH, Myers RAM, Marzella L. Hyper- oxia prolongs the aminoglycosideinduced post antibiotic In {iabetic lesionsof limbs,even when hypergly- effect in pseudomonas aeruginosa. Antimocrob Agents caemia is correctedthe neuro-vasculopathypersists Chemotherl99l:35 : 691-5.

28 Jour. Marine Medical Society,July 1997, Vol. 4, No. : [3,6]. )nina PSYCHOLOGICALASPECTS OF blood UNDERWATERENDEAVORS e rigid small ility of Surg Cdr MJ JOHN*, Surg Cdr S NANGPAL+, ments, Surg Cdr VSSR RYALI#, Surg Cdr KK DUTTA GUPTA** nicron ABSTRACT ed the Man's reluctanceto venturein to the :oblem depthsof the ocean,be it in a diving suit or in a submarine,is understandable.This is possiblybased on his subconsciousunwillingness to take a retrogradestep, as life is supposedto haveevolved from theseas and going back to seamay imply retrogression. Ventrfringinto thedepth ofthe oceanexposes man to extremepsychological stress due to the attendantisblation, r:Physi- rapid changesin pressure,artificial breathing gas mixtures , everpresent danger ofvenomous marine animals : D (edi- and fearofdrowning. r.541 KEY WORDS : Psychological,Underwatei warfare, Stress, Anxiety. : effects er€upon al meta- INTRODUCTION 1940s. It is however important to realise that the problem of man's.adaptationto the watery environ- erg Med ll /fan's attempt to explore outer space has taken him millions ment has always been that of temperament. lf1/ I of kilometers away NA. The I Y Linto outer space.However inspite of tech- The important stressesworking on man in the 994;301 nical advance, man has not been able to venture watery environment are monotony of long periods beyond 500 meters into the seausing diving equip- of decompressionentailing virnrally nill activitiy : oxygen ment. Mariana Trench, the deepestspot in the ocean and socialisolation. Emotional stability and intelli- sis.Surg is only l2 km deep yet man has hardly explored it. gencehave always beenco-related with a successful The reluctanceof man to venture deep is under- diver. Psychological mechanism of denial may be ibiotic,a standableand basedon his fear oftaking a retrogade valuable as they help the diver to deny the existence lntration of hazardsand allow him to work inspite of stress eatance. step although the history of diving stretchesback into antiquity. Essentiallyman can go into the depth which may be disruptive to an average"Land Lub- ber". perbaric of the ocean either using diving set with all its udies. J accompanying risks of direct exposureto the ele- a. Anxiety ments such as high barometric pressure, marine Anxiety though natural in any human toxicity animals, loss of visual, proprioceptive and auditory being ex- . posed 6. )A) stimuli, thermal problems etc. or in a pressureresis- to the fear ofthe unknown, gets aggravatedin subaquatic tant one atmospherevehicle such as a submarine environmentand more so in a susceptible individual. past . Coliby alsowith theeverpresentpsycho-physiological dan- Any encounter with a traumatic gers. experiencesuch as near.drowning, dangerousma- . Hyper- rine animals etc. may initiate a vicious cycle and ntibiotic THE RISK FACTORS end up with a psychologically wrecked diver. Some Agenls taskssuch as buddy breathing,free ascent, open s€a DIVING diving etc.cause excess anxiety. Although compressedair diving has been in vogue for most of the presentcentury, it came into b)Blue Orb Syndrome its own with the invention of the Self Contained Sensory deprivation can lead to agoraphobia Underwater Breathing Apparatus (SCUBA) in the which is calledthe "Blue Orb Svndrome".A condi-

*Classified Specialist Marine Medicine, +Classified Specialist Marine Medicine, #Classified Specialisl Psychiatry, **Clasified Specialist PSM, Institute of Naval Medicine, Mumbai.

I, No.I Jour. Marine Medical Society, July 1997, Vol.4, No. I 29 tion of weighlessnesswith an absolutelystill and that of comparablenon diving population (2). How- silent world aroundand no visual bearingbelow or ever this disability is much lessprotracted amongst above make the diver acutely awareof his vulner- divers as compared to non divers and retum to ability and islotion, which may be further aggra- occupationis much faster . Suicide and substance vatedby NitrogenNarcosis. This may actby disrupt- abuseis comparablewith non diving population, but ing the psychologicalequilibriurn and predispose a diver may adopt innovative techniques to kill him to panic,manifested by palpitations,hypercap- himself, suchas self inducedpulmonary barotrauma nia, peculiar epigastricsensation, jerky and irra- by rapid ascentfrom depthwhile holding breath. tional behaviour,terror stricken facial expression, SUBMARINERS dilatedpupils andrapid jerky movements.This condition can be self perpetuating.Diver may reacha Submarineis a self containedmetalic underwater statewhere self preservationmay be threatened. vehicle barely able to contain between40 to 100 men who live totally enclosed,and isolated from the Panic has been associatedwith 40 to 80 % of rest of the world for severaldays to months. Unlike SCUBA fatalaties in some studies reported from in any other industrial or terrestrial environment, a USA andAustralia.[1]. submarineris continuously exposedto various fac- c) Conversion Reaction tors and there is no respite and period ofrecovery This is the equivalentof the ManchausanSyn- from exposureto thesefactors including atmosphere drome seen in surgical practice. The diver may pollutants. repeatedlycomplain of symptomsof decompression sickness and try to gain sympthay or attention and The pecularitiesof a submarine environment are psychologicalsupport. Artificial environment d) Illusions Adaptation and readaptation Sensory deprivation especially in the form of Alteration in work and rest routine impaired visibility is likely to aggravate the ten- Limited physical activity dency to misinterpret stimuli. Anxiety associated Restrictedpsycho physiological, social and sensory with this environment can result in heightenedsug- stimuli gestibility, eg terror or over reaction on suddenly Regular"escape training" sighting an objectunexpectedly , mistakinga diver However unlike a diver. the submariner is not for a shark or other marine predator. The psycho- directly exposedto water and high ambient pressure logical responseof any diver to abnormalpsycho- except under special circumstancessuch as subma- logical stateis likely to be relatedto the personality rine escapeand rescue or when a submarineaccident structure and the environment. takesplace. e) Organic Psychosis: The effectivenessof submarinesas weapon sys- The diving situationswhich can leadto develop- temsdepends on the performanceofthe submariners ment of this condition include variation in inert gas and stressis a variable associatedwith breakdown pressure,hypothermia, carbon dioxide and oxygen ofperformance. Stressis both a processand a prod- tension.The presenceofcerebral involvementdue uct. Stressorssuch as extreme of noise, heat and to micro aero-emboliin decompressionsickness or light, monotony,fatigue, commandresponsibility, arterial gas embolization can produce organic psy- mental and physical overload,time away from some chiatric syndrome such as toxic confusional state port, isolation, sleep deprivationn etc. are relevant and symptomatic depressionleading to long term to both. The engineering design which include effectssuch as emotional lability, anxiety,difficulty working environment, instrumentsand control sys- job in coping, delayedinsomnia and suicidalideation. tem, the design such as the peculiar watch system, organisationaldesign such as the manning lev- PSYCHIATRIC MORBIDITY els, commandresponsibiliry, changes in crew as- Data shows that the incidence of psychiatric signment and training etc. have peculiar morbidity amongstdivers is approximatelytwice psychological effects on the submariner and pro-

30 Jour.Marine Medical Society, Julv 1997,Vol. 4, No. l duce what can be termed as "Submariners svn- technology and specialsation in the demands im- drome" manifestedphysiologically as follows:- posed on various types of divers, the personality a) CVS.' A mean rise in pulse rate and systolic characteristicsrequired of amateur divers are quite blood pressure,decrease of minute volume and different from a military diver. Of all divers the hypodynamia. The MCV is consistentlyraised greatestphysical and mental demandsare placed on with leucocytosis. military and Naval divers who fulfil a combat role. b) GIT.' Frequentbelching, dyspepsiaand ano- There is only a very small margin underwater for rexia deviation from normal health and no one can predict when and in what circumstancesa c) CNS; Frequentcomplaints of headache,irrita- candidatswould be exposedto excessivepsychological bility, sleep disorders, mild depression.With stress. passage of time compatibility problems may REFERENCES arise due to mood alteration. I . Divingand subaquate Medicine: Third edition 1992 Edmond C, LowryPennefatherJ (Editors). Butter Worth Hennemann CONCLUSION . Chapter5. pp 54-60. The early divers were a little like early aviators. 2. HansenJ, KirsnerK. Measurementof stressin submariners. They were adventure seekers. With advances in DefenceScience and Technology reportAustralia I 99| .

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Jour. Marine Medical Society, July 1997, Yol. 4, No. I 3I CARCINOMAPROSTATE: PROFILESOF PRESENTATIONAND MODALITIESOF MANAGEMENT

Surg Cdr B FANTHOME*, Surg Lt Cdr S RANJAN+, Surg Cdr VK SAXENA VSM#

ABSTRACT Ten casesof carcinomaprostate were analyzedto determinepatterns of presentationand modalitiesof management.The ageranged from 54 to 83 years.Obstructive symptoms were the commonestpresenting symptoms (80%). Digital RectalExamination was suspicious in all cases(100%). Prostatic biopsy was confirmatory (90%). Bonescan was positivein a significantnumber of cases(40%). PSA was significantly elevated in all the live cases in which it was estimated.Bilateral orchiectomy was the commonestmode of treatmentin combinationwith Ftutamideand local radiotherapyin selectedcases. To assessthe sensitivityand specificityof Transrectal Ultrasoundguided biopsy, a further one hundredand forty fi.vecases clinically suspected to havecarcinoma prostateand subjectedto TransrectalUltrasound guided biopsy were analyzed to assessspecificity and sensitivity of the test. KEY WORDS : CarcinomaProstate, Prostate Specilic Antigen (PSA)

INTRODUCTION MATERIALS AND METHODS

A denocarcinomaof the prostate predomi- Cases of carcinoma prostate registered at the oncology center INHS ASVINI were analyzed to /\ nantly affects older men, however cases l- lhave beenreported in patientsas young as in identify modes of presentation clinical profile of their 30's. Symptomscommonly include obstruc- patientsand treatmentoffered. The total number of tive symptoms, hesitancy, slow streaming, fre- clinically suspectedcarcinoma patients who under- quency, nocturia or irritative symptoms like went Trans Rectal Ultrasound guided biopsies in frequency urgency and dysuria. In addition patients one year was analyzed to give the sensitivity and may present with metastatic disease,gross hema- specificity of the procedure. turia and have bone pain or other symptoms refer- able to the metastases. RESULTS Total number of prostate cancer patients regis- Populationbased studies have shown that 30%oof tered at the center was 10. The age distribution men older than 50 yearswith no clinical evidenceof ranged from 54 to 83 years. Obstructive and irrita- prostate cancerhave foci ofcancer within the pros- tive symptomswere the presenting feature in eight, tate. Such a high prevalenceis seenin no other organ which included two patients who presented with and makesprostate cancer the most common malig- retention of urine. One unusual casepresented with nancy in human beings. 24o/oof prostate cancer cervical lymphadenopathyalone and one presented patients have bone metastasisat presentation(M 2) with uremia due to obstructive uropathy causedby while 28o/ohave palpable cancerextending beyond multiple enlarged abdominal lymph nodes. Digital the capsuleof the prostate.Of the digitally palpable biopsy was confirmatory in 9 of the 10 cases.Pros- (TB) cancers 60Yo are found to have breachedthe tate Specific Antigen was significantly elevated in capsuleduring radical prostatectomy[]. all the five casesin which it was done. Bone scan was positive in four (Table l). The total number of

*Classified Specialist in Surgery and Oncosurgeon;+Graded Specialist in Medicine and Oncologist; #Classified Specialist in Surgery and Urology, INHS ASVINI, Colaba,Mumbai 400 005.

5Z Jour. Marine Medical Society,July 1997, Vol. 4, No. I Trans Rectal Ultrasound (TRUS) guided biopsres TABLE I for clinically suspectedprostate cancer done in last Clinicopathologicalprofile oneyearwere 145.Total positiveon TRUS biopsies Feature were 9. Total actually positive casesof carcinoma prostatein the sample 10 sensitivity 90%, specificity Age range 54 - 83 Years l0 100%.There were no falsepositives (Table 2).The Prostatism t) treatment modality offered to these patients was Retention 2 bilateral orchiectomy alone in seven. Bilateral or- Cervical Lymphadenopathy I chiectomy with flutamide in one and bilateral or- Vomiting and loose motions chiectomy with flutamide and local radiotherapyfor (uremia) I bony metastasesin two (Table 3). DRE Suspicious l0 TRUS biopsy +ve 9 DISCUSSION PSA rise significant 5 years of5 tested About 30% of men older than 50 with no ^ clinical evidenceof prostatecancer have foci of Bo4e scan*ve cancer within the prostate [2]. Such a high prevalence.is seen in no other organ and makes prostate TABLE2 cancer the most common malignancy in human be- TRUS biopsy gins [3]. Small clinically detectedprostate cancers have a slow doubling time but progressionis relent- TRUSBiopsies No less with local recurrence often preceding distant \Carcinoma prostatepatients in sample l0 metastasis.Although the diseaseaffects predomi- Positive on TRUS 9 nantly older men; caseshave been reported in pa- False positive Nil tients as young as in their thirties. In our seriesthe False negative I youngest patient was 54 years old, presentedwith Sensitivity 90% renal failure and had the most elusive histology. The Specificity t00% raised serum PSA, pattern of abdominal lymphadenopathy,the FNAC favouring adenocarcinomaover lymphoma and the response to bilateral orchiec- TABLE3 tomy, which was resortedto asa life savingmeasure, Treatmentmodality clinchedthe diagnosisin his case.It is a digeaseof Therapeuticmodality No older men; the age range in our serieswas form 54 to 83 years. Bilateral orchiectomy alone 7 Bilateral orchiectomy + Flutamide I The commonpresenting symptoms include hesi- Bilateral orchiectomy + Flutamide + Radiotherapy 2 tancy, slow streaming, frequency, nocturia, urgency, dysuria, hematuriaand retention of urine and thesewere the common presentingsymptoms in our it was estimated. Although the absolute value of cases.The rare presentationsinclude cervical lym- PSA is not by itself diagnostic,levels above 10 phadenopathy, abdominal lymphadenopathy and nglml should be considered highly suspect. The occasionally a clinical syndrome resembling either intermediate levels of PSA 4-10 nglml carry ap- primary or metastatic adenocarcinomaof the lung proximately 33% probability of carcinoma.The free [4,5]. In our seriesone patient presentedwith cervi- to total prostatespecific antigen ratio increasesthe cal adenopathyalone and one with abdominal lym- specificity of prostate specific antigen. Though phadenopathycausing bilateral ureteric obstruction ProstateSpecific Antigen density (PSAD) and Pros- and renal failure. tate Specific Antigen density of the Transition zone The diagnosis is suggestedby a Digital Rectal (PSADT)have been studied extensively, PSA levels Examination(DRE). DRE was suspiciousin all the continue to be recommended as indicators for bi- casesanalysed. The ProstateSpecific Antigen was opsy [6,7]. The PSA level risesby an averagerate significantly elevated in all the five casesin which of 3.5 ng/ml per gram for cancerand 0.3 nglml per

Jour. MarineMedical Society, July 1997,Vol. 4, No.I 33 gram of benign prostatic hypertrophy tissue. The REFERENCES PSA velocity is the assessedprogressive rise of l. JohnsonJE. Natural history oflocalised prostatecancer : A serumPSA on an annualbasis. Retrospective studies population based study in 223 untreated patients. Lancet have shown that an increase of 0.75 nglml or an 1989:I :799. increase of more than 20o/oin year is significant 2. McNeal JE, Kindrachuck RA, et al. Patternsof progrcssion in prostate cancer.Lancet 1986; I I : 60-63. [8,9]. The ProstateSpecific MembraneAntigen is part of a new generationof monoclonalantibodies 3. Dhom G. Epidemiologic aspectsof latent and clinically that may add to the present array of diagnostic manifest carcinoma of the prostate.Journal of Cancer Re- modalitiesand may help in clinching the diagnosis searchand Clinical Oncologt 1983; 106 : 210-18. when facedwith a diagnosticdilemma [ 0]. If either 4. GentilePS, Carlos HW, et al. Disscrninatedprostatic carci- the DRE or PSA is abnormal, Transrectal Ultra- noma simulating primary lung cancer.Indications for imrnu- 1988;62 (4) : 7l l-15. sound guided (TRUS) biopsy is indicated and was nodiagnosticstudies. Cancer donein all the casesstudied. The biopsywas confir- 5. RenshawAA, Nappi D, Cibas ES. Cytology of metastatic matory in 9 of the l0 casesanalysed giving a sensi- adenocarcinomaofthe prostate in pleural effusions. Dlrrg- nostic Cytopathologt 1996;'l5 (2) : 103-7. tivity of 90% andspecificity of 100%.The bone scan was positive for metastaticdisease in 4 of the l0 6. Gohji K, Nomi M, Egawa S, et al. Detection of prostate prostate antigen, its density, and patients;which is considerablyhigher than the24yo carcinoma using specific . the density of the transition zone in Japanesemen with metastatic disease at presentationsuggested by intennediate serumprostate specifi c antig! ioncentrations. population basedstudies []. The higher figure is Cancer 1997;79 (10) : 1969-76. is hospital understandablesince this study based. 7. Nixon RG, Lilly JD, et al. Variation of free and total prostate All l0 patientswere treatedby bilateral orchiec- specific antigen levels: the effect on the percent free/total tomy, three patientswere prescribedFlutamide in prostate specific antigen.Archives of Pathologt and Labo- ratory Medicine 1997: l2l (4) : 385-91. addition and two of these, further, required local radiotherapy to conhol symptomatic bony metasta- 8. SrinivasV. Cancerof the Prostatein Urological Oncology, ses.Treatment selection in eachcase was basedon Midland OdessaMedical, Texas, USA. 1997;51-64. the extent of the disease.Treatment options include 9. Michael S, Mike K, GordonW. A medicalreveals a slightly observation,hormonal manipulation,radiation ther- raisedPSA. ThePractitioner 199'7;241: 303-15. apy and surgery.Radical Prostatectomyis currently 10. Israeli RS, Grob M, Fair WR. Prostatespecific membrane advocatedfor organ confined disease(Stage TA and antigen and other prostatic tumour markers on the horizon. (2) 439-50. TB) with no metastasisto regional nodesconfirmed Urologt Clinics ofNorth Ameica 1997;,24 : by frozensection [8]. Local progressionoccurs long I l. LabrieF, DupontA, e/ a/. Combinationtherapy with castra- before identifiable distant metastasesand if the pa- tion and flutamide : today's treatment ofchoice for prostate canccr. Journal of Steroid Biochemistry 1989; 33 (4B) : tient does not have an estimated10-15 year life 8t7-21. expectancy,neither radical prostatectomynor irra- 12. Delaere KP, Van Thillo EL. Flutamide monotherapy as diation therapy should be considered.Orchiectomy primary treatment in advanced prostatic carcinoma. Semi- is as effective as radiotherapy in achieving local narsinOncologt l99l: l8 (5 Sup6): l3-18. control and not surprisingly, more effective in de- I 3. Benson RC . A rationale for the use of non-steroidal antian- metastases.The review by Labrie et laying time to drogens in the management of prostate cancer. Prostate - a/ complementsthe findings of the EORTC and the Supplement 1992; 4 :85-90. NCI trials, which suggestan advantageto flutamide, 14. SoderdahlDW, Wettlaufer JN, el al Neoadjuvant honnonal plus ablation of testicular androgens.Local radia- therapy in the managementofprostate cancer: a surgical and tion and Strontium 89 as monotherapyor adjunctive radiation therapy review. Techniquesin Urologt 19.96;2G) to radiotherapyis usefulfor pain control I l-15]. :194-206. 15. StameyTA, McNeal JE, in Walsh PC, Retik AB, Stamcy TA, VaughanDE Jr (Eds).Campbell's Urology. Sixth Edi- tion. Philadelphia,WB SaundersCO. 1992; ll59-1214.

34 Jour. Marine Medical Society,July 1997, Vol. 4, No. I ACCIDENTALPOISONINGS IN CHILDREN

SSMATHAI*, KS BAWA+, G GUPTA#, sR DAS@,RN MEHRJSHI**

ABSTRACT This retrospective study was designedto analysethe incidenceand causesof poisoning in children aged 0 to 10 years over the last four years. The incidenceof accidentalpoisonings in this population was low with the I to < 3 years age group having the highestincidence. Kerosene was the most common poison involved and the incidence of pulmonary involvement increasedwhen ingestionwas followed by choking or vomiting. The mortality rate was nil. Most casesoccurred at home and could have been prevented. KEY WORDS : Poisoning,Kerosene ingestion.

INTRODUCTION for observationfor at least 24 hours. A ccidental poisoningsremain a lamentably . Gastric lavage was done in all cases except A p."u"ntable carrseolpediatric morbidity and keronse/volatilesubstance ingestion or corrosive L lmortalitv in our country. The incidencein ingestion.No child was brought in an unconscious India varies from 0.3-7%o[I -3]. bral poisonsconsti- state.Specific antidote and antibiotics were used tute 60-95Yoof caseswith keroseneingestion ac- whereindicated. counting for 14-57% of oral poisons [4,5]. In keroseneingestion cases chest roentgenogram Pulmonary complicationsoccur in almost 50% of was done 6 to 12 hours after ingestionin all cases. keroseneingestion cases [5]. Householdchemicals, Pulmonary involvement was diagnosedif two or pesticidesand drugsare the otheragents commonly threecriteria were present - disproportionatetachyp- involved. noea, rhonchi on auscultation and roentgenogram METHOD findingsof pneumonitis,hyperinflation or air leak. A retrospective study was carried out from July No steroidsor liquid paraffin were used in any 93 to June 97 from service records including re- case.Antibiotic (Ampicillin only) was given for a trieval of casedocuments of all admittedcases of period of sevendays in caseswith positive X-Ray poisoningduring this period.Documents were stud- findingsto preventsecondary bacterial infection. ied for history,events in hospitaland final outcome. RESULTS Environmentalfactors as recordedin history were A total of49 casesofaccidental poisoning were assessed.Snake bite and insectbite caseswere in- admitted during the study period. Out of these 45 cluded in parentalpoisonings. were oral ingestionsand four were parental poison- The study group constitutedchildren in the age ing (snakeand insectbites). The incidenceofacci- group ofO-10 yearsofDefence personnel who were dentaloral poisoningsin children constituted0.8% adrnittedto the hospitalfor accidentalpoisonings. of all pediatricadmissions (49 out of 6650 pediatric The averagenumber of childrenper family was2.7 medicaladmissions). and the averagenumber ofpersons stayingper room Year-wise incidence was similar (1993- was3.6 94:0.74%. 1994-9 5 :0.81%. I 995-96: 0. 8 9%. | 996- The treatmentprotocols followed in the hospital 97:0.82%). were that all casesofaccidental ingestion ofpoison- The male/femaleratio was 1.9:1. ous substanceswere admittedto the pediatricward

*Classified Specialist Paediatrics,+Classified SpecialistPaediatrics, #Classified SpecialistPaediatrics @Post Graduate Trainee ++SeniorAdvisor Paediatrics,Department of Pediatries,INHS Asvini, Colaba,Mumbai-400 005.

Jour. Marine Medical Society,July 1997, Vol. 4, No. I 35 The average hospital stay was 4.2 days. (kpro- Pulmonary involvement was seen maximally in sene 5.2 days, drugs 2.9 days,chemicals 3.0 days, those children who had both cough/choking and insecticides5.7 days) vomiting. Besides pulmonary involvement and fe- The averagetime betweeningestion ofthe poison ver no other complication was seen. and hospitalization was 25 minutes. Hospital stay was as follows: The mortality rate was nil. With pulmonary involvement: 8.1 days. Without pulmonary involvement: 2.3 days. TABLEI Agentr involved Drugs

Agent No, of Percentage Drugs ingested included BB lotion, Syp Rifam- Cases picin, Syp Diphenhydramine,Syp Phenergan(iatro- genic overdose in one case), Tab Brufen and Tab Kerosene 25 5t.0 Iron. Prugs 9 18.36 Chemicals 5 lo.2 All casesresponded to gastric lavage and symptomatic treatrnent.Desferrioxamine was given for Insecticides J 6.1 poisoning. Naphthalene J 6.t Iron Parenteral 4 8.1 Chemicak Common householdchemicals ingested included TABLE 2 Brasso Dettol, and Phenyl. Lavage was done when Age Distribution indicated. Age Percenlageofcases Insecticides 0-5yrs 0.5 Enviromental factors 97% ofcases occurred at home. Kerosene Poisoning In 80% of families kerosenealone or along with Most children had coughed,choked and/or vom- LPG was used for cooking. ited immediately after ingestion. Supervisionof children prior to ingestion was as The exact quantity ingested could not be deter- follows: mined from history due to spillage but most parents TABLE4 felt that l0-15 ml had beeningested. The relation ofpulmonary involvementto cough- Supervision Kerosene Other ingestion poisoning ing/choking and fever was as follows: Unsupervised t7 8 TABLE3 Supervisedby 4 6 Friend/relative Pulmonary Fever Involvement Supervisedby eldersib 4 l0 No% No o/o

Cough/choking 88 450 3 37.s In 50% of cases children were playing unat- Vomiting 6 2 33.3 2 33.3 tended at the time of ingestion. Cough/choking 6 85.1 2 28.5 ln67% of caseskerosene was stored in a looselv And vomiting capped/uncappedcontainer. None Mistaken identity was the main causefor inges-

36 Jour. Marine Medical Society,July 1997, Vol. 4, No. I tion in the > 3yr, age group. the primary cause.This is collaboratedby other studies DISCUSSION AND CONCLUSIONS [5,6]. Thehospital stay in kerosenepoisoning The incidence of accidental poisoning in our without pulmonaryinvolvement was (2.3 population was 0.8% of all pediatric admissions short days).It is suggestedthat if onecan reliably confirm which was low compared to national figures that only [,2]. a small quantitywas ingested This was probably due to the smaller numbers in- and that it was not followedby coughing/choking volved and better awarenessin this population. or vomiting,hospi- talisationmay not be required.X-Ray chest6-12 Kerosene still remains the commonestoral poi- hoursafter ingestion could be done as an out-patient son in childhood. Singh, Singhi, et alhave shown a and furtherdecision regarding admission could be decrease in the incidence of kerosene poisoning takenthereafter. from 42Yoto l4Yo in the last decade[2]. The high incidence in our population is similar to that seenin REFERENCES other studies [3,4] and could be due to the fact that l. AlkaSingh, ChoudharySR. Accidental poisoning in chil- most families still use this for cooking even if LPG dren.Indian Pediatric 1996:33 : 39-40.

is available.Most studieshave shownthat coughing, 2. Singh S, Singhi S, Sood NK, er n/. Changing pattem of choking or vomiting increasethe incidence of pul- childhood poisoning (1970-1989). Experience in a large ' monary involvement in keroseneingestion [5,6]. In North Indian Hospital. Indian Pediatric 1996;32 :331-5. our study 12 out of 24 patients who had coughing, 3. Khadgawat R, Garg P, Bansal P, e/ a/. Accidental poison- choking or vomiting had pulmonary involvement ings. Indian Pediatr 19941'31: 1555-7. compared to 0 out of 4 who did not. 4. Kumar V. Accidental poisoning in south - west Maharastra. However, this could not be statisticallyevaluated Indian Pediatr 1995;28 :737-5. because of the small numbers involved. Fever is 5. Lucas GN. Kerosene oil poisoning in children. Indian J probably unrelated to pulmonary involvement and Pediatr 1994;61 : 683-7.

may be reactionary [3,4]. Environmental factors 6. Rice WH, Ward G, Kelley J, el a/. Pulmonary toxicity suggestedthat carelessnesson the part ofthe care- following GI ingestion of kerosene.An Emerg Med 1982; I I takers rather than fault on the part of the child was :138-40.

cl,UithQest Comp0tmonts

Stom

E,MERCKOITDIil LIMITED

Jour. Marine Medical Society, July 1997, Yol. 4, No. I 37 Emerging Trends NEWERPROGNOSTIC INDICATORS IN BREASTCARCINOMA

Lt Col S BHATTACHARYA*

INTRODUCTION TIIE PREDICTORS HORMONE RECEPTORS reast carcinomais the most common malignant tumor and the leading cause of carci- Estrogenreceptors (ER) and progesteronerecep- noma death in women in the Westem tors (PR) arenow included inbasic workup ofbreast countries. In the US 1,00,000new casesaro identi- cancer. ER and PR are both expressedon the nu- fied each year with the mortality figure of 30,000 clear membraneand are identified in paraffin sec- [l]. Cunently , approximately,75,000 new casesof tion using Immuno histochemistry (IH) techniques. breast cancer are estimated to occur in Indian ER/PR positivity means that the patient is likely to women every year. It is the second most common have an improved and prolonged diseasefree status, site for developmentofmalignancy after cervix uteri including a better overall survival. It also predicts [2]. However in most urban areas,it is the leading the tumor responseto adjuvant hormonal therapy. cancer in women and it is estimatedthat one out of However patientswho relapseafter having received every 55 Indian women would develop breastcan- adjuvant Tamoxifen therapy show a significant re- cer by the ageof 64. The annual age adjustedinci- duction in ER/PR expression. Relapse in these dence in urban areashas increasedfrom 21 to 28.3 casescould be associatedwith the development of per 1,00,000and from 5.2to 16.4per I ,00,000in the an ER/PR negative phenotype, and this provides a rural areasin last five years [3]. growth advantageto such cells [4]. Prognosticationof outcome like diseasefree sur- ps2 periods, to therapy and tumor related vival response It is an estrogeninducible cysteinerich secretary on age, menopausal death has largely been based protein expressedby nearly 50% ofbreast cancers. grade, invasion and lymph status,tumor size, type, High values correlate with hormone receptor posi- researchhas been undertaken node status.Extensive tivity, small tumor size, better grade of tumor and patients are at a higher risk for to identiff who low mitotic rate. It also indicates a better response relateddeaths. Currently, sev- recurence and tumor to treatmentfollowing initial relapse. The protein is eral other factors relevant to biology of breastcan- identified on paraffin sectionsby IH [5]. cer are being investigated, and many of them are being now used routinely in some centres.Under- Ki-67 taking such studieshas two objectives: It is a nuclear antigen found throughout the cell a. It identifies subgroupofpatients with a low risk cycle but is absentin resting cells. The findings are of recurrencewho would benefit from limited analogousto the determination of S-phasefraction or local conservative therapy and would not by flow cytometry and proliferating cell nuclear require adjuvant systemic therapy. antigen (PCNA). PCNA however is presently considered less sensitive. The antigen is identified on b. The second area is in the field of familial or paraffin sectionsby IH genetically predisposedbreast cancer. [6]. In this review someaspects ofthe stateofthe art, C-erbB-2 and newer concepts in the biologic proglostic pa- It is an oncogeneand can be detected by IH by rametersofbreast cancer are discussed. demonstrationof its protein product. Over expres-

*Classified Specialist (Pathology), INHS Asvini, Mumbai 400 005.

38 Jour.Marine Medical Societv, July 1997,Vol. 4, No.I sion of C-erb B-2 confersresistance to chemother- of prognostic indicators would leave a clinicran apy and has been associatedwith poor prognosis, more confusedthan enlightened.Fortunately, most especiallyin nodepositive patients.The meansur- ofthe good and bad indicators occur in the pattem vival time for those with tumour over expressing complimentingeach other, but no singleprognostic 'the' C-erbB-2 was only 29 monthsas comparedto 110 indicator can be called prognostic factor which months for thosepatients who did not expressC-erb the clinician can bank on. The information obtained B-2 Ul. C-erbB-2 expression predicts improved however yet cannot be translated into everyday responseto chemotherapywith Doxarubicin, than to clinical therapeuticdecisions. Cyclophosphamide,Methotrexate, 5-fluorouracil Refinements in therapy for breast cancer have (CMF) improved the overall survival rates remarkably. nm 23 With conventional grading and staging it has however been almost impossible to predict the outcome The nm 23 genehas been associatedwith metas- in individual casesleaving grey areas. These new tatic suppressiveability. Reducednm 23 expression prognostic indicators hold future promise. With correlateswith higher metastaticpotential. A case breast carcinoma now being the leading cancer in is considerednegative if the lesionalepithelium is urban India thereis needto considerapplication of unstainedfor nm 23 proteinby IH. thesetools routinely. p53 MUTATION REFERENCES The p53 gene,located on the shortarm ofchro- l. Sondlik EJ. Breast cancer trends. Incidence, mortality and mosome l7 encodesa nuclearphosphoprotein that survival. Cancer 1994;74 : 995-9. is involved in the control of cell growth by keeping 2. National CancerRegistry Programme,Biennal Report 1988- a check on the entry ofcells into the S phase.Thus 1989;An epidcrniologicalstudy, New Delhi: IndianCouncil a p 53 mutation correlatesa worse prognosis. Pres- of Medical Research1992. ence of mutant p53 gene is known to confer resis- 3. JussawalaDJ, Yeole BB, Natekar MV, Sunny L. Cancer tance to CMF therapy and correlateswith relapse morbidity and mortality in Greater Bombay, 1993. Bombay t8l. cancer Registry, NCRP, ICMR, The Indian Cancer Society, Bombay 1995. MICRO VESSEL DENSITY 4. JohnstonSRD, Saccani- Jotti G, Smith IE, et a/. Changesin prominent Invasive breastcarcinomas having a estrogen receptor, progesterone receptor, and pS2 expres- vascular component in the surrounding stroma be- sion in Tamoxifen resistanthuman breastcancer. Cancer Res have in a more aggressive fashion than others. 1995;55:3331-8. Angiogenesisand microvasculardensity is studied 5. Racca S, Conti G, Pietribasi F, et al. Conelation between by countingmicro vesselswhich arehighlighted by other prognostic factors in breastcancer. Int J Biol Markcrs factor VIII relatedantigen immunostaining by lH 1995:l0:87-93. tel 6. PageDL. Prognosisand breast cancer. Recognition of lethal and favourableprognostic types. I nt J Surg Pathol I 99 I I 5 PREDISPOSITION ; GENETIC :334-49.

Identification of breast cancer susceptibility 7. Bacus SS, Zelnick CR, Plowman G, Yarden Y. Expression genescalled the BRCA geneshas beenone ofthe of erb-2 family of growth factor receptorsand their ligands major success stories in breast cancer research. in breast cancer. Am J Clin Pathol 1994; lO2 (suppl.) : Mutations in the BRCA gene account for 50% of 5t3-24. inherited breast cancers.Women with mutations in 8. Peyrat JP, Bonneterre J, Lubin R, et al. Prognostic signifi- this genehave a high risk ofdeveloping earlyonset cance ofcirculating p53 antibodiesin patientsundergoing breastand ovariancancer. A predispositionto can- surgery for loco-regional breast cancer. Lancet 1995;345 : cer ofprostate and colon amongthe family members 621-2. is alsonoted [0]. 9. WeidnerN: Intra tumor microvesseldensity as a prognostic factor in cancer.Am J Pathol 1995: 147 :9-19. CONCLUSION I 0. Lynch HJ, Clinical/genetic featuresin hereditary breastcan- In the end one may wonder if sucha hugebattery cer. Breast Cancer ResTreat 1990: l5 : 63-71.

Jour. MarineMedical Society, July 1997,Vol. 4, No. I 39 EMERGINGTRENDS IN ALCOHOLRELATED DISORDERSAND THE NAVY

Surg Cdr VSSR RYALI*, Surg Cdr MJ JOHN**, Surg Lcdr A TRIPATHI***, Surg Lcdr KK MISHRA+

ABSTRACT Trendsindicate that alcoholis hazardousin all dosesboth moderateand heavy.World HealthOrganization has broadenedthe criteria for diagnosisof alcoholrelated disorders which will increasethe alreadyheavy burden on Naval psychiatricservices. A broad etiopathologicalmodel combining genetic and neurobehavioralaspects is neededto understandthese chronic disabilities.Advances in management focussed on drugsand therapieswhich reducerelapses. Navy has built cosiderableinfrastructure to accomodatethese advances.Prevention would require both medicaland administrativemeasures. Areas where infrastructure needs to be strengthenedin the coming decadeare identified. KEY WORDS: Trends,Alcohol, Navy.

INTRODUCTION major depressionand dysthymia[3]. f1l'th. decade 1987-96 visualized radical World Health Organizationin it's tenth edition of internationalclassification of diseases(ICD-10) I changesin the conceptualization,etiopathol- I- ogy, managementand prevention of alcohol useda broadercriteria for inclusionofpatients in the related disorders.Corrosponding developments in group (F-10), mental and behavioraldisorders due the Navy are highlighted to identify the strengths to useof alcoholunlike theprevious edition 0CD-9) andweaknesses ofmedical servicesin tacklingthese which used a narrow criteria for alcohol depend- widely prevalentchronic disorders. ence.Armed forceshave not adoptedICD-10 and evenby the narrowcriteria of ICD-9 alcoholrelated CONCEPTUALIZATION disordersaccount for 10.7 to 21.9 percent with a meanof 17.6percent of all freshpsychiatric admis- The decadebegan by contradictionofone ofthe sionsin men and 4.5 to 46.1percent with a meanof longest standing beliefs that moderate drinking is 21.2 percentin officers (Fig I ). Eventualadoption protective against death due to cardiovasculardis- of ICD-10 criteriawill essentiallylead to increasein ease.A 7.5 year prospectivestudy by the British load due to inclusion of casesof hazardousand heartfoundationl (1988) involving 7735 men aged harmful use of alcohol. Harmful use constitutes 40-59 years found no protection offered by alcohol alcohol use leadingto motor vehicle accidents,in- consumption, both moderate and heavy against juries inflictedon self or others,physical disabilities death due to cardiovascular disease. Chang et al like gastritis, peptic ulcer, hepatitis, peripheral (1988) on the other hand confirmed that drinking neuropathiesand anaemiasto list a few. Casuality and driving do not mix. They reporteda median medical centresneed to be equipped with blood blood alcohol level of 200mg/dl, which is well alcoholdetection kits and provostunits with breath abovethe driving skills hamperinglevel of 50mg/dl analysersto detect hazardousand harmful use. in 53 out of 80 driversin motor vehicleaccidents. A comorbidity studyon 51I patientswith alcoholand O'Brien (1994) conceptualizesalcoholism as a drug problernsshowed that 78 percenthad lifetime chronic medical disorder like arthritis or diabetes psychiatricdisorders like antisocialpersonality dis- wherecomplete abstinence is the preferredgoal but order, phobic disorder,psychosocial dysfunction, rarelyachieved. Treatment benifits need to be meas- tClassifiedSpecialist (Psychiatry); ++Classified Specialist (UnderWater Medicine) and Psychiatrist; t**Graded Spccialist(Psychiatry); Instituteof Naval Medicine,Murnbai.f00 005. +GradedSpecialist (Psychiatry), CGS Veera,Mumbai 400 023.

Jour. Marine Medical Society,July 1997, Vol. 4, No. I Ten-Beddedpsychiatric centreswere also set up at two Naval Hospitals at Cochin and Vishakha- patanam. Treatmentof acute alcohol intoxication is symptomatic and consistsofcorrection ofacid-base and electrolyte imbalance, hypoglycemia, hypovitami- nosesand maintaining a patent respiratory airway. Metodoxine may be usedto accelarateurinaryelimi- nation of ethanoland aldehyde.Alcohol withdrawal is managedby alcohol itself, chloralhydrate, paral- dehyde, chlormetiazole and large doses of ben- zodiazepines[8]. Drug of choice in the serviceshas been chlordiazepoxide dose titrated against signs and symptomsof withdrawal. Detoxification is uni- versally succesful and there was no mortality at Fig. l: Alcoholics as a percentage of all psychiatric Asvini DAC during the period 1987-96. admissions. Preventionof relapseto alcohol dependenceis ured by length of remission, reduction in alcohol not assuccesful. Kristenson (1995) reported that the use, improvement in health and enhancementin best out of antabusedrugs like disulfiram and cal- socialfunctioning[4]. cium carbimide is obtained when they are taken in ETIOPATHOLOGY adequatedoses and under direct supervision of a therapist [9]. Asvini DAC was involved in a mul- Twin and adoption studiesin men earlierstrongly ticentre AFMRC project using disulfiram at a dos- suggestedgenetic factors especially D2 dopamine age of 500mg administered twice a week under receptor geneplaying an important role in the etiol- direct supervision.Results of the study are being ogy of alcoholism.Kendler et al (1992)conducted processed[0]. personal structured psychiatric interviews of 1030 female-female twin pairs with known zygosity and Opioid antagonist naltrexone is reported to re- concludedthat heritable liability to alcoholismin duce the pleasurableeffects ofalcohol and thereby women ranged from 50-60 percent depending on reducerelapse. Volpicelli et al (1995) and O'Mal- whether a narrow or a broad criteria is applied [5]. ley (1995)showed that naltrexoneworks bestwhen Anton et al (1995) proposed a neurobehavioral combinedwith psychosocialtherapies. These stud- model for alcohol abuse.Reinforcement and stress ieshighlight the pressing need for counsellorsin the reduction are prominent in the initiation of alcohol psychiatristunits u 1,121. use while neuroadaptationto chronic alcohol expo- Other drugs studied for their effect in preventing sure and Pavlovian conditionine results in alcohol alcohol relapsesinclude gamma amino butyric acid dependence[6]. (GABA) analogueacamprosate (1995) serotinin re- MANAGEMENT uptakeinhibitors fluoxetine and zimelidine (1990) as well as citalopram and centrally acting highly A Deaddiction centre (DAC) was establishedat selective5 -HT 1C/2 antagonistritanserin I 3- I 5]. Asvini in May 89. The treatmentschedule at Asvini [8, Fluoxetine has been regularly used at Asvini DAC DAC resembledthe older alcoholics rehabilitation during the last one year. (OAR) programme of Keshner el a/. The OAR programme comprised2-7 daysof inpatient detoxi- Goodman et al analysedthe varibles related to fication, 3-4 weeks inpatient treatment and l-year the costs of alcohol treatment. Patients detected outpatient aftercare whereas the DAC programme early and with low severity of illness can be treated comprised of 7-14 days inpatient detoxification, 4-6 as psychiatric out- patients and inpatient treatment weeks inpatient treatment and 2-years outpatient shouldbe reservedfor severecases ofdependence aftercare and surveillance. and thosewith comorbidity.

Jour. MarineMedical Society, July 1997,Vol. 4, No. I 4I Brady reviewed the potential for genetherapy rn tality in British men: Explaining the U-shaped curve. Lancet alcoholism. Suggestions were made conceming 1988;2: 1269-73. identification of candidate genes, design of gene 2. Chang G, Astrachan BM. The Emergency Deparfnent Sur- antisenseconstructs and techniquesfor their organ veillance ofalcohol intoxication after Motor Vehichle accidents.JAMA 1988:260 :2533-36. specificdelivery [7]. 3. Ross HE, Glaser FB, Germanson T. The prevalence of PREVENTION psychiatric disorders in patients with alcohol and other drug Ritson summarizedpreventive strategiesfor al- problems.lrcl General Psychiatry 1988;45 : 1023-31. cohol related disorders. However, prohibition is 4. O'Brien CP. Treament of alcoholism as a chronic disorder (Review). (6) consideredinappropriate I I 8]. Preventivestrategies l/coiol 1994; I I : 433-37. should focus on the whole service population, high 5. Kendler KS, Heath AC, Neele MC, Kessler RC, Eaves LJ. risk groups like children ofalcoholics and high risk A population based twin study of Alcoholism in women. -82. behaviors like drunken driving and offending. Pri- JAMA 1992:.268 :. 1877 mary prevention includes control policies, educa- 6. Anton RF, Kranzler HR, Meyer RE. Neurobehavioural as- tion and provision of altematives. Fiscal measures pectsof the pharmacotherapyof alcohol dependence.Clini- cal Neuroscience 1995;3 (3) : 145-54. are of proven value and increasingcosts of alcohol 7. Keshner TM, Rodell DE, Ogden SR, Guggenheim FG, Kar- in service canteensand clubs could be considered. ' Regulatory controlls include use ofbreath analysers son CN. Outcome and cost of two VA inpatient treatment progmmmes for. older alcoholic patients. Hosp Community on duty staff especiallydrivers. Altematives include Psychiatry 1992; 43 : 985-89. provision of gymnasia, sports complexes,comfort- 8. GessaGI. Guidelines for the drug therapy of alocoholism. able well stocked libraries and alcohol free bever- RecentProg Med 1990;8l (3) : l7l-75. ages in clubs and canteens.Secondary prevention 9. Kristenson H. How to get the best out of antabuse(Review). includes early detection of casesby blood alcohol Alcohol and Alcoholism 1995;30 (6) : 775-83. estimation in all medicolegal casesand exercising 10. AFMRC Project high index ofsuspicion in alcohol relateddisorders. No.2044l95. Alcoholism treaftnent-Low dose biweekly disulfiram project. CONCLUSION I l. Volpicelli JR, Volpicelli LA, O'Brien CP. Medical manage- Trends indicate that alcohol is hazardousin all ment of alcohol dependence: Clinical use and limitations of naltrexone treatment (Review). Alcohol and Alcoholism doses.ICD-10 recommendsa broad criteria for di- 1995;30 (6) : 789-98. agnosesofalcohol relateddisorders. A broad model 12. O'Malley SS. Intergation of psy- encompassing genetics and neurobehavioral sci- opioid anagonists and chosocial the;apy in the treatment of narcotic and alcohol encesis essentialto understandthis chronic disabil- dependence. (Review). Jourdal of Clinical Psychiatry ity. 1995;56Suppl7:30-8.

Advances in alcohol therapiesfocussed on meas- l3 Chick J. Acamprosate as an aid in the treatment of alcohol- ures to prevent relapses.Prevention would neccesi- ism (Review). l/cohol and Alcoholism 1995;30 (6) : 785-7. tate medical, administrative and regulatory meas- 14. Narajo CA, Poulas CX, Bremner KE, Lanctot KL. Citalo- ures. pram decreasesdesiariblity, liking and consumption ofalco- :,r't Navy has built considerableinfrastructure in the ,hd in a,ba\o),@ru|c,nt dr':nkas, Ct u" P'l,zrmac u" Zfter 1992;51:729-39. form of a deaddiction centre and two psychiatric centresover the last decade.Areas where infrastruc- 15. JanssenPA. Addiction and the potentjal for therapeuticdrug development (Review). EX,S 1994'11 : 361-70. ture needsto be strengthenedover the next decade include procurement of breath analysersand blood 16. Goodman AC, Holder HD, Nishiura E, Hankin JR. An Analysis ofshort - term alcoholism treatment cost alcohol detection kits, increasing manpower re- functions. Med Care 1992;30: 795-810. sources especially counsellors and earmarking I 7. Brady gene funds for research. RO. Potential therapy for alcoholism (Review). EXS1994:71 : 383-93. REF'ERENCES 18. Ritson B. Preventive Strategies for alcohol releated prob- l. ShaperAG, WannametheeG, Walker M. Alcohol and mor- lems (Review).lddiction 1994;89 (l l) : l49l-96.

)) Jour. Marine Medical Society,July 1997, Vol. 4, No. t t.How- RECENTDEVELOPMENTS IN THE MANAGEMENTOF mongst tum to BENIGNPROSTATIC HYPERPLASIA bstance ion,but SurgCdr VK SAXENAVSM*; Lt Col D BATURA* to kill rtrauma reath. INTRODUCTION i. Alpha Adrenergic Blocking Agents : These enign Prostatic Hyperplasia (BPH) is the have proved useful in the treatment of BPH, in cases where the dynamic component of ob- trwater most common causeof abnormalvoiding in struction is prominent. They are also useful to 100 men above40 yearsof ageresulting in clini- during the period when the patient is waiting or romthe cally significantsymptoms in l0-20% of patients.It is not fit for surgery. Unlike is estimatedthat one in five males will need an ment,a operationfor BPH []. It is observedthat surgeries a. Phenorybenzamine:This blocks both alpha-l rusfac- for BPH are increasing every year due to an ever and alpha-2receptors. It is now well understood )covery increasing aging population and increasedaware- that alpha-2blockade may not help in prostatic rsphere NCSS. adenoma.By blocking extra prostatic sites, it Transurethral resection of Prostate(TURP) re- may cause side effects. Some mutagenicity is mains the mainstay of all surgeries.As there have alsoseen with prolongeduse. ent are been improvements in endoscopicand electro sur- b. Prazocin: The drug most frequentlyused over gical equipmentover the last few decades,the safety the last l5-20 years,it selectivelyblocks alpha- efficacy and acceptanceofTURP hasincreased. I receptors. with Since TURP is associated sigaificant mor- c. Terazocin : This is now the drug of choice. made to look for alternate bidity, efforts are being With minimal side effects and a half life of approachesto the problemofBPH [2]. 12 it sensory about hours can be used as a day therapy. ALTERNATE APPROACHES d. Doxazosin : This drug has a half life of 20 A. Drugs hours. It is still under trials and subject of fur- r is not i. Alpha adrenergicblocking agents ther research. )ressure ii. 5-alphareductase inhibitors e. Tamsulosin: This selectivelyacts on alpha-lc subma- receptorsand possibly has the leastside effects. iii. Leutinising hormone releasing hormone rccident However, more studiesare under way. (LHRH) antagonists iv. Anti androgens ii. S-alphaReductase Inhibitors: To be active in ronsys- the prostate,testosterone must be converted to B. Minimally InvasiveStudy rariners dihydrotestosterone(DHT) by the enzyme 5-al- *down i. Prostaticstents pha reductase.Finestride is a potent 5-alpha a prod- ii. Balloon dilatation reductaseinhibitor. An oral doseof five mg per eat and day producesgood therapeutic action however iii. Hyperthermia sibility, it takes3-6 months for clinical response.The n some iv. Trans urethral needleaspiration (TIJNA) drug doesnot affect the testosteronelevel. In a elevant v. Trans urethral incision of prostate(TUIP) small percentageof patients this may decrease include vi. Trans urethral vapourisation of prostate the libido or causeimpotence. rol sys- (ruvP) ;chsys- LHRH antagonistsand anti androgens are not inglev- vii. Laser prostatectomy much usedin clinical practice. iew as- A. Druss B. Minimally InvasiveSurgery reculiar rd pro- +ClassifiedSpecialist in Surgeryand Urology, Dept of Urology, INHS Asvini, Mumbai 400 005.

4,No.I Jour. Marine Medical Society, July 1997, Vol. 4, No. l 43 i. Prostatic stents : These are inert, flexible and Due to less absorbtion of water no changesin 2. Pt (r bio-compatible stents. These are reserved for electrolytes occur [9]. The technique is safe. old males with retpntion of urine, who are unfit However only time will tell if it can replace gl for anaesthesiaand surgery. These stents are TURP. th placedunder direct vision underlocal anaesthe- gl vii. Laser prostatectomy : Laser is often enone- ir sia.[3] ously thought of as a magic wand. Most com- St ii. Balloon Dilatation: A speciallydesigned bal- prostatectomy monly used laser for is Nd : dr loon is placed in the prostatic urethra.The bal- YAG. Laser application causesrise in tempera- loon is inflated to 3-4 ATA. This pressure is ture. Ireversibledamage begins at 45oC,coagu- 3. Pr maintainedfor about 10-15minutes. This pos- lation necrosis and sloughing occurs at 60 w sibly acts by fracturing the prostatic commis- degrees,vapourisation and ablation at 100 de- e\ sure and by disrupting the alpha adrenergic grees.In contact tissue ablation, adequateure- th pr receptor sites [4,5]. This procedurerequires thral passage is established during the anaesthesia. procedure.The catheter can be removed after til n( ili. Hyperthermia : The prostatic tissue is heated 24-48 hrs. Laser ablation is safe and effective; til with a microwave probe. Subjective symptoms bleeding is minimal and electrolyte absorption get relieved in about 50Yoof the patients, but of fluid does not occur. However the main TREI disadvantageis that no tissue is obtained for very few show objective improvement. It is I. Pr histopathology, hence unsuspectedcarcinoma difficult to predict the result [6]. The procedure bt may be missed. Secondly there are prolonged can be done under local anaesthesia(LA) and ol initative symptomsdue to delayedsloughing of is easyto perform. However it requiresa special tir machine and repeatedsittings. High costsare a the tissue, and at times, need prolonged II. Pr limiting factor. catheterization[0,] l]. he iv. TUNA : In this, needles are inserted into the Criteria for treatment p( prostate under vision. Radio frequency energy A. SubjectiveEvaluation III. In is delivered into prostatic tissue.The tempera- m ture goes upto l00oC. The urethra is protected American Urological Association(AUA) and 5- by insulating the baseofthe needlewhich keeps WHO have devised a scoring system basedon ta the urethral temperaturebelow 42oC. The rise patient'sanswers to questionsabout his symp- bi in temperaturecauses coagulation necrosis and toms to score the voiding pattem and how it ultimately destruction of tissue. This can be effectsthe quality of life. A scoreof 0-7 indi- IV. Sr . cates mild, 8-19 moderateand 20-35 severe done under LA. [7]. lis symptoms. v. TUIP : The procedure is suitable for small a. glands and is recommendedin glands upto 30 B. ObjectiveEvaluation n( gm size.In this,incisions are made at 5 O'clock In addition to the traditional investigations,uro- b. and/or at 7 O'clock position. These start just dynamics has played a major role in obtaining it inter-uretericridge distal to the and extendupto preciseobjective data. c. the verumintanum.This is easyto perform. The re time of hospitalisationand complicationsare Patient Selection la shortened,but it needsanaesthesia [8]. With various options available today, it may not r€ vi. TUVP : In this, specially designedvapotrode be easyto decide the right treatmentfor a particular loops are used. It is basedon the principle that patient.However, following guidelinesmay be use- CHO] if higher power (about 240 watts) is used, the tul: I.T tissuesnot only get dessicatedbut vaporize.The 1. An acuteor chronic retentionof urine associ- S1 biggest advantagehere is that existing equip- atedwithorwithoutcomplications such as UTI, a ment and energysource can be used.The results bladder diverticulations. calculus etc are clear are similar to TURP with the advantage of indications. Cystometry at times may help if minimal blood loss and effect on haematocrit. atonicity of the bladder is suspected.

44 Jour. Marine Medical Society,July 1997, Vol. 4, No. I Jour. ngesin 2. Patientsthat presentwith obstructedsymptoms II. TURP is still the gold standardfor moderate is safe. (moderate or severe) with or without a large sizeof adenomaupto 60 gm. replace gland, very minimal work up is required and III. Openprostatectomy is requiredfor very large they are likely to be benefitedby prostatic sur- adenomas.Laser prostatectomy and TIJVP are gery. Ifneuropathic dysfunction is suspectedas elTone- gettingestablished. Whether they will replace in diabetesmellitus and Parkinsonisma pres- ;t com- TURPor not is yet to be seen. sure flow study and cysto-metryare essentialto sNd: decide the line of treatment. REFERENCES mpera- 3. Patientswho present with irritative symptoms l. Wein AJ. Benign Prostatic hyperplasia. In clinical manual coagu- of urology Hanro Wein (editors) with or without large adenomataneed further PM, AJ 2ndEd. McGraw ar 60 Hill Inc Singapore 1994:379. 100de- evaluation and are difficult to treat. These are the patients who may not be satisfied after 2. Mebust WI! et a/. Trans urethral prostatectomy immediate Ite ure- and post op complications - A cooperative study of 13 prostatesurgery as the initative symptomscon- rg the participating institutions evaluating 3885 patients. ./ Urol :d after tinue and may need drug therapy. They may 1987;l4l:243-7. need complete urodynamic evaluation to iden- fective; 3. Yachia D, Beyor H, Aridogan TA. A new large calibre, self orption ti$ the bladder instability. expanding and selfretaining temporary inter prostatic stent in the treatrnent e main TREATMENT OUTLINES ofprostatic obstructors.Br J Urol 1994;74 ned for :47-9. I. Patients with eaily prostate symptoms should cinoma 4. Maseley WS. Balloon dilatation of prostate. Keys to sus- be watched and early surgery should not be llonged tained favourable results. Urologt 1992;39 : 314. offered. Fluid discipline may help such pa- of 5. Lepor H, SypherdD, Machi G, Derus J. Randomised double ;hing tients. llonged blind study comparing the effectivenessofballoon dilation II. Patients with moderate symptoms may be of the prostate and cystoscopy for the heatrnent of sympto- helped with alpha blockers and surgery can be matic benigr prostatic hyperplasia.J Urol 1992;147 :639- postponedto a time when it is really necessary. 6. Richiter S, Rotbard M, Nissenkom L Efficacy of Trans patients III. In with mild to moderatesymptoms, a urethral hyperthermia in benigr hyperplasia of prostate. A) and moderate size adenoma may be helped with Urologt 1993;41 :412. S-alphareductase inhibitors. The action ofthis asedon 7. Schulman CC, Zlotta AR. Trans urethral needle ablation of i symp- takes some time to start, hence it may be com- the prostate for feaEnent of bgnign prostate hyperplasia. how it bined with alphablockers for immediateaction. Early clinical experience.Urologt 1995;45 : 28-33. -7 indi- IV. Surgical intervention is required in the settings 8. Serls LT, CamabathiK, Zimmem PE, Roskamp DA, Wolde severe listed below. T, Sadik G, Leach GE. Transurethralincision ofthe prostate: an objective and zubjective evaluation oflong term eflicacy. a. Patient with obstructive symptoms who do J Urol 1993: 150 : l6l5-21. not respondto drugs. 9. Kaplan SA, Te AE. Trans urethral electrovaporisationof the ns,uro- b. Median lobe with intravesicalenlargement as prostate: A novel method for treating men with benign ,taining it does not respondto drugs prostatic hyperplasia. Urologt I 995; 45 : 566-72. c. Patients with complications, such as recur- 10. Keoghane SR, Cranston DW, Lawrence KC, Doll HA, Fel- rent urinary infections, diverticular calculi, di- lows.GJ,Smith JC. The Oxford laserprostateTrial : a double - blind randomisedcontrolled trial ofcontact vaporisation of lated upper tracts and significant post void the prostate against transurethral resection; preliminary re- 0aynor residues. rticular sults. British J Urol 1996:77 : 382-5. beuse- CHOICE OF SURGERY I l. Narayan P, Foumier G, Indudhara R, Leidich R, Shinohara K, Ingerman A. Trans urethral evaporation of prostate I. TUIP may be consideredfor bladder neck ob- (TUEP) with Nd : YAG laser using a contact free beam assocr- struction associatedwith small (upto 30 gm) technique : results in 6 I patients with benign prostate hyper- rsUTI, adenomaof fibrous prostate plasia. Urologt 1994;43: 813-20. e clear help if

I, No.I Jour. Marine Medical Society, July 1997, Vol. 4, No. I 45 DECLININGTRENDS IN CASESOF SEXUALLY TRANSMITTEDDISEASES AMONG ARMED FORCESPERSONNEL : THE INHS ASVINI EXPERIENCE

SurgCdr PLK DESYLVA*, SurgCapt KM SHAH+

ABSTRACT A five year retrospectivestudy was carried out to determinethe trends in thc frequency and distribution of various sexuallytransmitted diseases(STD) admitted to the STD ward at INHS Asvini. There were 593 STD casesadmitted in this period. The commonest STD was chancroid (33.9%) followed by lymphogranuloma venereum (167o) syphilis (12.3V'), gonorrhoea 10.2o/oand penile warts (8.6%). The number of casesadmitted showed a declining trend.

The genito ulcerative STDs accountedfor 280 (47.22%) cases.Comparatively the percentageof primary syphilis caseshave shown an increasealthough the total number of caseshave decieased. Of the 188 HIV seropositivecases detected 73 were associatedwith STDs. A large number of the remaining 115 casesof HIV seropositivity gave a history of promiscuity many having had sexual contact with commercial sex workers (CSW). KEY WORDS : Sexually transmitted disease,Epidemiology

INTRODUCTION anus[1,3]. A strong associationhas been found between 11 exually transmitted diseases(STD) are a diseasesthat are humanimmunodeficency virus (HIV) infection and \Stoun of communicable \-f transmittedpredominantly by sexualcontact. other STD [4,5] especiallythose causing genital Over 20 pathogensare known to be spreadby sexual ulcerssuch as chancroid,syphilis and herpesgeni- contact.(Table1) In developedcountries Chlamydia talis [6-8] It is believed that a high prevalenceof trachomatisand viral agentsare tendingto replace STD led to increasedsusceptibility to HIV infection the classicalbacterial disease viz syphilis, gonor- [9,10]. rhea and chancroid in importance and frequency. Changing patterns in the trends of STDs have These agents are potentially able to cause serious been noted all over the world. In order to develop complicationsresulting in chronic ill-health, dis- effective preventive measures,a study of the trends ability and evendeath []. is essentialI I, 10].We havepresented a studyof the The complicationsand late sequelaeof STDs morbidity trendsof STDs casesadmitted to the STD period years. include adverseoutcomes ofpregnancy and ofthe ward of INHS Asvini over a of five new born. Infections in newborns and infants may MATERIALS AND METHODS occure.g. ophthalmia neonatorum, chlamydia pneu- group monia,congenital syphilis. Pelvic inflammatory dis- The study comprisedof individuals admit- ward ease can cause infertility and ectopic pregnancy ted to the STD of INHS Asvini from Jan l99l whereas urethritis and epididymitis may result in to Dec 1995.Patients were diagnosedon the basis of history,clinical examination,bacteriological and urethral stricture and infertility [,2]. Viral infections viz genitalwarts and herpes genitalis are asso- VDRL and ELISA testfor HIV. ciatedwith cancersof the cervix, vulva, penis and The medical records of these patients u'ere then

*Classified Specialistin Dennatologyand Venereology,INHS Sanjivani,Naval Base,Willingdon Island, Kochi-682 004.+ Senior Advisor and Head of the Department of Dermatology and Venereology, INHS Asvini, Colaba, Mumbai - 400 005.

Jour. Marine Medical Society,July 1997, Vol. 4, No. I analyzedand a attemptto understandthe morbidity TABLE 2 trendsamong various STDs was made. Number rnd percentrgeof cesesof STD edmitted to INHS ASVINI from l99t to 1995 RESULTS A total of 593patients were admitted to theSTD wardof INHS Asvini in thestudy period. The num- Chancroid 201 33.9 berand percentage ofvarious STDs in thesepatients LGV 95 l6 is placedat Table2. Themost frequently occurring Syphilis I5 t2.3 STD was chancroid(33.9%) followed by LGV Gonorrhoea 60 l0.l (16%),syphilis (12.3%), gonorrhoea (10.1%) and Penilewarts 5l 8.6 penilewarts(8.6%). Herpessixplex 26 4.4 Balanitis 23 3.9 TABLE I GranulomaInguinale 0.3 Classificrtionof serurlly trrnsmitted dlseaseagents Miscellaneous 62 t0.5 (Scabies,Nonspecifi c urcthritis, t. Treponemapallidum Phthirispubis infestation etc) Neisseriagonorrhoeae Haemophilusducreyi 593 Chlamydiatrachomatis Calymmatobacteriumgranulomatis Mycoplasmahominis TABLE 3 Ureaplasmaurealyticum Shigellasp Number of STD cesesedmitted to STD ward INHS ASVINI from 1991to 1995 Campylobactersp Group B streptococcus Year Bacterialvaginosis-associated organisms Viruses Herpessimplex virus (HSV) l+2 l99l 183 Humanpapilloma virus (HPV) t992 148 Molluscumcontagiosum virus r993 tt4 Humanimmunodeficiency virus (HIV) 1994 78 HepatitisB virus Cytomegalovirus l99s 70 3. Protozoans Trichomonasvaginalis Total Entamoebahistolyica GiardiaIamblia 4. Fungii Candida The numberofgonorrhoea and LGV caseshave 5. Ectoparasites Sarcoptesscabiei alsodecreased from 20 and39 casesrespectively in Phthiruspubis l99l to five casesofeach in 1994.This decrease wasalso constant as compared to otherSTDs. How- ever,there was slight increase in bothSTDs in 1995 Table 3 showsthe total numberof STD cases of l3 and9 casesrespectively. admitted annually, There has been a gradual decreasein total numberof admissionsfrom 183 in The numberof herpesgenitalis cases annually 1991to 70in1995. hasbeen fluctuating. However, there were only two casesadmitted in 1995.Only two casesof granu- Table4 showsthe morbiditytrends among vari- lomainguinale (GI) weretreated in this periodand ousSTDs. The number of syphiliscases has shown no caseswere admittedfrom 1993 to 1995.The a graduallydecreasing trend from l7 in l99l to 13 numberof penilewarts, balanitis and other STDs in 1995.However, in relationto other STDs the havealso shown a gradualdecrease from 1991to percentageslowly increasedfrom9.3Yo in l99l to 1995. 18.6%oin1995. The total number of chancroidcases has similarly shown a gradualdecrease from 68 Table 5 showsthe morbidity trendsin the 73 casesin l99l to 19in 1995. syphilispatients admitted in this period. Primary

Jour. Marine Medical Society, July 1997, Yol. 4, No. I 47 TABLE 4 Morbidity trends amongvarlous STDS in prtienb rdmitted to STD ward INHS ASVINI from 1991to 195.

Year Syphilis Chancroid Gononhea LGV Penile Herpes GI Balanitis Misc Total No.(%) No.(%) No(%) No(7o) warts simplex No.(%) No(%) No.(%) No(%) No(%)

l99l t7(e.3) 68(37.2) 20(10.e) 3e(2r.3) I 6(8.8) 4(2.2) l(0.5) ll(6) 7(3.8) 183 1992 l6(10.8) 4t(27.7) 13(8.8) 32(2t.6) l 2(8.1) 8(5.4) 00(00) 8(5.4) t8(t2.2\ 148 t993 l3(r1.4) 47(41.2) 9(7.e) 10(8.8) l2(10.5) 6(5.3) l(0.e) r(0.e) l5(r3.2) r 14 1994 t4(r7.9) 26(33.3) 5(6.4) 5(6.4) 6(7.7) 6(7.7) 00(00) 2(2.6) 14(17.9) 78 I 995 r3(18.6) t9{27.1) l3(18.6) 9(12.9) 5(7.l) 2(2.9\ 00(00) l (r .4) 8(l 1.4) 70

Total 73(12.3) 20r(33.9\ 60(10.1) es(r6) 5r(8.6) 26(4.4) 02(0.3) 23(3.9) 62(10.s) 593

TABLE 5 Morbidity trendsin sub groupsof syphilisIn patlentsrdmitted to INHS ASVINI from 1991to 1995.

Year Primary Secondary Latent Syphilis Total Tertiary Total no of Syphilis Syphilis Early Late Latent cases No.(%) no.(Vo) no.(%) no(%) no(%) no.(%) no.(%)

1991 9(s2.e) s(29.4) l(5.e) 2(rr.8) 3(r7.6) 00(00) tt t992 6(3'1.5) 5(31.3) 3(18.8) 2(r2.s) 5(31.3) 00(00) l6 l 993 5(38.5) 4(30.8) 4(30.8) 00(00) 4(30.8) 00(00) l3 1994 5(35.7) 4(28.6) 3(21.4) l(7.1) 4(28.6) 1(7.1) t4 l 995 3(23.l) t(7.7) 4(30.8) 5(38.s) 9(69.2) o0(00) IJ

Total 28(38.4) re(26.0) l 5(20.5) l0(l 3.7) 2s(34.2) l(l.4) I5

TABLE 6 Mobidity trendsamong ulceratlve STDs in casesrdmltted to STD werd INHS Asvinl from 1991to 1995.

Year Primary Chancroid Horpes Balanoposthitis GI Total Syphilis no(%) Genitalis no(%) No.(7d no.(7o) no.(%)

t99l e(e.7) 68(73.1) 4(4.3) l l(l 1.8) l(l.l) 93 t992 6(e.5) 4r(65.r) 8(r2.7) 8(r2.7) 00(00) 63 t993 5(8.3) 47(78.3) 6(10) r(1.7) l(l.7) 60 1994 5(12.8) 26(66.7\ 6(15.4) 2(5.l) 00(00) 39 I 995 3(r2) re(76) 2(8) t(4) 00(00) J\

Total 28(10) 201(71.8) 26(e.3) 23(8.2',) 2(0.7r) 280

syphilis cases showed a gradual decreasefrom 1995.However, a suddenincrease of 9(69.2%)pa- 9(52.9%)in l99l to3(23j%) in 1995.The number tientswas seen in 1994.There was only onecase of of casesof secondarysyphilis remainedabout the asymptomaticneurosyphilis admitted in 1994.The samefrom l99l to 1994.However, in 1995,there diagrrosiswas based on abnormalCSF examination was only one caseadmitted. There were 3-5 cases resultsduring surveillance in absenceof any clinical of latent syphilisadmitted per year from l99l to signs.

48 Jour.Marine Medical Society, July 1997,Yol.4, No. I Table 6 shows the morbidity trendsamong geni- cuity due to the fear of AIDS and due to various tal ulcerative STDs. Out of a total of 280 cases measruesand awarenessprograms that have been admitted, chancroidwas the most common although introducedto control the spreadof AIDS and STDs. the number of caseshas gradually decreasedfrom Furthermorein our study this low incidence is also 68 (73.1%)in 1991to 19(76%)in 1995.Similarly probably due to compulsory notification, efficient the number of balanitis casesshowed a decreasein health education,regular medical check up and ade- number from 1l to one. The number of primary quate recreational facilities provided to the service syphilis casesshowed a decreasefrom 9 in 1991to personnelI l] genital 3 in 1995.However, as comparedto other Early syphilis has a higher incidence in develop- ulcerative STDs there was an increase seen from ing countries than in industrialized ones and even 9.7%oin 1991to 12%in 1995. though the incidence varies in different centres, The distribution of herpes genitalis cases was syphilis is found to be the most common STD in erratic with a minimum of two casesper year and a many studies,viz between l0% and70% of all STD maximum of 8 casesper year. There were only two casesin thosecentres [ 1 I , I 2]. In our study we found casesof granuloma inguinale seenin this period. that syphilis was the third most common STD ac- Table 7 shows the number of HIV casesdetected counting for 12.3o/oof all cases.The total number of annually.Total numberof 188cases of HIV seropo- syphiliscases has been gradually reducing annually. sitive were detected in this period. Of these 73 However, the percentageof syphilis casescompared (38.8%)were associatedwith an activeSTD or gave to other STDs has gradually been increasing every history of STD at the time ofdetection, fifty (26.6%) year. We observeda gradual decreasein the number of thesehad genital ulcerative diseases. 115 (81.2%) and presentationof syphilis casesalthough this was were not associatedwith STD infections but a large the commonestpresentation of syphilis in our study number of thesecases gave a history ofpromiscuity, (38.9%). There has been no increasein the number most having had sexualcontact with commercialsex oflate syphiliscases. The numberofcases ofsecon- workers. dary syphilis annually remained steady about 30% from 1991to 1994except in 1995when therewas a TABLE7 fallto7.7o/o.The numberof latentsyphilis cases also Number of HIV seropositive casesand association with remainedconstant except in 1995when therewas a STD detectedannually at INHS Asvini from 1991to 1995 sudden spurt to 69.2%ocases. Only one case of asymptomatic neurosyphilis was admitted in this Year No of HIV No of HIV No of HIV Total HIV +ve +ve +ve +ve period. With Gud Without Gud Without STD Chancroid is the leading causeof genital ulcera- (other STD) tion in developing countries and a major risk factor in the acquisition of HIV infection. Various Indian t99l ll ) ) 2l studiesdemonstrate it to be among the commonest 1992 l0 J l6 29 STDs encountered In our study too, it was 1993 9 2 33 44 [3,14]. the commonestSTD observedaccounting for 33.9% t994 7 6 Jf 48 of the total number of cases.The number of cases I995 tf 7 26 46 however has been gradually decreasingfrom 68 in Total )U z) 188 1991to l9 in 1995. GI is a diseasethat is endemicin Madras,Orissa and Himachal Pradesh. In various studies it was DISCUSSION observedto be | .5-44.2Yoof all STD cases[ 15,16]. There has been a decreasingtrend in STDs all Low socio economic status, ignorance and lack of hygiene are predisposing factors. This diseasewas over the world and in India too [1,10].In this study we have observeda progressivedecrease in the total rarely encounteredin our study probably becauseof good number of STD casesbeing admitted annually.This hygiene and better living conditions decreaseis probably due to the decreasingpromis- Herpesgenitalis is an STD which is encountered

Jour.Marine Medical Society, July 1997,Vol. 4, No. I 49 frequently in industrializedcountries []. We have since 1991. 73 (38.8%) of these were associated noted it to have an incidenceof 4.4% of all STDs. with other STD, 50 (26.6%) casesbeing due to which is similar to many Indian studies,where it is genital ulcerative diseases.Of the remaining I l5 not found to be oneofthe leadingSTDs. The annual (61.2%)who were not associatedwith STD, rnany trend has been erratic. Balanitis of bacterial and gave a history of promiscuity, most having had candidaf etiology accountedfor 3.9Yoof all cases sexual contact with commercial sex workers in which is lower than that noted by other Indian stud- whom it is found thatHIV prevalenceand incidence ies I I 0] probablybecause solne of thesecases were are alarmingly high in Mumbai ll7,201. not referred to this STD center and were managed CONCLUSION by the unit medicalofficer. The total numberof STD caseshas been showing LGV was the secondmost common STD encoun- decreasingtrend. Genital ulcerative STDs were pre- tered in our study accountingfor l6Yoofall cases. sentin 280 (47.22%) casesin this study. This is similar to the findingsof otherIndian studies I I ]. There hasbeen a gradualdecrease in the number The commonestSTD observedin our study was ofcascsfrom l99l to 1994.However, 1995 showed chancroidfollowed by LGV, gonorrhoea,syphilis a small increase in the number and percentageof and penile warts. cases. 188 casesof HIV seropositivitywere detected, The incidenceofgonorrhoea has been variable in 73 (38.8%)were associatedwith STD, 50 (26.6%) various centres in India, ranging from 3-l4Yo being due to genitalulcerative diseases. [0,13,14]. We havenoted a gradualdecrease in the REFERENCES numberof casesfrom 20 in 1991to 5 in 1994.But L Dc SchyrverA, MeheusA. Epidemiologyof sexuallytrans- in 1995there was a suddenincrease in the numbcr mitted diseases:the global picture. Bulletin of the World and percentageofcases. This is probablydue to the HealthOrganization 1990;6(5) : 639-654. emergenceof drug resistantorganisms especially in 2. WflO technicalreport serics No. 736, I986 (Expertcommit- Mumbai[7]. tee on venereal diseasesand treponematoses,sixth report). The percentageof caseswith genital warts re- 3. StoncKM, Zail A, Rosero-BixbyH, Obcrle MW, Reynolds mained constantthough the total number of cases G, LarsenS, NahrniasS, Lee FK, SohachterJ, Guinan ME. decreasedfrom l6 in l99l to five in 1995. Sexual behavior, sexually transmitted diseasesand risk of cervical cancer.Epidenriologlt I 995; 6(4) : 409- | 4. ulcerative STDs are a high risk factor for Genital 4. Piot P, Laga M. Genital ulcer, other STDs and the sexual HIV transmission[9,10,18]. Of 593 casesof STD transmissionof HlY. BMJ 1989;298 : 623-4. admitted, 280 (47.2%) were ulcerative diseases, 5. RodriguesJJ, MehendaleSM, ShepherdME, Divekar AD. the most common (71.8%) fol- chancroid being Gangakhcdkar RR, Quinn TC, Paranjape RS, Risbud AR, lowed by syphilis (10%), herpesgenitalis (9.3%) Brookmeyer RS, Gadkari DA et al. Risk factors for HIV and balanoposthitis(8.2%) There were only two infectionin peopleattending clinics for scxuallytransmitted casesof GI. diseasesinlndia. BM J 1995: 3 I | : 283-6. The total numberofchancroid caseshas gradu- 6. Stamm WE, Handsfield HH, Rompalo AM, Ashley RL, RobertsPL, Corey L. The associationbetween genital ulcer hasbeen observed in most Indian ally decreasedas diseascand acquisition of HIV infectionin homosexualmen. studies.However, it continuesto be the most com- JAMA 1988: 260 : 1429-33. mon encountered S'l'D [3,14,19]. 7. HolmbergSD, StewartJA, Gelbcr AR, Bycrs RH, Lec FK, The numberof primary syphilis casesshowed a O'Mailey PM, l.,lahmiasAJ. Prior herpessimplex virus type decrease. However, the percentage of this ulcer 2 infcction as a risk factor for HIV infection. JAMA 1988: among other ulcerative STDs has been gradually 259: 1048-50. risingsince 1991. 8. BehetsFM, LiornbaG, Lule G, DallabettaG. Hoffrnan IF, Harnilton HA, Moeng S, Cohen MS. Sexually tmnsmitted The number and percentageof balanitis cases diseases and human irnmunodeficiency virus control in showed a decreasing trend, whereas the trend in Malawi:A field study of genital ulccr disease.J Infect Dis casesof herpesgenitalis was erratic.We have de- 1995:l7l :451-5. tected 188 casesof HIV serooositiveindividuals 9. Kinghom GR, Epidemiology of genital herpes (revicw).

50 Jour. Marine Medical Societv, Julv 1997, Vol. 4, No. I Journal oJ lnternational Medical Research. |994;22 Suppl 16. Ramanan, Manglani PR, Panigrahi D. Donovanosis in an : 14-23. industrial hospital. India J SexTransm Dis I 983; 4 : 12- I 5.

10. Krishnamurty VR, RarnachandranV. STD trends in Chen- 17. Gohil Ah, Kalkar SS. Antibiotic sensitivity of Neisseria galpattu Hospital. Ind J Dermatol VenereolLeprol 1996;62 gonorhoearecorded in a Bombay hospital in 1979-80.Indian : f-12. J Med Res1985;82 :304-10. I l. Kapur TR. Pattern of STDs in lndia. [nd J Dermatol Ven- 18. Sassan-MorokoM, GreenbergAE, Coulibaly IM, Couibaly eraol Leprol 1982; 48 :23-34. D, Sidibe K, Ackah A, Tossou O, Gnaore E, Wiktor SZ, De 12. SiddappaK RavindraK. Syphilis.In : Valia RG, Valia AR Cock KM. High ratcs of sexual transmitted diseasesand cditors. Textbook and Atlas of Dermatology. Bhalani Pub- condom neglect among HIV infected and uninfected men lishing HouseMurnbai, 1994: I188-1307. with tuberculosis in Abidjan, Cote d'lvoire. Journa! ofAc- 13. Singh KC, Joshi MK, Bajaj AK. Pattern of sexually trans- quired Immune DeJiciency Slmdromes and Human Retrovi- mittcd diseasesin Allahabad Indian. J Sex TransmDrs 1990: rologt 1996;I l(2) : 183-7. ll:6-8. 19. JonassonJA llaemophilusducreyi (Editolial, Rcview). ,In- 14. SahibMKB, Pai GS, PintoJ, KamathKN. Pattemof genital tenntional Jotu'nal of STD and AIDS 19931.4:317-20. ulcers in and around Mangalore. Indian J Sex Trartm Dis 20. Bhave G, Lindan CH, Hudes ES, Desai S, Wagle U, Tripathi 1990;ll:52-3. SP,Mandcl JS. Impact on and intervention on HIV, Sexually 15. Subramanium S. Sclerosing granuloma inguinale. Br "/ tranmittcd diseases,and condom use arnong sex workers in VenerDis l98l:57 :210-12. Bombay,lndia. AIDS 1995(Jul); 9 Suppl l : 521-30.

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Jour. Marine Medical Society,July 1997, Vol. 4, No. I {t CaseReports DELAYED THERAPEUTICRECOMPRESSION IN TYPE II DECOMPRESSIONSICKNESS

Surg Lt Cdr GSR JAYAWARDANA*

KEY WORDS : DecompressionSickness, Delayed therapy, Therapeutic Recompression, Spinaldecompression sickness.

INTRODUCTION developed weakness and numbness of both upper and lower limbs with difficulty in breathing, swallowing and talking. he majormedical emergencies occurring after diving andrequiring recompression ther- On admission to Naval Hospital Trincomalee, 24 hours after the onset ofsymptoms, patient was confused dysphagic, dyspha- apy(RT) are: sic, quadriplegic and bladder was distended due to retention of a) Arterial air embolism due to pulmonary over urine. inflation Neurological examination revealed a flaccid paralysis with grade.l power in all muscle groups with absent tendon reflexes b) Decompressionsickness (DCS) and involvement of lOth and l2th cranial nerves.He had complete DCS is a clinical manifestation due to rupture sensory loss below C I and C 2 spinal level. Examination of of cells or due to ischaemic damageas a result Respiratory system revealed diaphramatic breathing. Other sys- of formation of inert gasbubbles in the circula- tems were normal. Since a diagnosisof type II spinal decompression sicknesswith cord lesion around Cl C2 and involvement of tion or tissues due to reduction of ambient lower two cranial nerves was made, RT was commenced in the pressure(during ascentfrom depth). Hyperbaric chamberat the Diving Unit using US Navy treatment DecompressionSickness can take two forms tablesix []. a. Type I - Mainly muscular-skeletaland cutane- Since there was no improvement afrer 24lv, above schedule ofRT was repeatedover the next three days. ous involvement and - Patient improved over the next 72 hr and was able to talk b. Type II With neurological and cardiopulmon- swallow liquids. Power improved to grade III-IV in both upper ary symptoms This may be life threatening and limbs, with improvement of sensationsupto sixth thoracic nerve needsimmediate recompressiontherapy (T6) but he continued to have sensoryloss below T6 and grade I power in lower limbs. Four patients out of five divers who developed type II spinal decompressionsickness (DCS) fol- CASE II lowing repetitive dives and were treated with de- A 22 yearc old diver was diving in open sea off the coast of layed therapeuticrecompression showed good neu- Kalpitiya Western coast of Sri Lanka in a SCUBA set. The rological improvement . The risk taken by Sri maximum depth of the dive was 85 feet and the duration of Lankan civil divers and prevention of diving related approximately 105 minutes. This consisted of three repetitive medical emergenciesare briefly discussed. dives with surface intervals of 10-12 minutes between each dive. No proper decompressionschedules were used for the ascent. Case I Five minutes after the final dive he developed weakness and numbnessof both lower limbs with retention of urine. A 38 years old experienceddiver was diving in open seaoff the coast ofGall Southem Sri Lanka. His breathing medium was He was admitted to Naval Hospital Trincomalee two days air from a self contained under water breathing apparatus after the onset ofsymptoms. Neurological examination revealed (SCUBA). Maximum depth of dive of 120 ft consistedof three flaccid paresis wilh grade II power in all muscle groups with repetitive dives within 90 minutes with surface intervals of l0- exaggeratedlower limb reflexes and loss ofbladder/bowel func- 15 minutes between each dive. No proper dccompressionwas tions. There was no other neurological abnonnality. Therapeutic planned for the ascent.Five minutes after the final dive the diver recompressionusing US Navy table six was instituted in a hyper-

*Command Medical Oflicer, Eastem Naval Command, Sri Lanka.

52 Jour. Marine Medical Society,July 1997, Yol.4, No. I baric chamber at the Diving Unit. The first two casesof spinal decompressionsick- Since the symptoms did not improve during or after lst RT, nessin Sri Lankan literature were reported in 1986. second RT was given the next day. The diver showed improve- Both patientsdid not undergo RT and were left with ment of power in both lower limbs to grade IV-V. disabling neurological deficits. On discharge patient was walking unaided and had regained bladder control. In the present series however, out of five cases with spinal decompression sickness four showed CASE III & ry fair neurological improvement even when recom- 43 year year from Two divers, and 32 old Kalmune were pressiontherapy was instituted after 72 hr of onset admitted to Naval hospital Trincomalee with weaknessof both lower limbs and retention ofurine after 24 hrs and 72 hrs ofonset of symptoms. of symptoms respectively. One of them had performed four The delay in recompressionwas unavoidable as repetitive 75 feet dives with bottom stay of 15-20 minutes each the only recompression chamber available in Sri and surface stay of I 5-20 minutes. The other had performed three repetitive 60 feet dives with bottom stay of l5 minutes each. Lanka is atNaval Diving Unit in Trincomalee,while the patients had been evacuated from the West, Neurological examination of both patients revealed flaccid paraplegia and lcs of bladder/bowel control. First diver had South and South East of Sri Lankan coast through grade III power in all muscle groupsof both lower limbs with loss areaswhere war is being fought. Although therewas oftendon reflexes while the seconddiver had grade II power in satisfactoryneurological improvement in them this all muscle groups with exaggerated tendon reflexes in both lower delay could have caused permanent neurological limbs. First patient was administered two consecutiveRT while sequalae. second patient was administered three consecutive RT and both patients showed dramatic improvement of power to grade. IV - There are thousandsofprofessional civil diver's V in all muscle groups in both lower limbs. On dischargeboth in Sri Lanka. Most of them including our patients patients were walking unaided and had regained bladder and have had no formal training in diving physics and bowel control. physiology or the use of diving equipment. There is CASE V also no provision for medical supervision of Sri A 32 year old diver developedweakness ofboth lower limbs Lankan civil diver's and diving medicine has yet to with retention ofurine following four consecutivedives to 80 feet becomea recognisedspeciality. Thesediver's are at depth with bottom stay of 15-20 minutes each and surfaceinter- increased risk of diving related hazards such as vals of 30 minutes. He was admitted to Naval hospital Trinco- pulmonary over inflation syndrome (arterial malee four days after the onset of symptoms. Neurological ex- air em- amination revealed flaccid paralysis of both lower limbs with bolism, mediastinal and subcutaneousemphysema, power of grade II and grade I in left and right lower limbs pneumothorax)and decompressionsickness. These respectively with absent tendon reflexes. He had a sensory loss can be prevented by proper medical selection of upto the tenth thoracic dermatome with loss of bladderlbowel diving personnel,education ofdivers in diving re- function. lated hazardsand use ofscientific dive plan includ- There was no neurological improvement even after three ing decompressionstoppages. consecutive RT given by using US Navy Table 6 Efforts should also be made to increase aware- DISCUSSION nessamong the generalpublic and the medical offi- During diving, inert gasesdissolve in the blood cers who are working in the coastal areas about and saturatethe body tissues.Due to reduction of medical emergenciesthat are diving related. ambient pressure during rapid ascent from depth, Thesecase reports show that a delay ofeven up these dissolved gasescome out of the solution and to three days in recompression can still lead to form bubbles in the tissuesand circulation, causing neurological improvement in spinal decompression thrombo embolisation and disruption of tis$.re. sickness. Therapeuticrecompression is aimed at reduction ofthe size ofgas bubblesand then eventualdissolu. REFERENCES tion and elimination through respiratorypassage. l. US Navy Diving Manual,Volume I, Revision3, 1993.

Recompression therapy should be carried out 2. Edmond C, Lowry C, PennefatherJ. Decompression Sick- immediately after the onset of D.C.S. for effective ness.In : Diving and SubaquaticMedicine, secondedition. prognosis. Australia: Diving Medical Center 1983; 129-80.

Jour. Marine Medical Society,July 1997, Vol. 4, No. I 53 BOWENOIDPAPULOSIS (A Case Report)

SurgCdr R DHIR*, SurgCapt KM SHAH@, Col AK HUKOO+

KEY WORDS : Bowenoid Papulosis,Condyloma Acuminata.

INTRODUCTION diagnosedclinically as condyloma acuminata.In owenoid Papulosis(BP) is an uncommon casesof condyloma acuminatanot respondingto or disorder characterisedby papulesor plaques recurring after conventionalmodalities of treatment on the genitalia showing characteristic a diagnosisof BP shouldbe considered.Unlike BP, Bowenoid histology. BP is causedby various sub anogenital Bowens disease presents as a solitary typesof humanpapilloma virus. It is usuallyseen in plaque that is slowly progressivewith no tendency sexually active men and women with an overall for spontaneousremission. Besides, histologically meanage of 31 years.The lesionsof BP may persist BP lacks the full thicknessdysplasia and disordered maturationcharacteristic of Bowensdisease, rather for prolonged periods or regressspontaneously or 'shotgunned' rarely progressto squamouscell carcinoma. it has dysplastic keratinocytes throughout the epidermis, often with keratinocytes CASEREPORT in metaphase. A 2l yeu old unmarried male patient presentedwith com- plaints ofwarty lesions on the prepuce ofthree months duration. In addition,one needsto enquirewhether Podo- He gave a history of repeated protected sexual contacts with a phyllin has been applied topically, since it causes conrmercial sex worker in the preceedingsix months. Thcrc was metaphaseanest with bizarre Keratinocytic fonns no past history ofany sexually transmitted disease.Venereologi- and sometimesa pattem of pseudoepitheliomatous cal examination revealedmultiple discretevemrcous papules and hyperplasia.Such changes persist at the most for a plaques on the prepuce. The size ofthe lesions varied from l-3 week. cm. There were no similar lesions else where on the body. Examination of the buccal mucosa, glabrous skin, palms and REFERENCES soles,testes, epididymis and urethra did not reveal any abnormal- L SchwartzRA, JannigarCK. Bowenoidpapulosi s. J Atn Acad ity. VDRL was non reactor and HIV was negative. He was Dermatol l99l:.24 :261. initially diagnosedas a caseofCondyloma acuminataand treated 2. Bocking A, et al. Bowenoid papulosis,Classification as a with repeated applications of podophyllin. Due to inadequate low gradein situ carcinomaofthe epidennison thc basisof responsethe treatment was changedto Trichloracetic acid appli- the histomorphologic and DNA pilot studies.Anal cation and then electrocautery.The lesions did respondto elec- Quaint Cytol Histol 1989; I I : 419. trocautery only to recur after a few days. At this stagea diagnosts ofBowenoid papulosis was entcrtained and confinned by exci- 3. Patterson I\N, et al. Bowenoid Papulosis. A Clinico- sion biopsy and histopathology. pathological study with ultrastructural observations.Cancer 1986;57 : 823. DISCUSSION 4. Civatte J. Pseudo-Carcinomatous hyperplasia. J Cutatt It is well documentedthat rnaiorityof BP is Pathol 1985:12:214.

*Classified Specialist,Dennatology; @Senior Adviser, Dermatologyand Venerology;+Senior Adviser, Pathology,INHS Asvini, Mumbai 400 005.

54 Jour. Marine Medical Society,July 1997, Vol. 45, No. I MIGRATION OF UNTHREADEDPIN INTO POPLITEALFOSSA (A CaseReport)

Lt Col SM BHATNAGAR* Surg Cdr P SARIN*

KEY WORDS : Pins,K-Wire, Poplitealfossa, Osteochondral farcture.

INTRODUCTION Factorswhich contribute to such migration in- a varietv of oins and nails etc. are used in clude the use of unthreadedpins without lateral bend,low gradeinfection ofthe pin-hack,threaded I orthopaedic practice to immobilise or fix l- lfractures. Casesofmigration ofthese device pins without lateralcheck, breaking of pins or the from their original place have been reported in lit- pin gettingdisengaged from its lateraldevice. Pins erature.Intra pelvic migration of pins causingblad- may also migrate if fracturesremain un-united or der perforation and vascular injury unstable.Early mobilisation of unstableor un- and migration of 'united SP nail causing perforation of rectum have been fracturesmay provide some direction and forcefor migration. documented[-4]. An unusual case of migration of an unthreaded Therisk factorinvolved in our casewas that the pin used to immobilise an osteochondralfracture of pin was not threadedand therewas no lateralbend, lateral femoral candyle in to the poplitial fossa detected during a routine check radio graph is described. To our knowledge this type ofcase has not been reported in the literature. CASEREPORT A young woman sustained Osteochondral fracture ofthe right lateral femoral condyle due to sudden getting up from squatting position. A radiograph showed displaced osteochondral fracture in the lateral compartment of the knee joint involving the middle and posterior portion of articular surface of lateral femoral condyle (Fig l). Open reduction and Intemal Fixation ofthe fracture was done with K-wire and the joint was immobilised with POP. Per operative check X-Ray revealed satisfactoryreduction ofOsteo- chondral fracture and perfect placement ofK-wire (Fig 2). A check radiograph after six weeks revealed complete migration of one K-wire into the popliteal fossa (Fig. 3). On removal ofPOP the pin end was palpable in the popliteal fossa. The pin was easily removed under local anaesthesiafrom the soft tissue as it was not anchored to the underlying bone. No damage to adjacent blood vesselsand nerves was incurred. DISCUSSION Migrationof variousdevices including pins used for fixation of fracturesaround the hip havebeen reportedin literature,but migrationof pins in the Fig. I : Displaced osteo-chondral fracture involving lateral compartment of the knee (R). poplitealfossa has not beenreported.

*Classified Specialist Surgery and Orthopaedic Surgery, IHNS Asvini, Colaba, Mumbai 400 005

Jour. Marine Medical Society, July 1997, Vol.4, No. I 55 Fig. 3 : One of the K-Wire migrated into the popliteal fossa. with injury to various structure such as urinary bladder, rectum and blood vesselsetc. [4]. In our case damageto blood vesselsand nerves in the popliteal fosbawas fortunately preventedby timely detection and removal of the device REFERENCES l. AlpersDD. Migration of brokenpin into urinary bladder. J AMMed Assoc 1970;212 : 2123-24.

Fig. 2 : Fixation of osteo-chondralfracture with K-Wire. 2. Cohen MS, Wamer RS, Fish D, Johanson KE, Farcon E. Bladder perforation after orthropaedic hip surgery . (Irologt but it is difficult to understandwhy the pin migrated 197'7;9:291-93. when the limb was immobilisedwith POP.In our case,migration could have been prevented by lateral 3. Posman CL, Norawa LG. Vascular injury from intrapelvic migration ofa threadedpin. A casereport. J.Bone and Joint pin, pin bendingof but we did not bendthe dueto Surgery 1985;'l 6-A : 8M-6. fearof thepin beingpulled out inadvertentlyduring changeofdressing. 4. Seitz WH Jr, Beradis JM, Ciannaris T, Schreiber G. Perfo- ration of the rectum by a Smith-Peterson Nail. J Trauma Migration of thesedevices may be associated 1982;22: 339-40.

56 Jour. Marine Medical Society, July 1997, Vol. 4, No. I TUBERCULOSISOF PATELLA (A CaseReport)

Lt Col SM BHATNAGAR*, Surg Cdr P SARIN+

KEY WORDS: Tuberculosis.Patella.

INTRODUCTION uberculosisof Patellais uncommon,but tu- berculosisproducing osteolytic as well as sclerotic lesionsdo not appearto havebeen reportedearlier thoughosteolytic lesions ofpatella hasbeen reported only on five previousoccasions. In view of its rarity, this caseis reported.

CASE REPORT A 25 year young man not in good health, being treated earlier as fracture of patella and chronic osteomyelitis, presented with one year history of pain, swelling and restricted mov€ments of the right knee. Patient had no otherjoint involvementexcept for generalised weakness. Examination ofthe knee revealed an effir- sion with restricted terminal flexion with marked wasting and spasm of muscles around the knee. Radiograph of the kiee demonstrated a large sclerotic lesion as well as osteolyic les{ih in the patella and another osteolyic lesion in the lateral tibial condyle. Radiograph ofthe chest revealed no abnormality.

Histopathological examination of the cwettage specimen from patella was reported as chronic osteomyelitis, but sub. sequent histopathology ofthe synovial tissue showed features of tuberculosis. The patient was started on anti-tubercular therapy Fig. I : X-ray patella one year before presentation showing which resulted in marked improvernent. DISCUSSION Tuberculosisof a boneor joint is merelythe local manifestationof a generaliseddisease. Even though bone or joint involvement may be the presenting feature, a secondfocus in the lung or uro-genital tact etc.may co-exist.Tuberculosis involving the patellain isolationis very rare[-3]. To thebest of our knowledgethis is only the eighth such case reportedin literature. Bony tuberculosisis a locally destructivelesion and occurs due to hematogenousspread from the. 'X-ray primary lesion.The lesionin the boneconsists of an ' Fig. 2 : patellaShowing cystic aswell assclerotic lesions ' and anothercystic lesion in the lateral tibial plataeu. inegular cavity in the metaphysisor epiphysis

*ClassifiedSpecialist Surgery and Orthopaedics,+Classified Specialist Surgery and Orthopaedics, INHS Asvini, Coloba,Mumbai 400 005.

Jour. Marine Medical Society,July 1997, Yal. 45, No. I which can spread inside the joint producing tuber- treated with anti-tubercular drugs without sacrific- cular arthritis. ing the patella as tuberculosisis a treatabledisease. Cavity or cystic lesionsin the patella arerare and Ifthe diagnosisis suspectedradiologically, and the histopathologicalspecimen patella associatedsclerotic lesions are extremely rare [4]. from is not con- Mixed or combined lesions may co-exist. These firmatory then synovial tissue biopsy should be need to be differentiated from pyogenic sclerosing done. Antiltubercular therapy without resorting to osteomyelitis, gouty arthritis, chondroblastoma, patellectomyin order to preservethe functions ofthe osteoblastorna,and osteoidostoma. If sequestrumis knee should be tied. seen along with new bone formation, it suggests REFERENCES pyogenic osteomyelitis. Presence of sclerosis l. Tazi Moukha K, Lezrek M, Rachid K, Choho A, Aouan H, around the cystic lesion without para articular scle- Moulay I. Tuberculosis ofPatella. An unusual localisation rosis suggeststuberculosis as seen in ourcase.When apropos oftwo cases.Journal de Chirurgie 1995: 132 (4) : tubercular lesion is suspectedradio-nuclide bone 20t-5. scan should be done as cystic tuberculosisofbone 2. Hartofilakidis- GarofalidisG. Cystictuberculosis ofpatella. can affect several other sites [5]. We did not do TheJournal ofBone and Joint Surgery1969;5 I A : 582-85. radio-neuclide study in this caseas clinical exami- 3. GimenzMH, BeltranJVT, Sequi,MIF GomejEP. Tubercu- nation did not suggestlesions at any other site. losisofPatella. Paediatic Radiolog 198'l;17 :328-29. In the presentcase, diagnosis oftuberculosis was 4. ShahP, RamaKanlan R. Tuberculosisofthe patell . Bnfish strongly suspectedbut could not be confirmed on Jounnl of Radiolog 1990;63(749):3$a. histopathological examination of the currettage 5. O'Conner,BT, SteelWM - SaundersR. Disseminatedbone specimen from the patella. This could however, be tuberculosis.Journal of Boneand Joint Surgeryl97O; 52 : confirmed after synovial biopsy. The patient was s3740.

Qittn QestConrp0irnents

Snom ATISJESIOA CHEITTOALS

BYRAMJI MANSION,IST FLOOR, SIR,P.M. ROAD, FORT. MUMBAI4OOOOI. PHONE:2664052, 266057 4,2666283

J8 Jour. Marine Medical Society,July 1997, Vol. 45,'No. I MUCOSAASSOCIATED LYMPHOID TISSUE LYMPHOMAS RARE TYPEOF NON-HODGKINLYMPHOMA

Surg Lt Cdr S RANJAN*, Lt Col VP SINGH+, Surg Cdr B FANTHOME#, Dr SH ADVANI@, Brig D PRASAD**

INTRODUCTION given treatmentwith anti-H pylori drugs.Subsequcnt endoscopy and biopsy showed chronic gastritis only but on evidence of has been a steadyrise in the incidence rfvarious 41here MALTOMA. The patientis presentlyunder close follow up. (NHL) in- admitted I of Non Hodgkin's Lymphoma m (16%) r cluding rare type of NHL due primarily to DISCUSSION declining recentdevelopment in diagnosticmethodology. In- Extra nodal low gradeB cell lymphomasof mu- itially labelled as pseudolymphomasbecause of cosa associatedlymphoid issue (MALT) occur in y syphilis their normal germinal centres and polymorphous gastrointestinaltract, salivarygland, thyroid, orbit, cytologic compositionthey now are known as Mu- lung,breast and skin.Law gradeMALTOMAs may cosa Associated Lymphoid Tissue Lymphomas arisein or secondarilyinvolve the skin and subcuta- ining115 (MALTOMA), ercialsex as their small lymphocyticcompo- neoustissue and have a tendencyto affect middle nent is monoclonal and they are CD 5 negative. agedto older women []. Since MALTOMAs are rarity we presenttwo such Unlike other small lymphocytic malignancies casesdiagnosed at our hospital these seem to have low risk of disseminationto CASE I lymphnodes,bone marrow or peripheralblood, but A 50 years old female presentedwith nodular enlargementof they havehigh risk ofrelapse in diverseextranodal between thyroid lobes, progressively enlarging over a period oftwo years sites.The most common sites of involvement in- ction and and right sided neck swelling for the last six months.She was clude lung, stomach,salivary glands and lacrimal clinically euthyroid.A neartotal thyroidectomywith right sided g genital glands,but almostevery extranodal site is at risk [2]. pesgeni- neck swelling (lyrnph node level III) biopsywas'carried out. NHL of thyroid is a rare disease.This type of alenceof HistopathologicalExamination of thyroidgland revealed non - lymphomatends to appearin patientswith history infection I{odgkin's lyrnphoma small lymphocytictype with prominent plasmacyticdifferentiation (low grade)originating from mucosa of autoimmune diseaseor chronic inflammatory associatedlymphoid tissue ofthyroid. Thetumour had arisen over disorders[3]. Hashimoto'sthyroiditis was the prob- lDs have backgroundof Hashirnoto'sthyroiditis. Regional lyrnphnodes ablepreceding cause in the first patient. r develop were involved. Shc was finally stagedas stageII EA. She was givcn GastricMALT lyrnphomacan be histologically ,hetrends six cycles of Cyclophosfamide,Adriamycin, Vincristine, Prednisolone(CHOP) chenrotherapyat monthly interval and classifiedinto low grade(LG) andhigh (HG) which rdy of the Eltroxin to look after post operative hypothyroidisrn. Presently show striking clinical and prognostic differences. rtheSTD sheis having diseasefree status. Howevertheir naturalhistory is poorly understood. ) years. CASE 2 Besideshistological grading, staging is the most important prognostic feature A 52 yearsold individualpresented with non ulcerdyspepsia [4]. with pangastritis of five to six years duratiou. He was sympto- In stomachthis lesionis inducedby Helicobacter rlsadmit- matic with upper abdominaldiscomfort for the last six months. pylori and is characterisedby an accumulationof Janl99l His physicalexamination was non-contributory.Upper gastroin- lymphoidtissue leading to chronicgastritis. H pylori the basis testinalendoscopy rcvealed severe antral gastritis. Antral mucosa associatedMALT lyrnphoma (LG) can be com- rgicaland biopsy showed difhrse antral gastritis associatedwith H pylori infection. Additional featureswere lymphomatousinvolvement pletely cured by eradicating the organism with (NHL-low gradeentrocyle likc cell)-MALTOMA. Furtherwork Amoxicillin, Bismuth and Metronidazolewithout werethen up of lyrnphomadid not revcaldisease activity anywhere. He was any adjuvant chemotherapyor surgery[5]. .

+Oncophysician; i+Consultant 04.+ Senior +Oncosurgeon;#Oncosurgeon; @Chief of Medical Oncology; Tata Memorial Hospital, Mumbai. Medicine.INHS Asvini. Mumbai. o1.4,No. I Jour. Marine Medical Society,July 1997, Vol. 4, No. I 59 phoidtissue type) ofskin andsubcutaneous In inflammatory bowel diseasesany dense lym- tissue.,{ m J Surg Rumin phocytic infiltrates seen in biopsy specimensob- Pathol 1996;20 : l0l l-23. tained from ulcerative colitis and Crohn's disease 2. SundeenJf, LongoDL, JaffeES. CD5 expressionin B cell FORT should be assessedto exclude gastrointestinallym- smalllymphocyic malignancies : correlations with clinical presentationand sites ofdisease. I m J SurgPathol 1992;16 phoma [6]. :130-7. SurgCn CONCLUSION 3. ThieblemontC, BergerF, Coiflier B. MucosaAssociated MALTOMAs are rare kind of Non Hodgkin's LymphoidTissue Lymhoma. Cun€nt Opinion Oncol 1995; 7(s):415-20 Lymphoma withvariedpresentation. They areas yet on poorly understood.We have presentedour two en- 4. MontalbanC, CastrilloJM, AbrairaV, et a/. GastricB cell de mucosa associatedlymphoid tissue (MALT) lymphoma. counterswith such type of illnesg. A larger number vi< AnnOncol 1995; 6(4) :355-62. forensicr of patients will be neededto draw definite conclu- 5. BleckerU, Mc KeithanTW, sions. HartJ ResolutionofHelicobac- . a) Eval ter pylori associatedgastric lymphoproliferative disease. teett REFERENCES Gastroenterologt1995; 109(3) : 973-7. b) Exar l. BaileyEM, Ferry JA, Harris NL. Marginalzone lymphoma 6. Ialzen \ BorchandF, Lubke H. Colitis ulcerosacompli- (low grade B cell lymphoma of Mucosa Associated lym- catedby malignantlymphoma. Gut 1995;36(2): 306-10. espe idenr Teeth lifetime. remain ir filling an only banl dental res plete den carefully odontolol QUithQest Comp0iments group, ec Dental than fingr accident Sr,om wiped ofr individua Accon us oETERAI|IOUSIR|/U r HllAlfCECoRPoRAilor tionale, a tion, 65 / identifiet . fluent oo 64 B, NARTMANBHAVAN, tient's de 6TH FLOOR,NARIMAN POINT, tional w - mytilatec MUMBAI 4OO021. " fntional /of immer ./ Denta tify Char Nacy. W features r

tDental Ad

60 Jour. Marine Medical Society,July 1997, VoL4, No. I Jour. Mat J Surg Ruminations

B cell FORENSICODONTOLOGY linical rqt. | 6 Surg Cmde (D) ML GUPTA* rciated | 1995; orensic odontology deals with evaluation of data.He had lost four front teeth from his lower jaw B cell dental data to identifr criminals and accident in a riding accidentwhich helped to identi$ his rhoma. victims. The two major areasof activity in body. forensic odontology are: In may 1945,when the Russiansentered Berlin, rcobac- a) Evaluation and examination of injuries to the they found two badly bumed and mutilated bodies lisease, teeth,jawsand oral tissuesfrom various causes; in a bunker. When all conventional methods of b) Examinationof bite marks on human bodies, identification failed, the Russians obtained ante- ;ompli- 6-10. especially in sex related crimes, for possible mortem dentalrecords and X-rays of Hitler and Eva identificationof a suspect. Braun and conclusively proved the identities of Teeth are more prone to decay during a persons both. lifetime. After a person's death,however his teeth A young woman was found murdered in a Frank- remain in an excellent state of preservation.Even furt park in 1976. The murderer had left bite marks filling and restorations remain intact. Experts not on her body. Police arrested an American army only bank upon the total number of teethbut also on deserter.During his trial, he claimed that he was dental restorations,bridgework and partial or com- innocent but could not fumish any alibi. He was in plete denturesfor the purpose of identification. By trouble until an American Forensic odontologist carefully examining a tooth an experiencedforensic testified that the accusedcould not have inflicted the odontologist candetermine a personssex, age, blood bite wounds on the victim, as one of his canine tooth group, economic statusand even occupation. was missing whereasthe bite definitely showed the Dental recordsare now consideredmore reliable mark of a canine tooth. The suspectwas acquitted than finger prints for identification of criminals and on the strength of this evidence. Later, the culprit accident victims. Fingerprints can be altered or was identified and convicted. His teeth marks were wiped out by plastic surgery or injuries. But an as good ashis "calling card. individual'steeth are not easilytampered with. When an Indian Airlines plane crashed According to the Federation Dentaire Interna- outside Delhi one of the passengerswho died in the mishap tionale, an affiliate of the World Health Organisa- was the then Union Minister tion, 65 percent of mass-disastervictims can be of Steel and Mines, Mohan Kumaramangalam,but his body could be identified by dental records. Dental surgeonsin af- identified only by his dental records. fluent countries are now required to store their pa- Similarly the remains of late PresidentZia-ul-Haque Pakistan tient's dental records. In these days of unconven- of were identified only by dental records as severe tional war, victims of mishap are often so badly burns and mutilation in the air disaster made it mutilated that they cannot be identified with con- diffrcult otherwise. ventional methods.In such cases.dental recordsare of immensehelp. Dental record would be of immense help in es- Dental data was used way back in 1447 to iden- tablishing the identity of individuals, in this age of tify Charles the Bold who had died in the battle of weaponsofmass destruction.Maintenance of dental Nacy. Without armour, clothes or any recognizable records is an inescapablerequirement both from featureson the body, he was identified by his dental clinical aswell as forensicpoint of view.

*Dental Adviser (Navy), IHNS Asvini, Mumbai 400 005.

,No.l Jour. Marine Medical Society, July 1997, Vol. 4, No. I 6I BLEACHINGOF TEETH

Surg SLt(D) S PAHWA*

INTRODUCTION such as from smoking. Also in caseswhere crowns iscolored teeth are consideredunattractive, and porcelain veneersare to be fabricated, the arch prior provide therefore,a potential to producepsychologi- can be lightened to treatrnentto a more cal problems, such as lack of self-esteem,is estheticresult. present. This is easy to understand because the CONTRA INDICATIONS mouth is located at the anatomic focus of the face Tooth bleaching is contra indicated in 3rd or 4th and teeth are clearly visible during every day activi- degreestains, especially dark gray or blue stain and ties, suchas talking and laughing. tetracycline banding. It is also contraindicated in Currently, several methods are available to re- casesof history of sensitive teeth, leaking restora- storediscolored dentition. These include porcelain tions, microcracksin the teeth, large pulp chambers, veneers,full coveragecrowns, bonding and me- improper endodontic therapy, periapical pathology chanicalor chemicalstain removal [ -3] and unco-operativepatient attitude. The clinical procedure to restore stained denti- BLEACHING TECHNIQUES tion dependson variables, including the nature and intensity of stain, the age of the patient, and the Teeth can be chemicallv whitened bv three meth- desired esthetic effect of these methods. Porcelain ods. veneers and full coverage crown are considered (i) In Office Bleaching: most invasive becausesound tooth structure is re- Commonly known as ""Power Bleaching", moved to achieve an acceptablelevel of esthetics which uses a 30%oto 50o/ohydrogen peroxide t2l solution in conjunction with heat and Iight to The most common and accepted procedure to increasethe kinetics of stain removal. remove discoloration from acceptablyshaped den- (ii) Dentist Prescribed Home Bleaching or Night tition is by the use of abrasives, such as prophy Guard Bleaching: pastes,where superficial stains are removed by an This method, first describedby Haywood and abrading action. Abrasion of tooth surfaces re- Heymanns, involves fabrication of mouth moves extrinsic stain, but some'times does not sat- guard that contains peroxide preparations and isfactorilyremove gross discoloration. is wom over the teeth to gradually obtain the Bleachingofteeth and estheticshave been a part desired esthetic effects. The predominant type of peroxide used is 10% carbamide peroxide of dentistrysince 1805[4], An acceptedmethod to whiten teeth is by the use of chemical agents,such t4l. as peroxides.This method is consideredto be the (iii) Over the counter home bleaching systems: safestmeans to restorediscolored dentition because These lack the safety ofproper diagnosis and it does not entail removal of sound tooth structure, controlled application technique, and either it is the least invasive,and the agentsused in this lack in efficacy or in prosthesisfit. While some procedurehave a recordofsafety [5]. systemsmay be effective for some people, the risks and short comings seem to out weigh the INDICATIONS lower cost. Tooth bleaching is the most conservativetreat- mentmodality for mild tetracyclinestains, flourosis, PROCEDURE:HOME BLEACHING aging, yellow teeth and acquired superficial stains Routine prophylaxis shouldbe carried out. Shade

+DentalOfficer, NDC, INHS Asvini

A) Jour. Marine Medical Society,July 1997, Vol. 4, No. I matching is done prior to bleaching. An alginate of night guard bleaching the arch to be treated is made. From the resultant l. Hydrogenperoxide: (Peroxyle, Brite smile so- stonecast, a vacuum formed soft plastic night guard lution, Natural White solution) is fabricated. The night guard should completely 2. Carbamideperoxide: (Proxigel, Dental Brite, cover all the teethin the arch while leaving the palate Opalescence,Glyoxide, White and Brite) and as much contiguousgingival tissueas possible uncovered. Try-in of the night guard to assessthe Night guard bleachinghas many advantagesover accuracyofthe fit and to verify that no rough edges the office techniques. exist. is recommended. A) Safer,more effective, tissuefriendly and has no A 1.202gms tube of 18%carbamide peroxide is odour or bad tastefollowing the procedure. prescribedor given to the patient. B) Cost effective and time saving to the patient since majority of the INSTRUCTIONS TO THE PATIENT IN bleaching can be accom- plished the oflice. PRINTED FORM outside C) No preoperativeetching or post operative pol- l. At bed time. brush and floss teeth. then rinse ishing reqirired. mouth well. D) 2. Place 2-3 drops of carbamideperoxide into the No significant caustic chemical used. deepestpositions ofthe tray spaces. E) It can be resumedat any time and only peilodic 3. Insert night guard in mouth over teeth, gently supervision is required by dentist, should re- gression wipe out excessgel and rinse with water. occur. 4. Wear the loaded tray during sleep every night SUMMARY AI\D CONCLUSION until treatment is complete. Bleaching discolored teeth must now be consid- 5. Clean and rinse night guard every morning and ereda viable heatment for although it doesnot offer clean teeth as usual. the predictability ofmany cosmetic options, its sim- 6. Don't disturb the tray while wearing by lifting plicity and economics demand attention. It can re- with tongue,fingers ect. Take carewhen to bite turn a smile to the, not so affluent, conservative or with pressureinto tray. apprehensivepatient who doesnotwish to face tooth reduction and full coveragerestoration. If instructions are followed, more predictable results are obtained in days rather than weeks. REFERENCES l. Arens D. The role of bleaching in esthetics. Dent Clinic POSSIBLE SIDE EFFECTS North America I 989; 33 : 3 19-36. There may be increasedsensitivity to cold during 2. Ferimammra Gold Stevin RE, Garber DA. Bleaching Teeth treatment,temporary discomfort like gum and tooth Quitessencepublishing 1987; I 8-35. sensitivity, lip and tongue.soreness,throat or mod- 3. Croll TF, Cavanugh RR. Enamel color modification by erate continuous tooth pain. These side effects usu- controlled hydrochloric acid pumice abrasion. Quintessence ally resolve with in l-2 days after intemrption or Inf1986;l?:881-87. completion of the treatment. 4. Haywood VB, Heymenn HO. Night guardvital bleaching. Quintessence Inf 1989; 20 : 173-'16. MARKET PRODUCTS 5. Van B Haywod, Harld O Heyman. Night guard vital bleach- There are two classesofperoxide being used for ing: How safeis it? QuintessenceInf199l;22 (7) : 515-23.

Jour. Marine Medical Society, July 1997, Yol. 4, No. l 63 ECG QUTZ

'B' SUMMARY 2. What arethe findings in ECG ?

IJorty-nine year old male was admitted with 3. What is the complete diagnosis ? giddines. H palpitation and Examination re- I. vealedheart rate of 170per minute,BP 82160 4. How was the patient managedinitially ? mm I{g, regr{lar'a' wavesin JVP,and no abnormal- 5. Which drug not be used as a ity on systemicexamination. ECG recordedinitially should single drug 'A'. why is reproducedat After initial managementhis in this case,and ? heart rate came down to 72 per minute, BP 124180 6. Which drug may be used to prevent events 'B' 'A' mm Hg and ECG at was recorded. similar to that recorded at 2

QUIZ 7. Is there any modality of treatrnent other than l. What arethe findingsin ECG 'A' ? drugs for this patient ? if so what?

lrg.n

Jour. Marine Medical Society,July 1997, Vol. 4, No. l SPOT THE DIAGNOSIS

Surg Cdr AC PRAVEEN, Surg Lt Cdr SAI PRABHU, BTig DINESH PRASAD

45 year old male patient complainedof diffrcultyin swallowingforboth liquidsand solidsoftwo yearsduration. The severity of dysphagiafluctuated, but did not worsenwith time. There was no history of significantweight loss. Specificmaneuvers like straighteningthe back or standingat verycorrect posture improved his symptoms. He also gave a history of regurgitationof undigestedfood overthe lastone year. Investigationsincluded radiographic studies, a bariumswallow with fluroscopyand upper gastro- intestinalendoscopy. A bariumesophagogram from thispatient is depictedin Fig. l.

Fig.1 :

Jour. Marine Medical Society, July 1997, Vol. 4, No. I 65 ANSWERS TO THE ECG QUrZ over accessorypathway. l. Tachycardia with a rate of 230 per min. QRS 4. DC shock in view of haemodynamiccompro- complex is narrow, with possibly retrogradeP mise. waves. 2. Sinus rhythm at 63 per min. PR interval 0.06 5. Digoxin. It may acceleratethe heart rate by reducing period sec. QRS widened to 0.16 sec. Delta waves the refractory of accessory seen,negative in V,II,ilI, avF, positive in I, avl-, pathway V2 -V6. ST depressionin I, ayl., V3-V6. 6. Amiodarone;combination of quinidine + pro- 3. Pre-excitation syndrome (Wolff Parkinson pranolol; procainamide+ verapamil, sotalol, White syndrome) with posterior septal acces- classI C drugs. sory pathway, with paroxysmal supraventricu- lar tachycardia,with antegradeconduction over 7. Yes Radio frequency ablation of accessory normal pathway and retrograde conduction pathway.

SPOT THE DIAGNOSIS DISCUSSION Diagnosis- Achalasia Cardia I . Motor disorder of the esophagus 2. The causeof achalasiaremains unknown 3. Abnormalities in both nerve and muscle com- ponents can be detectedin this disease 4. Physiologic studies have confirmed the presence of denervationof smooth muscle segment ofthe esophagus 5. Dysphagia is the predominant symptom for both liquids and solids 6. Radiographic studiesare the primary screening tests. The esophagealbody is dilated and dila- Fig.2: The waist produced in the centre of the lower tation is greatestin the distal esophagus.Bar- esophagealsphinctcr indicatcs its appropriateposition. ii. Slight indentationpersists while the bag is inflatedto ium column terminatesin a taperedpoint. The maximal pressure.iii. This indentationnearly resolves location of the tight, non relaxing sphincter. as dilation is successfullvcomoleted. This smoothly taperedprojection is commonly 'birds called a beak'. namely, pharmaco therapy, dilation and surgi- 7. Endoscopy should be performed even if the cal myotomy.The choiceof one over the other radiographic evaluation is typical, to exclude dependson several factors. several other diseasesthat mimic achalasiaand 10. Pneumaticdilation by Brown-McHardy pneu- to evaluate the esophagealmucosa. The eso- matic dilator is shown in Fis. 2. phagogastricjunction must be examined care- REFERENCES fully for any neoplasm. l. Barrett NR. Achalasia of the cardia, reflections upon a 8. Manometry is also a part of the investigations clinical studyofover 100 cases.BMJ 1964; I : I 135. workup. 2. VentrappanG , et al.Treatmentof achalasiawith pneumatic 9. Three palliative treatments are available, dilatations.Gut 197l: 12 : 268.

66 Jour. Marine Medical Socictv, Julv 1997. Vol. 4, No. I BOOK REVIEWS

HAEMATOLOGY FOR STUDENTS by Dr.VH Talib presentedin two major sections. Section one comprising and Dr.SK Khurana Second Edition - 1997. Published ofthirty nine chapters,covers the clinical, theoretical and by CBS PublishersAnd Distributors ,4596/lA, I I Darya therapeutic aspects of anaemias, bleeding disorders, Ganj,New Delhi I 10002(INDIA). Volume I & 2 . Pages haemo- parasites, immunohaematology, blood banking 1010,Price: Rs. 190/- and transfusion medicine. Section two concentrates on ISBN:81-239-0386-3 routine laboratory tests, special laboratory tests, haemo- globinopathies,bone marrow examination, cyto chemis- This is a highly informative and comprehensivebook try, screeningand coagulationassay rechniques. The prin- on haematology. The presentation and write up of the ciples and interpretation of various tests are very well subject is simple, where in the text, diagram and micro incorporated. photographsblend togethersmoothly. The book is the first of its kind written by Indian authors on haematology. It is an excellent book which covers every aspectsof Adequate emphasis has been placed to cover clinical haematologywithout being voluminous and will prove to laboratory techniquesand other practical aspectsof hae- be a boon to studentsand practitionersalike. This concise matology. It is well illushated with diagrams, coloured book would certainly alleviate the need to refer to volu- micro photographs and sketch diagrams for better and minous literature, to an extent. easy understanding.The colour micro photographsbeing a major highlight of the publication CoI S BHATTACHARYA The book comprises offorty five chaptersand seven ClassifiedSpecialist in Pathology,INHS Asvini, appendices,in two volumes bound togetherandis broadly Mumbai 400 005

THE PHYSIOLOGY AND MEDICINE OF DIVING women world wide. David .Published by Peter Bennett and Elliott by WB Each of the previous editions contains papers by Road SaundersCompany, Oral London,4thedition 1993. authorsnow no longer active in the field. This edition Pages613; Price:- US $ 132.50. containsmuch new material, every single chapterhas been ISBN-0 -7020-1589-X revised and many completely re-written. This book also Sincethe third editionof this collectionof reviews introduces a revised descriptive classification of decompression disorders. published in 1983, there has been a greaterunder- standingof someof the many physiological, bio engineer- Several new topics including a chapter on fitness to ing and medical problems associatedwith human expo- dive and anotherreviewing the long-term health effects of sure to raised environmental pressure.At the same time, diving have been included in this edition which will be the continuing growth of diving across the world has usefulto the practitionersof diving medicine. demandeda fresh appraisalofcurrent statusofknowledge The descriptionofvarious underwater phenomenalike and researchin this field. thermal problems and their prevention and treatment, This book comprising of twenty one chapterscontrib- pathogenesisand treatment of decompressiondisorders uted by an intemational panel of experts,serves this aim and,dysbaricosteonecrosis is so vivid and exhaustivethat admirably. This fourth edition emergesafter a period of the readeris not drawn to the fact that there are only a few ten years, during which commercial deep diving has had illushations provided. considerable operational experience in the depth range 300-400m (1000-1300ft) and during which recreational Surg LCdr GD BHANOT diving has become increasingly available to men and Schoolof Naval Medicine.Mumbai 400 005.

Jour. Marine Medical Society,July 1997, Vol. 4, No. 67 NEUROLOGY OF TIIE NEWBORN, third edition, developmentand evaluation.Thereafter, issues of sei- Ed. Joseph J Volpe. Publisher WB SaundersCo, zures,hypoxic ischaemic encephalopathy and intracranial Philadelphia,1995, Pages 876, Price Rs.3300/- haernorrhageare discussed at greatlength. Subsequently, This long awaitedthird editionhas just becomeavail- Dr. Volpe has candidly,discussed metabolic diseases, ablein the Indianmarket, after nearly l0 yearsofpubli- degenerativediseases, trauma, infections and mass lesions cation of previousedition in year 1987.Neurology in of brain.The book has ended with themost useful chapter general,has been considered a difficult subjectand hence on effectsof drugson thedeveloping brain in foetus. onecan well understandthe difiicultiesin neonatalneu- The only desiredareas in the book havebeen, firstly, rology.There is a strongneed to understandthe newborn theneed ofmore detailed but simplifiedformat of clinical nervoussystem, it's development,developmental aberra- neurologicalexamination in term and pretermneonates. tions,the art and methodologyof newbomneurological Secondly,more illustrative clinical photographsofeach examination,detection and relevancc ofabnormal neuro- abnormalclinical neurological sign could have helped the logical signs,appropriate selection of the investigations readers- from rapidlyincreasing list ofnewersophisticated inves- tigationand planning of treatmentand prognostic proto- In conclusion,this is oneofthe most authoritative book colsincluding genetic counselling. Dr. JosephJ Volpehas in the neonatalneurology of presenttime. It is recom- donea wonderfuljob in addressingall theaforementioned mendedto Paediatricians,Neonatologists, Neurologist, issues comprehensivelyin this edition. The special Imagingspecialists and physicians for both quick refer- strengthsof this editionare simple language, comprehen- encewith thehelp of illustrativeinformation and also for sive tables, illustrative figures, clinical photographs, detailedinformation. This bookwill be an assetto everv pathologicalspecimens, flow diagrams,relevant details of institution,though individuals may find it expensive. the mostup to dateneuro-investigations and exhaustive list ofreferences.Therefore, this book gives clear under- Surg Cdr GIRISH GUPTA standingand authoritative and most upto dateinformation Neonatologist,INHS Asvini, Colaba, on the subjects.Initial chapterscover the basicissues of Mumbai- 400005.

68 Jour. Marine Medical Society,July 1997, Yol. 4, No. I JOURNALWATCH

a)BMJ Vol 13 Jun 1997 Physicalfitness, acclamatisation to high altitude and maintenanceof equipment need The article "brain damagein divers(Diving itselfmay to be resorted to scrupu- lously. The suggestionof replacingthe faulty Neoprene cause brain damage- but we needevidence )" by Dr.Peter suits with the more hardy rubbber "skin suits" will be Wilmshurst , consultantcardiologist , Royal Shrewsbury Hospitalpublished in BMJ Vol 13 of June97 enlightened helpful in future expeditions. The role played by regular us on the various aspectsofneurological damageto central hot drinks and high caloric food in keeping hypothermra nervous system due to diving resulting in decompression away was also highlighted. sickness. The authors also report that there was no evidence of The article coversmost ofthe aspectofneurological Clinical hypothermiaduring the entire duration of high -40 damageto the divers due to decompressionsickness and altitude stay inspite ofsurface temperaturereaching C it only confirmsthe belief that neurologicalpresentations at times. The wooly bearsand thermal underwearused have have produced great deal of interest and controversy. It donetheirjob, it appears. has been cynically and perhapsaccurately statedthat the The teamhad used USN diving tablesfor no-stopdives way to reduce the incidence ofcerebral manifestationsof with no modifications.The speculationof Sahni,John and decompression sickenss is to omit a full neurological Chatterjeeenvisaging oxygen toxicity at much shallower examinations. depths in high altitude due to low partial pressureof The author has exhaustivelydiscussed the various oxygenon the surfacervas shown to be ill founded.Also was the prediction, pathophysiologicalaspects ofgas bubbleformation in the that air starvation and breathing diffi- circulation.One must not forgetthat almost30% popula- cultieswill be facedwhile switchins to surfacebreathine tion has patent ductus arteriosuswhich may contribute to afterdiving. arterialisation of the venous gas emboli, not to forget the ONE HUNDRED YEARS AGO contributionof septaldefects, especially when the pulmo- THE COST OF A MEDICAL EDUCATION nary artery pressure increaseswith emboli blockage of pulmonary circuit producing a right to left intracardiac Thereare few thingsmore seriousthan the choiceofa profession,and there is no doubt that in many homesat shunt( Paradoxicalemboli ). Howeverthe authorfails to present discussthe other probableconditions which may create the time anxious family council are being held regardingthe careeroflads who are now leaving school, similar effectsand could be inducedby straining, sneez- ing, coughing,valsalva manouwe etc. and must some way or anotherbe launchedupon the world. Among the careersin which the highestprizes are It may be easyto say tlrat we still needmore evidence open to all who have wit and energy and can afford the to prove that diving itself may cause brain damage in cost ofthe necessarycourse ofshrdy, medicineoffers to divers,but with a backgroundhistory of diving evenif it many the highestattractions. The scientific characterof be adventure or sports diving corelated with various , the study, the purely personal nature of the work, the life clinical findings and further fortified with resultsof vari- of intimacy with many peopleof many ranks,the possi- ous diagnostic evidence using computerisedtomogra- bility - dim perhaps,but still thepossibility - of wealthand phy(CT), magnetic resonanceimaging(MRl), or single honour, and the almost certainty at least of brcad and photon emission computed tomography (SPECT), it cheeseas the reward ofpatience, sobriety, and hard work, would be fairly reasonableto attributethe various findings are sure to draw many to medicine as their career in life. to diving activity. It would be well, however, beforecoming to a decision, b) Under SeaBiomedical ResearchVol 2l Dec 1994 that they should consider the drawbacks and the hard- ships.Noone will deny that thc prices are great and that The article "High altitudedives in Nepali Himalayas" thosewho win them find their way smoothedto wealth, by J.Leach,A . Mclean and F.B. Mee publishedrn influence,and position.These, however, are but few. It UnderseaBiomedical Research vol 2l no.4 of Dec'94 is must not be thought that all men of consulting rank, discussed. howeversuccessful they may be in science,are successful High altitudediving which involves interplayof Hy- also as the world counts success.No; to the immense perbaric and hypobaric forces of nature is a fascinating majority who next Octobercommence their professional prospect.The study on three experiencedBritish divers at studiesmedicine will prove but a harshmother, and will altitudes of I 5700 and I 6000 feetson Oxygen and Nitrox give little beyondthe necessariesof a simple and frugal gasesreveals certain interesting facts. life. (British Medical Joumal , 1895,ii : 574)

Jour. Marine Medical Society,July 1997, VoL 4, No. l 69 NEWS FOR THE DEEP COMMANDING OFFICERS OF NAVAL HOSPITALS

I INHS Asvini SurgRADM HP Mukhefee 4 INHS Dhanvantari Surg Capt JP Gupta VSM 5 INHS Jeevanti Surg Capt PC Mohanty n INHS Sanjivani SurgCapt AJ Moraes 6 INHS Nivarini Surg Cdr MW Malse 3 INHS Kalyani SurgCapt K Satsangi INHS Kasturi Surg Cdr P Mjay Shankar

NAVAL MEDICAL OFFICERS IN NON NAVAL POSTINGS 1 DGAFMS : SurgCapt P Sivdas 4 CH (SC) SurgCdr A Behl VSM SurgCapt Surjeet Singh SurgCdr RA Manghani SurgCdr R Bhalla 5 CH (EC) SurgCdr R Malik 2 AFMC SurgCapt VK SinghVSM SurgCdr RS Lamba SurgCapt Ratan Singh SurgLCdr TR Behra SurgCdr S MohantyVSM 6 MIICTC SurgCapt JM Borcar SurgCdr E James SurgCdr J D'Souza SurgCdr RN Mishra 7 MH Kirkee Sulg Cdr M Balakrishnan SurgCdr YD Singh 8 NDC SurgCapt M Keshavan SurgCdr S Goel 9 AFMSD SurgCmde VK Jain SurgLt Cdr KJ Singh IO AF CME SurgCdr H Jaganykulu 3 Army Hospital SurgCdr YP Monga II AFC Surg Cdr A Bhagra (RR) : SurgCdr VS Bedi SurgLt P Joshi SurgLt Cdr KSK Patrulu 12 AF Hospital : SurgCdr KMR Nair SurgLCdr MS Sahi 13 Deputation : SurgCdr JP Lazarus SurgLCdr TK Malhoha 14 StateGovt Delhi: SurgCdr M Paul 15. DEBEL SurgCdr PPBellubi VSM

STUDY LEAVE AWARDSAIID DECORATIONS AVSM : SurgVADM CD Sasikumar SurgLCdr S Ganguli SurgLCdr CS Naidu VSM : SurgCdr VK Saxena SurgLCdr IK Inde{it SurgLCdr A Ahluwalia SurgLCdr H Mani SurgLCdr G Vishwanath COMMENDATION BY CHIEF OF NAVAL STAFF GRADED SurgCdr (D) BharatBhushan SurgCdr G Verghese SurgLCdr A Tripathi SurgCdr VK MohendraNM SurgLCdr KJ Singh SurgLCdr S Choudhary M MandalLMAAN I (SD) SurgLCdr V Hande SurgLCdr S Tandon SurgLCdr MY Dharmamer SurgLCdr CS Saxena COMMENDATION BY FLAG OFFICER SurgLCdr NS Rao SurgLCdr KB Sunder COMMANDING IN CHIEF SurgLCdr (Mrs) PC Hande SurgLCdr RK Verma WESTER}I NAVAL COMMAND SurgLCdr KK Mishra SurgLCdr S Deb Capt(MNS) MS SantanaRoy

COMMENDATION BY FLAG OFFICER CLASSIFIEI) COMMANDING IN CHIEF SurgCdr VS Bedi SurgLCdr TR Behra EASTERN NAVAL COMMAND SurgCdr B Sudarshan SurgLCdr IK Indedit SurgCdr (Mrs) V Mohendra SurgCdr RA Manghan SurgLCdr CS Naidu HP Dhali MCPOMA I SurgLCdr (Mrs) CS Naidu SurgLCdr R Koshi R SinghMCPOMA II SurgLCdr S Badhwar SurgLCdr J Chatterjee KA Kumar POMA SurgLCdr A Ahluwalia SursLCdr S Goel U KumarPOMA COMMENDATION BY FLAG OFFICER PROMOTIONS COMMANDING IN CIIIEF I. SOUTIIERN NAVAL COMMAND To Flag Rank of Surg VADM Surg RADM JC Sharma,VSM B Lal POMA II. To Flag Rank of Surg RADM JEEVAN RAKSHA PADAK : Surg Cdr MW Malse SurgCmde HP Mukhe{ee,VSM III. HONORARY I.JTS To the Rank of Surg Cmde JP SharmaMCPOMA I Surg Capt BPS RAwa! VSM M Urkude MCPOMA I Surg Capt UPV Rao and reappointed HONORARY SLTS Comdt MH Meenrt in the rank of Brigadier RPB SinghMCPOMA I Surg Capt VK Jain as CommandantAFMSD RamKishan MCPOMA I IV. To the RankofSurg Capt Surg Cdr SD AhlawatMCPOMAI ' JP Gupta HS BabraMCPOMA I Surg Cdr S Kundu L TeteMCPOMA I Surg Cdr GC Tripathy SurgCdr VS Dixit, VSM SD LIST COMMISSION Surg Cdr PC Mohanty BS RAWATPOMA (Ag SLt) V. Tlansfers/?ostings/Appointments SurgVI{,DMJC SharmaVSM as DGMS (N) MODERNIZATION NAVAL MEDICAL EACILITIES SurgRADM VK Pahwaas CMO WNC Surg RADM HP MukhedeeVSM as *INHS Asvini CommandingOffrcer, INHS Asvini OperatingArthroscope SurgCmde SP Malhota as DMS (P&M) NIIQ PanoramicX-ray System Surg CmdeNR RahaVSM as Director INM Holter Monitor Surg Capt MK Gupta, Sr Adv Pathology, Lithotryptor INHS Asvini TissueProcessor SurgCapt JP Gupta, Co INHS Dhanvantari PaediatricMonitoring System SurgCapt S KunduAsstt XO INHS Asvini AutomaticX-ray processor SurgCapt UPV Rao CommandantMH Meerut SurgCmde VK Jain CommandantAFMSD *INIIS Kalyani SurgCapt Dixit VSM JDMS (P) NHQ DentalX-ray unit VI. Secondmentto Navy C-3 Modularbox Lt Col (D) JB Singhas SurgCapt Ultrasonograph Lt Col (Mrs) M Pahwaas SurgCapt Automaticx-ray processor VII. Tlansferredout ofNavy Surg Capt UPV Rao on Promotion to the *INHS Sanjivani rank ofBrigadier Fibre optic bronchoscope VIIL Retirement/Release Micro drill ENT l. SurgVADM CD Sasikumar,AVSM Micro surgeryequipment for ear surgery 2. SurgRADM Indru Kamani Automaticx-ray processor 3. SurgCapt VK Malhotra 4. SurgCapt DM Gupt *INHS Jeevanti 5. SurgCapt SK Canguli Ultra Sonograph 6. Surg Cdr KV Suryanarayana Pulseoxvmeter 7. Surgcdr P Sethumadhavan 8. SurgCdr MV Rao *INS Rajali 9. SurgCdr (D) PC Bhoil, VSM Ultra Sonograph 10.Surg Cdr BP Das I l. SurgCdr DN Ray *Naval Dental Centre Mambai 12. Sug Lcdr J Makhijani Ultra SoundScaler 13. SurgLcdr RS Rao LETTERSTO THE EDITOR

ROLE OF ITYERBARIC OXYGEN THERAPY IN TREATMENT OF HANSEN'S DISEASE

Dear Editor, all the casesshowed decrease in numberof granulomas The article "Role of Hyerbaric Oxygen Therapy in and cellularity.Improvement in cosmeticapppearance treahnentofHansen's Disease" published in JMMS issue like flatteningof raisedlesions and decrease in erythema vol 3 No.l of Dec 96 is an interesting original research. makesit more patientfriendly thereby probably reducing The fact that India has the highest prevalence rate of thepatient dropout rates.Altogether HBO therapyis an Leprosy in the world, makes IIBO therapy an ideal thera- atffactivetherapeutic adjunct in HansensDisease deserv- peutic adjunct for quick control ofinfection and thereby ing widepublicity and usage. its too. spread Surg Lt Cdr GAGAIT{DEEPBHANOT The study shows that there is an accelerated response Schoolof NavalMedicine, Colaba,Mumbai 400 005. in the skin lesions in that the post HBO histopathology in

A STUDY OF BLOOD GLUCOSELEVEL CHANGESDURING IryPERBARIC OXYGEN THERAPY

Dear Editor, foot and other late effects ofDiabetes. The above mentioned article published in JMMS issue Keeping in view , the hlpoglycemic effect of HBO of Dec 96, Vol 3, No. l, made very interestingand enlight- therapy, it would be worthwile to do further studies on ening reading. Hyperbaric Medicine, no doubt, is an diabetics receiving insulin/oral hypoglycemic drugs and evolving medical speciality and ongoing research con- compare with the metabolic control achieved by their firms the high potential of HBO therapyboth as a primary combination with HBO therapy. mode of treatment and as an adjunctive therapy for various Blood insulin disorders. assaysduring the courseof therapy may be more helpful in monitoring the glycaemic control. The definitive conclusion that HBO therapy leads to There may possibly be a reduction in the required dose of lowering of blood glucose levels in patients, more so in Insulin/OHD too. diabetics, is quite a significant finding. In our institute,we are using HBO therapy successfully in treating Diabetic Surg LT HBS CIIAUDHRY School of Naval Medicine, Colaba,Mumbai 400 005.

MEDICAL MARITIME IIISTORY - MY PERSPECTIVE

DearEditor, increasingobesity ofNaval Personnelwas not lost in the all pervading good humour. A fat lot of good, all this I haveread with interestthe abovementioned article obesity will do us! Corrective stepsare urgently required publishedin Joumal Marine of MedicalSociety issue of to alter the food habits and lifestyle in the Indian Navy. Dec 1996,Vol 3,No.l . Thehumourous article gave a good accountof the healthof seafarersin the era long gone. Altogether the article makes good, light reading and Although,I'm not too sureif the Genoaincident quoted one hopes that more and more authors resort to laughter -the by theauthor could have ended in a different(and perhaps best medicine known to mankind. delighttul)way. Surg Lt, P GOKULAKRISHNAN The messagegiven in thelast paragraph regarding the School of Naval Medicine, Colaba,Mumbai 40 005.

72 Jour. Marine Medical Society, July 1997, Vol. 4, No. I GUIDELINESFOR AUTHORS

l. Joumal of Marine medical Society (JMSS) The Editorial Board has the right to introduce such publishesoriginal articles,case reports, topical reviews, changesas may be considerednecessary. When necessary, editorials, special articles, letters to the Editor, book one copy of the typescript, suitably modified, will be sent reviews, and other scientific information in all disciplines to the author for revision and resubmission. ofmedical sciences. All the material pertaining to an article, which is not 2. Contents of the JMSS are covered copy right, accepted,will be returned by ordinary post. Articles are accepted for publication with the 7. Reprints : 15reprints of eacharticle will be sentfree understandingthat their contents,all or in part, have not of cost to the author whose name is given on the title page beenpublished and will not be publishedelsewhere except for that purpose. in an abstractform of with the consentof the Editor. JMSS Extra reprints will not be supplied. does not acceptthe responsibility for statementsmade by the authors.The Editorial Board has the right to introduce 8. Author's and OC certificatesas per SAO l518/81 such changesas may be considerednecessary. must accompany the article in duplicate, as per thoro forma given below: 3. Authorship Author's certificate : Certified that I have not used those who have materially participated Only in the any information or material from official documents preparation the article, of should be selected for graded,restricted and above or any classified information authorship.The final typescriptmustberead and approved obtained in my oflicial capacity. by all the authors and a statementto that effect signed by each author must accompanythe article. If more than four I have checkedthe article for grammar and spellings. authors contribute to the article, an accompanying Principal Author statement must specify briefly the work done by each Certificate from OC author. Certified that I have no objection to the publication of 4. Manuscripts must be neatly typed, in double space thearticle entitled throughout, on one side ofthe sheetofgood quality white written bond paperof the size 28 x 22 cm with 3 cm margin on by both sides.Words should not be hvohenatedat the end of a line. OC Three copies,including the original,of the typescript should be submitted along with two sets of illustrations. THE VANCOWER STYLE Authors must retain a copy of all the above material, as In keeping with the current trends in Medical the Journal cannot be held responsible for its mutilation Joumalism and for the sake of ensuring international or loss in transit or due to any other reason. uniformity the "Vancouver Style" of publication is to be 5. The typescripts should be enclosed in a large followed. Detailed information regarding the pattern to be envelope, superscribed'Article for Publication', followed for articles is given below. Conhibutors are preferably not folded and sent under registeredcover to: eamestly requestedto note and strictly follow them. Editor Classification and Length of Articles Journal of Marine Medical Societv INHS ASVINI. I. ORJGINAL ARTICLES Colaba,Mumbai 400 005. The subject should decide the length of the article. 6. AcknowledgemenUDecision : Material received However, the text should not exceed eight typed pages for publication will be acknowledgedimmediately. (double space)or about 4,000 words, excluding title page abstractpage, references, tables and legends.The number Besides being evaluated for scientific value and oftables. illushations and referencesshould be keot to the accuracy, the typescript is edited for the contents and minimum. preciseness as also for the style of expression and presentation.Each articlemust not only high-lighta new 2. CASE REPORTS aspect of the subject, but must also make enjoyable Case reports are accepted only if they describe reading. interesting facets of a particular disease,an unusuaVrare The article may further be reviewed by a referee. entity or finding. As a rule, Case Reports are given low

Jour. Marine Medical Society,July 1997, Vol. 4, No. I 73 pnorrry. References Thetext should not exceed 1500 words. There is no Responsibility of accuracy of the references lies need to give a comprehensivereview ofliterature. entirely with the authors.It must be ensuredthat the names ofthe authorscited areconectly typed both in the text and 3. REVIEW ARTTCLES in the Referencelist. Review articles are acceptedonly by invitation. Referencesshould be listed in the order in which they 4. MISCELLANEOUS ARTICLES are cited in the text, and not in the alphabetical order of the author's nan e. They should be indicated in the text by Technical notes, letters to the Editor, briefnotes, etc. arabic numeralsenclosed in squarebrackets (e.g. on will be acceptedonly on their merit. [2]), the line ofthe text and no as superior numbers. The Editorial Board may reduce the number of tables, Ensure that all the references cited in the text are referencesand illustrations. included in the list, and vice versa.Underline the name of The Typescript booVjoumal in the list of references. The typescript comprises (a) Title page, (b) Abstract The following examples will amply serye to guide in and key words, (c) Text, (d) References,(e) Tablesand (f) presentingthe various kinds ofreferences. Legends.All thesemust startoureparate pages andinthe above order. Journals (a) Title page gives the title of the article, full names StandardJoumal Article (List all authors when six or ofthe author(s),afliliations ofauthors, place ofwork, and less; when sevenor more, give only first three and add el name and addressof the author for correspondenceand al). requestfor reprints. Give respectivePIN. One-word names of Joumals should be given in full, Ideally, the title should be of about 60 characters.It e.g. Cancer,Gastroenterology, Surgery. shouldhave no abbreviations.Give full first namesof the For correct abbreviationsofJoumals refer to the latest authors, middle initials and last name(s).No degreewill Index Medicus. be printed. Names of all the authors must be typed one Names of Joumal not indexed must be given in full. below the otherwith properfootnote marks afterthe name. No full point in abbreviations of the Journal's name affiliations (with Other items, viz. corresponding (e.g.NEnglJMed). footnote marks at the beginning), name and addressof author for correspondenceand requestfor reprints,should l. You CH, Lee KY, Chey RY, Menguy R. Electrogas- be typed as footnotes.The following marks are available, trographicstudy ofpatients with unexplainednausea, and should be used in the sameorder. bloating and vomiting. Gastroenteroloy 1980; 79 : *+#'l'|++f# 3I l-14. 2. CorporateAuthor) (b) Abstract (p.2) should be typed on a separatesheet. The Royal Marsden Hospital Bone-Marrow Trans- It is a synopsis of the main article and gives an plantationTeam. Failure of syngenericbone-manow opportunity to the author to inducethe readerto go through graft without preconditioning in post-hepatitis mar- the article in its original form. In about 200 words, (100 row aplasia.Lancet 1977;2 : 24244. for casereports), divided into a few sentences,it must give briefly the history and nature of the disease/subjects;the 3. No Author Given methods, results, diagnosis and conclusion, giving facts Anonymous. Coffee drinking and cancerofthe pan- and not description. creas(Editorial). Br Med J l98l; 283 : 628. Speculativesurmises, and referencesto otherworks on 4. Joumal Supplement the subject should not figure in the abstract. Mastri AR. Neuropathy of diabetic neurogenic blad- - Remember An abstractis mini-article. der.Ann InternMed 1980;92 (2Pt2): 316-18. Key words : Not more than five impodant words Frumin AM, Nussbaum J, Esposito M. Functional which will help the indexer. asplenia : demonstrationof splenic activity by bone (Abstract). (Suppl The Text marrow scan Blood 1979; 54 l) : 20a. The text should be divided into sections, e.g. introduction, materiaVsubjecVpatients and methods, 5. Joumal Paginatedby Issue results,and discussion.Each should have its individuality SeamanWH. The caseof the pancreaticpseudocyst. and must not be mixed with others. Hosp Pract 1981; l6 (Sep): 24-25.

74 Jour. Marine Medical Society,July 1997,Vot. 4, No. I Books and Other Monograph Pleasenote that 6. PersonalAuthor(s) l. The initials haveno periods; Eisen HN. Immunology: an introduction to molecu- 2. The y ear follows the periodicaVpublisher's name lar and cellular principles of the immune response. (in caseofBooks); 5th ed.,New York: Harperand Row. 1974;406. 3. Editorial, Abstract, etc. appearin parenthesis; 7. Editor, Compiler, Chairman as Author 4. Both beginning and ending pages are given. owns DaussetJ, Colombani J, eds.Histocompatibility test- Ifthe ) arch referenceis ofonly one page,underline the page ing 1972. CopenhagenMunksgaard. 1973: 12-18. number (see 3 above). more 8. Chapterin a Book Tables (follow references) Weinstein L, Swartz MN. Pathogenicproperties of Tablesmay be types in betweentext matter, preferably invading microorganisms. In L Sodeman WA Jr, after on near about the paragraph in which the table Sodeman WA, eds. Pathologic physiology mecha- )r 4th number is mentioned. They should be serially numbered nisms of disease.Philadelphia WB Saunders.1974; n and in arabic numerals (Table l, Table 2) and a short title 457-72. ed in should speciff the contents. 9. Published ProceedingsPaper stora- Horizontal lines in the bodycMDNM> of lbers, Dupont B. Bone malrow transplantation in severe the table, except between a column heading and its immunodeficiency with ology combined an unrelated subheadings,should be avoided. Similarly, the vertical MLC compatible donor. In : White HJ, Smith R, eds. lines separatingthe columns should be totally omittec. Proceedingsofthe third annual meeting ofthe Inter- national Society for Experimental hematology. Legends (follow tables) Houston : International Society for Experimental Legends should be brief(rarely exceeding 40 words), meth- Hematology. 1974; 44-46. but must explain the salient featuresof the illustration.

10. Monographin a Series Illustrations Hunnighake GW, Gadek JE, Szapiel SV, et a/. The Illuskations should be presented only if they depict hing", human alveolar marcophage. In : Harris CC, ed. 'oxide something new or unusual. They should be serially Cultured human cells and tissues in biomedical re- numbered in the order of their mention in the text, ght to search.New York: Academic Press.1980: 54-56. irrespective of their nature, viz. photograph, drawing or (Stoner perspective GD, ed. Methods and in cell chart, using only the word Figure and not diagram, graph, biology;vol l). Night etc. I 1. Agency Publication Figures should be numbered to correspondto the case rd and Ranofsky AL. Surgical operations in shortstayhos- numbers,e.g. Fig. lA, Fig. lB, Fig. 2A, Fig. 28, etc. - mouth pitals:United Stated 1975.Hyattsville, Maryland : Illustrations are of the following kinds: National Centerfor Health Statistics.1978: DHEW 15and 1. Photograph, 2. transparency; 3. diagram or line publication no (PHS) 78 1785, (Vital and health in the drawing; and 4. chart. statistics;series l3; no. 34). rt type Photographs:Unmounted glossy prints - not matfinish 'oxide Other Articles - ofexcellent clarity should be selected.Their size ideally 12. Dissertationor Thesis shouldbe 13x l8 cm (5" x 7").

S: Caims RB. Infrared spectroscopicstudies of solid Do not write anyhing on the photograph, either on the is and oxygen (Dissertation).Berkeley, California: 1965; back or on the front. either l 56. Do not mount the photographs. some 13. NewspaperArticle Do not use pins, staplesor even paper clips to put the e,the Shaffer RA. Advances in chemistry are starting to photographstogether. Enclose the photos in thin cards, so that they do not get mutilated. ;h the unlock mysteriesofthe brain: Discoveriescould help cure alcoholism and insomnia, explain mental ill- Avoid identifiable photographs, unless you have ness.How the messengerswork. Wall StreetJoumal. obtained the patient's permission to reproduce them. (vol. 1), (vol. l) 1977;Au'g 12:l l0 2. Transparenciesand coloured photographs are not ihade 14. MagazineArticle accepted. Roueche B. Annals of medicine: the Santa Claus 3. Diagrams should be drawn on thin, white, smooth culture.The New Yorker I 971; Sep4 : 66-8I . or glazed card in Indian black ink, and not in any other

No.I Jour. Marine Medical Society,July 1997, Vol. 4, No. I 75 colour. Unfamiliarabbreviations, medical jargon and passive 4. Chartsshould be drawn in the sameway asdiagrams. voice. Type a label indicating the top 0 principal author' Repetition of material in resultVobservationsand name, short title of the article and the figure number, and discussion,in tablesand text, and in text andlegends. paste it on the back ofthe illustration. Suggestionson writing an artlcle Units Write your manuscript(fint rough version), improve Use metric measurements,ch, B, kg, ml (not cc). No upon it and at this stagedecide on the references,tables periods, no plural form (e.g. 30 cm, 48 kg, l5 ml. etc.). andfigures (second rough version). Keep it asidefor 2-3 Use radiograph, radiographic and radiographical not weeks. Write on separatesheets any improvemantsin x-ray, skiagram, roentgenogram, roentgenographic and language,presentation, etc., or removal,replacanent ofa roentgenologic. paraor two. Write thethird versionwhich will now be in *ir - Man/woman insteadof male/femalqpatient etc. Patient a presentableshape, get it read by a colleagueor a instead ofcase. specialistin anotherfield. Implement their suggestionsif 'Significant' you approveof them. And get set for typing the final should be reserved for use in statistical versionfor submissionto theEditor. sense. For moredetails, please refer to the following: Spellings l. InteniationalCommittee ofMedical Joumal Editors. British spellings are preferred to American spellings. Uniform requirementsfor manuscriptssubmitted to (e.g. colour, fumour and not colour, tumour). biomedicaljoumals. Ann Intern Med 1988; 108 : In words with diphthongs (ae, oe) retain only e and 258-65. delete or o, (e.9. etiology (aetiology); hemo (haemo), 2. LentleBrain C. Informationfor authors../CanAssoc cecum (caecum); esophagus(oseo-phagus) etc. Radiol 1988;39(June): 157-59. Avoid 3. Anonymous.Information for readersand authors. Names, initials, hospital numbers of the patiants, and AnnIntern Med 1989;I l0 : 14 - l-7. dates. Acknowledgement Small articles on single individual aspect of the subject, when one larger article, discussingall the aspects Theseguidelines for authorshave been adapted from would carry more weight. theMedical Joumal of ArmedForces of India.

76 Jour. Marine Medical Society,July 1997, Vol. 4, No. I andpassive ations and .egends. LIFE MEMBERS OF t), improve rces,tables MARINE MEDICAL SOCIETY tidefor 2-3 \ rementsin I :ementof a I now be in I. SURGVADMGKSONIVSM 23. SURGLT S GANGOPADHAYA ague or a 2. LIGENVKTEWARI 24. SURGCDR PPNAIR ;gestionsif g the final 3. SURGVADMBKRAKSHIT 25. DR. SURESHPUROHIT ing: 4. CAPT CEDNICIGNATIUS ANDAFE 26. SURGCDR S NANGPAL nl Editors. .27. rbmittedto 5. SURGVADM OPCHAWLAAVSM SURGCDR MJ JOHN 188;108 : 6. SURGUT PROMOD KUMAR JENA 28. SURGLI G KRISHNAN

CanAssoc 7. DR.VJRUPAREL 29. SURGLCDRCSSAXENA rd authors. 8. SURGLCDR SUNDEEPBHANDARI 30. MAJ GEN S VENKATRAMAN VSM

9. DR.NEEPATHACKER 3I. SURGCDRVS DIXITVSM lpted from IO. SURGLTAKVATWANI 32. SURGCDRANILAHUJANM I I. SURGLT MK KUMARAN 33. SURGCAPT GC TRIPATHY

12. SURGLT PRAKASHSHARMA 34. SURGCDRSROY

13. SURGCDRBFANTHOM 35. SURGUI J SRIDHAR

14. SURGCDR KG PAUL 36. SURGLCDR VRG PATNAIK

15. LT COL R PAUL 37. DR.SAKELKAR

16. GROUPCAPTAIN RANJIT KUMAR 38. SURGLTCDRHSNAGAR

17. SURGCAPT SURJIT SINGH 39. SURGCDR R TIWARI

18. SURGUICDRKKMISHRA 40. SURGLCDRGDBHANOT

19. SURGCDR KV SURYANARAYANA 4I. SURGLI HBS CHAUDHARY

20. SURGCDRTKSAHANI 42. SURGLCDR A CHATTERJEE

2I. SURGLT R SHARMA 43. DR. MRINAL BHAITACHARYA

22. SURGCDR KK DUTTA GUPTA

4, No.I