Contents Editorial Understanding of small, minimum and large sample size 1 and its clinical implications S.N. Dwivedi

Facing the challenge of tobacco in India - 3 National Tobacco Control Programme R.K. Srivastava, Jagdish Kaur

Commentaries Tele-ophthalmology: a new initiative of 8 National Programme for Control of Blindness (NPCB) Sandeep Sachdeva

Paradigm shift in pathology education in India 11 Karuna Rameshkumar, Bipin Batra

Occupational health and safety 14 R. Rose, Sandeep Sachdeva Review articles Preeclampsia and associated risk factors 21 Betsy Varughese, Manoj Dhingra, Rani Kumar, Renu Dhingra

Renal Tubular Acidosis(RTA) in children 27 Sanjiv Nanda, Ashish Marwah, Poonam Marwah

Recurrent pain abdomen in children 33 Venkatesh.C, VishnuBhat.B

Neonatal Necrotizing Enterocolitis 37 Prabha, Vishnu Bhat Original Article Assessment of bronchial liability on exposure to isometric 46 Exercise during different phases of menstrual cycle Mona Bedi, V P Varshney, Shilpa Khullar

Availability and consumption pattern of iodised salt in 50 the villages of ballabgarh, district, Haryana Radhika Sood, Misha Sharma, Chandandeep Gujral

Correspondence Quality control program for HIV diagnostic laboratories – an Indian experience 58 Dimple Kasana

Intra abdominal desmoid tumor presenting with bleeding 59 Ram Prakash Gupta

49th Annual conference of the college of Surgeons of West Africa 62 J.K. Bnerjee

Klippel Trenaunay Weber syndrome : a case report 63 Deepak Badgujar, M K Mittal, Abhay Aryan, Sheetal Kaur N K Bhambri, B B Thukral 1 Understanding of Small, Minimum and Large Sample Size and Its Clinical Implications Editorial

S.N. Dwivedi Department of Biostatistics, All India Institute of Medical Sciences Ansari Nagar, New Delhi basic important question account of objective under study, known as a minimum sample size under planning of a case of one-tail (one-sided) or required to answer that specific Aany study including two-tail (two-sided) test is question under used considera- randomized controlled clinical trial considered. These basic issues tions. Most of the time, as (RCT), especially of phase III, is involved in sample size calculation reported earlier, attempt is made the required sample size 1, 2. My will be explained in future to consider a small sample size experience of working in the field communication. that is smaller than the required of epidemiological research for In developing countries like minimum sample size. It is very more than two decades shows India, without knowing clinical rare that a large sample size is that most of the time meaning implications, an investigator may considered, which means of small, minimum and large purposefully try to consider a consideration of sample larger sample size is misunderstood and small sample size taking into than the required minimum quoted in a wrong sense account all or some of the sample size. Hence, on account of knowingly and/or unknowingly. considerations like higher levels of the need of appropriate clinical Hence, clarifying this issue group specific cure rate, broader practice, there is need to through a reputed journal/ differences in cure rates between communicate reminders from Bulletins becomes essential in groups, lower confidence level, time to time to ensure use of at view of the need of better lower power of the study, higher least minimum sample size if one epidemiological understanding. relative precision, and one-sided really wants to conclude the study. To make the communication test. While doing so,(s)he may To support his stand in favor more effective among the clinical think of that small sample size is of a small sample size, an colleagues, who are quite often enough for his study to answer investigator may argue that a little responsible to plan the study (e.g., the question under study. Further, difference between cure rates may as Student/ Principal Investig- to justify his consideration, he be shown as significant under ator), this issue may be explained may quote statistical theory that a large sample size. Accordingly, taking RCT as a case that is familiar large sample size will show a consideration of a large sample topic for them. small difference in cure rates size may be just wastage of time, In general, RCT involves a between the groups as a money etc. without much clinical problem of testing of hypothesis- significant result. Why should he use. However, he forgets the fact comparison of proportions or unnecessarily consider large that : it is very rare that a large means 3 between treatment sample size which is just wastage sample size, more than required groups (including placebo group, of time, money etc.? This type of minimum sample size, is if any). In view of specific practice or thinking itself comes considered. Sometimes, a large objective of the trial, using best mainly because of misconceptions sample size being quoted by him available probable information like misunderstanding of may be even less than required (e.g., group specific cure rate) on meanings of small, minimum minimum sample size to answer the topic under investigation, the and large sample size. a specific question under required sample size is calculated As a matter of fact, in general investigation. He may be doing at considered level of confidence practice, required sample size so only because of a sample size (e.g., 95%), power of the study calculated with all valid scientific which involves much time and (e.g., 90%) and relative precision considerations (inputs) is referred money; consideration of a small (e.g., 10%). Further, again on as a minimum sample size. It is sample size, less than required

Journal of Postgraduate Medical Education, Training & Research 1 Vol. IV, No. 1-5, January-October 2009 minimum sample size, may result try to conclude the study that may soon became a widespread in lower power of the study which result into wrong clinical practice. indication for therapeutic may give the message that new References endoscopy. The placement of a drug is as good as old drug. As a 1. Pocock Stuart J. Clinical Trials: PEG tube involves but a few result of this, use of new drug A Practical Approach. John ingenious steps. First, a cannula will come into clinical practice that Wiley & Sons, New York, containing a suture is inserted may not be appropriate in real 1983. through the skin into the sense. Further, as an availability of abdomen of the patient. An new drug, the physicians may get 2. Altman DG. Practical Statistics endoscope is inserted down the tempted to prescribe this more for Medical Research. esophagus to the stomach and the frequently. In reality, new drug Chapman and Hall, India.1991 endoscopist snares the suture may not be appropriate, but : 514-517. from the cannula. The suture is wrong perception/ practice about 3. Fleiss JL.Statistical methods then pulled up through the sample size may result into bad for rates and proportions. esophagus and out of the mouth clinical practice; and consideration John wiley & Sons, New York, where it is tied to the enteral of even large sample size, more 1981. feeding tube. The tube is then than required minimum sample pulled back down through the size, may not have bad clinical Percutaneous hole in the stomach wall and skin implications. If we get significant Endoscopic until it is partly out of the body. result, either old drug may be The mushroom tip on the better than new one or new drug Gastrostomy, 1979 internal end of the tube keeps it may be better than old drug. In in the stomach. After the tube is first case, old drug will continue inserted, nutrients may be fed to be used in clinical practice. In directly into the stomach via second case, use of new drug may syringe after twenty-four hours. not be that much dangerous PEG could be performed either because result being based on a as an inpatient or outpatient large sample size will have more surgery. The procedure eliminated precision (accuracy). In this case, risks associated with laparotomy, we may feel more comfortable including anesthesia complic- using new drug. When patients have difficulty ations, infection, and organ Taking into account above- swallowing, as a result of disease rupture. In their review of 150 mentioned brief facts, it is or injury, a feeding tube can be cases published in the Archives of necessary to consider at least inserted to provide the nutrients Surgery ( August,1983), Gauderer minimum sample size in a RCT/ to sustain life. In 1979, Micheal and Ponsky found no deaths as a other studies making us able to Gauderer, a pediatrician from result of the procedure, and conclude the results without University Hospitals of Cleveland, complications (in only ten percent much distortion in clinical practice. and Jeffrey Ponsky, a University of cases) were minor and easily There is no dispute in a study Hospitals endoscopist, devised treated. The apparatus seen here based on larger sample size in real Percutaneous Endoscopic is the PEG feeding tube and a sense, which will obviously Gastronomy (PEG) to insert syringe that would be used to provide more precise and stable these feeding tubes that was both administer the nutrients. results. Otherwise, if minimum inexpensive and low risk. This sample size is not considered, the procedure comprised an attractive study may be reported as a pilot alternative to laparotomy, a surgical study. In this case, one should not incision of the abdomen, and

Journal of Postgraduate Medical Education, Training & Research 2 Vol. IV, No. 1-5, January-October 2009 2 Facing the challenge of tobacco in India - National Tobacco Control Programme Editorial

R.K. Srivastava, Jagdish Kaur Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, Nirman Bhawan, New Delhi

obacco is the foremost And during this period, ever The tobacco epidemic has four cause of preventable death smoking of cigarettes had stages, based on the percentage of T and disease in the world significantly increased in the adult male/female smokers and today. Globally approximately 5.4 central, southern and north- percentage of deaths caused by million people die each year as eastern regions. More than 0.8 smoking. As the prevalence of use result of diseases resulting from million people die due to tobacco as well as deaths due to tobacco tobacco consumption. More than consumption every year (Report are on the rise, India is in the 80% of these deaths occur in the on Tobacco Control in India, second stage of tobacco epidemic, developing countries. Tobacco is 2004). There are studies to indicate whereas, most of the developed a risk factor for six of the eight that approximately 40% of the countries have a decrease in leading causes of death i.e. IHD, overall disease burden in the prevalence as well as deaths due cerebrovascular diseases, lower country is associated with tobacco to tobacco and are in the fourth respiratory infections, COPD, use and almost 50% of all cancer stage of tobacco epidemic. In tuberculosis, and trachea/ deaths in the country occur due to addition to the disease and death bronchi/lung cancer (World tobacco related cancers. The burden resulting from tobacco Health Statistics, 2008). India is majority of the cardio vascular use, it has other implications also the second largest consumer and diseases and lung disorders are in the form of social, economic third largest producer of tobacco directly attributable to tobacco and ecological or environmental in the world. As per National consumption. Studies have effects. approximately 0.27% of Family Health Survey -III, 2005- indicated that incidence of irrigated land is under tobacco 06, the prevalence of tobacco impotence is 85% higher in crop in India. More than 10 consumption in India is on the smokers. Tobacco use by million farmers, farm workers, rise, with 57% males and 10.9% pregnant women leads to low tendu leaf pluckers, bidi rollers, females reportedly consuming birth weight babies and birth middlemen, agents, retailers tobacco in some form (NSS, 52nd defects.The second hand smoke constitute tobacco workforce. Round, 1995-96 showed 51.3% (SHS) or environmental tobacco (ILO 2002 estimates- 5.5 million prevalence among males and smoke (ETS) contains more than bidi hand rollers, 85% of whom 10.3% among females). The 4000 chemicals, many of which are are women and children). Tobacco Global Youth Tobacco Survey carcinogens. Recent research has farmers suffer from “Green (GYTS), 2006 also indicates that shown that SHS causes lung cancer Tobacco sickness”, due to 14.1% children in the age group in adults and SIDS (Sudden absorption of nicotine through of 13-15 years are consuming Infant Death Syndrome), skin. Bidi rollers are one of the tobacco in some form. Compared exacerbation of asthma and other lowest paid workers in the country to GYTS, 2003 findings, respiratory ailments in children and are trapped in a vicious cycle prevalence of current use of any (The Health Consequences of of poverty. They are exposed to tobacco product had not changed involuntary exposure to tobacco absorption of nicotine through significantly over three years at the smoke – Report of the Surgeon skin and inhalation of tobacco national level, but had increased General, CDC, US Dept of Health dust, making them vulnerable to in the central region of the country. and Human Services, 2006). many diseases. Tobacco

Journal of Postgraduate Medical Education, Training & Research 3 Vol. IV, No. 1-5, January-October 2009 contributes to deforestation in Tobacco Control legislation The supply reduction strategies three ways: forests cleared for Government of India enacted include : cultivation of tobacco, fuel wood “Cigarettes and other Tobacco  Combating illicit trade in stripped from forests for curing Products (Prohibition of tobacco of tobacco and forest resources Advertisement and Regulation of  Providing alternate livelih- used for packaging of tobacco, Trade and Commerce, oods to tobacco farmers and tobacco leaves, cigarettes, etc. Production, Supply and workers. Tobacco growing depletes soil Distribution) Act (COTPA), In 2008, WHO came out with a nutrients at a much faster rate than 2003” to discourage the policy package to reverse the many other crops, thus rapidly consumption of tobacco in the tobacco epidemic, namely, decreasing the fertility of the soil. country. The specific provisions MPOWER package. Specific Tobacco is a sensitive plant and of this Act include: therefore, requires huge chemical interventions for the countries,  Prohibition of smoking inputs and fertilizers. Such listed in the package are : public places. chemicals may run off into water M-Monitor tobacco use  Prohibition of direct and bodies, contaminating local water P indirect form of advertising, -Protect people from tobacco supplies, causing excessive smoke leeching etc. Frequent contact with promotion and sponsorship and spraying of chemicals, and of cigarettes and other tobacco O-Offer help to quit tobacco use storage of tobacco in the products. W-Warn about the dangers of residential premises of farmers  Prohibition on sale of tobacco have adverse health effects.A cigarette or other tobacco E-Enforce ban on tobacco Health Cost Study conducted by products to minors (<18 advertisement and promotion ICMR/AIIMS in 1998-99 years of age) and within 100 R-Raise taxes on tobacco products showed that cost of treatment of yards of educational just three diseases caused by institutions. National Tobacco Control Program tobacco use i.e. cancers, lung  Mandatory depiction of disease and cardiovascular diseases pictorial warnings on all National Tobacco Control far exceeded the economic tobacco products packs. Program (NTCP) was conceived benefits from tobacco. It was International Obligations keeping in view the provisions estimated that the economic under “Cigarettes and other estimate/health cost of these India also ratified the WHO- Tobacco Products (Prohibition of three diseases was Rs. 30,833 Framework Convention on Advertisement and Regulation of crores (extrapolated to rates of Tobacco Control (FCTC) in 2005. Trade and Commerce, 2002-03), which far exceeded the FCTC provides a key set of Production, Supply and revenue collected (approx. Rs. recommendations for reduction Distribution) Act (COTPA), 27,000 crore) for the same year. in demand as well as reduction in 2003” and spirit of FCTC, by According to another study, the supply of tobacco products.The bringing together appropriate and total economic cost of tobacco use demand reduction strategies effective tobacco control strategies amounted to US $ 1.7 billion for include to tackle the tobacco problem in the year 2004. The study took into  Price and tax measures the country. The main objective is account four major categories of  Non price measures (statu- to bring about greater awareness tobacco related diseases – tory health warnings; about the harm effects of tobacco, tuberculosis, respiratory diseases, comprehensive ban on and institute a regulatory cardiovascular diseases and advertisement, promotion mechanism including laboratory neoplasms. This was 16% more and sponsorship; cessation facility for effective monitoring than the total tax revenue from facilities, tobacco product and implementation of anti tobacco. regulation etc.). tobacco initiatives at State/

Journal of Postgraduate Medical Education, Training & Research 4 Vol. IV, No. 1-5, January-October 2009 District level. The pilot phase of For the 11th Five year plan,  Opposition of tobacco cont- the NTCP was launched in 2007- Ministry of Finance approved the rol initiatives by tobacco 08 in 18 Districts of 9 States (two following components of NTCP : industry. districts in each state) i.e. Assam,  Capacity building of states/  Providing alternative livelih- West Bengal, Madhya Pradesh, districts for promoting oods to large number of Tamil Nadu, Karnataka, Gujarat, awareness and for workers engaged in tobacco Rajasthan, Delhi, Uttar Pradesh. monitoring/enforcement of farming, manufacturing and The main components of the COTPA will form a part of sale. programme were : the state health delivery  Lack of inter-sectoral  Setting up of State Tobacco mechanism under the overall coordination- various stakeh- Control Cells framework of National Rural older departments work in Health Mission (NRHM).  District Tobacco Control isolation.  Establishment of one apex Programme with  Lack of regulatory mechanism research lab and five tobacco components of training, at the national level to testing labs. school programme, cessation spearhead the tobacco control facilities, IEC and monitoring,  National public awareness activities and monitor the evaluation and reporting of campaign. implementation of tobacco tobacco control laws.  Research in alternate crops for laws and tobacco control  IEC campaign tobacco will be undertaken by programme. ICAR/DARE (Indian  The way forward Setting up of tobacco testing Council for Agricultural India Global Health Professional labs Research). Research projects Student Survey (GHPS), 2006,  Research for alternate livelihoods to persons engaged in tobacco carried out amongst third year  Monitoring and Evaluation, medical and dental students, including Global Adult sector will be taken up by Ministry of Rural reported the lifetime prevalence of Tobacco Survey – India cigarette smoking (ever smoked a (GATS) Development through their various ongoing schemes. cigarette, even one or two puffs) District Tobacco Control and use of other tobacco products  Global Adult Tobacco Survey. Programme was expanded to as 28.2% and 22% respectively. cover 24 new districts (in 12 states) Challenges in implementation Over 70% of these students during 2008-09. of NTCP wanted to quit tobacco. Nearly Budget for the Pilot phase of  Low priority to tobacco 91% students expressed the need NTCP during 2007-08 was 30 control initiatives by the policy for specific training on cessation crores and it was 39 crores for 2008- makers. techniques. COTPA is a public 09.The Government is required  Low awareness regarding health act. Awareness regarding under FCTC to provide alternate tobacco laws and harm effects various provisions under it, which safeguards against harm effects of livelihoods to tobacco farmers and of tobacco, including, health, tobacco, needs to be raised. As far tobacco workers including bidi socioeconomic and ecological as hospitals, health facilities, health rollers. Tobacco farmers are effects. educational institutions are encouraged to shift to alternate  Limited capacity of states to concerned, strict compliance with crops and for this Ministry of undertake implementation of smoke free rules shall be ensured. Health & Family Welfare tobacco laws and tobacco The undergraduate medical, supported Central Tobacco control activities. dental, nursing and other Research Institute (CTRI), for a  Limited availability of paramedical curricula and pilot project on alternate cropping resources to fund tobacco postgraduate curriculum for strategies. control initiatives. medicine, community medicine,

Journal of Postgraduate Medical Education, Training & Research 5 Vol. IV, No. 1-5, January-October 2009 psychiatry, and surgery need to comforting not only for you, but surprising because the movement include tobacco control strategies, also for your supporters is a common response in other with special focus on formal painful circumstances. Likewise, Heat and cold-Two further tobacco cessation techniques. A during labour, many women simple ways of easing pain and tobacco cessation facility shall be instinctively have a strong urge to assisting relaxation during labour available at all levels of health care be active. Movement provides a are through the application of heat delivery system. Training on source of counter-stimulation and cold. They provide a source tobacco cessation for medical, and may stimulate the release of of counter-stimulation.Heat can dental, nursing students and endorphins within the nervous be applied in several ways: existing staff may be carried out system. For example, rocking the at these cessation facilities. The  by taking a hot shower pelvis backwards and forwards tobacco control initiatives need to or bath during contractions is often be synergised with National Rural  via a hot water bottle or found to be soothing. This can Health Mission and integrated hot wet towel over the be performed while standing, with ongoing national health abdomen sitting, kneeling, lying down or programmes e.g. National Cancer on hands and knees.Other  by applying a hot Control programme, National rhythmical movements include programme for prevention and compress over the tapping your fingers, rubbing control of CVD/DM/Stroke, perineum your abdomen, breathing RNTCP and also state initiatives Instead of applying heat to the rhythmically and stamping your such as school health programme, skin, some women find that cold feet. Some women find it helps training of health professionals is more soothing. A cool, damp to count, sing, shout or howl at and IEC/BCC campaigns etc.The face-cloth is always refreshing, awareness campaigns regarding the same time!. Whichever while an ice pack can easily be harm effects of tobacco and SHS manoeuvre appeals to you, the applied to the lower back. need to be intensified with focus action should be rhythmical and on BCC strategies as nicotine Imagery -Creative mental activity, repetitive, and make you feel contained in tobacco is highly known as imagery, can also be used better. addictive and requires behaviour to encourage relaxation and help TENS-Transcutaneous Electrical change and treatment. women manage their pain during Nerve Stimulation (TENS) labour. Many people use imagery provides yet another form of Pain relief during in everyday situations. For counter-stimulation and has been example, when we feel hungry we used for several years in the labor can often ‘see’ (visual imagery) management of postoperative Music -Historical records reveal and ‘taste’ (taste imagery) an and cancer pain. It has been that the ancient Greeks played imagined meal in front of us - postulated that TENS helps to soothing instrumental music to even to the extent of making our relieve pain by stimulating the women in labour. Music can have mouths water. The word imagery release of endorphins. The TENS a relaxing effect in labour due to (or visualisation) implies that only equipment consists of a small, its ability to alter mood, reduce the visual sense is used. However, battery driven pulse generator, stress and promote positive all senses (vision, touch, hearing, connected to one or two pairs of thoughts. It can be used as a taste and smell) can be included in electrodes which are attached to trigger for a breathing response this mental activity. the skin with adhesive tape. When or as a cue for relaxation. It may Rhythmical movements-Many it is turned on, the TENS also be used as a distraction women find that rhythmical machine causes a tingling although this is a less effective use movement helps to ease pain sensation underneath the for music in labour. Music can be during labour. This is not electrodes - the strength of which

Journal of Postgraduate Medical Education, Training & Research 6 Vol. IV, No. 1-5, January-October 2009 can be adjusted at the generator fact that someone cares for you  a long stroke down the controls. TENS is most useful and that you are not alone. length of the back, during labour in helping to relieve Moreover, by providing a source buttocks and down the pain. Consequently, the electrodes of counter-stimulation touch and back of the legs; are usually placed on each side of massage can sooth pain. stroking across the the lower spine. A back-ground Therapeutic massage (eg: shiatsu) forehead, down the stimulation is set and the hand has been recommended as a neck and down the control unit is used to increase the means of preventing and treating arms; intensity of the current during a many of the ailments associated  simply holding hands! contraction. In order to be of with pregnancy and as a means Shiatsu- Shiatsu is a Japanese benefit, it is necessary to turn the of easing the pain of labour. form of therapeutic massage. control to a setting which is Perineal massage (the area Shiatsu means ‘finger pressure’. ‘almost painful’. The most between the vagina and anus) The basis and application of effective time to begin using during the last six weeks of Shiatsu is similar to that of TENS is early in labour before the pregnancy may reduces tearing or acupuncture. For example, when pain becomes too intense. TENS the need for an episiotomy using shiatsu to relieve labour is non-invasive and simple to use. during delivery. Touch and pain, pain-relieving pressure It does not have any side effects massage can be provided in points (‘tsubo’) are stimulated (apart from irritating the skin) and several ways: is controlled by the mother which are similar to pressure herself. TENS is also portable and does not interfere with the mother’s ability to move around. (Sometimes, TENS can interfere with the signal from an electronic fetal monitor. In this event, TENS may have to be abandoned). Women differ considerably in their opinions about the effectiveness of TENS  lightly stroking the in labour. In practice, additional points used in acupuncture but abdomen; analgesia is often needed - without the use of needles. although it is possible that drug  vigorously firm dose requirements may be less stroking where it hurts with the aid of TENS. Not most; everyone finds TENS effective  firm circular massage and some dislike the tingling using the palm of the sensation. hand over the centre of Massage-Touch has been the back or sacrum. associated with the power of This is most useful healing since the beginning of when the pain is being civilisation. During labour, many felt mainly in the back; women find comfort through  rhythmical squeezing being touched, stroked and and letting go of the massaged. touch reinforces the shoulder muscle;

Journal of Postgraduate Medical Education, Training & Research 7 Vol. IV, No. 1-5, January-October 2009 3 Tele-ophthalmology: A New Initiative of National Programme for Control of Blindness (NPCB) Commentary

Sandeep Sachdeva Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, Nirman Bhawan, New Delhi E-Health is a relatively  Evidence Based Medicine who collaborate and share recent term for healthcare and Health Knowledge information on patients E practice that describes the Management: entails a through digital equipment like application of information and system that provides inform- mobile on real-time monit- communications technologies ation on appropriate oring of patient vitals, and across the whole range of treatment under certain direct provision of care (via functions that affect the health patient conditions. A mobile telemedicine). sector from the health personnel healthcare professional can Types of Telemedicine: look up whether his/her to hospital manager, via nurses, Telemedicine could be broadly diagnosis is in line with upto data processing specialists, social grouped into [1] based on date scientific research, security administrators and-of specialty: Tele-radiology, pathol- overview of latest medical course-the patients. In a broader ogy, psychiatry, cardiology, journals, best practice sense, the term characterizes not ophthalmology, dermatology and guidelines or epidemiological only a technical development, but surgery [2] based on interventions tracking also a state-of-mind, a way of : Tele-consultation, diagnosis, thinking, an attitude, and a  Consumer Health Inform- treatment, monitoring [3] based commitment for inter-linked atics: Empowered healthy on time frame: store & forward, global thinking, to improve individuals and patients want real time, and collaborative. health care locally, regionally, and to be informed on health worldwide. This brief provides an issues. Current Scenario of Teleme- dicine1, 2, 3 overview of e-health, current  Medical research: uses e- scenario of telemedicine in India Health Grids that provide  Telemedicine implementation and initiatives taken by National powerful computing and has outgrown from its infancy Programme for Control of management capabilities to stage as interest and activity Blindness [NPCB], Government handle large amount of data. have grown phenomenally of India with regard to Tele-  Telemedicine: Telemedicine, during this decade e.g. a day ophthalmology in the Eleventh as the name suggests, is after the earthquake in Gujarat five-year plan. the application of commun- during 2001, Ahmedabad- The term E-Health encompass ication and information based Online Telemedicine range of services in health sciences, technology for remote Research Institute (OTRI) namely consultation and diagnosis of came to the rescue and established the first commun-  Electronic Medical Reco- diseases by medical professio- ication link from Bhuj, which rds [EMR]: enable easy nals. It is a procedure through which medical services are was close to the epicenter of communication of patient the quake. Specialists were able data between different made available remotely, through a combination of to provide consultations from healthcare professionals far-off places, For example, (general physician, specialists, telecommunications, multimedia technologies and after the telemedicine center nursing care team, pharmacy) was set up at Bhuj hospital, and the accounting team. medical expertise. It also includes health professionals an X-ray facility was provided

Journal of Postgraduate Medical Education, Training & Research 8 Vol. IV, No. 1-5, January-October 2009 to the people, whereby a revision of medical curriculum paving the way for availability specialist provided online is under process. of high bandwidth terrestrial consultation from  Ministry of Health and Family connectivity to build Ahmedabad. During the Welfare has set up a National ubiquitous health network for subsequent days, quake Task Force to address various telemedicine country wide victims could get medical issues to promote teleme- with competing price. Some advice from other doctors, dicine in the country and has of the other challenges and based at Ahmedabad and launched a major country wide concerns are sustained Bangalore. Over 750 sessions network of district hospitals funding, availability of trained were conducted in a period of and medical colleges under the manpower, level appropriate 30 days, thus saving many Integrated Disease Surveill- infrastructure/facility lives/limbs. ance Project [IDSP]. National development, confidentiality,  The major support and thrust Cancer Care Network, Tele- ethical & legal practices. What provided by Department of ophthalmology network, started as application of Information Technology National Digital Medical science and technology in the [DIT] has been through Library Consortium and field of telemedicine has now various projects and system Medical College network are got a significant attention as development; organizations going to be implemented in an important national like ISRO, reputed academic the near future. Other programme. medical institutions like international projects in the Tele-ophthalmology SGPGI, AIIMS, PGIMER, pipeline are SAARC Under the Telemedicine progra- AIMS, SRMC, C-DAC, telemedicine network and mme, National Progra-mme for Arvind, Shankar nethralaya Pan-African e-network Control of Blindness [NPCB], and corporate hospitals like  While there are over 20,000 Government of India initiated Asia Heart Foundation, PHC’s providing primary care Tele-ophthalmology project on Apollo Hospitals, SGRH, services in the rural areas, and pilot basis in Apr 2007 with the Fortis, Max etc. have taken and more than 500 district objective of making eye care continue to take significant hospitals, Telemedicine has services available to the people initiatives for installation of reached to about 100 centers across the country especially rural/ telemedicine systems in however more than 50% of tribal/hilly and other hardcore/ different parts of the country. them are in the urban areas un served areas. Based on the  The Department of only. Integrated information encouraging results and on Information Technology has on agriculture, health, approval of Eleventh five-year taken a pivotal role in defining education, natural resources plan [2007-12] period under and shaping the future of are initially being made NPCB, tele-ophthalmology since Telemedicine application in available in the Andaman and then has up-scaled and extended India. DIT has been involved Nicobar Islands and some to need based areas. Till date, 20 at multiple levels including parts of Kerela & North East Tele-ophthalmology projects have development of technology, States. been assisted by NPCB. initiation of pilot schemes and  One of the key factors to Financial assistance for Tele- standardization of Telemed- success of Telemedicine in ophthalmology under NPCB icine in the country. Some of India is going to be the In the approved Eleventh plan the other policy initiatives reliability of telecommun- under NPCB, financial assistance have been development of ication link. Fiber optic upto Rs. 60 lakhs is being standardi-zation guidelines, network across the country has provided to government/ national broadband policy, been laid down by public voluntary organization for dedicated satellite for sector and private telecomm- initiating/strengthening tele- education and health, & unication service providers ophthalmology projects in the

Journal of Postgraduate Medical Education, Training & Research 9 Vol. IV, No. 1-5, January-October 2009 country.4 The financial assistance Epidemiology to Benefit Asia alcohol was also used in labour. can be spent towards procure- and the Pacific Region. Oct At the beginning of the ment of approved list of 20th - 23rd 2008, SGPGIMS, nineteenth century other equipment/instrument/vehicle Lucknow, Uttar Pradesh, ‘remedies’ were introduced. In and adjusted for extending service India. 1806 a thesis by Miller, entitled on Cataract surgery, treatment of 3. Jagjit Singh Bhatia, Mandeep “Means of Lessening Pain of Diabetic retinopathy, glaucoma, Kaur Randhawa, Harpreet Parturition”, recommended low vision, dispensing of glasses, Kaur Khurana, Sagri Sharma. vigorous exercise, bloodletting corneal blindnes. The grantee India’s Tryst with Teleme- and a variety of medications institute based on the dicine. E-Health, May 2007; 2 designed to induce vomiting. One recommendation of State/UT [5]: 6-9 can imagine that treatments such government gives its commit- 4. Office memorandum. Pattern as these would have been quite ment by signing a bond to bear of assistance for National effective in distracting women all recurring expenditure, to Programme for Control of from their pain! provide free services to the poor Blindness during 11th five year and to abide by guidelines of Medical history abounds with plan. No. G.20011/1/2005- programme as announced from episodes where new treatments Ophth/BC. Ministry of time to time. have been embraced with well- Health and Family Welfare, intended but misplaced Conclusion Nirman Bhawan, New Delhi: enthusiasm. The introduction of Healthcare is increasingly 21st Oct 2008. anaesthesia and pain relief in becoming technology driven to childbirth in the nineteenth and make it accessible, interactive, Childbirth early twentieth centuries was no interoperable, intelligent, transp- arent and paper-less. Teleme- techniques exception. Some practitioners dicine, Tele-health, Hospital & were so seduced with the powerful Childbirth has been associated effects of the new drugs available Health information system, with pain since the beginning of Picture Archiving and Commun- to them (chloroform, opioids, time, and throughout history ‘Twilight Sleep’), that they used ication Systems [PACS] is the measures have been introduced them indiscriminately. However, future of India and Government to help relieve it. Various when revolutionary new remedies of India is committed for exorcisms can be found in the are promoted uncritically, they advancement of health objectives records from the ancient invariably lead to counter- & development of E-health by civilisations of Babylon, Egypt, revolution. The excessive use of ensuring favorable, supportive China and Palestine. Primitive and sustainable environment. sedative and analgesic drugs used attempts to help relieve pain were during labour at the beginning of References based mainly on suggestion and this century was a prelude to the 1. National Rural Telemedicine distraction. The former embraced so-called Natural Childbirth Network. Suggested Archite- the use of rings, necklaces, cture and Guidelines: Draft. amulets and other magical Movement. The origins of this Ministry of Health and Family charms; while the latter included movement go back to 1914 when Welfare, Nirman Bhawan, counter-stimulation i.e. the Behan wrote: “Like menstruation, New Delhi; 2007 infliction of a painful stimulus childbirth should be a painless 2. Prof. S K Mishra. India sufficient to detract from a natural process. It is only as culture Country Report on Tele- one. In the Middle Ages various advances that the labour becomes health Initiatives. United herbal concoctions based on painful, for in women of Nations/India/ Regional extract of poppy, mandragora, primitive races pain is absent.”.Dr Workshop on Using Space henbane and hemp were Grantly Dick-Read proposed the Technology for Tele- introduced. There is evidence that same argument in 1933.

Journal of Postgraduate Medical Education, Training & Research 10 Vol. IV, No. 1-5, January-October 2009 4 Paradigm Shift in Pathology Education In India Commentary Commentary Karuna Rameshkumar, Bipin Batra Department of Clinical Pathology, St.John’s Medical College hospital Bangalore and National board of Examinations, New Delhi

edicine is an ever- approach to the diagnosis by private labs and increase in the changing science. The training in different aspects of lucrative practice of laboratory M earlier one to one pathology and to provide medicine, the scenario changed. physician patient relationship adequate hands on experience to National Board of examinations which traditionally characterized establish or run a laboratory. So a (NBE) was established in 1975, the practice of medicine is changed pathology postgraduate is as a response to the demand for as the setting in which the expected to achieve at the end of increase in postgraduate programs medicine is being practiced is the training for three years, core and the need to establish an all changing. Now in India, 136 competency in clinical pathology India examination of high and medical schools admit more than including hematology, histopath- uniform standard. There are 55 6000 trainees into postgraduate ology and cytology and adequate seats in pathology across the programs1. Almost all of them exposure to microbiology and country, in different institutions have either postgraduate diploma biochemistry. Though essentially recognized by NBE. In addition, and or degree in pathology. The the goal has remained the same, introduction of DM and Ph.D paradigm shift in pathology the entry, course content and the program, has changed the education is parallel to the change evaluation has been changing over perception in the academic in the practice of medicine. Some the years.The post graduate scenario. Recently with the concept of the important reasons include degrees in pathology established of integration of different – one, the increasing reliance on by Medical council of India are disciplines, a postdoctoral technologic advances and MD, a three year course and fellowship in laboratory medicine computerization for many aspects Diploma in Clinical Pathology, a has been instituted by NBE. of diagnosis and treatment. two, two year course. Though the Course and Evaluation- In the increasing mobility of both Medical council of India, which is 1970s, the emphasis was on patients and physicians and three, the premier policy making anatomic pathology. The post the need for more than one single Institution was established in graduate program was loosely physician to be involved in the case 1934, by the Indian medical structured. Day in and out, the of most patients who are council act (1933) before student worked in the same seriously ill. The objective of this independence, the increase in department and had hands on paper is to trace the shift through number of colleges with experience. The relationship last 30 years.If you want to build a postgraduate programs was only between the mentor and the 2 ship, don’t drum up the man to go to after 1980s . The competition was student was more one to one forest to gather wood. Instead teach always high for the clinical subjects basis. The evaluation consisted of them the desire for the sea. Antoine and pathology was not generally a mainly essay questions and the Se Saint exupery, WWII fighter and primary choice for many of the grueling practical exam which a poet.A pathological diagnosis aspirants of the postgraduate lasted for three days. There was requires both aspects of logic – course. So many a times , the seats no dearth of autopsy material. As analysis and synthesis and the were vacant ,especially the seats for both theory and the practical more difficult the problem, the the diploma course. The valuation were together, the result more important is the logical introduction of the competitive was totally dependent on the approach to it. The primary exams for admission in 1990s did examiners. In traditional autopsy objective of pathology training not change the scenario much. and slide and viva examination, program is to encourage a logical With the awareness about the the examiners have liberty to ask

Journal of Postgraduate Medical Education, Training & Research 11 Vol. IV, No. 1-5, January-October 2009 whatever questions they wish the quality over the degree course examination pattern also changed around any one slide or specimen. by the Medical council of India. with constructed autopsies, Although the reliability is generally But the success rate in DNBE was Instrumentation, interpretation acceptable in this format, the low which was a deterrent to the and clinical utilization of difficulty is that if one examines postgraduate aspirants. A major laboratory tests and the number the correlation across session or shift happened in the 90s and the of days decreasing from three to cases, the reliability drops to policy decisions were taken in two days. In some of the centers, unacceptable low around of 0.35. 2000. The reasons are probably, part of the viva was conducted as It is also compromised by lack of  An increase in the number OSPE ( objective structured standardization of examiners, and application of laboratory practical examination) introducing cases and questions3,4,5.The tests more objectivity in to the syllabus of Diploma in clinical evaluation. However, the pattern  Decreasing rate of autopsy Pathology was variable in different of evaluation is not uniform, universities across the country.  Setting up of autonomous irrespective of whether it is the Some universities like Mumbai institutions and degree by the university or by (earlier referred as Bombay)  4. the most important, the National board of examinations. included microbiology as part of emergence of subspecialties The careers which student takes the course. Some of them allowed of pathology as major up after the training has also a student who entered the degree disciplines like Hematology, changed. In the 1970s, once they course to take the exam at the end transfusion medicine, Clinical finish, they entered either into an of two years E.g. Madras pathology and cytopathology. academic setup or setup private University (Now the medical and These disciplines were laboratories. Now the career dental disciplines are referred advancing very rapidly and an options include administration, under MGR university of Health exposure to all these informatics, scientific advisers for sciences). This was possible as the disciplines required a instrumentation, research officers curriculum was loosely structured. structured curriculum. for clinical research organizations Later at the end of 80s, this Seeping corruption in few of the which conduct clinical trials and practice stopped and the takers for major organizations also led to pharmaceutical companies. But the DCP also declined. The other this shift. The stress was now laid research as the primary option, reason was probably in an on practice based learning and remains poor unlike in the west. academic set up, a person with improvement exercises for The responsibility for the training DCP could not go beyond the learning by reflective practices by of pathologist is an obligation of level of lecturer, as for further the post graduates, as they enter the faculty and the ultimate promotion a post graduate degree postgraduate training with success of medical curriculum was required.As the National different prior experience, reforms is largely dependent upon Board of examinations set up a knowledge and skill. They have the faculty’s ability to adopt and parallel postgraduate program, a different intellectual ability, sustain new attitude and behavior. shift in the evaluation system starting points and learning rates The reforms are prompted by started. The diploma course in are highly variable. The reconsideration of the expanding clinical pathology which is for two introduction of log book and knowledge base and professional years, gained popularity as after the internal assessment by some of competencies that are most DCP, students were able to take the universities are in that essential in training the the final DNBE exam which was direction .If effectively used pathologists for the future. The offered by National board of during the training period, these concept of faculty development is examination. This helped in tools of formative assessment can catching up and is already in students not to waste many years achieve more reliability .They also practice in some of the in waiting to get into postgraduate can provide fair direction as to institutions. However, the need training. The All India nature of the future of assessment in post for internal quality control, the examination gave an edge in graduate evaluation. The external review and accreditation

Journal of Postgraduate Medical Education, Training & Research 12 Vol. IV, No. 1-5, January-October 2009 system to ensure uniformity program at Case Western Reserve across the country still remains. Obstetrics forceps University so that students did For that , policy makers at the not simply witness confinements, To Arthur H. Bill (1877-1961), highest level should make policies but helped deliver as many as 40 obstetrics in the early 20th century that will encourage and drive such babies and attend innumerable confronted a two-fold challenge. changes and the personnel labors. By his retirement in 1948, First, obstetrical procedures responsible for implementation Bill had trained over 2,000 required substantial improvement should design tools needed for obstetricians-gynecologists in this and second, individuals needed to effective implementation, so that manner. Bill also developed the be trained in the application of student and finally public will reap Bill Axis Traction Handle, which these methods. As Bill noted at the reward. further reduced the chance of the end of his career, “instead of damage to the child and References bringing our art down to the level lacerations to the cervix of the of general practitioners, let us 1. Mendis L, Adkoli BV, mother. This attachment was bring our art up to a higher level Adhikari RK, Huq MM and placed over the front of the and educate those who do Qureshi AF: Postgraduate forceps handles and made the obstetrics to that point.” Bill education on south east asia instrument more accurate in promoted the methods of the – Time to move on from delivery by reducing and “new obstetrics” pioneered by post colonial era BMJ 2004; determining the force needed for Joseph Bolivar De Lee of Chicago. 328:779 a forceps delivery. Arthur Bill As Bill observed, “the old plan employed the forceps and axis 2. Medical council of India. [which] allowed nature to take its traction handle seen here during Directory of postgraduate course, even in the face of his tenure at MacDonald House, medical education courses abnormalities with the hope that the maternity hospital of 2000. New Delhi: Medical eventually the abnormalities University Hospitals of council of India, 2000 might correct themselves, has Cleveland. For obstetricians, the given way to far more scientific 3. Hall P, weaver L. Interdis- choice of forceps could be and humane methods of ciplinary education and team overwhelming; some six hundred correcting abnormal conditions work, A long and winding variants had been devised since the and thus assisting natural forces.” road. Med. Edu. 2001; 35: 867- introduction of the instrument by The approach endorsed by De Lee, 75 the Chamberlen family in early- Bill, and their adherents revolved 17th century England. For most 4. Menin Sp, Krekov Sk. around such procedures as the use forceps assisted deliveries, Bill Reflection on relevance, of scopolamine or “twilight preferred the Tucker McLane resistance and reforms in sleep,” prophylactic forceps forceps, introduced around 1880- medical education Acad. Med. delivery, and episiotomy. The 85: They were especially 1998; 73: supplement 860 -64 “new obstetrics’ was highly appropriate for outlet and low interventionist in character. When 5. Turnbull J, Danoff D, forceps deliveries, where the head entering the field of obstetrics, Norman GR. Content specif- is less than 45 degrees rotation Arthur Bill was alarmed that many icity and oral certification from the occiput anterior physicians lacked adequate training examination Med.Edu 1996; position. The Tucker-McLane is in the proper use of forceps. The 30: 56-59 distinguished from other forceps consequence: damage to both by its solid or non-fenestrated 6. Website: mciindia.org mother and child. He worked to blades, prominent pelvic curve, remedy this by carefully teaching and overlapping shanks, and his students the technique. Bill articulating lock. structured the obstetrics training

Journal of Postgraduate Medical Education, Training & Research 13 Vol. IV, No. 1-5, January-October 2009 Occupational Health and Safety 5 Commentary R. Rose, Sandeep Sachdeva Commentary Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, Nirman Bhawan, New Delhi hat is your occup- & legislation in India, present  There is growing need to ation?” a very pert- status, challenges and solutions. study the health status “W inent question with Need 3,4,5,6 among employees at Inform- ation Technology Enabled a potential implication on the  Workers are exposed to a wide Services [ITES], since the health of an individual was first range of safety and health raised by Bernardino Ramazzini, hazards on the job. Exposure number of workers is rapidly father of Occupational Medicine differs from trade to trade, growing and will touch 1.2 1 some 3 centuries ago. He is from job to job, by the day million in the next three years credited for his profound study and even by the hour. in India from a figure of on work-related sickness. Exposure to any one hazard 2,50,000 in March 2004, Workplace fatalities, injuries and is typically intermittent and of according to National Associ- illnesses remain at unacceptably short duration but is likely to ation of Software and Service high levels and involve an recur. The severity of each Companies. Similarly, there are enormous and unnecessary health hazard depends on the upcoming developmental burden, suffering, and economic concentration and duration of issues like Nanotechnology, loss amounting to 4–5% of gross exposure for that particular robotics etc which may also national product [GNP].2 No job. have an effect on occupational health and safety. doubt that Industrial develop-  Today, many people work for ment is a barometer of nation longer hours, hold multiple  In medical sciences, health care prosperity & progress leading to jobs, do shift work, work professionals are exposed to attenuating the problem of from home, have reduced job variety of dangers like growing unemployment, howe- security, and perform part- infections [HAI], cuts and ver, it is no more viewed as a time, contractual or temporary needle stick injuries, exposure simplistic and harmless tool for work. It is estimated that of to anesthetic gases, radiation, progress. Proliferation of human the total 3 billion workers in dermatitis causing substances, settlement surroundings such the world over 80% work and vaccines & serums and industrial nuclei cause serious live without having access to experiences severe stressful concern not only for human occupational health services. situations with little time to safety, protection of other life, The coverage today is spare for personnel & social property but also the diminishing rather than activities. Most of the environment. The damage is expanding. paramedical staff is exposed considered to be acute in the area  In the 21st century, Multi to HAI and repetitive strain of safety, chronic in the area of National Enterprises [MNEs] injuries (mainly lower occupational health and are significant source of backache) due to patient persistent in the case of economic growth and lifting, transportation, long- environment. OHS comprises employment around the standing duties and bad work many diverse but inter-related world. Estimated 65,000 postures. issues and through this article an MNEs and their 800,000 attempt is made to provide an Burden of occupational subsidiaries employ upward morbidity and mortality: World overview of burden of of 90 million people occupational morbidity & worldwide or 5.0% of global  There is 30%-50% of the mortality, institutional framework workforce. world’s population at work-

Journal of Postgraduate Medical Education, Training & Research 14 Vol. IV, No. 1-5, January-October 2009 related risks i.e. exposed to vast informal sector, less health research in India has physical, chemical, biological, attention to industrial hygiene also reflected high burden of psychosocial and/or ergono- and poor surveillance data.9 morbidity at workplace.13 C mic hazards. Globally, there  There are figures from various Kesavachandran et al in their were 337 million occupational studies/estimates to provide review article concluded that accidents causing 4 or more an insight to the burden of musculo-skeletal, ocular days of absence from work; problem as reported figure do disorders and psycho-social 358,000 work related fatal not reflect the true magnitude. problems were some of the accidents, 1.95 million works Some of these are, Leigh et al. key health problems observed related fatal diseases and 2.31 among Information Techno- 7 estimated the annual incidence million total fatalities. of occupational disease logy [IT] professionals.14 According to estimate for the between 924,700 and Definitions15 year 2000 there are 2.0 million 1,902,300, leading to over work-related deaths per year 121,000 deaths in India.10 Before going further we should [WHO/ILO]. According to a survey of be clear with certain terminologies  United States [USA] labour injury incidence in agriculture that are encountered in context of department recorded a total of conducted in Northern India, occupational health and safety. 5,488 & 5,840 fatal work an annual incidence of 17  Hazard: The inherent poten- injuries in 2007 & 2006 million injuries per year (2 ial to cause injury or damage respectively for the country. million moderate to serious to people’s health. This figure represented the events) and 53,000 deaths per smallest annual preliminary year was estimated.11 Nearly  Risk: A combination of the total since the Census of Fatal 50,000 to 60,000 accidents are likelihood of an occurrence of Occupational Injuries (CFOI) occurring annually in the a hazardous event and the program was first conducted manufacturing sector. These severity of injury or damage in 1992. Based on these accidents results in injuries of to the health of people caused counts, the rate of fatal injury varied severity and about 1000 by this event. for U.S. workers in 2007 was people die every year. The  Occupational injury or illness: 3.7 fatal work injuries per frequency rate has not come 100,000 workers, down from down significantly over the An injury or illness is the rate of 4.0 per 100,000 years.12 considered to be work- 8 related if an event or workers in 2006.  Another source has mentio- exposure in the work ned the estimate of burden Burden of problem statement environment either caused or in India of occupational diseases (1.83 million) and occupational contributed to the resulting  The major occupational injury (18.3 million) in India, condition or significantly morbidity of concern in India the figure indicate that as a aggravated a pre-existing 16 include silicosis, musculoske- nation, India is contributing condition. letal injuries, coal workers’ nearly 20% of the global  Conventions: are interna- pneumoconiosis, chronic burden in respective areas. tional treaties and are obstructive lung diseases, Prevalence studies on instruments that create legally asbestosis, byssinosis, pesti- occupational disease in many binding obligations on the cide poisoning and noise- parts of the world have countries ratifying them. induced hearing loss. In India, shown such burden to vary occupational health is more from 5 to 20%.1  Recommendations: are non- than simply a health issue,  Agnihotram through his binding guidelines, which which includes child labour, paper based on review of orient national policies and poor industrial legislation, literature on occupational actions.

Journal of Postgraduate Medical Education, Training & Research 15 Vol. IV, No. 1-5, January-October 2009  Occupational Health: is the 1000 inspectors across more than statutes could be broadly promotion and maintenance 200 offices, and Health services in divided into three domains i.e. of the highest degree of USA. However, 40% of the statutes for safety at workpl- physical, mental and social workforce of some 130 million aces, statutes for safety of well-being of workers in all people in US does not have access substances and statutes for occupations by preventing to adequate occupational health safety of activities. departures from health, services.2  controlling risks and the The acts and set of rules Institutional framework for framed there under have taken adaptation of work to people, OHS20 and people to their jobs. into consideration the articles  The Constitution of India (ILO/WHO 1950] under different ILO has specified provisions for Conventions and Recomm-  Occupational Safety Health ensuring occupational health endations. The practice [OSH] management system: and safety for workers in the followed by India so far has includes organizational struc- form of three Articles i.e. 24, been that a Convention is ture, planning of activities, 39 (e and f) and 42. The ratified only when the national assigning responsibilities, regulation of labour and safety laws and practices are in detailing procedures, in mines and oil fields is conformity with the provis- processes and mobilizing under the Union list while the ions of the Convention in resources for implementing, welfare of labour including question. India has so far reviewing and updating conditions of work, ratified 41 ILO Conventions occupational health & safety provident funds, employers’ out of 182 conventions and policy to manage the risk invalidity, old age pension and associated with the business 190 recommendations. 17 maternity benefit are in the of the organization. Concurrent list.  Three schedules include list of What is Occupational and 20 industries involving  The Ministry of Labour, Health Safety Administration hazardous processes, the Government of India, nodal [OSHA] Act18, 19 permissible levels of certain agency for employment & chemical substances in work The OSHA act was created on labour-related statistics along environment and the list of December 29, 1970 by United with labour departments of 29 notifiable diseases. States of America to provide US the States/Union Territories workers with a safe working are responsible for safety and Status in India 2, 23, 24 environment. OSHA is admini- health of workers. Directorate  Industries were established in stered through the department of General of Mines Safety India as early as 1850’s. After labour but many states have their (DGMS) and Directorate Independence in 1947, own OSHA laws. Its statutory General Factory Advice country had about 31,000 authority extends to most Services & Labour Institutes factories employing about 2.5 workplaces where there are (DGFASLI) assist the million workmen. This figure employees and staff. Despite early Ministry in technical aspects of rose to 01 lakh factories and difficulties, over time, manuf- occupational safety and health 07 million workers during acturers of industrial equipment in mines and factories & ports 1981 and by 2005 India had have included OSHA-compliant sectors, respectively. safety features in new machinery, more than 2.3 lakh factories Occupational and Safety employing 08 million enforcement has become more 20, 21, 22 consistent across jurisdictions, legislation in India workers. The major chunk of inspection, recording & reporting  There are various work-related our workforce belonged to is regular and some of the more statutes in the country agriculture sector [69%], unpopular rules have been concerning safety, health and construction [16%] followed repealed. OSHA now has over environment [Table 1]. These by manufacturing [11%] and

Journal of Postgraduate Medical Education, Training & Research 16 Vol. IV, No. 1-5, January-October 2009 then sector. According to  The Factories Act and factory OHS units or organization Ministry of Labour, approxi- rules cover 5% of the and audiologist. mately 92% of the workforce workforce. Occupational  Inspite of ‘need’ for the is in the unorganized or health services are mandatory informal sector. only for factories with personnel there is neither ‘demand’ nor any well defined  Though there are number of hazardous processes, which encompass 1% of the Indian carrier progression path. For laws relating to occupational medical graduates there are safety and health enforced by workforce. There are handful of medical colleges different enforcing agencies. numerous units employing that offer post-graduate course Some of them also contain less than 10 workers which on occupational health. requirement which are not handle hazardous chemicals Physicians, chemists, phys- consistent with one another. and undertake dangerous icists, safety officers often On the other side, the operations. The workers perform some of the requirements under the employed in these units are Factories Act 1948 are so not protected against hazards. functions of occupational detailed and exhaustive that  The major hindrance of hygienists. small factories are unable to occupational health  National Safety Council comply with procedural development in India is that [NSC] set up by Labour requirement. There is no the subject was never given Ministry in 1966 has grown legislation which covers the proper attention in presence into a well-organized national OHS aspect of agricultural of other pressing issues like body with an all India operations. The Building and malnutrition, communicable network of 14 State Chapters other Construction Workers diseases & unemployment etc. and 31 Action Centres with [Regulation of employment Most of the state governm- members from industry, trade and condition of services] ents have inadequate staff to unions and professional Rules are notified by 09 states statutorily inspect the bodies and emerged as a only. As such, the benefit of establishments, compared to National Resource Centre on protection is not extended to 3000 factory inspectors in a Safety Health and Enviro- construction workers in other small country like Japan, we nment. states. Minor, intermediate have no more than 500 ports, inland containers inspectors. The deficiency is  Short orientation & specialized depots and container freight further compounded by training courses, symposia, stations are out of the scope absence of basic infrastructural seminars, conferences and of any statue relating to safety and communication support educational campaigns are and health. system. conducted regularly on  There is no single authority to Teaching and Training25, 26, 27 occupational hygiene in India address the OHS require-  The dedicated occupation by various institutes such as ments of various sectors and health personnel that can play National Institute of there is little coordination a critical role in ensuring Occupational Health (NIOH), amongst different players with occupational health & safety Ahmedabad; central & poor implementation. There services in the country are regional labour institute at is no penalty for non- Occupational health physician Mumbai, Chennai, Kolkata, compliance and often, and nurses; physiotherapist; & Kanpur; All India Institute statutory procedures are such Ergonomists; Occupational of Hygiene and Public Health that there are more penalties or industrial hygienists; Safety [AIIH&PH], Kolkata; Indus- for disclosure than for non- engineers; Occupational trial Toxicology Research reporting. psychologists, Managers of Centre [ITRC], Lucknow;

Journal of Postgraduate Medical Education, Training & Research 17 Vol. IV, No. 1-5, January-October 2009 Regional institutes in Calcutta  Till few years ago, safety and ensuring basic health and Bangalore under Indian management has been to a needs. Council of Medical Research great extent, the concern of  Bureau of Indian Standard (ICMR), Lok Manya Medical Government agencies limited [BIS] formulated an Indian Research Centre, Pune and to the compliance with the Standard of OHS managem- Centre for Occupational and laws relating to this domain. ent system based on Environmental Health Even in situations involving voluntary adoption for a (COEH), MAMC, New Delhi safety and health problems, comprehensive framework & and a professional bodies like which are not specifically specification with guidance for Indian Association of covered by the statutes, the OHS. It is called as the IS Occupational Health [IAOH]. response to the management 18001:2000 Occupational was only reactive.  There are few others national Health and Safety [OHS] level disability prevention and  India had adopted a self- Management Systems with rehabilitation institutes in regulatory [voluntary, self- the following revised edition New Delhi, Deharadun, compliance, certification, or IS 18001:2007. This standard Mumbai, Secunderabad, accreditation] approach since prescribes the requirements for Kolkata, Cuttak, Chennai and 1987 through amendments to an OH&S Management Mysore, which offer such the factory act 1987. The vast Systems, to enable an courses. The Master of majority of the sector should organization to formulate a Industrial Hygiene (MIH) be encouraged to develop, policy, taking into account the course being conducted by adopt and/or adapt quality legislative requirements. It Sardar Patel University, Vallabh safe work practices by fostering also provides information Vidyanagar, Anand, in a conducive environment of about significant hazards and collaboration with Cincinnatti teaching, training, sensitizing risks to be analyzed & University, USA. and advocacy opportunities evaluated at workplace, which Solutions27, 28, 29, 30 for owning & empowering the organization can control stakeholders on the issue of in order to protect its  The requirement is to have a health and safety. employees and others, whose single point responsibility health and safety may be  Over the year, occupational with adequate authority to affected by the activities of the health and safety [OHS] issues address needs, ensure compl- organization. iance and disseminate OHS have improved considerably in Conclusion information to all concern. In India due to intense advocacy the countries like Australia by media, activist, profess- Occupational health and safety is and even in USA separate OH ional bodies, public interest an important strategy not only to & S act has been made. litigation’s [PIL], and societal ensure health of workers, but also However it also needs to be demand due to occurrence of to contribute positively to the ensured that implementation national disasters that have national economies through of legislation does not remain spurred management to improved productivity, quality of confine to papers. Therefore change its approach towards products, reduced absenteeism, public sector manpower OHS. Organizations have work motivation and job strengthening, infrastructural started attaching importance satisfaction. Accident prevention and commun-ication support to occupational safety & health has to be perceived not as a is required for improving through adoption of a separate and independent compliance of statutes, structured approach for the discipline but rather interwoven monitoring & supervision at identification of hazards, their philosophy of any management hazardous workplace. evaluation, control of risks function.

Journal of Postgraduate Medical Education, Training & Research 18 Vol. IV, No. 1-5, January-October 2009 Table-1, Various legislative acts & rules drafted there under concerning Occupational health & safety and social aspect, India* The Explosives Act, 1884 The Radiological Protection Rules, 1971 The Indian Electricity Act, 1910 The Dangerous Machines (Regulations) Act, 1983 Workman compensation act, 1912 The Dock workers (safety, health and welfare) Act, The Indian Boilers Act, 1923 1986 The Petroleum Act, 1934 Environment Protection Act, 1986 The Factories Act 1948, amended 1954, 1970, 1976, The Manufacture, Storage and Import of 1987 Hazardous Chemicals [MSIHC] Rules, 1989, amended in 1990, 1994 Employee State Insurance [ESI] Act, 1948 Chemical Accidents [Emergency Planning, The Plantation Labour Act, 1951 Preparedness and Response] Rules, 1996 The Mines Act, 1952 The Building and other construction workers The Indian Atomic Energy Act, 1962 [Regulation of Employment and Conditions of Beedi and Cigar Workers’ (Conditions of Labourers] Act, 1996 Employment) Act, 1966 Biomedical Waste Management and Handling Rules, The Insecticide Act, 1968 1998, 2003 * Not an exhaustive list References Institute of Occupational 9. Joshi TK, Smith KR. 1. Kulkarni GK. Occupational Health. Helsinki; 24 Jan 2005. Occupational health in India. Occup Med 2002; 17:371-89. diseases and disorder: How 5. Sharma LK. Call centers-The relevant are they in clinical sunshine sector. Employ- 10. Leigh J, Macaskill P, Kuosma E, Mandryk J. Global burden practice? Indian J Occup ment News: 2005. p. 1 Environ Med 2006; 10: 51-52. of disease and injuries due to 6. Kulkarni GK. Health of occupational factors. 2. NK Chandrasekaran. Occupa- health care professionals. Epidemiology 1999;10: 626- tional Health: An investment Indian J Occup Environ Med 31. benefits of promoting 2006;10: 95-96. employee health. Indian J of 11. Mohan D, Patel R. Design of Occup and Environ Med May- 7. Annee Rice. Beyond Death safer agricultural equipment: Application of ergonomics Aug 2003; 7 [2]: 23-26. and Injuries: The ILOs global and epidemiology. Int J strategy & promotional 3. AK Ganguly. Safety and loss Industrial Ergonomics framework for Occupational control in construction 1992;10: 301-09. Safety & Health; 8th industry. Indoshnews, 12. SK Saxena. Perspective on newsletter, Oct-Dec 2004, International Congress on occupational Safety and occupational safety, health and Mumbai: DGFASLI; 9 [4]. environment of workers at Health at work, Porto 4. Jorma Rantanen. Draft the national level. Portugal, 3-4 July 2008. guidelines on Basic Indoshnews, newsletter, Jan- Occupational Health Services, 8. Census of Fatal Occupational Mar 2005. Mumbai: published as a response to the Injuries. US department of DGFASLI; 10 [1]. Joint ILO/WHO Committee labour, News Release August 13. Agnihotram RV. An on Occupational Health 20, 2008. Available from: overview of occupational priority area for ILO/WHO/ http://www.bls.gov/iif/ health research in India. ICOH collaboration, with oshcfoi1.htm [cited 2009 Jan Indian J Occup Environ Med support of the Finnish 20]. 2005; 9:10-14.

Journal of Postgraduate Medical Education, Training & Research 19 Vol. IV, No. 1-5, January-October 2009 14. Kesavachandran C, Rastogi 21. Occupational safety: Where 28. Bipraj. Industrial safety & SK, Das M, Khan AM. Ignorance is not bliss. OSH health- vision 2020: challe- Working conditions and legislation. Available from: nges, strategies, indu-stry health among employees at http://www.toxicslink.org/ perspective. Available from information technology - docs/06015_ http://dgfasli.nic.in/ enabled services: A review of Occupational_Safety.doc newsletter_html/ current evidence. Indian J [cited 2008 Nov 5] apr_jun08/article2.htm Med Sci 2006; 60:300-07. 22. A national priority on 29. Occupational Health and 15. Guidelines on occupational occupational health and Safety Management System safety and health manage- safety management system. [OHSMS]. Bureau of Indian ment systems. ILO-OSH ICMR Bulletin, Nov-Dec Standard. Available from: 2001; Geneva: ILO; 2001. 2003; 33 [11-12]: 1-16. ISSN http://www.bis.org.in/ ISBN 92-2-111634-4. 0377-4910. Available from other/is18001_rev.pdf [cited http://icmr.nic.in/ 2008 Nov 5] 16. Bureau of labor statistics, BUNOV-DEC03.pdf. United States department of 30. MK Malhotra. Standard on labor. Definition available 23. SK Saxena. Perspective on occupational health and from http://www.bls.gov/ occupational safety, health safety management system. iif/oshcfdef.htm [cited 2008 and environment of workers Indoshnews, newsletter, Dec 23] at the national level. Apr-June 2001. Mumbai: Indoshnews, newsletter, DGFASLI; 6 [2]. 17. Occupational Safety and Jan-Mar 2005. Mumbai: Health Management System. DGFASLI; 10 [1]. Indoshnews, newsletter. Mumbai: DGFASLI, July- 24. C Kesavachandran and SK Sep 1998; 3 [3]. Rastogi. Health, occupation and environment in the 18. Occupational Safety & Health unorganized sector. Current Administrations. United Science, 25 April 2005; 88 [8]: States Department of labor. 1217-18. What is OSHA. Available from http:// 25. SK Haldar. Modern concept www.osha.gov/as/opa/ of occupational health osha-faq.html [cited 2009 Jan services. Indoshnews newsl- 20] etter, Jul-Sep 2004. Mumbai: DGFSLI; 9 [3]. 19. Frequently asked questions on OSHA. Available from: 26. Meswani HR. Safety and http://www.18001.org/ occupational health: Challe- modules.php?name= nges and opportu-nities in FAQ&myfaq= emerging econo-mies. yes&id_cat=1&c Indian J Occup Environ Med ategories=OSHA [cited 2009 2008; 12:3-9. Jan 20] 27. DJ Parikh, HN Saiyed. 20. Occupational Health and Education and Training in Safety (OH&S): Key Occupational Hygiene in Regulations India. Available India. Indian J of Occup and from www.business.gov.in Environ Med Jan-April [cited 2008 Nov 5] 2003; 7 [1]: 11-15.

Journal of Postgraduate Medical Education, Training & Research 20 Vol. IV, No. 1-5, January-October 2009 6 Preeclampsia and Associated Risk Factors

Review Betsy Varughese, Manoj Dhingra, Rani Kumar, Renu Dhingra Department of Anatomy, All India Institute of Medical Science, New Delhi and Article Department of Health, Institute of clinical Research of India, New Delhi reeclampsia contributes preeclampsia at the beginning of For most healthy nulliparous about 8 to 10% of maternal pregnancy, as reflected in few women, the factor that P deaths in India and 5 to reported randomised controlled differentiates preeclampsia from 10% of maternal deaths in trials on which this recomm- other gestational hypertensive western countries.1 The incidence endation was based. These trials disorders is concomitant proteinuria, varies about three fold in various could not identify important which is defined as the excretion geographical areas with different outcomes such as mortality, which of 30 mg/dl of protein in a ethnic and social characteristics. may be due to the lack of random urine specimen or more Globally, the hypertensive awareness and thus identification than 0.3g/l protein or more than disorders of pregnancy together of existing risk factors at the time 1+ on a dipstick test strip in a 24 are responsible for up to 50,000 of registration. A comprehensive hour urine specimen, with loss of maternal deaths and as many as 9, knowledge gained from systemic serum protein, increased 00,000 perinatal deaths annually . review of published literature will creatinine, alanine amino- Prompt diagnosis and interven- provide an evidence base from transferase, aspartate amino tion is of vital importance in which healthcare professionals can transferase, lipids, triglycerides, reducing maternal mortality. This assess each pregnant woman’s risk low platelets count and increased has guided the development of of pre-eclampsia at her first urea. Preeclampsia can be antenatal care preventive antenatal visit or the time of associated with edema, visual management strategies such as registration and tailor her disturbances, headache, epigastric regular monitoring of maternal antenatal care accordingly. or upper right quadrant pain with blood pressure and early detection Clinical Symptoms-Hyperte- nausea and vomiting. Its life of proteinuria. Preeclampsia nsion and proteinuria are threatening complications include resolves postpartumly, that is why considered as the cardinal features seizures, cerebral hemorrhage, presently premature delivery of of preeclampsia. Hypertension in disseminated intrav-ascular the baby is followed as an optimal preeclampsia is defined as an coagulation, and renal failure. The strategy to save the mother’s life. elevation of more than 30 mm clinical diagnosis of edema is Consequently, many of the Hg systolic pressure or more than made when swelling is evident, infants born to preeclamptic 15 mm Hg diastolic pressure however fluid retention may also mothers require expensive above the patient’s baseline blood manifest as a rapid increase in the therapeutic support in the form pressure. This definition proved body weight without evident of NICUs. The burden of to be a poor indicator of outcome swelling. Kidney function is preeclampsia on health care and was redefined by the National dependent on adequate settings is therefore substantial. High Blood Pressure Education glomerular blood flow and Progress in the prevention and Program3 in 2000. The criteria selective permeability of treatment of this condition defined hypertension as a systolic glomerular capillaries. The renal requires an in-depth analysis of blood pressure more than 140 dysfunction may manifest as a the risk factors. The National mmHg or a diastolic level vascular irregularity, decline in renal Institute for Clinical Excellence (Korottkoff V) more than 90 blood flow and glomerular (NICE) guidelines on antenatal mmHg on two or more occasions, filtration rate and clinically care have reduced the number of at least 4 - 6 hours (but not more significant proteinuria . Oliguria antenatal visits recommended for than 7 days) apart after 20 weeks or anuria can occur in patients with healthy woman at low risk.2 It is of gestation in a woman with severe preeclampsia as a result of important to define risk of previously normal blood pressure. low cardiac output and high

Journal of Postgraduate Medical Education, Training & Research 21 Vol. IV, No. 1-5, January-October 2009 systemic vascular resistance. partner. According to this 2.87).8 Nulliparity almost triples Preeclampsia can rapidly progress hypothesis, a new partner presents the risk for pre-eclampsia (relative to a convulsive phase termed new antigens, which results in a risk 2.91, 95% confidence interval eclampsia, especially if untreated. risk of preeclampsia that is similar 1.28 to 6.61) (three cohort Impaired uteroplacental blood to the risk during a first pregnancy. studies).9,10,11 Women with pre- flow or placental infarction can The evidence from the Medical eclampsia are twice as likely to be affect the feto-placental unit, Birth registry of Norway indicates nulliparous as women without causing intra uterine growth that the protective effect of pre-eclampsia (relative risk 2.35, restriction, intrauterine fetal multiple pregnancies is 95% confidence interval 1.80 to demise, oligohydramnios, or confounded by the time interval 3.06) (six case-control placental abruption. Generally, between the births.5 The studies).9,12,13,14,15,16 Women who maternal and perinatal outcomes association between risk of pre- have pre-eclampsia in the first are better in mild preeclampsia eclampsia and interval was more pregnancy have seven times the that develops after 36 weeks of significant than the association risk of pre-eclampsia in a second gestation than in cases that are between risk and change of pregnancy (relative risk 7.19, 95% symptomatic before 33 weeks of partner. The risk in a second or confidence interval 5.85 to 8.83) gestation.The duration between third pregnancy was directly related (five cohort studies).11,17,18,19,20 A the first detection of hyperten- to the time elapsed since the family history of pre-eclampsia sion and proteinuria and the previous delivery. A cross sectional nearly triples the risk of pre- subsequent development of these study from Uruguay found that eclampsia (relative risk 2.90, 95% complications can be extremely women having time interval with confidence interval 1.70 to 4.93) short in many cases. Maternal more than 59 months between (two cohort studies).21,22 When a death is more likely in the presence pregnancies had significantly woman is pregnant with twins, of severe hypertension and increased risks of pre-eclampsia her risk of pre-eclampsia nearly eclampsia. So far no effective (relative risk 1.83, 95% confidence triples (five cohort studies, relative intervention for prevention of interval 1.72 to 1.94) compared to risk 2.93, 95% confidence interval preeclampsia is available globally. women with intervals of 18-23 2.04 to 4.21).9,11,15,23,24 Neither the The only known cure is delivery months.6 A Danish cohort study chorionicity nor zygosity of the of the placenta.4 If maternal signs found that a long interval between pregnancies alters this increased develop before the fetus is mature, pregnancies was associated with a risk.25 One cohort study found the risk of neonatal morbidity and significantly higher risk of pre- that a triplet pregnancy nearly mortality due to premature eclampsia in a second pregnancy triples the risk of pre-eclampsia delivery is markedly increased.4 when pre-eclampsia did not exist compared with a twin pregnancy Risk factors associated with in the first pregnancy and paternity (relative risk 2.83, 95% confidence preeclampsia (Table-1)- had not changed.7 The data interval 1.25 to 6.40).26 The Preeclampsia is primarily regarded obtained from more than 1.8 likelihood of pre-eclampsia nearly as a disease of first pregnancy. The million births over 31 years, quadruples if diabetes is present risk of preeclampsia is at least twice showed that when the birth before pregnancy (relative risk as high during first pregnancies as interval was more than 10 years, a 3.56, 95% confidence interval 2.54 during second or later multiparous woman had the same to 4.99) (three cohort 11,24,27 pregnancies. Recent studies have risk of developing preeclampsia studies). In a population suggested that the risk may as a primiparous woman. based nested case-control study, decrease with a second pregnancy Women aged e” 40 had twice the Davies et al found that the only if the mother’s partner is the risk of developing pre-eclampsia, prevalence of chronic hypert- same. The hypothesis is that the whether they were primiparous ension was higher in women who risk of preeclampsia may be (relative risk 1.68, 95% confidence developed pre-eclampsia than 28 reduced with repeated maternal interval 1.23 to 2.29) or women who did not. Sibai et al exposure and adaptation to multiparous (relative risk 1.96, found that higher systolic and specific foreign antigens of the 95% confidence interval 1.34 to diastolic blood pressures at the

Journal of Postgraduate Medical Education, Training & Research 22 Vol. IV, No. 1-5, January-October 2009 first visit were associated with an supplementation is beneficial to relationship of preeclampsia increased incidence of pre- women at high risk of gestational and the subsequent risk of eclampsia.29 In another popula- hypertension and in communities hypertension and stroke later tion based nested case-control with low dietary calcium intake.33 in life and found that any study Odegard et al found that a Preeclampsia and associated hypertensive disorder of systolic blood pressure e” 130 mm complications-Chesley, who is pregnancy increased the later Hg compared with < 110 mm Hg the father of modern preecla- risk of hypertension and at the first visit before 18 weeks mpsia research was of the opinion stroke.38 The relative risk of was significantly associated with that once the condition was over, stroke was increased in the development of pre- the mothers had no greater risk women who had preecla- eclampsia later in pregnancy of adverse long – term out comes mpsia (Relative Risk: 3.59). (relative risk 3.6, 95% confidence than women without preecl-  Renal disease- Bar et al 15 interval 2.0 to 6.6). The ampsia from the general reported that microalbumi- 34 association with a diastolic population. In contrast, many nuria persisted in most of the pressure e” 80 mm Hg compared studies have linked preeclampsia preeclamptic women for three with < 60 mm Hg was similar but to increased risk of both renal to five years after the child not significant (relative risk 1.8, disease and cardiovascular disease birth.39 Davies et al also found 95% confidence interval 0.7 to in mothers in later life. that the prevalence of renal 4.6). In a case-control study  Cardiovascular disease-The disease was higher in women Stamilio et al found that a mean data obtained from a cohort who developed pre-eclampsia arterial pressure > 90 mmHg at study of 626,272 live births compared with those that did the first prenatal visit was in Norway between 1967 and not38 .A Norwegian study significantly associated with the 1992 states that the risk of which investigated compreh- development of severe pre- death from cardiovascular ensive data from the Medical eclampsia (relative risk 3.7, 95% causes had increased eight fold Birth Registry of Norway and 16 confidence interval 2.1 to 6.6). in preeclamptic women with Norwegian Kidney Biopsy The antipho-spholipid antibo- a child of low birth weight Registry found a strong 35 dies have more than nine fold risk than the control subjects. correlation between preecla- of preeclampsia (relative risk 9.72, Sattar and Greer focused on mpsia during pregnancy and 95% confidence interval 4.34 to pregnancy complications and later incidence of kidney 30,31 21.75) (two cohort studies). maternal cardiovascular risk, disease in mothers and One cohort study showed that suggested that women with a especially when the babies had women with a body mass index history of adverse pregnancy very low birth weight. > 35 before pregnancy had over outcome are at increased risk  Microvascular four times the risk of pre- for cardiovascular disease later complications-Preeclampsia eclampsia compared with women in their life.36 is associated with endothelial with a pre-pregnancy body mass  Ischemic heart disease- dysfunction, insulin resistance index of 19-27 (relative risk 4.39, Smith et al studied the and elevated homocysteine 95% confidence interval 3.52 to pregnancy complications and levels and these conditions 5.49).32 The protein–calorie mal the maternal risk of ischemic continue after delivery and nutrition has been identified as an cardiac death in 129,290 births represent a long term risk. important risk factor in 37 and found that preeclamptic developing countries however a women, who delivered a small Conclusion-This review of 1000 negative correlation between infant early, had a risk of controlled studies (from 1966 to calcium intake and incidence of ischemic heart disease or death 2002) brings up certain interesting preeclampsia was found in seven times higher than the conclusions. Firstly, a previous Guatemala, Colombia and India. control women. history of preeclampsia, multiple This finding is in support with  Hypertension and Stroke- pregnancy, nulliparity, pre-existing the observation that calcium Wilson et al examined the diabetes, high BMI before

Journal of Postgraduate Medical Education, Training & Research 23 Vol. IV, No. 1-5, January-October 2009 pregnancy, maternal age more than Group on High Pressure in 11. Lee CJ, Hsieh TT, Chiu TH, 40 years, renal disease, Pregnancy. Report of the Chen KC, Lo LM, Hung TH. hypertension, ten years or more National High Blood Pressure Risk factors for pre-eclampsia than ten years of difference Education Program Working in an Asian population. Int J between the pregnancies, presence Group on High Blood Gynecol Obstet. 2000; 70: of antiphospholipid antibodies, Pressure in Pregnancy. Am J 327-33. insulin resistance in concert with Obstet Gynecol. 2000; 183: 12. Eskenazi B, Fenster L, Sidney obesity and thrombophelia are S1–S22. SA. Multivariate analysis of the major risk factors of 4. Levine RJ, Karumanchi SA. risk factors for preecla- preeclampsia. Further, data on Circulating angiogenic factors mpsia. JAMA. 1991; 266: these risk factors of preeclampsia in preeclampsia. Clin Obstet 237-241. will have an immense value as it Gynecol. 2005; 48:372-386. 13. Stone JL, Lockwood CJ, would help to assess risk at the 5. Skjaerven R, Wilcox JA, Lie Berkowitz GS, Alvarez M, first antenatal clinical visit. A TR. The interval between Lapinski R, Berkowitz RL. suitable surveillance regimen pregnancies and the risk of Risk factors for severe could be initiated to detect pre- preeclampsia. N Engl J Med. preeclampsia. Obstet eclampsia and instituted for the 2002; 346: 33–38. Gynecol. 1994; 83: 357-361. rest of the pregnancy (Table-2). 6. Conde-Agudelo A, Belizan 14. Chen CL, Cheng Y, Wang PH Also the studies on associated JM. Maternal morbidity and complications of preeclampsia et al. Review of pre-eclampsia mortality associated with in Taiwan: a multi- necessitate the need to monitor interpregnancy interval: cross women throughout life who are institutional sectional study. BMJ. 2000; study. Zhonghua Yi Xue Za suffering from this condition. In 321: 1255-1259. addition, effective preventive Zhi (Taipei) 2000; 63: 869- 7. Basso O, Christensen K, steps, and or the use of early 875. Olsen J. Higher risk of pre- maternal serum markers to screen 15. Odegard RA, Vatten LJ, eclampsia after change of for the condition together with Nilsen ST, Salvesen KA, partner. An effect of longer the development of a truly Austgulen R. Risk factors and interpregnancy intervals? effective therapy would go a long clinical manifestations of pre- Epidemiology. 2001; 12: 624- way towards reducing the eclampsia. Br J Obstet 629. morbidity and mortality of both Gynaecol. 2000; 107: 1410- mothers and their babies, thereby 8. Bianco A, Stone J, Lynch L, 1416. Lapinski R, Berkowitz G, increasing hope for safe 16. Stamilio DM, Sehdev HM, motherhood in the world. Berkowitz RL. Pregnancy outcome at age 40 and Morgan MA, Propert K, References older. Obstet Gynecol. 1996; Macones GA. Can antenatal clinical and biochemical 1. Gupta N. Maternal Mortality: 87: 917-922. markers predict the Magnitude causes and 9. Coonrod DV, Hickok DE, development of severe Concerns. Obstet Gynecol. Zhu K, Easterling TR, Daling preeclampsia? Am J Obstet 2004; 9: 555-559. JR. Risk factors for Gynecol. 2000; 182: 589-594. 2. National Institute for Clinical preeclampsia in twin pregnancies: a population- 17. Campbell DM, MacGillivray I, Excellence. NICE Guideline Carr-Hill R. Pre-eclampsia in CG6 Antenatal care—routine based cohort study. Obstet Gynecol. 1995; 85: 645-650. second pregnancy. Br J Obstet care for the healthy pregnant Gynaecol 1985; 92: 131-140. woman. London: NICE, 10. Lawoyin TO, Ani F. 2003. Epidemiologic aspects of pre- 18. Sibai BM, El Nazer A, eclampsia in Saudi Gonzalez-Ruiz A. Severe 3. National High Blood Pressure Arabia. East Afr Med J. 1996; preeclampsia-eclampsia in Education Program Working 73: 404-406. young primigravid women:

Journal of Postgraduate Medical Education, Training & Research 24 Vol. IV, No. 1-5, January-October 2009 subsequent pregnancy and risk of preeclampsia. Am outcome and weight gain outcome and remote J Obstet Gynecol.2001; 185: recommendations for the prognosis. Am J Obstet 819-821. morbidly obese wom- Gynecol 1986; 155: 1011- 26. Skupski DW, Nelson S, an. Obstet Gynecol. 1998; 91: 1016. Kowalik A et al. Multiple 97-102. 19. Makkonen N, Heinonen S, gestations from in vitro- 33. Hofmeyr GJ, Roodt A, Kirkinen P. Obstetric fertilization: Successful Atallah AN, Duley L. Calcium prognosis in second implantation alone is not supplementation to prevent pregnancy after preeclampsia associated with subsequent pre-eclampsia—a systemic in first pregnancy. Hypertens pre-eclampsia. Am J Obstet review. S Afr Med J. 2003; 93: Pregnancy.2000;19: 173-181 Gynecol. 1996; 175: 1029- 224–228. 20. Dukler D, Porath A, Bashiri 1032. 34. Chesley LC, Annitto JE, A, Erez O, Mazor M. Remote 27. Garner PR, D’Alton ME, Cosgrove RA. The remote prognosis of primiparous Dudley DK, Huard P, Hardie prognosis of eclamptic women with preeclam- M. Preeclampsia in diabetic women: Sixth periodic report. psia. Eur J Obstet Gynecol pregnancies. Am J Obstet Am J Obstet Gynecol. 1976; Reprod Biol. 2001; 96: 69-74. Gynecol. 1990; 163: 505-508. 124: 446–459. 21. Arngrimsson R, Bjornsson S, 28. Davies AM, Czaczkes JW, 35. Irgens HU, Reisaeter L, Irgens Geirsson RT, Bjornsson H, Sadovsky E, Prywes R, LM, Lie RT. Long term Walker JJ, Snaedal G. Genetic Weiskopf P, SterkVV. mortality of mothers and and familial predisposition to Toxemia of pregnancy in fathers after pre-eclampsia: eclampsia and pre-eclampsia Jerusalem I. Epidemiological Population based cohort in a defined population. Br J studies of a total commu- study. BMJ. 2001; 323: 1213– Obstet Gynaecol. 1990; 97: nity. Isr J Med Sci. 1970; 6: 1217. 762-769. 253-266. 36. Sattar N, Greer IA. Pregnancy 22. Cincotta RB, Brennecke SP. 29. Sibai BM, Gordon T, Thom complications and maternal Family history of pre- E et al. Risk factors for cardiovascular risk: Opport- eclampsia as a predictor for preeclampsia in healthy unities for intervention and pre-eclampsia in primigr- nulliparous women: a screening? BMJ. 2002; 325: avidas. Int J Gynaecol prospective multicenter 157–160. Obstet 1998; 60: 23-27. study. Am J Obstet 37. Smith GC, Pell JP and Walsh 23. Santema JG, Koppelaar I, Gynecol. 1995; 172: 642-648. D. Pregnancy complications Wallenburg HC. Hypertensive 30. Pattison NS, Chamley LW, and maternal risk of ischemic disorders in twin McKay EJ, Liggins GC, Butler heart disease: A retrospective pregnancy. Eur J Obstet WS. Antiphospholipid cohort study of 129,290 Gynecol Reprod Biol 1995; antibodies in pregnancy: births. Lancet. 2001; 357: 58: 9-13. prevalence and clinical 2002–2006. 24. Ros HS, Cnattingius S, associations. Br J Obstet 38. Wilson BJ, Watson MS, Lipworth L. Comparison of Gynaecol. 1993; 100: 909-913. Prescott GJ et al. Hypertensive risk factors for preeclampsia 31. Yasuda M, Takakuwa K, diseases of pregnancy and risk and gestational hypertension Tokunaga A, Tanaka K. of hypertension and stroke in in a population-based cohort Prospective studies of the later life: Results from cohort study. Am J association between study. BMJ. 2003; 326: 845-849. Epidemiol. 1998; 147; anticardiolipin antibody and 39. Bar J, Kaplan B, Wittenberg C 11(suppl): 1062-1070. outcome of pregnancy. Obstet et al. Microalbuminuria after 25. Maxwell CV, Lieberman E, Gynecol. 1995; 86: 555-559. pregnancy complicated by Norton M, Cohen A, Seely 32. Bianco AT, Smilen SW, Davis preeclampsia. Nephrol Dial EW, Lee-Parritz A. Y, Lopez S, Lapinski R, Transplant.1999; 14: 1129– Relationship of twin zygosity Lockwood CJ. Pregnancy 1132.

Journal of Postgraduate Medical Education, Training & Research 25 Vol. IV, No. 1-5, January-October 2009 Table-1, Studies on risk factors of preeclampsia Risk factor Study Number of Unadjusted relative Reference Design studies risk (95% CI) Time between Cross 1 1.83(1.72 to1.94) Conde-Agudelo et al pregnancies> 59 months sectional 2000 Age >40 primiparous Cohort 1 1.68 (1.23 to 2.29) Bianco et al 1996 Age >40 multiparous Cohort 1 1.96 (1.34 to 2.87) Bianco et al 1996 Nulliparity Cohort 3 2.91 (1.28 to 6.61) Coonrod et al 1995 Lawoyin et al 1996 Lee et al 2000 Case control 6 2.35 (1.80 to 3.06) Coonrod et al 1995 Eskenazi et al 1991 Stone et al 1994 Chen et al 2000 Odegard et al 2000 Stamilio et al 2000 Previous pre-eclampsia Cohort 5 7.19 (5.85 to 8.83) Lee et al 2000 Campbell et al 1985 Sibai et al 1986 Makkonen et al 2000 Dukler et al 2001 Family history Cohort 2 2.90 (1.70 to 4.93) Arngrimsson et al 1990 Cincotta et al1998 Twin pregnancy Cohort 5 2.93 (2.04 to 4.21) Coonrod et al 1995 Lee et al 2000 Odegard et al 2000 Santema et al 1995 Ros et al 1998 Triplet v twin pregnancy Cohort 1 2.83 (1.25 to 6.40) Skupski et al 1996 Pre-existing diabetes Cohort 3 3.56 (2.54 to 4.99) Lee et al 2000 Ros et al 1998 Garner et al 1990 Systolic >130 mm Hg at Cohort 1 3.6 (2.0 to 6.6) Odegard et al 2000 booking Diastolic >80 mm Hg at Cohort 1 1.8 (0.7 to 4.6) Odegard et al 2000 booking Mean Arterial pressure > 90 Case control 1 3.7 (2.1 to 6.6) Stamilio et al 2000 Autoimmune disease Case control 1 6.9 (1.1 to 42.3) Stamilio et al 2000 Antiphospholipid Cohort 2 9.72 (4.34 to 21.75) Pattison et al 1993 antibodies Yasuda et al 1995 BMI>35 Cohort 1 4.39 (3.52 to 5.49) Bianco et al 1998

Table-2, Risk factors that can be assessed at first antenatal visit History Pre-existing medical conditions Examination Age Insulin dependent diabetes (IDDM) Body mass index (BMI) Parity Chronic hypertension Blood pressure Previous pre-eclampsia Renal disease Proteinuria Family history of pre-eclampsia Autoimmune disease Multiple pregnancy Antiphospholipid syndrome Time between pregnancies

Journal of Postgraduate Medical Education, Training & Research 26 Vol. IV, No. 1-5, January-October 2009 7 Renal Tubular Acidosis(RTA) in Children Review Article Sanjiv Nanda, Ashish Marwah, Poonam Marwah Article Department of Pediatrics, PGIMS, Rohtak

cidosis due to renal disease secretion of H+ ions in the citrate and decrease its urinary is considered in two absence of a marked decrease in excretion. This hypercalciuria, Acategories, depending on the glomerular filteration rate hypocitraturia and alkaline urine whether the predominant site of (GFR) is characteristic of distal leads to calcium phosphate stone renal involvement are the RTA. Patients with distal RTA formation in the kidneys + glomeruli or the renal have inappropriately low NH4 ion (nephrocalcinosis and nephrolit- tubules.Predominantly tubular excretion when compared with hiasis). damage – “normal anion gap the normal rate of acid Etiology acidosis”- Distal (or type 1) RTA; production. The deficiency here is Proximal (or type 2) RTA; Type 4 secondary to either a secretory Primary -Genetic(Autosomal - RTA. Predominantly glomerular (rate) defect or a gradient dominant:- Mutation in the Cl / HCO - exchanger of intercalated damage – “high anion gap (permeability) defect. In the 3 acidosis”-Acidosis of acute renal secretory defect, the rate of discs; Autosomal recessive:- + failure; Uremic acidosis secretion of H+ ions is low for Mutation in the H /ATPase as Definition- It is a disease state the degree of acidosis. It is due to found in some families associated secondary to reduced proximal defective function of H+ ATPase, sensorineural hearing loss + + - - (SNHL) is common; Sporadic – tubular reabsorption of H /K ATPase or the Cl /HCO3 - medullary sponge kidney bicarbonate ions (HCO3 ) or the exchanger (“weak pump”). In the distal secretion of protons (H+ gradient (permeability) defect, Secondary- Autoimmune- ions) or both, resulting in an there is normal secretion of H+ Sjogren syndrome (most impaired capacity for net acid ions but an increased back leak common), systemic lupus excretion and persistent resulting in dissipation of the pH erythematosis (SLE); Disorders hyperchloremic metabolic acidosis. gradient (“leaky membrane”) as causing nephrocalcinosis-Primary Three main clinical categories of seen in RTA due to amphotericin renal tubular acidosis (RTA) are hyperparathyroidism, Vitamin D B. The low titrable acidity and intoxication; Toxins- Ampho- now recognized and classified on NH + secretion in distal RTA 4 tericin B, lithium, toluene, the basis of their pathop- leads to systemic acidosis. cisplatin; Miscellaneous- obstru- hysiology as - Hypokalemia is attributed due to ctive uropathy, vesicoureteral reflux  Type 1 (DISTAL) RTA increased potassium losses in the (VUR), pyelonephritis.  Type 2 (PROXIMAL) RTA tubular lumen, urinary sodium losses and volume contraction Clinical Profile  Type 4 (secondary to true / leading to aldosterone stimulation apparent hypoaldosteronism).  Failure to thrive, growth which inturn causes increased retardation (most common). The above conditions are either tubular potassium secretion and secondary to other causes, or decreased proximal potassium  Polyuria, polydipsia primary with or without known reabsorption.2 Chronic acidosis  Nephrocalcinosis, nephr- genetic defects.1 also lowers the tubular olithiasis Type 1 (Distal RTA)- It is also reabsorption of calcium causing  Rachitic manifestations (later referred to as the classical RTA. renal hypercalciuria and in childhood) The problem here is inability to hyperparathyroidism. Acidosis maximally acidify urine.Metabolic and hypokalemia stimulate the  Weakness, transient paralysis acidosis secondary to decreased proximal tubular reabsorption of (due to hypokalemia)

Journal of Postgraduate Medical Education, Training & Research 27 Vol. IV, No. 1-5, January-October 2009  Sporadic or autosomal Clinical Profile blockers, ACE inhibitors, K+ recessive cases may have  Failure to thrive, growth sparing diuretics, cyclosporine) associated SNHL that may retardation (most common). Clinical Profile present at birth or later.  Polyuria, polydipsia  Growth retardation (most Type 2 (Proximal) RTA-It is  Dehydration (due to sodium, common) called as proximal RTA because H O Losses)  the primary defect here is the 2 Polyuria, polydipsia, impaired reabsorption of  Rachitic Manifestations. dehydration. bicarbonate ions in the proximal  (Common in fanconi  Signs and symptoms of tubule resulting in bicarbonaturia. syndrome because of obstructive uropathy and The primary defect in proximal hypophosphatemia) features of pyelonephritis. RTA is the reduced renal threshold  Irritability, listlesseness,  Bone diseases are generally for HCO resulting in 3 anorexia or preference for absent. bicarbonaturia. The proposed savoury foods. mechanisms include defective Diagnosis-Metabolic acidosis can Type 4 RTA-The underlying pump secretion or function of the result from either renal (RTA, defect here is the impaired cation H+/ATPase, the Na+/H+ CKD) or extrarenal processes exchange in the distal tubules with antiporter, the Na+/K+ ATPase or which result from an increased reduced secretion of H+ and K+. the deficiency of carbonic indigenous acid production It occurs as a result of impaired (ketoacidosis) or enhanced HCO - anhydrase in the brush border 3 aldosterone secretion membrane. This results in losses (diarrhea, pancreatic/ biliary (hypoaldosteronism) or an increased urinary loss of HCO fistula). RTA may be due to either 3 impaired renal response to HCO - wasting (proximal) or causing systemic acidosis with 3 aldosterone. Aldosterone inability to generate new HCO - inappropriately high urinary pH. increases Na+ reabsorption 3 The increased distal Na+ delivery ions to buffer endogenous acid (pseudohypoaldosteronism) and (distal RTA).Since all types of results in hyperaldosteronism results in a negative intratubular with consequent renal K+ wasting. RTA are associated with a normal - potential. It also increases luminal plasma anion gap, it is the initial As plasma HCO3 levels fall, the + - membrane permeability to K and step in evaluation of metabolic lowered filtered load of HCO + + 3 stimulates basolateral Na /K acidosis. can now be reabsorbed by ATPase, causing increased K+ proximal tubule resulting in a losses in urine. Since, aldosterone Plasma Anion Gap-It represents normal distal delivery of HCO -. the difference of unmeasured 3 directly stimulates proton pump, At this point, the distal nephrons aldosterone deficiency or resistance anions and cations in the plasma can acidify urine normally resulting should lead to hyperkalemia and and is measured as -Anion gap = in a normal excretion of daily Na+ - (Cl- + HCO -).The normal acidosis. Other factor that causes 3 metabolic acid produced. a decreased H+ excretion in type 4 value of plasma anion gap is 12 + Hypercalciuria is present but as RTA is the inhibition of 2 meq/L. urine citrate levels are normal, ammoniagenesis due to Metabolic acidosis with normal nephrocalcinosis or lithiasis is a hyperkalemia.4 anion gap- Diarrhea, RTA (Both rarity. Etiology-Type 4 RTA is most distal and proximal). This normal Etiology- It may present as an often seen in children with plasma anion gap metabolic isolated or generalized proximal obstructive uropathy or as a acidosis is also known as 3 tubular dysfunction (i.e. Fanconi transient phenomena during “Hyperchloremic metabolic syndrome with tubular infancy.5 Primary-(Sporadic; acidosis.” proteinuria and aminoaciduria Hereditary); Secondary (Hypoa- Metabolic acidosis with increased with variable degrees of ldosteronism, Pseudohyp- anion gap-Diabetic ketoacidosis bicarbonaturia, phosphaturia, oladosteronism, Chronic kidney + + (DKA) ,Lactic acidosis due to Na , K wasting and glucosuria). disease; Drugs (NSAIDS, b- shock, Ethylene glycol, aspirin

Journal of Postgraduate Medical Education, Training & Research 28 Vol. IV, No. 1-5, January-October 2009 poisoning, Uremia, Some inborn defective distal secretion of H+. secretion and is considered a errors of metabolism Acidic Urine-Proximal RTA; sensitive indicator of distal Urinary Anion Gap (UAG)- The Alkaline Urine- Distal RTA, acidification. After achieving a - next step is to distinguish RTA Acute/chronic Diarrhea , Urinary urine pH >7.5 and plasma HCO3 from extrarenal causes. Urinary tract infection (with urea splitting levels > 23-25 meq/L, difference anion gap (net charge) provides organisms). between the urine and blood + PCO (i.e. U-B PCO ) is measured an estimate of urinary NH4 ion Ammonium Chloride (Nh4Cl) 2 2 excretion. According to Principle Loading Test-Administration of as- U-B PCO2 >20mmHg - Normal / Proximal RTA; U-B of electroneutrality- Sum of oral NH4Cl (0.1mg/kg) challenge urinary cations = Sum of urinary might be given followed by PCO2 <10mmHg - Distal RTA anions. i.e. Na+ + K+ + Ca2+ + measurement of urine pH every Fractional Excretion of 2+ + - 2- 3- Mg + NH4 = Cl + So4 + Po4 hour for the next 8 hours to look Bicarbonate (FeHCO3%)- It is etc. On usual diets, excretion of for renal response to the induced an important marker of proximal 2+ 2+ 2- 3- Ca , Mg , So4 , Po4 and other metabolic acidosis. Normally, a tubular handling of bicarbonate. organic ions is fairly constant. fall in plasma total HCO3 levels Normally, proximal tubules Also, urinary Na+, K+, Cl- can be by 3-5meq/L induces urinary pH reabsorb most of the filtered + easily measured but NH4 and to be <5.5. If in the presence of bicarbonate (i.e. Fractional other ions are usually unmeasured metabolic acidosis Urinary pH excretion is < 5%). The fractional and since the contribution of <5.5( Normal response rules excretion of bicarbonate is - HCO3 to urinary anion is out distal RTA); Urinary pH calculated following adequate negligible unless the urine is >5.5(Distal RTA – likely cause). alkalinization as shown - + alkaline, therefore, Urinary Na However, patients with chronic FeHCO % = urine bicarbonate x + + - 3 + K + NH4 = Cl + other metabolic acidosis (e.g. after plasma creatinine x 100 plasma + + - anions; Urinary Na + K - Cl = - chronic diarrhea) show increased bicarbonate x urine creatinine NH + + other anions. Now, from ammoniagenesis that consumes 4 FeHCO < 5% - Normal / Distal a practical point of view:- urinary most distally secreted H+ ions 3 RTA; FeHCO > 5% - Proximal anion gap i.e. ( Na+ + K+ - Cl- = - resulting in an enhanced urine 3 RTA; Hyperchloremic distal RTA NH + ) and this gives us a fair NH + excretion, therefore, “urine 4 4 - FeHCO varies from 5-10%. estimation of NH + ion excretion. pH in these cases may be high 3 4 - Normal value of urinary anion gap is despite appropriate H+ excretion.” Tests for phosphate handling Fractional excretion of PO 30-35 meq/L. Bicarbonate Loading Test- 4 (FePO4 %)-Phosphate Positive UAG-RTA (because of Sodium bicarbonate is homeostasis is chiefly regulated at decreased NH + production, administered as half strength 4 level of proximal tubules. FePO DKA, toluene poisoning, intravenous infusion at 3 ml/ 4 (%) determined on timed (6hr, alcoholic ketoacidosis.) min, while measuring urine pH 12hr, 24hr) urine specimen is used in timed samples every 30-60 Negative UAG-Diarrhea as a measure for phosphate minutes apart. A steady state is URINE pH-It assesses the handling. achieved after 3 to 4 hours of start overall integrity of distal urinary of infusion, and the test FePO4 (%) = Urine phosphate x acidification and provides an terminated when three urinary plasma creatinine x 100 Plasma estimate of the number of free samples with pH > 7.5 are phosphate x urine creatinine H+ ions in the urine secreted in collected. Interpretation of this Now, tubular reabsorption of response. In the presence of test allows characterization of type PO (%) = 100 - FePO systemic acidosis present 4 4 of RTA as follows: (%).Normal range is 85 - 95%. It spontaneously or induced by is reduced in cases of proximal ammonium chloride (NH Cl) Urine to Blood CO2 Gradient- 4 tubular defect and hyper- loading, the urinary pH is <5.5 In alkaline urine (i.e after a parathyroidism. Since, tubular normally. If the pH >5.5 during NaHCO3 loading) urine PCO2 + reabsorption is markedly metabolic acidosis, it suggests increases due to distal H

Journal of Postgraduate Medical Education, Training & Research 29 Vol. IV, No. 1-5, January-October 2009 influenced by changes in GFR and Frusemide Test- Response to bicarbonate required to maintain dietary changes, it has led to frusemide helps determine the acid base status may be as high as anincreasing use of the index: possible site and mechanism of 5-10meq/kg/day and the

Tubular maximum of PO4 defect in type 1 RTA. Frusemide duration of therapy is usually corrected for GFR i.e TmP/GFR increases the luminal electronega- lifelong. Various alkali solutions (Bijovet index). tivity by increasing Na+ delivery to used are-Sodium bicarbonate Bijovet Index (TmP/GFR)- and reabsorption in the cortical solution (7.5%);Citrate solutions Tubular maximum of phosphate collecting tubule. The changes (Polycitra solution (2 meq/ corrected for GFR (TmP/GFR) brought about by frusemide in ml),Shohl solution (1 meq/ represents the concentration above H+ and K+ excretion in normal ml),Potassium alkali salts should which most phosphate is excreted subjects and in those with various be used if hypokalemia is a and below which most is defects of distal RTA (Table- persistent problem). In case of reabsorbed. It is an index of renal 1).8Once the diagnosis of RTA is associated rickets or osteopenia, threshold for phosphate which established, it can then be Vitamin D should be can be calculated as follow- TmP/ categorized further as supplemented. The relatives of summarized by the results of patients with idiopathic distal GFR (mg/dl) = Plasma PO4 - urine phosphate x plasma investigations in different forms RTA should be screened for this creatinine. Normal value = 2.8 - of RTA (Table-2). In addition disorder as timely intervention can 4.4 (mg/dl). to these, children with proximal prevent growth retardation in Transtubular potassium (Type 2) RTA should undergo children. gradient (TTKG)-Renal tubular evaluation for other proximal Type 2 (Proximal) RTA- disorders are associated with both tubule functions (phosphate, Alkali supplementation again hypokalemia and hyperkalemia. electrolytes, glucose, amino acid remains the treatment of choice. TTKG provides an accurate excretion) and screening for an Children with proximal RTA estimate of aldosterone effect on underlying etiology (wilson generally require greater amounts sodium potassium exchange in disease, cystinosis). Children with of alkali per day (approximately the late distal and cortical collecting distal RTA, on the other hand 5-20 meq/kg/day) as compared tubules. TTKG is an index of the should be investigated for urinary to distal RTA patients. A thiazide gradient of potassium in distal calcium excretion, ultrasound for diuretic can be used in conjunction tubular lumen and interstitial renal calcification, a work up for with low salt diet to reduce the blood capillaries, independent of secondary causes (e.g. obstructive amount of bicarbonates required. urine flow rates.7 It is calculated as uropathy, reflux nephropathy, Thiazides act by causing follows: chronic tubulointerstitial extracellular fluid contraction and TTKG = urine K+ × plasma nephritis) and hearing evaluation. increasing proximal bicarbonate osmolality plasma K+ x urine Management reabsorption. Potassium osmolality Alkali supplements are the supplementation is done to Normal value = 6-12;TTKG < 2 standard therapy in all types compensate for the increased - hypokalemia (extrarenal causes); Type I (Distal) RTA-Electrolyte potassium excretion caused by TTKG is higher - hypokalemia abnormalities should always be thiazides.Phosphate supplements (renal losses) e.g hypoaldo- corrected before treating acidosis. (e.g. joulie solution, neutral steronism. In hyperkalemia - Acidosis is corrected by phosphate solution) and expected TTKG is >10; an administration of alkali solutions. moderate doses of Vitamin D inappropriately low TTKG (<8) Initial dose is 2-3meq/kg/day may be required. Joulie solution- in hyperkalemia suggests and can be increased until the 1ml= 30mg inorganic hyoaldosteronism or renal blood bicarbonate levels become phosphorous; Neutral phosphate tubular resistance to aldosterone. normal. The amount of solution-1ml=20mg inorganic

Journal of Postgraduate Medical Education, Training & Research 30 Vol. IV, No. 1-5, January-October 2009 phosphorous. Specific therapy for distal RTA. 4. Soriano JR. Renal tubular an underlying disorder (cystea- Prognosis- Usually depends on acidosis, the clinical entity. J mine for cystinosis, D- the nature of underlying disease. Am Soc Nephrol 2002; 13: penicillamine for wilson disease Subjects with RTA usually 2160-70. and lactose free diet in demonstrate a dramatic improve- 5. Hanna JD, Scheinman JI, galactosemia) is indicated in few ment in growth provided serum Chan JCM. The kidney in acid patients. bicarbonate levels are maintained base balance. Pediatric Clinics Type 4 (Hyperkalemic) RTA- within the normal range. Patients of North America 1995; 42: The main goal of therapy here is of fanconi syndrome and systemic 1365-94. to reduce serum potassium levels illnesses may have difficulties with 6. Goldstein MB, Bear R, (as acidosis improves once the growth failure, rickets and various Richardson RMA, Marsden hyperkalemic block of ammo- signs and symptoms pertaining PA, Halperin ML. The urine nium production is removed). to their disease. anion gap: a clinically useful Children are put on a low References index of ammonium potassium diet and any drug excretion. Am J Med Sci 1986; suppressing aldosterone produc- 1. Dell KM, Avner ED. Renal 292: 198-9. tion is discontinued. Mineraloco- tubular acidosis. In Behrman rticoid supple-mentation with RE, Kliegman RM, Jenson 7. DoBose TD Jr. Hyperkalemic fludro-cortisone will improve HB, ed. Nelson Textbook of hyperchloremic metabolic hyperkalemia and acidosis. In Pediatrics. Philadelphia; WB acidosis: pathophysiologic children with hypertension or Saunders, 2003; 1758-62. insights. Kidney Int 1997; 51: heart failure, mineral- 2. Soriano JR. New insights into 591-602. ocorticoids are contraindicated, the pathogenesis of renal 8. Bagga A, Sinha A. Evaluation potassium exchange resins (e.g tubular acidosis from of renal tubular acidosis. kayexelate), however, may be functional to molecular Indian J Pediatr 2007; 74: 670- required. studies. Pediatr Nephrol 2000; 86. Follow Up- A regular follow up 14: 1121-36. must be done for Assessment of 3. Bagga A, Bajpai A, Menon S. growth;Blood levels of electro- Approach to renal tubular lyes, pH and bicarbonate levels; disorders. Indian J Pediatr Ultrasound screening for 2005; 72: 771-6. nephrocalcinosis in subjects with Table-1, Response of urine Ph and potassium (K+) excretion following frusemide administration in normal subjects and various defects causing distal RTA.8 Defect Site of Defect Urine pH K+ Excretion During After Baseline After Acidosis Frusemide Frusemide Normal None <5.5 Further Normal Increased Decline H+ ATPase defect Diffuse, cortical >5.5 >5.5 Normal Increased collecting tubule H+ ATPase defect Medullary >5.5 <5.5 Normal Increased collecting tubule alone Voltage defect Cortical collecting >5.5 >5.5 Decreased Unchanged tubule

Journal of Postgraduate Medical Education, Training & Research 31 Vol. IV, No. 1-5, January-October 2009 Table-2, comparison of various types of RTA Proximal RTA Distal RTA Type 4 RTA Classic Hyperkalemic Plasma K+ Normal/Low Normal/Low High High Urine pH <5.5 >5.5 >5.5 <5.5 Urine anion gap Positive Positive Positive Positive + Urine NH4 Low Low Low Low - Fractional HCO3 >10-15% <5% <5% 5-10% excretion

U-B PCO2 mmHg >20 <20 L20 >20 Urine Ca2+ Normal High High Normal/low Other tubular defects Often present Absent Absent Absent Nephrocalcinosis Absent Present Present Absent Hippocrates different schools. It has thus contradistinction to the become customary to designate schematizing of the school of contribution to the writings ascribed to Cnidus. By the observation of all medicine Hippocrates by the general title the principles were gradually of the “Hippocratic Collection” derived from experience, and Tradition knows seven physicians (Corpus Hippocraticum), and to these, uniformly arranged, led by named Hippocrates, of whom the divide them according to their induction to a knowledge of the second is regarded as the most origin into the works of the nature of the disease, its course, famous. Of his life we know but schools of Cnidus and of Cos, and its treatment. This is the little. He was born at Cos in 460 and of the Sophists. How origin of the famous or 459 B.C., and died at Larissa difficult it is, however, to “Aphorismi”, short rules which about 379. How great his fame determine their genuineness is contain at times principles derived was during his lifetime is shown shown that even in the third from experience and at times by the fact that Plato compares century before Christ the conclusions drawn from the same him with the artists Polycletus and Alexandrian librarians, who for source. They form the valuable Phidias. Later he was called “the the first time collected the part of the collection. The school Great” or “the Divine”. The anonymous scrolls scattered of Cos and its adherents, the historical kernel is probably as through Hellas, could not reach a Hippocratics, looked upon definite conclusion. For the follows: a famous physician of this medical science from a purely development of medical science name from Cos flourished in the practical standpoint; they regarded it is of little consequence who days of Pericles, and subsequently it as the art of healing the sick, composed the works of the many things, which his ancestors and therefore laid most stress on school of Cos for they are more or his descendants or his school prognosis and treatment by or less permeated by the spirit of accomplished, were attributed to aiding the powers of nature one great master. The secret of him as the hero of medical science. through dietetic means, while the The same was true of his writings. his immortality rests on the fact whole school of Cnidus prided What is now known under the that he pointed out the means itself upon its scientific diagnosis title of “Hippocratis Opera” whereby medicine became a and, in harmony with money with represents the work, not of an science. His first rule was the the East, adopted a varied individual, but of several persons observation of individual medicinal treatment. of different periods and of patients, individualizing in

Journal of Postgraduate Medical Education, Training & Research 32 Vol. IV, No. 1-5, January-October 2009 8 Recurrent Pain abdomen in children Review Venkatesh.C, VishnuBhat.B Article Department of Pediatrics, J.I.P.M.E.R, Puducherry. ecurrent abdominal pain school going child or adolescent organic cause for pain 1, 3. (RAP) in children is with evidence of limitation in daily Causes of RAP- The causes of R defined as continuous or activities1, 2. RAP is a description recurrent pain abdomen are near continuous abdominal pain and not a diagnosis. It affects extensive. It is useful to classify on 3 or more occasions over a 15% of middle and high school them as either organic or period of at least 3 months in a children. Five to 10% percent have functional (non organic) causes. Functional Organic Gastrointestinal GB&Pancreas Genitourinary Miscellaneous Functional abdominal Chronic constipation Cholelithiasis Urinary tract Abdominal epilepsy pain syndrome Lactose intolerance Choledochal infections Gilbert syndrome Nonulcer dyspepsia Parasitic infestation cyst Recurrent Hydronephrosis Sickle cell crisis Irritable bowel Fructose/sorbitol pancreatitis Urolithiasis Lead poisoning syndrome ingestion Henoch -schonlein Aerophagia Crohn disease purpura Abdominal migraine Peptic ulcer Angioneurotic- edema Esophagitis Acute intermittent Meckel‘s diverticulitis porphyria. Recurrent intussusception Inguinal/abdominal wall hernias Chronic appendicitis Appendiceal mucocoel

Functional Gastrointestinal Functional abdominal pain For all of the above subtypes, disorders 4, 5- Specific functional syndrome-It is diagnosed when there should be no evidence of gastrointestinal disorders are there is abdominal pain with one inflammatory, anatomical, diagnosed if the following criteria or more of the following-Some metabolic or neoplastic processes are met-Functional dyspepsia-( loss of daily functioning, to explain the pain and the criteria Persistent or recurrent pain Additional somatic symptoms should be fulfilled for at least once centered over upper abdomen (headache, limb pain, sleep a week for 2 months prior to (above umbilicus);Not relieved by difficulty) diagnosis. defaecation or associated with Abdominal migraine- Pathophysiology of Functional change in form or frequency of Paroxysmal episodes of intense pain abdomen-There are bowel action periumbilical pain lasting 1 or multiple factors which are Irritable bowel syndrome- more hours (2 or more times in thought to influence the Abdominal discomfort or pain the preceding 12 months) ; perception of pain by the brain associated for 25% of the time or Healthy in between for weeks or from stimuli emanating from more with 2 or more of the months; Pain interferes with visceral receptors in the following-Improvement with normal activities; Pain associated gastrointestinal tract (G.I.T). defaecation ,Change in frequency with 2 or more of Some of these factors are genetic of stool , Change in form or Anorexia,Nausea, Vomiting, and environmental whereas appearance of stool Headache, Photophobia, Pallor others are either physiologic or

Journal of Postgraduate Medical Education, Training & Research 33 Vol. IV, No. 1-5, January-October 2009 psychosomatic in nature. Studies rigidity can be present on local H.pylori infection and have found that children with examination. Systemic symptoms recurrent pain abdomen- recurrent pain abdomen have like fever, weight loss, rash, Community based case control increased sensitivity to stress vomiting, diarrhea, hematochezia studies from the west have shown which impact the physiology of and joint pain may be present. that there is no association the G.I.T leading to pain as well Child may have jaundice. The pain between H.pylori infection and as slow recovery of autonomic disturbs sleep and may cause recurrent pain abdomen and nervous system following growth deceleration. In one large therefore investigating for stressful responses. They have Indian series, parasitic infestation H.pylori infection in these children abnormal perception of was found to be the most are not recommended9. However gastrointestinal sensation and also common cause of recurrent pain the data was obtained from have a lower threshold to pain. abdomen in children aged between children from higher Studies in patients with irritable 3 and 12 years 8). socioeconomic strata and hence bowel syndrome indicate that Red flag symptoms indicating extrapolating the same to the these patients have altered brain organicity5- Involuntary weight Indian context would not be response to rectal stimuli and may loss;Growth faltering; applicable. Indian studies on be related to central noradrenergic Gastrointestinal bleeding; Pain recurrent pain abdomen have modulation6. Children with RAP abdomen in right upper or right yielded mixed results with some have also been found to have studies not recommending lower quadrant; Significant 10 attentional biases and often vomiting or chronic diarrhea. evaluation for H.pylori and other associate their pain to certain studies indicate the need for Evaluation-Extensive lab tests are H.pylori eradication therapy11. environmental factors or normal not necessary for nonorganic pain. Treatment-Treatment of gastrointestinal sensations and However following screening tests underlying cause if organic increase their anxiety and fear may be helpful - Complete blood (antibiotics for urinary tract which in turn exacerbates the count for evidence of infection or 7 infection & bacterial overgrowth pain . And finally parents and inflammation; ESR (increased in syndrome, deworming for caregivers may reinforce the child’s inflammatory bowel diseases, parasitic infestations, surgery for symptoms and encourage the infections and neoplasm); Stool acute appendicitis, child to adopt a sick role. microscopy, reducing substance, intussusception etc). Clinical features-Non organic occult blood, parasite ova and cyst; pain (Age is usually more than 6 Urine analysis and culture Non organic Pain-Reassurance years and the commonest site is sensitivity for cystitis, of children and family members periumbilical. Pain can sometimes pyelonephritis or renal calculi. is important. Instructions to be localized to epigastric or Other investigations depending avoid reinforcing symptoms for suprapubic region. It interrupts upon history and clinical findings secondary gain. Provide less routine activity. Pain is not for organic pain (Liver function attention to the symptoms and associated with vomiting or tests, serum amylase, more attention to the child. diarrhea and has no relation to ultrasonography of abdomen, Biofeedback and relaxation meals. It does not wake up the radiograph of abdomen, barium techniques for stress management child from sleep. In case of IBS, series, fluoroscopy, Upper are often helpful. Medications pain is associated with bloating G.I.endoscopy. Breath hydrogen have a limited role particularly sensation and incomplete test, breath urea and rapid urease visceral muscle relaxants and evacuation and relieved by test to diagnose H.pylori antacids. Close follow up is defecation). Organic Pain(More particularly in patients with necessary in doubtful and difficult common in children less than 6 gastritis and peptic ulcer disease, cases. years. Site is usually away from the EEG, urine for porphyrias, serum Specific Treatment umbilicus, well localized and lead levels and Hb electrophoresis  Irritable bowel syndrome consistent. Tenderness and in selected cases). (IBS): Dietary modification in

Journal of Postgraduate Medical Education, Training & Research 34 Vol. IV, No. 1-5, January-October 2009 the form of avoiding or ing for parents and self regulation erology 2006; 130(5): 1459-65. limiting fat, alcohol, caffeine, training for the affected child has 5. Chronic abdominal pain in sorbitol, fructose and corn. shown to be effective in the children. American academy Medical management includes management of recurrent pain of Pediatrics subcommittee anti cholinergics like abdomen. When compared to on chronic abdominal pain. dicyclomine or hyoscine daily standard pediatric care, children Pediatrics 2005;115(3):812-5 initially and then as and when receiving cognitive behavioral 6. Naliboff BD, Derbyshire SW, necessary. Low dose tricyclic therapy have shown significant Munakata J, Berman S, antidepressants or 5HT3 improvements in the domains of Mandelkern M, Chang L, receptor antagonists and pain intensity and pain behavior Mayer EA. Cerebral activation 5HT4 receptor blockers like with complete resolution of in patients with irritable bowel tegaserod may be useful. symptoms and a very low relapse syndrome and control rate12.  Functional Dyspepsia: A diet subjects during recto sigmoid 13 similar to that of IBS. Medical Prognosis - One third of stimulation. Psychosom Med management essentially Children with recurrent pain 2001; 63(3):365-75. consists of H2 receptor abdomen can go on to develop 7. Vasey MW, Daleiden EL, blockers or prokinetics and chronic abdominal pain in Williams LL, Brown L. Biased low dose tricyclic antidepr- adulthood. Children with chronic attention in childhood anxiety essants. abdominal pain are more likely to disorders: A preliminary study. have emotional and psychological  Abdominal Migraine: Prop- J Abnormal Child Psychology problems later in life. Irritable ranolol, cyproheptadine, 1995; 23:267-279. pizotifen, tricyclic antidepre- bowel syndrome is likely to persist 8. Bansal D,Patwari AK, ssants or carbamazepine can well into adulthood often needing Malhotra VL, Malhotra V, be tried. longer duration of treatment especially cognitive and behavioral Anand VK.Helicobacter  Aerophagia: Reassurance and therapy. pylori infection in recurrent limitation of gum chewing abdominal pain. Indian References and avoiding consumption of pediatr 1998; 35(4):329-35. carbonated beverages. 1. Apley J, Naish N. Recurrent 9. Macarthur C, Saunders N, abdominal pains. A field  Functional constipation: Feldman W, Ipp M, Winders- survey of 1000 school Increase dietary fibres, fruits Lee P, Roberts S, Best L, children. Arch Dis Child 1958; and green leafy vegetables. Sherman P, Pencharz P, 33: 165-170. Laxatives and stool softeners Veldhuyzen van Zanten SV. to ease the pain associated 2. Schurman JV, Friesen CA, Helicobacter pylori and with passing hard stools. Danda CE et al; Diagnosing childhood recurrent Polyethylene glycol or lactulose functional abdominal pain abdominal pain: community solution is often used with with the Rome II criteria: based case-control study. BMJ dose titration to achieve the parent, child, and clinician 1999; 319(7213):822-3. agreement. J Pediatr Gastroen- required stool frequency. 10. Poddar U, Yachha SK. terol Nutr 2005; 41(3):291-5. Chronically distended rectum Helicobacter pylori in children: and fecal impaction are 3. Liebman WM. Recurrent an Indian perspective. Indian managed by administration of abdominal pain in children. A Pediatr 2007; 44(10):761-70. rectal enema. retrospective study in 119 11. Biswal N, Ananathakrishnan  patients. Clin Pediatr 1978; 17: Cyclical vomiting: Adequate N, Kate V, Srinivasan S, Nalini 149-153. hydration and antiemetics like P, Mathai B. Helicobacter ondansetron are helpful. 4. Drossman DA, et al. Rome pylori and recurrent pain Cognitive behavioral therapy- III, the functional gastroint- abdomen.Indian J Pediatr Contingency management train- estinal disorders. Gastroent- 2005 72(7):561-5

Journal of Postgraduate Medical Education, Training & Research 35 Vol. IV, No. 1-5, January-October 2009 12. Sanders MR, Shepherd RW, student, Larry Curtiss, devised a have imagined. Endoscopic Cleghorn G, Woolford H. makeshift, but effective method procedures become safer and The treatment of recurrent of drawing out their own glass hence more commonplace, and abdominal pain in children: a fibers. In late 1956 Curtiss virtually no region of the controlled comparison of succeeded in producing the glass- gastrointestinal tract remained cognitive-behavioral family coated fiber with the optical unexplored. William Haubrich, intervention and standard qualities required for the fiber editor of Gastrointestinal pediatric care. J Consult Clin bundle of a gastroscope. Endoscopy, recalled that Psychol 1994; 62(2):306-14. Following the demonstration of “improvements in endoscopic 13. Berger MY, Gieteling MJ, the new fiberscope incorporating design were so numerous and Benninga MA Chronic this advance in 1957, Hirschowitz rapid during the early 1970s that abdominal pain in children. collaborated with ACMI one could hardly purchase a new BMJ 2007; 334(7601):997- (American Cystoscope Manufac- instrument and become 1002. turing Inc.) to produce a practical acquainted with its use before that instrument. Finally, in October, instrument was rendered obsolete Hirschowitz 1960, Hirschowitz received the first by a new model.” The expanding fiberoptic production model, and presented diagnostic capabilities of it in Lancet, confidently asserted endoscopy were soon complem- Endoscope, 1960 that “the conventional gastrosc- ented by new therapeutic ope has become obsolete on all applications, including colon counts.” polypectomy with a wire loop This instrument diminished snare (1971), cannulation of the patient discomfort by enhancing pancreatic duct (1972), removal of flexibility and by reducing bulk. biliary stone (1975), and Notable endoscope refinements placement of feeding tubes by of the late 1960s and early 1970s gastrostomy (1979). The range of included re-positioning of lenses technical developments in Fiberoptic endoscopy entered the gastrointestinal endoscopy was so realm of practicality in February extensive across a broad front that 1957 when Basil Hirschowitz John F. Morrissey was prompted passed the first prototype to claim that “I think we are instrument down his own throat approaching a plateau in and, a few days later, down that instrument development.” This of a patient. Hirschowitz began conclusion proved premature, but work on the “fiberscope” in 1954 nonetheless conveys the when he was on a fellowship with amazement that Morrissey and Marvin Pollard at the University his fellow gastrintestinal of Michigan. After reading an Basil Hirschowitz examining a patient with the fiberscope, 1961. endoscopists felt when surveying article by Hopkins and Kapany the recent instrumental develop- for wider field of vision, addition describing recent advances in ment of their field. Indeed, of channels for biopsy forceps, fiberoptics, Hirschowitz visited fiberoptic technology spread suction, air, or water, and four- the authors in Britain and rapidly from gastroscopy to way controlled tip deflection. discussed the application of colonoscopy, bronchoscopy, and Fiberoptic technology transfo- fiberoptics to endoscopy. Over the other endoscopic domains. next three years, Hirschowitz and rmed gastrointestinal endoscopy his associates in Ann Arbor, in ways even more profound than physicist C. Wilbur Peters and his its most ardent advocates might

Journal of Postgraduate Medical Education, Training & Research 36 Vol. IV, No. 1-5, January-October 2009 9 Neonatal Necrotizing Enterocolitis Review Prabha, Vishnu Bhat Article Department of Pediatrics, JIPMER,Puducherry

ecrotizing enterocolitis intestinal ischaemia are thought intestinal epithelial cells, leading to (NEC) is primarily a to play central role in disease a reduction in the severity of N disease process of the pathogenesis. The sequence of intestinal injury. In animal gastrointestinal (GI) tract of events leading to the development models, EGF administration premature neonates that results in of NEC is complex and still increased intestinal barrier inflammation and bacterial incompletely defined. Although strength and reduced the severity invasion of the bowel wall. It the pathophysiology of NEC has of experimental NEC. occurs in 1%to 5% of all NICU not been completely elucidated, Furthermore, decreased levels of admissions and 5% to10% of very progress has been made in the EGF have been shown in the low birth weight infants. More characterization of the molecular saliva and serum of premature than 75% of cases occur in infants events which may take place infants with NEC, decreased born at less than 36 weeks of during an episode of ischemia. heparin-binding EGF-like growth gestation and weighing under This possible initiating event is factor have been found in NEC- 2000 g. The postnatal age of onset followed by a complex cascade of affected areas of the intestine and is a function of the gestational age, inflammatory mediators active in a recent study suggests that with the peak incidence occurring NEC; epidermal growth factor, salivary EGF levels in the first and approximately 3 weeks after birth platelet activating factor and nitric second week of preterm life may in infants born at <32 weeks, oxide. Platelet-activating factor has have predictive value for NEC. whereas disease develops been considered as one of the Nitric oxide plays a paradoxical role approximately 2 weeks after birth most important mediator in the in intestinal physiology, low levels in infants born between 32 and pathophysiology of NEC. PAF enhance the mucusal blood flow and are key to maintaining 36 weeks and under 1 week of has a short half-life, and is mucusal intergrity , whereas postnatal age in infants born at regulated by PAF-degrading sustained high levels cause >36 weeks of gestation. enzyme acetyl hydrolase (PAF- cytopathic effects on gut Although NEC occurs primarily AH) activity of which degrades epithelium. Upregulation of in infants born prematurely, PAF into the inert lyso-PAF. There nitric oxide plays an integral role approximately 10 % 0f NEC is considerable evidence that PAF- in the development of epithelial occurs in full term AH may play a role in the injury in NEC. Nitric oxide (NO), infants.Necrotizing enterocolitis is occurrence of NEC. PAF-AH activity is decreased in sick infants an important second messenger predominantly a disease of and inflammatory mediator and with NEC, and the administration preterm. NEC in term infants is its reactive nitrogen derivative, of PAF-AH in animal models of often assosciated with risk factors peroxynitrite, may affect gut NEC reduces the incidence of like maternal toxemia, birth barrier permeability by inducing NEC. PAF-AH activity has also asphyxia, cyanotic heart disease, enterocyte apoptosis (progra- been demonstrated in breast milk, polycythemia, acidosis ,shock, mmed cell death) and necrosis, or exposure to cocaine etc. suggesting it might be one of the by altering tight junctions or gap Pathophysiology- Epidemio- factors which makes breast milk 1 junctions that normally play a key logic studies have identified protective against NEC . EGF role in maintaining epithelial multiple factors that increase an also plays an important role in monolayer integrity2. As a result, infant’s risk for the development intestinal barrier function. In some treatment strategies have of NEC, although premature response to injury, EGF enhances been aimed at abrogating the toxic birth, bacterial colonization and the migration and proliferation of effects of nitric oxide.

Journal of Postgraduate Medical Education, Training & Research 37 Vol. IV, No. 1-5, January-October 2009 Prematurity- In the preterm may render the mucosal barrier to luminal pathogens and may be infant, mucosal cellular more susceptible to induced by collections of small immaturity and the absence of injury. Intestinal regulatory T-cell lymphoid aggregates, which are mature antioxidative mechanisms aggregates are a first-line defense absent or deficient in the premature infant3

Fig-1, Pathogenesis of NEC Bacterial colonization- Whether bacteria are primary in the initiation of NEC, or whether bacterial invasion occurs secondarily following the breakdown of the epithelial barrier is not known. So far, however, a single bacterial species or virus has not been consistently isolated in cases of NEC . Enterobacteriaceae sp. are the most commonly described bacteria to be found in association with NEC . Clostridia sp. and Staphylococcus sp. have also been isolated from infants with NEC . Although bacteria are clearly the most commonly associated microbe with this disease, isolation of viruses and fungus have been described . Fig-2, Bacterial colonization and NEC

Journal of Postgraduate Medical Education, Training & Research 38 Vol. IV, No. 1-5, January-October 2009 Intestinal ishaemia-NEC in X-ray should be obtained if any and peritoneal space. Depending term infants is due to risk factors sign suggestive of NEC is on the baby’s age and feeding which implicate an insult to the present Laboratory studies regimen, baseline sodium levels intestinal blood supply. The are helpful if the baby is having may be low-normal or diving seal reflex is a mechanism systemic signs-CBC count with subnormal, but an acute decrease by which intestines suffer most manual differential to evaluate the (<130 mEq/dL) is more following a hypoxic injury. The WBC, hematocrit and platelet significant; Metabolic acidosis: ileocaecal region is most frequently count; WBC count: marked Low serum bicarbonate (<20) is involved which is watershed area elevation may be present, but seen in conjunction with poor in the intestine, also suggesting leukopenia is more concerning; tissue perfusion, sepsis, and the hypoxic ishaemic event in the RBC count: Premature infants are bowel necrosis. Thrombo- pathophysiology of NEC. prone to anemia due to iatrogenic cytopenia, persistent metabolic Despite convincing that evidence blood draws,as well as anemia of acidosis and severe refractory that hypoxic ishaemic stress is prematurity; however, blood loss hyponatremia constitute the most involved in term NEC, preterm from hematochezia and /or a common triad of laboratory NEC appear to involve a different developing consumptive signs; Stool analysis- presence of disease altogether , althogh it still coagulopathy can manifest as an blood and carbohydrate is a plays a secondary role due to acute decrease in hematocrit; frequent and early indicator of immature circulatory regulation Platelet count: NEC is commonly NEC when associated with the in response to ishaemia. associated with thrombocytopenia signs of NEC; Serial CRP may Clinical Features-Initial (<100,000/ì L). Thrombo- help in monitering the progress symptoms may be subtle and can cytopenia may become more of the disease. Although all of include one or more of the profound in severe cases that these initial laboratory studies following:Feeding intolerance, become complicated with taken together may aid in the delayed gastric emptying consumption coagulopathy. diagnosis of NEC, they do not ,abdominal distention, Consumption coagulopathy is substitute for an appropriate abdominal tenderness decreased characterized by prolonged PT, appreciation of clinical bowel sounds ,abdominal wall prolonged aPTT, and decreasing presentation and appearance of erythema, bloody stools, fibrinogen and increasing fibrin the infant. The laboratory values persistent localized abdominal degradation product can give insight into the severity mass, ascites. Systemic signs are concentrations; Blood culture: of the disease and can aid in nonspecific and can include any Obtaining a blood culture is the provision of appropriate combination of the following: recommended before beginning therapy. Respiratory distress, apnea antibiotics in any patient Imaging Studies- The mainstay ,lethargy, decreased peripheral presenting with any signs or of diagnostic imaging is perfusion, temperature symptoms of sepsis or NEC. abdominal radiography. An instability,poor feeding, irritability, Although blood cultures do not anteroposterior (AP) abdominal acidosis , shock, cardiovascular grow any organisms in most cases radiograph and a left lateral collapse, bleeding diathesis.The of NEC, sepsis is one of the decubitus radiograph (left-side physical findings in patients who major conditions that mimics down) are essential for initially develop NEC can be primarily NEC and should be considered evaluating any baby with gastrointestinal, systemic, in the differential diagnosis. abdominal signs. Abdominal indolent, fulminant, or any Therefore, identification of a radiograph should be taken serially combination of these. A high specific organism can aid and at 6-hour or greater intervals, index of clinical suspicion is guide further therapy; Serum depending on presentation and essential to minimize potentially sodium: Hyponatremia is due clinical course. Characteristic significant morbidity or mortality. to capillary leak and “third findings on an AP abdominal Laboratory Studies- Abdominal spacing” of fluid within the bowel radiograph include an abnormal

Journal of Postgraduate Medical Education, Training & Research 39 Vol. IV, No. 1-5, January-October 2009 gas pattern, dilated loops, and distention that changes over time. venous system and occurs when thickened bowel walls (suggesting Pneumatosis intestinalis is a intramural air is absorbed into the edema/inflammation). Serial radiologic sign pathognomonic mesenteric venous circulation radiographs helps in assessing of NEC. It appears as a Ascites is a late finding that usually disease progression. A fixed and characteristic train-track lucency develops when peritonitis is dilated loop that persists over configuration within the bowel present or after bowel several examinations is especially wall. Intramural air bubbles result perforation. Ascites is observed important. The finding of a fixed from bacterial invasion, on an AP radiograph as centralized loop that remains unchanged for fermentation and hydrogen bowel loops that appear to be 24 to 48 h is often associated with production in the intestinal wall. floating on a background of transmural necrosis. Radiographs Pneumatosis intestinalis is density. can sometimes reveal scarce or thought to be the hallmark of Ultrasonography- It can be used absent intestinal gas, which is NEC disease but may also be to identify areas of loculation and more significant than diffuse present in advanced cases of abscess consistent with a walled- Hirschsprung’s enterocolitis or off perforation when patients severe gastroenteritis. with indolent NEC have scarce gas or a fixed area of radiographic density. Ultrasonography is excellent for quantifying ascites. Serial examinations can be used to monitor the progression of ascites as a marker for the disease course. Portal air can be easily observed as bubbles present in the venous system. Ultrasonographic Abdominal free air is ominous assessment of major splanchnic sign. The presence of abdominal vasculature can help in the free air can be seen as oblong differential diagnosis of NEC Fig-3, Pneumatosis intestinalis lucency over the liver and from other more benign abdominal contents. It represents disorders. Doppler study of the the air bubble that has risen to splanchnic arteries early in the the most anterior aspect of the course of NEC shows increased abdomen in a baby lying in a peak flow velocity and it can help supine position.Left lateral view distinguish developing NEC allows the detection of from benign feeding intolerance intraperitoneal air which rises in a mildly symptomatic baby. above the liver shadow and can Imaging techniques, such as be visualized easier than on other views. Free air in the abdomen can contrast radiography, portal vein be seen as a central collection of ultrasonography, MRI, and air on the anteroposterior film of radionuclide scanning, may play a the abdomen, or can highlight the role in diagnosis. These techniques falciform ligament. Portal gas is are not currently in common use. thought to be ominous when GI tonometry is an infrequently detected. Portal gas appears as used technique that may be linear branching areas of decreased helpful in distinguishing benign density over the liver shadow and feeding intolerance from early Fig-4, Pneumoperitonium represents air present in the portal NEC.

Journal of Postgraduate Medical Education, Training & Research 40 Vol. IV, No. 1-5, January-October 2009 Modified Bells Staging

Stage Systemic signs Intestinal signs Radiological signs Treatment Stage 1A Lethargy, apnea, bradycardia, Increased gastric residuals, Normal or mild NPO -3days & (suspected temperature instability emesis, mild abdominal nonspecific dilatation IV antibiotics disease) distention, gauic positive stool IVF, TPN Stage 1B Same as above Gross bloody stool Same as above Same as above Stage IIA Same as above Same as above plus abdominal Illeus, intestinal Supportive (definite tenderness absent bowel dilatation, treatment, NPO, disease) sounds pneumatosis intestinalis iv antibiotics for (mildly ill) 14 days,TPN Stage IIB Same as above plus mild Same as above plus definite Same as above plus NPO, antibiotics (moderaty ill) metabolic acidosis and tenderness, erythema or portal vein gas,+/- for 14 days, mild thrombocytopenia other discolouration, ascitis Surgical right lower quadrant mass consultation as needed Stage IIIA Hypotension,bradycardia, Marked distension with Definite ascitis NPO for 14 (advanced respiratory failure, severe signs of generalized days, fluid NEC) metabolic acidosis, peritonitis resuscitation, severly ill, coagulopathy, ventilator bowel intact neutropenia support, surgery consultation, TPN Stage IIIB Same as above Same as above Intestinal perforation Same as above severly ill, and surgery bowel perforated

Treatment appropriate. Broad-spectrum glycoside (eg, gentamicin) or Medical Care-Diagnosis of parenteral therapy is initiated at the third-generation cephalosporin necrotizing enterocolitis (NEC) is onset of symptoms after (cefotaxime), and clindamycin or based on clinical suspicion obtaining blood, spinal fluid, and metronidazole. Vancomycin supported by findings on urine for culture. Antibiotic should be included if radiologic and laboratory studies. coverage for staphylococcus staphylococcus coverage is Treatment of NEC depends on should be considered in neonatal deemed appropriate. This ICUs (NICUs) that have a high the degree of bowel involvement combination provides broad colonization rate. Antifungal and severity of its presentation. gram-positive coverage (including therapy should be considered for Objective staging criteria staphylococcal species), excellent premature infants with a history developed by Bell have been gram-negative coverage (with the of recent or prolonged exception of pseudomonas), and widely adopted or modified to antibacterial therapy or for babies help tailor therapy according to who continue to deteriorate anaerobic coverage. disease severity. clinically or hematologically despite Diet-When NEC is suspected, Antibiotics-Although no single adequate antibacterial coverage. enteral feedings are withheld and infectious etiology is known to Various antibiotic regimens can be parenteral nutrition is initiated. cause NEC, clinical consensus used; one frequently used regimen Centrally delivered formulations finds that antibiotic treatment is includes ampicillin, amino with appropriate nutritional

Journal of Postgraduate Medical Education, Training & Research 41 Vol. IV, No. 1-5, January-October 2009 components are infused for somewhat lower, a negative tap colon. Radiographic imaging may optimal IV nutrition. Enteral does not exclude perforation and confirm bowel obstruction, with feedings can be restarted 10-14 should not be considered evidence a transition zone and air–fluid days after findings on abdominal against exploration if clinical signs levels. If a stricture is suspected a radiographs normalize in the case suggestive of necrosis or contrast enema (or an upper of nonsurgical NEC. Reinitiating perforation. Free air visible on gastrointestinal study) should be enteral feeds in postsurgical abdominal radiograph is an performed to assess intestinal babies may take longer and may indication for surgery. Surgical patency. If a stricture is also depend on issues such as the treatment includes resecting the demonstrated, surgical resection is extent of surgical resection, return affected portion of the bowel, indicated at this time. In addition of bowel motility, timing of which may be extensive. Initially, to intestinal strictures, almost reanastomosis, and preference of an ileostomy with a mucous 10% of patients with a history of the consulting surgical team. fistula is typically performed, with NEC and surgical intervention Because of the high incidence of reanastomosis performed later. develop short gut syndrome. The postsurgical strictures, intestinal Strictures may occur, with or neonatal gut grows and adapts patency can be evaluated by without a history of surgical over time, but long-term studies contrast studies prior to initiating intervention, which may require suggest that this growth may take enteral feeds. When feeds are surgical treatment. Patients who as long as 2 years to occur. During restarted, formulas containing are extremely small and ill may not that time, maintenance of an casein hydrolysates, medium- have the stability to tolerate anabolic and complete nutritional chain triglycerides, and safflower/ laparotomy. If free air develops state is essential for the growth sunflower oils may be better in such a patient, one may and development of the baby. tolerated and absorbed than consider inserting a peritoneal This is achieved by parenteral standard infant formulas. drain under local anesthesia in the provision of adequate vitamins, Surgical treatment-Despite nursery which will allow minerals, and calories; appropriate appropriate and timely medical stabilization of the infants before management of gastric acid management, approximately 30% laparotomy. hypersecretion; and monitoring of patients with NEC require Complications- The for bacterial overgrowth. The surgical intervention.Clinical management of NEC is not addition of appropriate enteral deterioration or the development without complications. The most feedings during this time is of worsening signs on the serious complications of acute important for gut nourishment abdominal x rays may indicate a NEC include intestinal necrosis and remodeling. Many of these need to proceed with surgical and perforation, which may occur infants eventually require small management. Paracentesis can be in up to one-third of patients. bowel transplantation and performed at the bedside in the However, some patients who occasionally, combined liver and event of deterioration at the initially appear to respond well to small bowel transplantation bedside when there is no clearcut medical management develop Prognosis-Currently the radiographic evidence of signs of intestinal obstruction mortality remains estimated at perforation. However, there are no upon resuming enteral feedings 20% to 50%. Very low standard guidelines for when this due to the development of birthweight infants and those tool should be used. With a ischemic strictures in the small or with low gestational age continue reported specificity of 100%, a large intestine. Intestinal strictures to have the highest mortality. In positive tap, evidence by an develop in up to one-third of several studies, extent of bowel aspirate containing bile or stool patients with a history of NEC. involvement has been found to or one which shows organisms The most commonly affected be predictive of mortality. Infants on gram stain, is an absolute areas include the terminal ileum, requiring surgical intervention indication for abdominal splenic flexure and the junction of also tend to be lower gestational exploration. As the sensitivity is the descending and sigmoid age and have a smaller birth

Journal of Postgraduate Medical Education, Training & Research 42 Vol. IV, No. 1-5, January-October 2009 weight. Necrotizing enterocolitis enzymes, enhance digestive optimized. Further under- was an independent risk factor for hormone release, intestinal blood standing of the pathogenesis of an abnormal neurologic flow, and motility in premature NEC and the mechanisms by examination . infants. In addition, infants which probiotics prevent it may Prevention provided early trophic feeds lead to evidence-based treatment appear to have improved feeding strategies. Feeding practices- Human milk tolerance, improved growth, feeding reduces the incidence of Epidermal growth factor- reduced sepsis, and reduced NEC. Human milk contains Heparin-binding epidermal hospital stay compared with secretory immunoglobulinA growth factor-like growth factor infants who do not receive trophic (IgA), which binds to the (HB-EGF) is a potent intestinal feeds. Furthermore, early trophic intestinal luminal cells and cytoprotective agent. HB-EGF feeds do not increase the incidence prohibits bacterial transmural reduces the incidence and severity of NEC. translocation. Other constituents of NEC in a neonatal rat model, of human milk, such as Probiotics-A proposed strategy with simultaneous preservation interleukin (IL)-10, EGF, TGF-â1, for the prevention of NEC is the of gut barrier integrity. These and erythropoietin may also play administration of oral probiotics. results support that HB-EGF a major role in mediating the Probiotics are food supplements administration may represent a inflammatory response. containing live bacteria that benefit useful therapeutic and Oligofructose encourages the recipient by improving the prophylactic therapy for the replication of bifidobacteria and microflora balance within the treatment of NEC. In addition, inhibits colonization with lactose- intestine. Several studies suggest several investigators have reported the cytoprotective effect of fermenting organisms. However, that the administration of epidermal growth factor, which is breast milk alone does not prevent probiotics may have a prophylactic found in high levels in breast milk, the development of NEC. effect for NEC and may reduce on the intestinal epithelium. Whereas conservative feeding morbidity and mortality rates for Thus, fortification of infant practices can reduce NEC, low birth weight infants. The formula with specific growth prolonged NPO treatment may most frequently used probiotics factors could soon become a worsen gut function by causing are lactobacillus and preferred strategy to accelerate gut atrophy and worsened Bifidobacterium. Potential intestinal maturation in the inflammatory responses, which mechanisms by which probiotics premature neonate to prevent the can predispose to NEC. Diet plays may protect high risk infants development of NEC6,7 an important role in intestinal from developing NEC and/or development and defense. sepsis include increased barrier to Oral antiobiotics- There have Nonnutritive dietary substances, migration of bacteria and their been reports published such as epidermal growth factor products across the mucosa , suggesting that the use of enteral and polyamines, stimulate competitive exclusion of potential antibiotics may be effective as 8 intestinal epithelial growth. pathogens , modification of host prophylaxis . However concerns Furthermore, certain nutrients response to microbial products , about adverse outcomes persist, (glutamine, arginine, omega-3 augmentation of IGA mucosal particularly related to the fatty acids) have been shown to responses, enhancement of development of resistant bacteria. counteract proinflammatory enteral nutrition that inhibit the Pentoxiyflline- Agents that activation and promote intestinal growth of pathogens, and up- modulate inflammation may barrier function, proliferation, and regulation of immune responses improve outcome in NEC. 4,5 healing. Therefore, initiation of . However, the data are Pentoxifylline, a phospho- trophic feeds should be insufficient to comment on their diesterase inhibitor when used as considered in all VLBW infants. short- and long-term safety. Type an adjunct to antibiotics reduces Trophic feeds have been shown of probiotics used, as well as the mortality without any adverse to improve activity of digestive timing and dosage, are still to be effects9

Journal of Postgraduate Medical Education, Training & Research 43 Vol. IV, No. 1-5, January-October 2009 Arginine- Metabolic role in intestinal development. 3. Hunter CJ, Upperman JS, abnormalities are also associated Further, Epo has been shown to Ford HR, Camerini V. Under- with NEC, one of which is increase cell migration and to have standing the susceptibility of reduced plasma arginine protective effects when cells are the premature infant to concentrations. Decreased arginine exposed to injury. These necrotizing enterocolitis availability causes diminished NO encouraging findings provide (NEC). Pediatr Res production via the NOS pathway, rationale to further investigate the 2008;63(2):117-23. and that this may be involved in possible role of Epo as a 4. Barclay AR, Stenson B, 13 the pathophysiology of NEC. preventive strategy for NEC . Simpson JH, Weaver LT, Both oral and intravenous Carbon monoxide- Carbon Wilson DC. Probiotics for arginine supplementation monoxide (CO), a byproduct of necrotizing enterocolitis: a suggests a beneficial role against the catabolism of heme, is known systematic review. J Pediatr 10 NEC in premature infants . to have anti-inflammatory and Gastroenterol Nutr 2007 Immunoglobulins- antiapoptotic properties. Animal ;45(5):569-76. Immunoglobulins are one of studies have shown that carbon 5. Gaul J. Probiotics for the many possible factors in human monoxide decreases enterocyte prevention of necrotizing milk responsible for it is protective production of inducible nitric enterocolitis. Neonatal Netw effects on NEC. Neonates have oxide synthatse(iNOS) and nitric 2008;27(2):75-80. decreased immunoglobulin levels, oxide ,inflamatory cytokines and 6. Feng J, El-Assal ON, Besner particularly secretory IgA. nitrites14. GE. Heparin-binding However, oral immunoglobulin Resveratrol- Resveratrol, a administration has largely been epidermal growth factor-like polyphenol compound from ineffective in preventing NEC, growth factor decreases the phytoalexins has antioxidant and although studies of enteral IgA incidence of necrotizing scavenger properties and also play are lacking. Intravenous enterocolitis in neonatal rats. a critical role in modulating key immunoglobulin(IVIG) has also J Pediatr Surg 2006 ;41(1):144- enzymes in cell cycle including failed to demonstrate significant 149. iNOS. Animal studies with reductions in NEC, sepsis, or 7. Nair RR, Warner BB, Warner newborn rats have shown that mortality11. BW .Role of epidermal enteral resveratrol has beneficial growth factor and other Glucocorticoids-Clinical studies effect on NEC by attenuating the growth factors in the have shown that the antenatal realese of iNOS and preservation prevention of necrotizing administration of glucocorticoids of mucosal integrity15. decreases the incidence of NEC. enterocolitis. Semin Perinatol References However, postnatal steroids do 2008 ;32(2):107-132. not appear to be as promising12. 1. Patricia W. L, Tala R. N and 8. Bury RG, Tudehope D. Stoll BJ . Necrotizing Erythropoitien-Erythropoeitin Enteral antibiotics for enterocolitis: Recent scientific (Epo) is another breast milk preventing necrotizing advances in pathophysiology component that may play a role enterocolitis in low birthwe- and preventon. Semin in intestinal development,cell ight or preterm infants. migration, and intestinal Perinatol 2008; 32(2):70-82. Cochrane Database Syst Rev restitution. Receptors for Epo are 2. Chokshi NK, Guner YS, 2000;(2):CD000405. also present in the intestine. Hunter CJ, Upperman JS.The 9. Haque KN, Mohan P. Contact with Epo occurs both role of nitric oxide in intestinal Pentoxifylline for treatment pre- and postnatally, through epithelial injury and restitution of sepsis and necrotizing exposure to amniotic fluid and in neonatal necrotizing enterocolitis in neonates. breast milk, respectively. These enterocolitis. Semin Perinatol Cochrane Database of Systematic findings suggest that Epo plays a 2008;32(2):92-9. Reviews 2003, CD004205.

Journal of Postgraduate Medical Education, Training & Research 44 Vol. IV, No. 1-5, January-October 2009 10. Josef N. Arginine supple- the Nestorian Abu Zeid Honein mentation for neonatal Arabian medical ben Ishak ben Soliman ben Ejjub necrotizing enterocolitis: are science el ‘Ibadi (Joannitius, 809-about we ready? Br J nutr 873), a teacher in Baghdad who Arabian medical science forms an 2007;97:814-815. translated Hippocrates and important chapter in the history Dioscurides, and whose work 11. 11.Foster J, Cole M. Oral of the development of medicine, “Isagoge in artem parvam immunoglobulin for not because it was especially Galeni”, early translated into Latin, preventing necrotizing productive but because it enterocolitis in preterm and was much read in the Middle preserved Greek medical science low birth-weight neonates Ages. Wide activity and with that of its most important Cochrane Database Syst Rev independent observation — representative Galen. It was, 2004;(1): CD001816. based, however, wholly upon the however, strongly influenced by doctrine of Galen — were shown 12. Crowley P, Chalmers I, oriental elements of later times. by Abu Bekr Muhammed ben Keirse MJ. The effects of The adherents of the heretic Zakarijia er-Razi (Rhazes, about corticosteroid administration Nestorius, who in 431 settled in 850-923), whose chief work, before preterm delivery: an Edessa, were the teachers of the however, “El-Hawi fi’l Tib” overview of the evidence from Arabs. After the expulsion these (Continens) is a rather controlled trials. Br J Obstet Nestorians settled in unsystematic compilation. In the Gynaecol 1990;97:1125. Dschondisapor in 489, and there Middle Ages his “Ketaab altib founded a medical school. After 13. Ledbetter DJ, Juul SE. Almansuri” (Liber medicinalis Erythropoietin and the the conquest of Persia by the Almansoris) was well known and incidence of necrotizing Arabs in 650, Greek culture was had many commentators. The enterocolitis in infants with held in great esteem, and learned most valuable of the thirty-six very low birth weight. J Pediatr Nestorian, Jewish, and even productions of Rhazes which Surg 2000;35:178–182. Indian physicians worked have come down to us is “De diligently as translators of the 14. 14.Zuckerbraun BS, Otterbein variolis et morbillis”, a book Greek writings. In Arabian Spain LE, Boyle P, Jaffe R, based upon personal experience. conditions similarly developed Upperman J, Zamora R, Ford We ought also to mention the from the seventh century. Among HR. Carbon monoxide dietetic writer Abu Jakub Ishak important physicians in the first protects against the ben Soleiman el-Israili (Isaac period of Greek-Arabic medicine development of experimental Judaeus, 830-about 932), an necrotizing enterocolitis.Am J — the period of dependence and Egyptian Jew; the Persian, Ali ben Physiol gastrointest liver of translations — come first the el Abbas Ala ed-Din el- physiol 2005;289(3):G607- Nestorian family Bachtischua of Madschhusi (Ali Abbas, d. 994) G613. Syria, which flourished until the author of “El-Maliki” (Regalis eleventh century; Abu Zakerijja 15. Ergün O, Ergün G, Oktem G, dispositio, Pantegnum). Abu Jahja ben Maseweih (d. 875), Selvi N, Doðan H, Tunçyürek Dshafer Ahmed ben Ibrahim ben known as Joannes Damascenus, M, Saydam G, Erdener A. Abu Chalid Ihn el-Dshezzar (d. Mesue the Elder, a Christian who Enteral resveratrol supple- 1009) wrote about the causes of was a director of the hospital at mentation attenuates the plague in Egypt. A work on Bagdad, did independent work, intestinal epithelial inducible pharmaceutics was written by the and supervised the translation of nitric oxide synthase activity physician in ordinary to the and mucosal damage in Greek authors, Abu Jusuf Jacub Spanish Caliph Hisham II (976- experimental necrotizing ben Ishak ben el-Subbah el-Kindi 1013), Abu Daut Soleiman ben enterocolitis. J Pediatr Surg (Alkindus, 813-73), who wrote a Hassan Ibn Dsholdschholl. 2007 ;42(10):1687-94. work about compound drugs, and

Journal of Postgraduate Medical Education, Training & Research 45 Vol. IV, No. 1-5, January-October 2009 10 Assessment of Bronchial Liability on Exposure to Isometric Exercise during Different Phases of Menstrual Cycle Original Article Mona Bedi, V P Varshney, Shilpa Khullar Department of Physiology, Maulana Azad Medical College, New Delhi

he effect of sex hormones .Some studies have concluded cycle. on airway function has not that physiologic changes in Material and methods-The T hormone levels during the study was conducted in the been well studied inspite of much menstrual phases are not in Department of Physiology, evidence to suggest that they are themselves associated with Maulana Azad Medical College, important. Epidimiologic studies changes in airway or skin New Delhi, India.It extended over 8 have demonstrated greater airway responsiveness to histamine . a period of one year between obstruction in men than women Chen and Tang (1989) March 2004 and March 2005. documented no obvious even when corrected for smoking Selection of subjects-30 healthy 1 difference in pulmonary functions habits . The menstrual rhythm female volunteers (25-40 yrs) with in different phases of menstrual has been well documented for regular and normal menstrual 2,3 cycle. Cortisol is known to increase exacerbations of asthma and a cycle were selected from amongst under stressful conditions. Also third of female asthmatics the students and staff of the there is cyclic variation in the basal reportedly suffer from college. They were studied in 4 levels of ACTH during the ‘premenstrual asthma’ . These different phases of the menstrual menstrual cycle 9,10. It seemed findings suggest possible role of cycle viz menstrual phase (MP), worthwhile to study the interplay gonadal steroids in cyclical proliferative phase (PP) and luteal of these hormones during the variation of bronchial tone. The phase (LP) respiratory stimulating effect of menstrual cycle after exposing the progesterone is well known. It is subject to isometric stress of short Excusion criteria-Subjects with also known that the level of duration. Also estradiol increases irregular cycles;Subjects on OCPs; progesterone varies during the the relaxant effect of Subjects with history of bronchial menstrual cycle in adult women 5. catecholamines , a falling estrogen asthma; History of cardiovascular The reported effects of level may reduce sensitivity to disease; History of restrictive lung exogenous progesterone catecholamines which in turn disorders; Subjects with musculo administration include affect airway response. 10 – skeletal deformities. hyperventilation, partially Although the effect of Menstrual phase was based on compensated respiratory alkalosis corticosteroid hormones on subjects’ statement. They were etc 6. Inspiratory muscle endurance bronchial smooth muscle is well further confirmed by measuring was found to be higher in the mid established, the effect of female the plasma level of estrogen and luteal phase than in the mid sex steroids has not been well progesterone. The basal oral follicular phase when the subjects studied. Hence, the present study temperature was also recorded had high plasma progesterone was planned to assess the role of during each phase. levels in the luteal phase, whereas gonadal steroids (estrogen and Recording of pulmonary no difference in the inspiratory progesterone) on bronchial functions- Spirometric muscle endurance was seen in lability under resting conditions measurements were done on the subjects whose plasma and when exposed to simple 2nd day of the menstrual cycle . 8th progestrone level was not high isometric exercises (hand grip) in – 12th day was taken as proliferative enough in the mid luteal phase 7 different phases of menstrual and 18th -24th day of menstrual cycle

Journal of Postgraduate Medical Education, Training & Research 46 Vol. IV, No. 1-5, January-October 2009 was taken as the luteal phase. grip exercises.Statistical analysis who showed that inspiratory 11The pulmonary functions were was done with the statistical muscle endurance in the mid tested under basal conditions and package PRISM. The data before luteal phase of the menstrual cycle then following hand – grip and after had grip test was when the plasma progesterone exercise in the three phases of compared using student’s ‘t’ test level was relatively high was greater menstrual cycle. The spirometric with ‘P’ < 0.05 considered to be than in the mid follicular phase. lung functions were recorded in significant. The muscle strength and resting the sitting posture using Results - The general characteri- pulmonary function , on the precalibrated spirometer ‘spirolab – stics of subjects are given in Table- contrary , were similar in these two II’ with nose clip on. All 1. Sex hormones level fluctuated phases of the menstrual cycle.7 It spirograms were recorded by one as expected with highest level of is possible that the effect of sex investigator to minimize inter – progesterone during luteal phase hormones relate not to peak observer variation. The ambient and that of estradiol during serum levels but rather to falling laboratory temperature was proliferative phase as shown in levels.8The general fall seen in all 0 maintained between 20-25 C. In Table-2. The pre- exercise and respiratory parameters in our order to allay anxiety and post- exercise values of different study could be due to psychic apprehension associated with parameters of pulmonary factors or fatigue.It could also be testing , they were explained the functions in the three phases of attributed to isometric exercise purpose of the study and also the menstrual cycle can be seen in mediated bronchoconstriction technical procedures to be Table -3.All values are expressed due to á adrenergic discharge.13-15 performed. Before the actual as mean ± S.E . Fall in FVC, In our study, significant decrease testing, each subject was PEFR, FEV (%) and FEF in PEFR was seen in all the phases familiarized with various test 1 25-75% was seen following exercise in all of menstrual cycle when exposed procedures viz breathing through three phases of menstrual cycle . to hand grip test. This is in mouth piece and valve. The forced However only the fall in PEFR contrary to the findings of Pauli expiratory maneuvers were was found to be significant (P< and co-workers (1989)16 who performed atleast 3 times for each 0.05) (Fig-2) ,whereas FVC (Fig- subject and best of three attempts stated that an increase in asthma 1), FEV (%) (Fig-3) and FEF were selected for data 1 25- symptoms and a slight decline in (Fig-4) decreased non – computation.A hand – grip 75% PEFR only in luteal phase was significantly (p>0.05) after sustained isometric contraction seen in asthmatics. Therefore it isometric exercise. (SIC) was performed in the seemed worthwhile to study the supine position using a hand Discussion-There is compelling relationship between the mechanical dynamometer . Initially evidence for hormonal influence menstrual cycle and the measures each subject was familiarized with on airways and changes in airway of airway function and airway the experimental device and responsiveness might occur reactivity in normal subjects also.It systematically trained. The during menstrual cycle. Our is well known that there is isotonic subjects were asked to grip results showed a generalized fall exercise induced broncho- maximally with their dominant in pulmonary function after constriction after completion of hand.The highest value of three sustained isometric contraction exercise rather than during it. This contractions was taken as the during all three phases of has been attributed to increased maximum voluntary contraction menstrual cycle. No difference was nor – adrenaline levels in the early (MVC). Hand grip was observed in pulmonary function post-exercise period which maintained steadily at 30 % of test under resting conditions in interacts with histamine , a MCV till the subject got the menstrual,proliferative and probable mediator of broncho – fatigued.12 Spirometric luteal phases of the menstrual constriction after exercise. 17-18It measurements were done within cycle. This is in accordance to the has been seen in our study that five minutes of cessation of hand findings of Chen and Tang (1988) there is significant fall in PEFR

Journal of Postgraduate Medical Education, Training & Research 47 Vol. IV, No. 1-5, January-October 2009 values after hand grip exercise. 4. Eliasson O, Scherzer HH, adrenal response to isometric Decrease in PEFR generally DeGraff AC Jr. Morbidity in exercise. Eur J Appl Physiol correlates with FEV1 which is a asthma in relation to 1980;45:147-154. 19 measure of airway obstruction. menstrual cycle. JAllergy Clin 13. Freyschuss U. Cardiovascular The absence of such correlation Immunol 1986;77:87-94. adjustments to somatomotor in our study may be due to 5. Hanley SP. Asthma variation activation. Acta Physiologica menstrually related variation in with menstruation. Br J Chest Scandinavia 1970:342. effort. Also the importance of Dis 1981;75:306-8. 14. Goodwin GM, McCloskey A, PEFR is more for longitudional 6. Lyons HA, Huang CT. Mitchell JH. Cardiovascular studies ,it is also not sufficiently Therapeutic use of progeste- and respiratory responses to sensitive to detect changes in rone in alveolar hypoven- changes in central command airway function on its own .20 We tilation associated with during isometric exercise at conclude that changes in healthy obesity. Am J Med 1968; constant muscle tension. J normal women of reproductive 44:881-8. Physiol 1972;226:173-190. age group with normal menstrual cycle show no deterioration 7. Chen H, Tang YR. Effects of 15. Nadel JA. Autonomic control (change) in airway responsiveness menstrual cycle on respiratory of airway smooth muscle and after isometric exercise. Our muscle function. Am Rev airway secretion. Am Rev negative findings do not exclude Respir Dis 1989;140:1359- Respir Dis 1977;226:173-190. the possibility of other sex 1362. 16. Pauli BD, Reid RL, Munt PW, hormones (testosterone) and of 8. Weinmann GG, Zacur H, Fish Wigle RD, Forkert L. Influence the fluctuating levels of female sex JE. Absence of changes in of the menstrual cycle on hormones to affect bronchial airway responsiveness during airway function in asthmatic lability under different conditions. the menstrual cycle. J Allergy and normal subjects. Am Rev Thus it may be an interaction of Clin Immunol 1987;79:634-8. Respir Dis 1989;140:358-362. many factors rather than hormone 9. Genezzani AR, Lamarchand- 17. Zielinski J, Chodosowska E, levels during menstrual cycle Berand TH, Aubert ML, Felber Radomyski A, Araszkiewicz before and after exercise which JP. Pattern of plasma ACTH, Kozlowski S. may lead to change in airway hGh and cortisol during the Plasmacatecholamines in responsiveness. menstrual cycle. J Clin exercise induced bronco- References Endocrin Metab 1975;41:431- constriction in bronchial 1. Enjeti S,Hazalwood B, 435. asthma.Thorax 1980;35:823- Permutt S, Menkes H, Terry P. 10. Foster PS, Goldie RG, 827. Pulmonary function in young Paterson JW. Effect of 18. Beil M, Brecht HM, Rasche B. smokers: male – female steroids on â –adrenoceptor Plasma catecholamines in differences. Am Rev Respir mediated relaxation of pig exercise induced broncho Dis 1978;118:667-676. bronchus. Br J Pharmacol constriction. Klin Wochenschr 2. Gibbs CJ, Coutts II, Lock R, 1983;78:441-445. 1977;55:577-81. Finnegan OC, White RJ. 11. Farage MA,Neill S,MaClean 19. Jain SK, Kumar R, Sharma Premenstrual exacerbation of AB. Physiological changes and DA. Peak expiratory flow rate asthma.Thorax 1984;39:833- menstrual cycle : a review. as a reversibility test in airways. 36. Obstet Gynecol 2008;64 Lung India 1983;5:199-201. 3. Gibbs CJ, Coutts II, White (1):58-72. 20. Stephart RJ. Some RJ. Bronchial reactivity during 12. Sanchez J, Pequignot JM, observations in peak the menstrual cycle. Thorax Peyrin L, Monod H. Sex expiratory flow. Thorax 1984;39:232. differences in the sympatho- 1962;17:39-48.

Journal of Postgraduate Medical Education, Training & Research 48 Vol. IV, No. 1-5, January-October 2009 Table-1,Baseline characteristics Table-2, Serum sex hormone levels (values are expressed of the subjects (values are as mean ± SD) expressed as mean ± SD) Proliferative phase Luteal phase Age (years) 29.2 ± 0.98 Estradiol (pg/ml) 156 ± 12.6 123 ± 10.6 Height (cms) 159.4 ± 1.98 Progesterone 1.06 ± 0.22 10 ± 0.98 Weight (kg) 56.3 ±1.67 (ng/ml)

Table-3, Pre exercise and post exercise values of pulmonary function parameters in the menstrual, proliferative and luteal phases (values are expressed as mean ± SE)

Parameter Mentrual phase Proliferative phase Luteal phase

Pre- Post- Pre- Post- Pre- Post- exercise exercise exercise exercise exercise exercise

FVC (L) 2.94±0.12 2.89±0.11 2.93±0.09 2.90±0.11 2.93±0.09 2.90±0.09 PEFR(L/s) 6.29±0.3 6.07±0.3* 6.30±0.2 5.92±0.2* 6.35±0.3 6.08±0.2*

FEV1(%) 86.8±1.1 85.9±1.05 85.8±1.1 85±1.1 86.5±1.1 86.4±1.0

FEF25-75%(L/s) 3.02±0.18 2.92±0.16 2.9±0.16 2.84±0.15 3.01±0.17 2.9±0.14 * - p value < 0.05

Journal of Postgraduate Medical Education, Training & Research 49 Vol. IV, No. 1-5, January-October 2009 11 Availability and Consumption Pattern of Iodised Salt in the Villages of Ballabgarh District, Haryana Original

Radhika Sood, Misha Sharma, Chandandeep Gujral Article Department of Nutrition, Lady Irwin College, University of Delhi odine deficiency is the world’s UNICEF global database region has shown that, the second most prevalent, yet easily indicates that the proportion of lowest regional rate of household I preventable, cause of brain households in the developing coverage, with just 51 % of damage. It is the cause of an world consuming adequately households consuming adequat- Ancient Scourge of mankind. This iodised salt officially remains at ely iodised salt in India. scourge includes goitre and brain about 70 %. While this lack of Iodine-Iodine is an essential damage at all ages beginning with change since 2000 reveals the component of the thyroid the foetus during pregnancy. challenges that some countries hormones that are involved in the Elimination of iodine deficiency face, it also reflects maturation of regulation of various enzymes is an important health and social the IDD elimination programme, and metabolic processes. Table-1 development goal for most which is significant but less visible. shows recommended daily intake governments. Its elimination is The studies done in South Asia of iodine. within reach and would constitute an unprecedented public health Table-1, Recommended daily intake of iodine success in field of non communicable disease. In 1990, Age group Requirement (mcg/d) seventy heads of state gathered at Preschool children (0-59 months) 90 the World Summit for children and pledged to make the School children (6-12 years) 120 elimination of iodine deficiency Above 12 years 150 disorder (IDD) one of the health Pregnant women 200 and social development goals to achieve by year 2000. Salt iodisation Lactating women 200 was identified as the main Source: www.iccidd.org intervention to deliver iodine on a continuous and self sustaining basis to population around the Causes of iodine deficiency- equences for both humans and world. Considerable progress has Iodine is only present in soil, animals as follows: been made in improving the hence iodine deficiency results  Fetus-abortions, Still births, availability and accessibility of from geological rather than socio- quality iodised salt. UNICEF economic conditions. The Congenital Anomalies Increa- estimates that less than 20 % of problem of IDD is aggravated by sed Perinatal Mortality, households in the developing environmental factors, such as Increased Infant Mortality ; world were using iodised salt in accelerated deforestation and soil  Neurological Cretinism the early 1990s (UNICEF 2001). erosion. Iodine is present in top ( Mental deficiency, Deaf- crust of the soil, frequent floods By 2000, the average had jumped mutism., Spastic diplegia, cause washing of iodine from soil to some 70 %. This is a remarkable Squint); Myxoedematous crust and same happens when achievement, especially consid- cretinism; Psychomotor glaciers slide down mountains. ering that as late as 1994, 48 defects countries with established IDD Health consequences of iodine problems had no salt iodisation deficiency-Lack of iodine in the  Neonate -Neonatal Goitre, programme at all. The most recent environment has serious cons- Neonatal hypothyroidism

Journal of Postgraduate Medical Education, Training & Research 50 Vol. IV, No. 1-5, January-October 2009  Child and Adolescents- prevalence of IDD below 10 % using salt that was not iodised at Goitre, Juvenile hypo- by 2010. all. The use of adequately iodised thyroidism, Impaired mental The important objectives and salt was much higher in urban function, Retarded physical components of NIDDCP are as areas (72 %) than in rural areas (41 development follows: %).The use of iodised salt varies dramatically from one state to  Adult - Goitre with its  Surveys to assess the another. The variations are due to complications, magnitude of IDD, universal a number of factors, including the Hypothyroidism, Impaired salt iodisation and supply of scale of salt production, mental function iodated salt all over the transportation requirements, country. Source: www.iccidd.org enforcement efforts, differences in  Resurvey after every 5 years to A less obvious but more serious state regulations, the pricing assess the extent of IDD and condition affecting millions of structure, and storage patterns. impact of iodated salt. iodine deficient children includes The use of adequately iodised salt impaired mental function, poor  Laboratory monitoring of is uniformly high (72 % or higher) intellectual performance, lowered iodated salt and urinary iodine throughout the Northeast Region, IQ, muscular disorders and excretion. in most states in the North impaired coordination and  Health education. Region, and in Kerala, reaching a high of 94 % in Manipur. The sluggishness. In pregnancy, Iodisation of salt-Salt is use of adequately iodised salt is iodine deficiency causes spontan- universally consumed by all lowest (< 40 %) in Andhra eous abortions, still birth and households. Hence this has been Pradesh, Madhya Pradesh, Uttar infant deaths. used as carrier of iodine to mitigate Pradesh, and Orissa. Despite the the problem of iodine deficiency. Magnitude of IDD in India- fact that the overall use of On an average10g of salt is India is the second most adequately iodised salt has not consumed per day per person. To populous country in the world, changed since NFHS-2, several meet daily requirement of 150 mcg and there is a high prevalence of states have made substantial of iodine from 10 g of salt so we goitre and cretinism in the improvements over time but the need to ensure 15 ppm or 15 mg Himalayan and sub-Himalayan situation has deteriorated in other of iodine kg of salt, at consumer region, from Jammu and states. The largest gains have been Kashmir in the West to Arunachal level. To ensure 15 ppm at consumer level it is necessary to made in Kerala (from 39 % in Pradesh in the east. In addition NFHS-2 to 74 % in NFHS-3), to the well known Himalayan ensure 30 ppm of iodine at production level so that when salt Goa (42 % to 65 %), Jammu and endemic belt, iodine deficiency and reaches at household level it retains Kashmir (53 % to 76 %), Tamil endemic goitre has been reported at least 15 ppm of iodine. Nadu (21 % to 41 %), Meghalaya from many other states in the (63 % to 82 %), and Nagaland (67 country as well. Present status of the % to 83 %). The states in which programme according to National Iodine Deficiency the use of adequately iodised salt National Family Health Disorders Control Programme has deteriorated substantially are Survey - 3 (NFHS- 3)-There was Haryana (71 % to 55 %), (NIDDCP)-Ministry of Health virtually no change in and Family Welfare is the nodal Himachal Pradesh (91 % to 83 %), consumption of iodised salt at the and Assam (80 % to 72 %) Ministry for policy decisions on household level since the time of NIDDCP. Other ministries such NFHS-2(1998-99), when 50 % of The study was conducted in as HRD, Railways, and households were using adequately twenty one villages of Ballabgarh, Information & Broadcasting are iodised salt. According to NFHS- district Haryana with an aim to also involved in several ways with 3 (2005-06), 25 % of households determine the availability and the NIDDCP. were using salt that was consumption pattern of iodised Objectives of NIDDCP-The inadequately iodised (< 15 ppm), salt. The specific objectives were goal of NIDDCP is to reduce the and the remaining 25 % were as follows

Journal of Postgraduate Medical Education, Training & Research 51 Vol. IV, No. 1-5, January-October 2009  To determine availability of random number tables.For Laboratory Analysis-Iodine in iodised salt. household section, 7 households the salt samples from retail  To find out the awareness of were selected from each cluster. outlets were analysed by the community about Nearly all retail shops selling salt iodometric titration at ICCIDD different types, and brands of in the cluster were included. lab, Shahapurjat, New Delhi. salt and cost. Hence, the sample size comprised Data Processing and Analysis- of 210 households and retail shop  To study the cooking and The responses to the questions storage practices of salt at owners (a maximum of 6 in each were entered into Epi info and household. cluster) analysis was done in Statistical Package for the Social Sciences  Survey Instrument(s) / Tools To assess the knowledge (SPSS). among people regarding the and Techniques- The Results advantages and disadvantages standardized ICCIDD interview of iodised salt and health schedules were used to assess, A total of 211 households and impact of iodine deficiency. knowledge, attitude, practices and 135 retailers were interviewed. Methodology beliefs about IDD and Iodised The iodisation status of salt salt amongst household and samples taken from house holds Study Design-The study was a shopkeepers. The interview (211) and retailers (234) was tested cross-sectional community based schedule had both closed and with Salt Testing Kit (STK). A field survey. The probability open ended questions. The total of 13 salt samples, collected proportionate to size (PPS) 30 interview was conducted in the from the retailers were analysed for cluster methodology was used for Hindi and the answers were iodine content by iodometric sample selection. translated into English and were analysis. Study Area-The study was done marked on the interview Responses of retailers on sales in villages under the schedule. Salt testing kit (STK) by of salt- According to retailers Comprehensive Rural Health ICCIDD lab, was used to interviewed (Table-2), the type of Services Project, Ballbagarh, determine the presence of iodine salt that was being sold most in district Faridabad, Haryana. The in salt samples. This is a qualitative the villages, was iodised salt (88.9 study area was selected because it and rapid test at field level and at %). The reason given by the has been adopted by the Centre consumer level. retailers for maximum sale of a for Community Medicine, All given brand of salt, irrespective of Data collection-The interview India Institute of Medical it being iodised or non-iodised schedule was administered by the Sciences, New Delhi. was that the customers asked for students involved in the project Study population-The study it (77 %). Only 10.4 % of the with the help of local coordinators respondents mentioned that the population comprised of the (health workers). The household shop keepers selling salt and the iodised salt is good for health questions were asked from the reasons. adult female house-hold member women of the selected involved in cooking and who Responses of household on households. If there were more consumption of salt-In the could give information on its than one woman in the house, storing and addition of salt household survey data was the senior-most one who looks collected from 211 respondents during cooking in the selected after the family kitchen was houses. (Table-3). Majority of the interviewed. The data collection respondents (53.6 %), procured 1 th Sampling-Twenty one villages of was started on 30 May 2008 and kg of salt at a time, and 43.6 % th Ballabgarh were selected to be the was completed by 13 June mentioned that they procured part of the study. Thirty clusters 2008.All participants were more than 1 kgs of salt at a time. from these villages were explained the purpose of the 90.6 % of these respondents determined by the method of study and a verbal consent was procured company packed salt, simple random sampling, using taken. 7.6 % loose salt and the rest had

Journal of Postgraduate Medical Education, Training & Research 52 Vol. IV, No. 1-5, January-October 2009 no fixed choice.Besides the retailers. Another reason given was Testing Kit (STK), revealed that human consumption of salt, 84.1 that iodised salt was important to most households were % of these households were also prevent goiter. From the results consuming iodised salt (Table-5). using the same salt for feeding the obtained, it was seen that most Also, of the various salt samples cattle and 15.9 % used the salt for of the respondents were ignorant kept with the retailers, 90.5 % were agricultural purposes. Most of the regarding the importance of iodised.Of the various salt brands respondents (48.8 %) were not iodised salt in the diet. Prevention available, most were within the aware how to differentiate iodised of cretinism as a reason for use price range of Rs.3-10/- per salt from non-iodised salt. Some of iodised salt was given by very kilogram. The iodised salt gave reasons that iodised salt was few households and retailers.The samples available were available in cleaner (2.8%) or that it was finer major source of information the range of Rs. 3-10/-per (1.4 %), and only 1.4 % said that (Figure-2) regarding the use and kilogram, while the company they identified iodised salt by advantages of iodised salt at the packed non-iodised salt brands looking at the smiling sun logo. rural level were television were available for Rs.3/- or Rs.4/ The households were also (households, 83.9 % and retailers, - per kg. The loose or the crystal questioned on the cooking and 64.2 %). As most of the salt was within the price range of storage practices regarding salt, as respondents were illiterate only Rs.1-4/-per kg. The availability of the iodine in salt is a volatile 4.9 % households said teachers as iodised salt at the retail level was substance, 88.2 % respondents the source of information,. adequate as all shopkeepers store said that they stored salt in a iodised salt. A total of 13 salt separate container with a lid, while Among retailers, 13.8% reported that they got information samples, collected from the 4.2 % stored in containers retailers were analysed for iodine without lid. Most of the regarding iodised salt from their school teachers. Health workers as content by iodometric analysis households (65.4 %) added salt (Table-6). A number of brands while cooking right in the a source of information scored very low responses. of salt were available at the rural beginning. Only 3.3 % responded level, of which very few brands that they add salt in the end. Salt Analysis-The iodisation had salt that was adequately Awareness of retailers and status of salt, on testing with Salt iodised (>15 ppm). household on consumption of salt-The awareness level about Table-2, Responses of retailers on the type of iodised salt of retailers and salt sold in the villages of Ballabgarh households were computed (Table-4), 34.6 % women perceived that consumption of Aspect covered No of Response iodised salt was important, while (n=135) 54.1 % of the retailers thought Z that consumption of iodised salt Type of salt sold was important. Of the small maximum* percentage (33.4 %) of Iodised 121 (88.9) households, who had heard Non-iodised 12 (9.3) about iodised salt, 17.8 % did not Z know the reason as to why Reason for consumption of iodised salt was maximum sales important (Figure-1). Amongst Customers ask for it 104 (77) the reasons given for the use of Easy to store 5 (3.7) iodised salt, “good for health” was Health reasons 14 (10.4) the most common response given Others 12 (8.9) by the 75.3 % respondents from the households and 52.1 % from The figure in parentheses denotes percentage,* n=133

Journal of Postgraduate Medical Education, Training & Research 53 Vol. IV, No. 1-5, January-October 2009 Table-3, Responses of household on consumption of salt Aspect covered No of Response (n=211) Procurement Z Quantity of salt bought at a time < 1 Kg 6 (2.8) 1 Kg 113 (53.6) >1 Kg 92 (43.6) Z Type of salt bought Company packed 191 (90.6) Loose 16 (7.6) No fixed pattern 5 (1.8) Consumption Z Use of salt besides human consumption* Agriculture 7 (15.9) Cattle 37 (84.1) Storage and cooking practices Z Storage of salt Same packet 16 (7.5) Container with a lid 186 (88.2) Container without lid 9 (4.2) Z Addition of salt while cooking In the end 7 (3.3) Beginning 138 (65.4) In between 61 (28.9) Others 5 (2.4) Awareness Z Identification of iodised salt Cleaner 6 (2.8) Finer 3 (1.4) Smiling logo 3 (1.4) Don’t know 103 (48.8) Others 15 (7.1) No answer 81 (38.5) The figure in parentheses denotes percentage;* n=44

Table-4, Retailers and household perception on consumption of salt

Type of salt Retailers (n=135) Household (n=211) Iodised 73 (54.1) 73 (34.6) Non-iodised 17 (12.6) 19 (9) Don’t know 44 (32.6) 101 (47.9) No answer 1(0.7) 18 (8.5)

The figure in parentheses denotes percentage

Journal of Postgraduate Medical Education, Training & Research 54 Vol. IV, No. 1-5, January-October 2009 Table-5, Iodisation of salt on testing with salt testing kit Type of salt Retailers (n=234) Household (n=211) Company packed Loose Iodised 212 (90.5) 0 (0) 189 (90.5) Non-iodised 4 (2.1) 18 (7.4) 22 (9.5)

The figure in parentheses denotes percentage Table-6, Iodisation status according to brands of the salt

Brand No. of Shopkeepers Iodisation status on Iodine content of the keeping each salt testing with spot test salt (n=135) kit (ppm) Crystal 18 (13.3) Non-iodised 0 International 1 (0.7) Iodised 5.3 i-shakti 7 (5.2) Iodised 31.7 Tata 76 (53.3) Iodised 43.4 Prince 1 (0.7) Non-iodised 0 Sri Ram 1 (0.7) Iodised 9.5 Captain cook 42 (31.3) Iodised 34.9 Shudh 58 (42.9) Iodised 6.3 Reliance 22 (16.2) Iodised 14.8 Taja 1 (0.7) Iodised 8.5 Amber 3 (2.2) Iodised 5.8 Sharma 2 (1.4) Iodised 5.3 Hindustan shudh 2 (1.4) Non-iodised 0 The figure in parentheses denotes percentage

Figure-1, Benefit stated by retailers and households for consumption of iodised salt

(n=73, household and retailers)

Journal of Postgraduate Medical Education, Training & Research 55 Vol. IV, No. 1-5, January-October 2009 Figure-2, Benefit stated by retailers and households for consumption of iodised salt

(n=81, household and n=87, ratailers)

Discussions-The study was done Ballabgarh. While studying, the NFHS-3. Bhat et al. (2008) in twenty one villages of awareness of iodised salt reported that nearly 98.17 % of Ballabhgarh. The study was a amongst retailers (64.2 %) and powdered salt samples in Jammu cross-sectional community based households (83.9 %), television region had an adequate iodine field survey. The probability was found to be the major source content of 15 ppm, which was proportionate to size (PPS) 30 of information. The present found to be very high when cluster methodology was used for study shows that, 65.4 % compared with the present study. sample selection. The study respondents added salt in the Kapil et al. (1996) reported from population comprised of 211 beginning during cooking, which Delhi that 41 % of the families households and 135 retailers.In was known to be a wrong practice, consume salt with adequate the study it was observed, that as salt should be added at the end iodine. According to NFHS-3 90.5 % of the respondents were so that iodine content is retained. data, 41.2 % of the rural consuming iodised salt but most As observed only 3.3 % of the households in India are of them were not aware of it. households were adding the salt consuming adequately iodised They used company packed salt as at the end.Two brands of salt were salt. The data also shows that, in it was easy to store and use as found to be non-iodised on the state of Haryana the use of compared to crystal salt. A study iodometric analysis, but they gave adequately iodised salt has done by ICCIDD and UNICEF wrong information on the label deteriorated substantially from 71 in the state of Orissa in 2003 of being iodised. The present % (NFHS-2) to 55 % (NFHS-3). showed that most people believe study reports that 53.4 % of salt The consumption of adequately that only refined and packet salt is available at the retailer level in the iodised salt in Haryana state is 55.3 iodised, which is expensive. The villages was adequately iodised (i.e. %, while 28.2 % of the same belief was observed among >15ppm), which was found to be households are not consuming subjects of the villages of consistent with the recent studies, iodised salt at all. Northeast India

Journal of Postgraduate Medical Education, Training & Research 56 Vol. IV, No. 1-5, January-October 2009 is perceived to have poor access ICCIDD, for helping us Due to Iodine Deficiency. and availability to adequately understand the concept of International Council for the iodised salt, but the results show iodometric titration. We thank Mr Control of Iodine Deficiency that the entire Northeast region Rajesh, in conducting iodometric Disorders, 2008 http:// has access to adequately iodised titrations at ICCIDD lab. We www.iccidd.org (Last accessed salt. 93.8 % households in the would like to thank Dr Vivek on 2008 June 28). state of Manipur are consuming Gupta, Senior Resident, for his 6. Towards sustaining elimina- adequately iodised salt. While the invaluable help in the statistical tion of Iodine Deficiency salt producing state of Gujrat has analysis of data. We are grateful Disorder, Orissa India, 2003. only 55.7 % households that are to him for giving us the benefit using adequately iodised salt. of his experience and his time for National Board of Conclusion-The study has completion of the work. We are Examinations offers shown that iodised salt is available also thankful to all the health in the villages of Ballabgarh but workers in the villages we visited following gold people are not aware that they are during the survey, for helping us consuming iodised salt. The approach the community. We are medal to the health workers and the grateful to Mrs. Saroja Narayanan meritorious DNB Anganwadi workers need to be for her utmost cooperation trained to dissipate the knowledge throughout the project. candidates on the benefits of consumption References Dr. H S Wasir Gold Medial for of adequately iodised salt and its 1. Bhat I A, Pandit I A, Cardiology cooking and storage practices. Mudassar S. Study on Dr. H L Trivedi Gold Medal for Acknowledgements-We express prevalence of Iodine Nephrology our sincere gratitude to Dr C.S Deficiency Disorder and Dr. S K Sama Gold Medal for Pandav, Professor and Head, Consumption Patterns in Gastroenterology Centre for Community Medicine, Jammu region. Indian Dr. C S Sadasivam Gold Medal for Cardio thoracic Surgery All India Institute of Medical Journal of Community Dr H S Bhat Gold Medal for Genito Sciences, New Delhi, for giving us Medicine. 2008; 30:11-14. Urinary Surgery an opportunity to work with the 2. Kapil U, Saxena N, Dr R.K Gandhi Gold Medal for village community. We would like Ramachandran S, Nayar D. Paediatric Surgery to express our heartfelt thanks to Assessment of IDD using Dr. B.R. Santhanakrishanan Gold Dr Puneet Misra, Assistant cluster approach in the Medal for Pediatrics Professor and Dr Sanjay Rai, National capital territory of Dr Sam G P Moses Gold Medal for Assistant Professor, CRHSP- Delhi. Indian Pediatr. 1996; General Medicine AIIMS, Civil Hospital Ballabgarh, 33:1013-7. Dr Satyapal Agarwal Gold Medal for for guiding and advising us in 3. National Family Health Radio Therapy conceptualizing the research work. Survey, India. National Family Dr. Arcot Gajaraj Gold Medal for Dr Anil Goswami, Supervising Health Survey Report-3 Radio-Diagnosis Medical Social Service Officer and http://www.nfhsindia.org Dr. B Ramamurthi Gold Medal for Dr Arijit Chakraborty, Program (Last accessed on 2008 June General Surgery Manager- Advocacy, were a source 16). Dr. K Bhaskar Rao Gold Medal for of much needed encouragement. Obstetrics and Gynaecology We are also thankful to Dr Kapil 4. Sustainable Elimination of Iodine Deficiency. UNICEF, Dr G Venmkataswamy Gold Medal Yadav, Senior Resident and Dr for Ophthalmology Rupa, Senior Resident, for 2008 http://www.unicef.org (Last accessed on 2008 July 1). Dr S. Kameswaran Gold Medal for teaching us sampling techniques. Otorhinolaryngology We extend our gratitude to Dr 5. Towards The Global Dr Balu Sankaran Gold Medal for M.G Karmarkar, President, Elimination of Brain Damage Orthopaedic Surgery

Journal of Postgraduate Medical Education, Training & Research 57 Vol. IV, No. 1-5, January-October 2009 12 Correspondence

Quality Control First Phase-A written EQAS participated in EQAS run by scheme was prepared and one NRLs. In this way a net work of program for HIV Apex and 12 National Reference trained laboratories developed Diagnostic laboratories Laboratories were identified and throughout the country and – an Indian experience were provided with essential performance of laboratories logistic and man power support. improved over a period of Standard Operative Procedures time.Number of participating ndia is large country with (SOP) for each laboratory were laboratories has now reached to second largest number of made and adhered to. Apex and 180, out of which 92 ( approx HIV /AIDS cases. No I National level laboratories were 50%) were found to be proficient quality assurance program or trained by Australian trainers in 5 and regular. government regulations were in days hands on training. At the end place for HIV diagnostic Results-In first year only 12 of training each participant was laboratories. Discrepancy in results laboratories were following quality given coded panel sera containing has grave consequences. Hence assurance practices. These 12 National AIDS Control true positives, true negatives and National reference laboratories in Organization initiated the quality week positive samples. They were turn trained 64 state reference assurance program in year 2001 instructed to test them and send laboratories in phased manner, with the following objectives: results within 4 weeks. Each lab over a period of one year. And complied with the instruction and  now we have 180 trained To improve reporting of HIV they in turn were informed about tests laboratories with regular EQAS their performance within one going on. Frequency of EQAS  To improve competency of week. has also increased from once a year laboratory staff Second Phase- National to twice a year. Number of poor  To identify and document Reference Labs (NRL) trained performers is decreasing every year. problems related to quality their respective State Reference Even private laboratories have  To monitor reliability of tests Laboratories (SRL) in a phased requested to be included in the  To inspect and analyze the cost manner. Coded panel sera were programme. Regular EQAS effectiveness and feasibility prepared by National Reference provides uniform results which Laboratories and was given to each gives credibility to our HIV testing Methods-National policy makers participating lab at the end of the laboratories. initiated the External Quality training for proficiency testing. Assurance Programme (EQAS) Conclusion-Quality assurance Week performers were provided after many rounds of brain has been followed by all the with re training. A time bound feed storming with experts in field of government laboratories. Process back was provided to each laboratories, epidemiology and of Accreditation has also been participating laboratory. Each State programme managers along with introduced in the country; Reference Laboratory was administrative officers from however cost and the large supervised, monitored and given Center and states.It was decided number of unregulated regular feed back on their to introduce the programme in laboratories are the bottlenecks. phased manner throughout the performance by Apex lab. Third Phase-State Reference country. A three tier system was Dimple Kasana established i.e. Apex, National Laboratories trained and and State Reference labs were supervised District level Safdarjung Hospital & identified. laboratories and also regularly associated VMMC, New Delhi

Journal of Postgraduate Medical Education, Training & Research 58 Vol. IV, No. 1-5, January-October 2009 Intra Abdominal which revealed chronic gastritis. diameter. On gross examination She also had a Tc 99 Scan which the mass showed white cut surface Desmoid Tumor showed ectopic gastric mucosa and the mucosa on the polyp was Presenting With lateral to the stomach. For further haemorrhagic. Bleeding elucidation of the lesion, a CT Histopathology-Section from Scan was done which revealed the the polypoid mass. The gastric desmoid tumor is a rare lesion to be a duplication cyst of mucosa was essentially type of tumor that the stomach. Her Hb was 6.2 gm unremarkable except for focal A develops in the fibrous %. Other hematological and congestion and erosion. There is tissue that covers muscles and biochemical investigation were extensive proliferation of spindle other organs. It is also sometimes with in normal limits. Peripheral shaped fibroblasts and called desmoid type fibromatosis Smear showed microcytic myofibroblasts in the serosa and or aggressive fibromatosis as a hypochronic anemia. Patient was omentum. These are extending group of locally aggressive fibro given blood transfusions. 4 units focally into the submucosa which connective tissue neoplasia that of blood were transfused and Hb is other places appears share the capacity for infiltrative, was brought upto 10 gm and oedematous, few histo cysts and destructive and commonly then she was taken for the surgery. no specific inflammation is also recurrent growth but have no On laparotomy we found a tumor seen. in the part wall of the stomach capacity to metastasize. Their Immunostaining-On biological behaviour is which was adherent to body of pancreas, from which it was immunostaining there is intermediate between fibrous positivity for SMA and the cells neoplasm and sarcomas. The intra dissected clear. There was no involvement of any other viscera. are negative for S 100 and CD 117. abdominal lesion as usually Focal CD 68 positivtiy is seen. divided into pelvic fibromatosis, The tumor was only in the posterior wall of stomach. Hence, There is no evidence of mesenteric fibromatosis and malignancy. Gardner’s syndrome. Gardner’s this tumor along with 1 cm syndrome is inherited as an margin of stomach was removed. Diagnosis-Compatible with autosomal dominant trait and The stomach edges were fibromatasis stomach or desmoid includes Polyposis, osteomata anastomosed with catgut and tumor of stomach. and cutaneous eysts in addition vicryle in 3 layers and ryles tube Discussion - The cause of most to fibromatosis.Mesentric was left in. In post operative desmoid tumor is unknown but fibromatosis occurs in the period patient was given IV fluids, inherited genes are sometimes mesentry of retroperitoneum and antibiotics, analgesics and H2 involved as they can run in blockers. Ater 96 hours clear fluids families. Hormones can be a occasionally in the gastrocolic th were started and on 5 day she was factor in some desmoid tumors. ligament or omentum. In this th report we present a rare type of given all fluids orally and or 6 For some people physical factors gastric fibromatosis with day she was given semisolids. She such as an earlier injury or trauma had uneventful Post op recovery may be a trigger. In children presented as a intra gastric tumor th with melena and anemia. and sutures were removed on 9 desmoid tumors affect boys and Post op day. Pathient’s Case Report-9 years old female girls equally. However in adults, hemoglobin was maintained post they are more common in child was admitted with history op and did not fall down. There of passing black stools for the last women. Pregnant women or were no more episodes of melena. women who have had a baby with 15-20 days. She had generalized It is one year post operative now weakness and complaint of in the past 2 years are affected more and she is maintaining normal Hb than average. So it is thought that vomiting on and off for the last and no pain in stomach. 4-5 days. She had been having female hormones such as chronic pain in epigastrium on and Specimen -Contained piece of oestrogen may sometimes have a off for the last 2 years. She already stomach wall 5 x 3 x 3 cm with a role in triggering the growth of a had an upper GI Endoscopy polypoid mass of 1.5 cm desmoid tumor. Trauma to a

Journal of Postgraduate Medical Education, Training & Research 59 Vol. IV, No. 1-5, January-October 2009 particular area of the body may and help the doctors to plan the various degrees of success. When occasionally trigger the growth of best treatment. These may include an operation is not possible, a desmoid tumor there. The X-ray. Ultrasound, CT or MRI radiotherapy, may be used to trauma could be a injury, an Scans and finally taking a Biopsy shrink the growth or to stop it operation or radiotherapy. from the tumor and examining it from increasing in size. Because Desmoid tumors, that occur in under a microscope. the tumors are often slow people with Familial adenomators Treatment – Depends on the growing, it may take months Polyposis (FAP) often develop in location of the tumor, its size, before the effects of radiotherapy an area, that has been previously how quickly it is growing and can be seen so it may be several operated on. Although desmoid whether it is causing symptoms month before a Scan can show tumors are rare sometimes more and what are the whether the tumor has shrunk or than one person in a family is symptoms.Treatment may stopped growing as a result of affected. In particular, people with include -Surgery ; Radiotherapy ; treatment. Occasionally a desmoid an inherited condition called Chemotherapy; Hormonal tumor completely disappears familial Adenomatous Polyposis therapy; Anti Inflammatory without any treatment. This is (FAP) have a much higher risk than drugs. The most commonly used called spontaneous regression or average of developing them. FAP treatment is surgery to remove all sometime a desmoid tumor is mainly linked to an increased the tumor. Unfortunately grows quickly and then stops risk of Bowel Cancer. But about sometimes, these recur. growing. Because of this, in some one in ten people with FAP Treatment maybe given after situations, doctors may keep the develop desmoid tumors. It is surgery to try to reduce chances of tumor under observation rather universally agreed that desmoid recurrence. ( Tamoxifen or than treat at once. tumors are not cancers because nonsteriod anti inflammatory Conclusion-Desmoid tumours they cannot spread to other parts drugs).Sulindac is an example of are slow growing deep of the body, although they can an NSAID that is commonly fibromatosis with progressive grow into surrounding tissue. used. It induces cell cycle arrest infiltration of adjacent tissue but They are usually slow growing and and apoptosis in cancer cells lines without any metastatic potential. the first sign is often painless or by decreasing prostaglandin Although rare, fibromatosis slightly painful lump. Many synthesis through the inhibition should enter into the differential desmoid tumors occur in the of cyclooxygenase – I enzyme diagnosis of masses developing tummy area (Abdomen) or in the (COX – 1). The anti-angiogenic in irradiated areas in patients treats Pelvis. Other parts of the body property of Sulindac and the more for Hodgkin’s disease. Complete that can be affected include the recently used interferon alfa – 2b excision is often impossible and chest, shoulders, thighs and the have been employed successfully therefore adjuvant treatments head and neck area. They can affect to achieve tumor regression and have been employed with various people of any age but are rarely sustained remission. Anti- degrees of success. found in children. The most oestrogens such as tamoxifen and References common first sign of a desmoid other selectie oestrogen receptor 1. Stout AP, Raffale L. Tumours tumor is a painless lump growing modulators (SERMs) e. g. of soft tissues. In Atlas of deep under the skin. But raloxifene, have been shown to be Tumor Pathology, Second symptoms vary depending on effective in regression of the series, Fascide A, Armed forces where the lump and its size. If tumor. Tumors may respond to Institute of Pathology. the mass is pressing on nearby second-line hormonal therapy as Washington DC 1967. nerve, organs or muscles this gosereline acetate (Zoladex) and 2. Murayama T. Imoto S. Ito M might cause pain. Rarely a tumor medroxyprogesterone acetate. Matsushita K, Matozaki S, growing in the abdomen or pelvis Cytotoxic chemotherapy has been Nakagawa T et al, Mesenteric may cause blockage or bleeding for used in cases of symptomatic fibromatosis presenting as the GIT. A number of tests may desmoid tumor unresponsive to fever of unknown origin Am J be done to diagnosis the tumor onventional medical therapy with Gastroentrol 1992;69: 1503 – 05

Journal of Postgraduate Medical Education, Training & Research 60 Vol. IV, No. 1-5, January-October 2009 3. Lai KKT, Chan YYR, Chan HCE, Chin CWA intraabdominal desmoid tumor, JHK Coll Radiol 2003; 6: 97-99. 4. Clark SK, Neale KF, Landgrebe JC, Philips RK. Desmoid tumors complicating familial adenomatous Fig 1 : Scanner picture showing muscle Fig-5, Low power picture of the polyposis. Br J Surg 1999; 9: coat and a mass made up of fibrous centre of the polyp showing the 1185-89 connective tissue in submucosa. fibrous connective tissue. 5. D Alteroche L, Benchellai ZA, Salem N, Regimbeau C, Picon L, Metman EH. Complete remission of a mesenteric fibromatosis after taking Sulindac. Gastroentrol Clin Biol 1998; 22 (12); 1098 – 101 6. Heidemann J, Ogawa H, Otterson MF, Shidham VB, Fig-6, Scanner picture of Binion DG Antiangiogenic Fig-2, Scanner picture showing disruption in muscle coat due to proliferation of mucosa showing haemorrhagic treatment of mesenteric fibrous connective tissue which is necrosis at the tip of polyp. desmoid tumors with extending from submucosa to serosa tamoxifien and interferon alfa – 2b. Report of two cases. Dis Colon Rectum 2004 Jan ; 47 (1) 118-22. 7. Tonelli F, Ficari F, Valanzano R, Brandi ML. Treatment of desmoids and mesenteric fibromatosis in familial adenomatous polyposis with Fig-7, Another picture showing reloxifene. Tumori 2003; 89 (4) Fig-3, Low power picture showing the haemorhage in lamina propria 391-96. fibroblastic tissue creeping through the and shedding off of the surface 8. Hamilton L, Blackstein M, muscle coat. epithelium. Berk T, Meleod RS, Gallinger S, Madlensky L, Cohen Z. Chemototherapy for desmoid tumors in association with familial adenomatous polyposis ; a report of three cases. Can J Surg ; 1996; 93 (3) 247-52. Fig-8, Naked eye-Gross picture Ram Prakash Gupta Fig-4, High mag showing the of microsection showing the Shanti Mukand Hospital fibroblasts with plump nuclei polyp sitting over the muscle Karkardooma, Delhi and fibrillary cytoplasm and lined by mucosa.

Journal of Postgraduate Medical Education, Training & Research 61 Vol. IV, No. 1-5, January-October 2009 49th annual development. This time we republic of Guimea (please take a traveled by Emirates. Dubai look in the atlas in the map of conference of the airport is very “user friendly”. And west Africa.) Flight time College of Surgeons the airline service is definitely 2hr.&40mts. This is a small of West Africa better than any other that I have country, smaller than Nigeria and traveled in before. My friend poorer as well. The people are very Dr.Awojobi was in Lagos airport nice. Konakry, the capital is part y trip to the 49th annual to receive us. That night we spent on an island and part on the conference of the College in a hotel in Lagos. The next mainland, earlier connected by a M of Surgeons of West morning he drove us to his causeway. Now the causeway has Africa has been a great eye opener “rural” hospital in Eruwa been broadened.The parliament for me.There are 25 medical 150kilometres from lagos to the house is located on it, and also colleges in Nigeria. Each country north.On the way we visited a the hall where our conference was has at least one (or more) medical district hospital recently upgraded held. From the porch of the hall colleges and a sprinkling of to a medical college, another rural we could see the sea on either side. doctors practicing surgery in rural surgeon and one of his teachers It was beautiful. There were more settings. The symposium in rural who had started the first than 1200 delegates, all blacks surgery was the main symposium community healthcare project in except just one white a Dr.William of the conference and had five Nigeria. This gentleman, now Thomson, a rural surgeon from speakers. Myself from India, one 86yrs.young and an FRCP, had Gabon (American) and director from South Africa, one from photographs with Dr. of “Pan African Association of Gabon and two from Nigeria Radhakrishnan and Dr. A.L. Christian Surgeons(PAACS)”. including Dr.Awojobi. I Mudaliar of India and seemed a Most of the blacks were either described the whole rural surgery man with radical ideas. Christians or Muslims. My friend movement and the training Dr.Awojobi runs a fifty bedded Awojobi was a Christian. But they programme of the CRS/DNB hospital. He has no papers of gave more importance to the course in India. It had a great ownership either of the land or philosophy of their respective impact and now many are keen to the building. His employees religions and little to the outward attend our conference. There were handles the money and pays him expressions. We were housed in a 1200 delegates from not only a “salary” every month. He has set five star hotel next to the general surgery but other up a stills distillation plant and conference venue, where we could specialties as well. It seemd that makes his own IV fluids, his have western food, except lunch Nigeria will start a postgraduate autoclave runs on fuel from at the venue which comprised of course in rural surgery soon. They discarded wood. He generates his a salad, and a large quantity of rice are very polite, God fearing and own electricity when the govt. or cassava “pudding” and beef warm in character. All of them had supply goes off which is curry. I thought I could eat it. But their independence after us and are sometime for days together. He after the first day, I just couldn’t now trying to emerge out of does all types of surgery and while the Africans devoured! No foreign (economic)domination maternity and child care. He has alcohol, even during banquet Half against many odds. Both I and done rain water harvesting, and the people (including short Shipra was overwhelmed with fish culture. We ate that fish which papers)were French speaking. The warmth and hospitality. Albeit was excellent. The local villagers inaugural address was also in they are poorer than us, and, I feel, have great respect for him. The French, by the new coup leader, a would eagerly accept our support next day we came to Lagos and captain Camara. Our reception in the field of health flew to Konakry, capital of the was very warm. I did not have a

Journal of Postgraduate Medical Education, Training & Research 62 Vol. IV, No. 1-5, January-October 2009 reentry visa for Nigeria. So I had Klippel Trenaunay angiography showed prominent to visit the Nigerian embassy venous system in the right lower there. The chief of the conference Weber Syndrome : A limb and also dilated and accompanied me. The Case Report prominent varicose veins [Figure -5].Trenaunay vein seen on ambassador had already heard of ntroduction-The cause and my presentation! She entertained ultrasound was also nicely processes surrounding appreciated on CT[Figure-6]. MRI us to tea and not only gave the Klippel Trenaunay Syndrome visa but also paid for it herself ! I I revealed extensive hypertrophy of (KTS) are poorly understood.The the subcutaneous tissue and have not had this treatment in birth defect is diagnosed by the muscles of the right lower Europe. Two days after return by presence of a combination of limb[Figure-7]. Contrast dint of luck, I listened to an Capillary malformations, soft enhanced CT scan of abdomen interview of Desmond Tutu, tissue and bone hypertrophy, an revealed retroperitoneal lymphan- Emeritus bishop of Cape town atypical varicosity (often on giectasia [Figure- 8]. in BBC world, and whose name approximately ¼th of the body, Discussion-Klippel Trénaunay and works we all know. I saw this though some cases may present Weber syndrome is defined as a picture exactly during my visit. more of less affected tissue)(1 combination of capillary Both Guinea and Nigeria grows a ).This particular case is studied by malformations, soft-tissue or lot of cocoa. I tried to buy some various imaging modalities and bone hypertrophy, and varicose cocoa powder locally. It was just their features described and veins or venous malformations. not available. All of this is presented. Few of the typical The diagnosis of Klippel purchased by foreign buyers and findings, not found in each case, Trénaunay Weber syndrome can be chocolate made in those countries. is also presented in this case report. made when any two of the three The local people do not get any to Case History-A 8 year old boy features are present(1-4). Most cases eat. The owners get paid in foreign presented with the complaints of are sporadic; the syndrome affects currency. The workers get paid swelling of the right lower limb, males and females equally, has no precious little. Same with oil. All which was progressively racial predilection, and manifests the oil from Nigeria goes to increasing since birth to the at birth or during outside refineries where shares are present state [Figure-1].There was childhood.Klippel-Trénaunay owned by the chieftains of their also presence of pinkish stain seen Weber syndrome must be country. The local people started in the right groin region.The distinguished from Parkes-Weber small refineries in their backyards entire right lower limb showed syndrome, in which an enlarged like home industry....many of features of stasis dermatitis. extremity occurs which is related to an underlying arterio-venous them with excellent results! Anteroposterior radiograph malformation (5). Hypertrophy is Guinea has the highest Bauxite demonstratedmarked soft-tissue enlargement of the right lower the most variable of the three deposit in the world plus a lot of extremity [Figure-2]. Ultrasound classic features of Klippel minerals. All the ores are exported. revealed extensive subcutaneous Trénaunay Weber syndrome. and soft tissue edema with few Enlargement of the extremity J.K. Bnerjee superficially dilated venous consists of bone elongation, circumferential soft-tissue Past President channels and presence of Trenaunay vein which is a large, hypertrophy, or both. At clinical Association of lateral, superficial vein seen in the examination, hypertrophy often Renval Surgereon India leg [Figure 3].CT scan of the lower manifests as leg-length extremities revealed hypertrophy discrepancy, although any limb of the right lower limb in respect may be affected. Capillary of the increased length and malformations are the most diameter of femur and tibia common cutaneous manifes- [Figure-4].Triple Phase CT tation of Klippel-Trénaunay Weber

Journal of Postgraduate Medical Education, Training & Research 63 Vol. IV, No. 1-5, January-October 2009 syndrome(6). Typically, capillary involved bones, chronic venous Trénaunay Weber syndrome is malformations involve the insufficiency, stasis dermatitis, conservative and includes enlarged limb, although skin poor wound healing and application of graded compressive changes may be seen on any part ulceration.Complications are most stockings or pneumatic compre- of the body. The lower limb is often related to the underlying ssion devices to the enlarged the site of malformations in vascular pathologic condition. extremity. Percutaneous sclerosis approximately 95% of patients. These include thrombophlebitis; of localized venous malforma- When found on the trunk, the cellulitis; and more serious tions or superficial venous malformations rarely cross the sequelae such as thrombosis, varicosities may be indicated in midline. If large enough, the coagulopathy, pulmonary some patients. Surgical treatment cutaneouslesions may sequestrate embolism, congestiveheart failure may include epiphysiodesis to platelets, possibly leading to (in patients with arterio-venous control leg length discrepancy, Kasabach-Merritt syndrome, a malformations), and bleeding excision of soft-tissue hypert- type of consumptive from abnormal vessels in the gut, rophy, stripping of superficial coagulopathy(7). Varicose veins are kidney, and genitalia(6,8).At varicose veins, or, less commonly, present in a majority of patients radiography, bone elongation reconstructive surgery at sites of with Klippel-Trénaunay Weber contributing to leg length deep venous obstruction. syndrome. Venous malformations discrepancy, soft-tissue thickening, can occur in both the superficial or calcified phleboliths may be References and deep venous systems(2). seen. At lymphangiography, 1. Klippel M, Trenaunay P. Du Superficial venous abnormalities hypoplasia of the lymphatic noevus variquex osteo- range from ectasia of small veins system has been reported. hipertrophique. Arch Gen to persistent embryologic veins Sonography may be used to Med 185: 641-672, 1900. and large venous malformations. identify the abnormal veins and 2. Kanterman RY, Witt PDt, Deep venous abnormalities varicosities. CT of the abdomen Hsieh PS, Picus D. Klippel- include aneurysmal dilatation, and pelvis provides a simple, aplasia, hypoplasia, duplications, noninvasive means of assessing Trenaunay syndrome: imaging and venous incompetence. The visceral vascular malformations. findings and percutaneous Klippel-Trenaunay vein is a large, Spin-echo MR images intervention. AJR 167: 989- lateral, superficial vein sometimes demonstrate a lack of enlarged 995, 1996. seen at birth(8). This vein begins high-flow arterial structures, and 3. Cihangiroglu M, Serhatlýoglu S, in the foot or the lower leg and T2-weighted images show Akfýrat M, Murat A, Özdemir travels proximally until it enters malformed venous and lymphatic H., Üst ekstremitede geliºen the thigh or the gluteal area.In our lesions as areas of high signal Klippel-Trenaunay sendromu. patient, the triad of marked intensity. MR imaging depicts TRD 33: 349-352, 1998. enlargement of the right lower deep extension of low-flow 4. Philips GN, Gordon DH, extremity, a cutaneous vascular vascular malformations into Martin EC et al. Klippel- lesion, and findings of extensive muscular compartments and the Trenaunay Syndrome: Clinic combined venous and lymphatic pelvis and their relationship to and Radiological Aspects. malformations suggested the adjacent organs as well as bone or Radiology, 28: 429- 434, 1978. diagnosis of Klippel-Trénaunay soft-tissue hypertrophy(9). More Weber syndrome.Other features recently, MR venography has been 5. Lindenauer SM. Congenital of this syndrome includes reported to display the significant Arteriovenous fistula and the lymphatic obstruction, spina findings in extremity venous Klippel Trenaunay syndrome. bifida, hypospadias, polydactyly, malformations with a capability Ann Surg, 174: 248-263, syndactyly, oligodactyly, equal to that of conventional 1971. hyperhidrosis, hypertrichosis, venography(10).Treatment in a 6. Jacob AG, Driscoll DJ, paresthesia, decalcification of majority of patients with Klippel- Shaughnessy WJ, Stanson

Journal of Postgraduate Medical Education, Training & Research 64 Vol. IV, No. 1-5, January-October 2009 AW, Clay RP, Gloviczki P. Klippel-Trénaunay syndrome: spectrum and management. Mayo Clin Proc 1998;73:28– 36. 7. Ghahremani GG, Kangarloo H, Volberg F, Meyers MA. Diffuse cavernous hemang- ioma of the colon in the Klippel-Trénaunay syndrome. Radiology 1976;118:673–678. 8. Baskerville PA, Ackroyd JS, Thomas ML, Browse NL. The Fig- 3, Ultrasound reveals Klippel-Trenaunay syndrome: subcutaneous edema and a clinical, radiological and linear venous channel haemodynamic features and (Trenaunay vein) on the lateral management. Br J Surg 1985; aspect of right leg and thigh. 72:232-236 Fig-1, Clinical photograph of 9. Gloviczki PS, Stanson AW, the patient reveals marked Stickler GB, et al. Klippel- enlargement and swelling of Trenaunay syndrome: the right lower limb in contrast to risks and benefits of vascular the other limb with features of interventions. Surgery 1991; dermatitis. 110:469-479. 10. Laor T, Burrows PE, Hoffer FA. Magnetic resonance venography of congenital vascular malformations of the extremities. Pediatr Radiol 1996; 26:371-380. Deepak Badgujar, M K Mittal Abhay Aryan, Sheetal Kaur N K Bhambri, B B Thukral Department of Radiodiagnosis VMMC & Safdarjang Hospital, New Delhi-110029

Fig- 2, Plain Radiograph of Fig-4, Volume Rendered(SSD) bilateral thighs show coronal CT image of bilateral hypertrophy of the soft tissue lower extremities shows with relative enlargement of the hypertrophy of femur and tibia femur on right side. on right side.

Journal of Postgraduate Medical Education, Training & Research 65 Vol. IV, No. 1-5, January-October 2009 Fig-5, Volume Rendered(MIP) Fig-7, CECT image reveals nonenhancing hypodense foci in the coronal CT angiography(venous retroperitoneum encasing the common iliac vessels consistent with phase)image of bilateral thighs lymphangiectasia show multiple prominent venous channels on the right the doctor brought along the side. Anatomical diagnostic doll. By marking the Manikins section giving her discomfort, the woman could communicate her

The anatomical manikin pictured problems to the physician. While here is a rarity among the cased both anatomical and diagnostic sets of surgical instruments, manikins were somewhat similar amputation kits, and other in appearance, the craftsmen medical items that make up the fashioned anatomical manikins artifact collection of the University with much more detail. Archives. Often these manikins are Sometimes produced in male and confused with Chinese diagnostic female pairs, it was far more dolls or “doctor’s ladies”. In common to create only the female Chinese culture, modesty forbade figure and always in an advanced Fig-6, T1 weighted spin echo a woman from undergoing a state of pregnancy. Medical history coronal MR image shows physical examination or even contains little information on the hypertrophic muscles and mentioning parts of her body to origin or intended use of the subcutaneous tissues of the a male physician. To circumvent manikins. right thigh. this situation, during a house call

Journal of Postgraduate Medical Education, Training & Research 66 Vol. IV, No. 1-5, January-October 2009 The Journal of Postgraduate Medical Education, Training & Research

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