lvlAnililHtiLiloAL SOOIETY +
MARINEMEDICAL SOCIETY
(RegdF-3611)
President SUTgVADM JC SHARMA PVSM, VSM' PHS DGMS (NAVY)
VicePresidents Surg RADM VK PAHWA Surg RADM HP MUKHERIBE AVSM, VSM CMO WesternNaval Command CommandingOfficer,INHS Asvini
Executive Committee Surg Cmde SP MALHOTRA Surg Cmde WP THERGAONKAR DMS (P&M) Naval Headquarters CMO, EasternNaval Command Surg Cmde BPS Rawat, VSM Surg Cmde N{L GUPTA VSM CMO, SouthernNaval Command Dental Adv. (Navy) Surg Cmde AK CHAUDHARI Surg Cmde PS Valdiya DMS (H& S) Naval Headquarters Director,InstituteofNavalMedicine Surg Cmde AK Paharia Surg Capt S NANGPAL ExecutiveOfficer,INHS Asvini Sr.Adv Marine Medicine Surg Cdr D D'Costa Surg LCdr S BHANDARI INS Vajrabahu SHO (Mumbai) Secretary Surg Cdr KBS CHEEMA Treasurer Surg Capt GS GREWAL
Address for Correspondence Secretary MARINE MEDICAL SOCIETY Instituteof Naval Medicine. Colaba,Mumbai 400 005.INDIA Fax:022-2150670 E-mail : [email protected]& [email protected] ?
JOURNAL OF MARINE MEDICAL SOCIETY
JAN-JUN2OOO
PublishedBiannually
Clief Editor SuTgRADMVKPAHWA
Editor Surg Capt S NANGPAL
Co Editors SurgCapt GS GREWAL Surg CdTGIRISH GUPTA
Sub Editors Naval Headquarters SuTgCdTAAHUJANM Western Naval Command SurgCdr D D'COSTA Eastern Naval Command Surg Cdr VRG PATNAIK Southern Naval Command SurgCapt MJ JOHN EditctrialAclvisory Board SurgCmde (D) MLGUPTA,VSM SurgCmde PSVALDIYA SurgCmde RTAWASTHI CoIHS PRUTHI SurgCapt RAMESH KUMAR
Addre s s fo r Co ne spondence Editor JOURNALOF IIIARINEMEDICAL SOCIETY Instituteof NavalMedicine, Colaba,Mumbai400 005. Telefax:022-215 0670 E-rnail: [email protected] & [email protected]
Printedand Publishedby SurgCdr KBS CHEEIviAon behalfof DirecrorGeneral of Medical Services(Navy) andprinted at Typo Graphics,Mumbai 400 103and publishedat Instituteof Naval Medicine,Colaba, Mumbai 400 005. Editor : SurgCapt S NANGPAL i JOURNAL OF MARINE MEDICAL SOCIETY sli df CONTENTS OJ In an From The Editor's Desk ttu ca EDITORIAL >( \ Medicineon theintemet : Thenew millennium beckons Surg Lt Cdr IK Indrajil, Surg Capt S Nangpal inj th: ORIGINAL ARTICLES in rie A Studyof InjuriesAmongst Naval Personnel of WestemNaval Comm and (1997 -1999) t2 SurgLt Cdr M llankumaran,Surg Mdm VK Pahwa,Surg Cap KK Dutta Gupta, Jurg Lt Cdr SundeepBhandari rat acl MagneticResonance Imaging (MRI) in Tuberculosisof theSpine l8 m: surg Lt cdr IK Indrajit, surg cdr s Ganesan,surg Cdr p sarin, surgcdr CC verma 8llr Aetiology - of UpperrGastrointestinal Haemorrhage An EndoscopicStudy rer Col HS Pruthi,Lt Col SK Sharma,.Wg Cdr B Singh,Lt ColAC Anand as FieldStudy of InsecticidesAgainst Mosquito Larvae 28 Di surg capt KK Dutta Gupta,surg capt MJ John, surgcapt s Nangpal,surg cdr A chatterjee, SurgCdr GSGrewal wi Resistotypingandzymogram Study of Klebsiellain NosocomiarInfection 3l SurgCdr RN Misra, Maj AD Sen an sai - TranscanalTympanoplasty Surgical Outcome J) SurgLt Cdr D Raghavan tra Importance of PhosphorousSupplementation in Prevention of Osteopeniain Preterms 39 frc surg cdr Girish Gupta,Dr. sushmitaGupta, surg Is Cdr G Khuttar, surgcapt KS Bawa of -Zstimation of MCV in Casesof AlcoholDependence 45 be surg cdr AA Pawar, surg CmdePS valdiya, surg Lt cdr KK Mishra, surg capt MK Gupta inj Prognosticvalue of clinical Varibalesin Patientsof SepsisSyndrome and ler Correlationwith Interleukin6 48 TA SugCdr YD Singh,Surg Cdr RN Misra,Lt Col IsaacMathew, Lt Col AS Kashyap,Col AS Kasthuri Dir MercurySphygmomanometer - Is it Timefor FinalCurtain Call? 55 SurgCdr MSNMurthy, Lt Col ASNarula Da
UPDATE ARTICLB HBOTand AIDS 58 M. surg LCdr c Kodange,surg Capts Nangpal,surg cdr B sudarshan,surg CaptMJ John Tu w TI COMMENTARY Fr SubmarineRescue - FutureTrends 6l Sa SurgCdr G Verghese Sr ComparativeStudy of Autoref/KeratometerWith ManualKeratometer and Retinoscope 65 SurgCdr SSPannu Tr I EMERGING TRENDS Monitoring and PatientCare Equipment in Clinical HyperbaricChambers 69 Cdr GeorgePaul, SurgCdr B Sudarshau SurgCapt S Nangpal
CASEREPORTS Multiple HydatidCysts Lungs and Liver - A CaseReport 75 Is Col G Ravindranath,VSM, Maj (AMC) SanjaySharna, SurgCapt RanteshKwnar, Is Col (AMC) S Saclnr, SurgIs Cdr Aarti Sorin Naidu PostVaccination Hepatitis-B Antigenemia in a Child with Jaundice SurgLt Cdr ShankarNarayan, SurgLt Cdr NavneetNath SurgIl Cdr VivekHande Aircrew - Aircraft Incompatibilitywith a SeaVariant Personal Sirrvival Pack SurgCdr I(Y Sundar An UnusualForeign Body in the bronchus SurgCdr PS Tampi, SurgCdr S Ganesan,Surg l*dr D Raglnvag Col HS Pntthi, Col BN Borgohain
PERSONAL COMMTJMCATION CorrectiveFlying Spectacles: Types and Designs 84 Wg Cdr GKG Prasad VSM
ABSTRACTS 86 FROM THE EDITOR'SDESK
This millennium'sfirst issueof thejournal is now in yourhands. Thisissue contains several articles, which were presented at the National Conference on Marine and Allied Medicineat Mumbaion 16and 17 Oct 99. Alcoholconsumption is wide spreadin all segmentsof our societyand is graduallyincreasing. This issue is of contemproaryinterest to the healthauthorities. Estimation of MCV is a simpleprocedure which can helpthe clinician in monitoringcases of alcoholdependence. An articleon thesubject by SurgCdr AA Pawar andSurg Cmde PS Valdiyaet al discussesthis issuein detail.Aetiology of upperGI tracthemorrhage has alwaysbeen a dilemmafor.the physician. Data painstakingly compiled over almost a decadeby Col Pruthi is presentedin his articlein the currentissue. The speedwith which internethas premeated our daily life is truly amazing.A majoroffshoot of this IT revolutionhas been the amountof medicalliterature available on line.An articlei'Medicine on the internet : thenew millennium beckons" by SurgCdr IK Inderjitet al compilesa list of themore reliable and important websitesand addresses for themedical fratemity. As Asvinimodernisition advances and we get progressively "online"this informationwill be of greatuse to theclinician. Althoughwe havebeen practicing hyperbaric clinical medicinefor nearlytwo decades,inadequacy of patientmonitoring facilities particularly the critically ill insidethe chamber remains. "Monitoring and patient careequipments in clinical hyperbaricchambers" an articleby Cdr G Paulet al liststhe advancedfacilities availableworld wide. Sphygamomanometeror the mercuryBP apparatushas been the gold standardand work-horsefor the clinicianfor morethan a century.However an obituaryof sortshas now beenwritten by SurgCdr Murthy et al in his article,but the questionis, "is this sturdy,solid and reliable instrument ready to be consignedto thedustbin ofhistory yet"? Any comments.
Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I Editorinl MEDICINE ON THE INTERNET : THE NEW MILLENNIUM BECKONS
SurgLt Cdr IK INDRAIIT*, Surg Capt S NANGPAL**
INTRODUCTION aspectof human interestincluding medicine,com- he internet is a vast network of computers munications,commerce, science, media, law, art spanningthe entire globe. Created initially to etc. are representedin some form or fashion. suit the requirements of the military in To leam the intemet, there are many basic books United Statesof America, it has now broken all available.However, for those who are desirousto barriersand hasbeen seamlessly integrated into the learn the Net on the Net itself. there are a host of personalcomputer, at home or office. From recrea- sitesthat fulfill the need.These include the under- tion to applied scienceand technology,and from mentioned : Doctors guide to Internet at critical care medicine case scenariosto digitized http://www.pslgroup.com/docguide.htm, Begin- radiology imagesand pathologyspecimens, the in- ners guide to Internet at http://www.silver- temet has become increasinglyuseful for medical link.net/poke/IlP/, Learn the net at practitioners.This anicle describesthe power of http://www.leamthenet.com/english/index.html internet when applied in the context of medicine. andHitchhikers web guide at http://www.hitchhik- Furthermorean attempt has been made to briefly ers.net/guide.phtml. overview the gamut of medical websites on the Relatedto Intemet is a working knowledge of internet,to provide the readera nutshellview ofthe computers.A conciseand informativeonline basic powerful and magicalworld of intemet. primer of computersin medicineis availablefrom WHAT IS INTERNET? the BMJ group of publications: ABC of Medical Computing The intemet was createdin 1969,when the ad- http://www.bmjpg.com/data/abcmc.htm.Another vancedresearch projects agency ofthe UnitedStates websitedealing with basicinformation of computers departmentof defensefunded up an experimentala is What is Computers http://www.whatis.com. long-distancetelecommunication network consist- Onceone becomes familiar with intemetthere many ing of only four computers. In the 1980s, AR- sitesoffering a variety of internetrelated features. PANET was supersededby NSFNET, a seriesof One such popular site is Internet Tools networkscreated by the National ScienceFounda- http://www.december.com/neVindex.html. tion, which establishedthe present-daystructure of the intemet []. Over the last few years there has OVERVIEW OF MEDICINE ON THE NET been an exponential explosion in the number of The intemethas 800 million sitesapproximately computersadded to this network.It is estimatedthlt at the moment,with a remarkabletendency to grow internettraffic doublesevery 100 days with more further. Of these,it hasalso beenestimated that there than 100 million people worldwide now on-line. areclose to 100million sitesdealing primarily with Telecommunicationson the intemet are stand- medicine.Truly, medicalteaching has evolved from ardizedby a set of communicationsprotocols, the Vesaliusto the electroniclibrary [2]. TCP/IP protocolsuite, that describerouting of mes- Clearly, it would be impossibleto browse and sagesover the internet,computer naming conven- evaluateall the million sites.At the momenta vari- tions, and commonly usedinternet services such as ety of techniquesare used to accessmedical infor- e-mail.The internetis so vast that practicallyevery
*ClassifiedSpecialist in Radiodiagnosisand Imaging, Departmentof Radiodiagnosisand Imaging, INHS Asvini; **Senior Adviser Marine and HyperbaricMedicine, Instituteof Naval Medicine.
Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I mation from the intemet. These include medical with thereare many searchengines and thereforethe search engines, general-purposesearch engines, selectionis a personalizedchoice. Another inherent medical meta-lists, and commercial sites on the problemis that a typical searchby a searchengine, Web. However,the best methodof informationre- eventualfy resultsin 40 to 50Eoof useful material, trieval from the Web is not known. with a bulk of the websitesnot cateringspecifically problem Recentlya study hascompared methods quanti- on thetopic asked for. To overcomethis the fying their efficiencyin retrievingmedical informa- secondstrategy, namely the useof medicaldirecto- ries is resortedto. tion [3].The mainoutcome measures were the num- ber of questionsanswered by each Web site, the Medical resourcesor medical directories deal correctnessof the answers,the number of links with a huge catalogueof topics by categorizing followed to get an answer, and how well docu- them, usuallyby specialities.The largestand com- mentedthe answerwas using the healthon the net prehensivemedical directory are accessible as Med- criteria. The results showed that MD Consult. a mark at http://www.medmark.org,Medmatrix at commercialsite, Hardin MD (a meta-list)and excite http://www.medmatrix,Galaxy Guide to Medical and HotBot (general search engines) found the Topics at http://galaxy.einet.neVgalaxy/IvIedi- greatestnumber of answerswhile the medicine-spe- cine.html and Virtual Hospital Major Links cific searchengines performed poorly. At the mo- http://www.vh.org/Providers/Providers.html.The ment, the method in the madnessto meaningfully directories host a huge collection of individual search and derive information that one wants websitesunder categories of variousspecialities. quickly relies on two strategies,namely searchen- ginesand medical resource sites. MEDICINE AND INTERNET: THE RANGE OF SITES SEARCH TECHNIQUES Intemet contains medical topics ranging from The first strategyemploys search engines. Search "thehistory of medicine"to "new mddicalsites" that enginesare comparable to yellow pages,delivering are added every week. Tracing of the history of a list of sitespertaining to any medicaltopic. Most medicineis depictedin engagingsites such as His- of the searchengines have a blank field where the tory of medicine at http://www.asap.uni- topic is typed,and utilisesa searchbutton, which melb.edu.au/hstm_medicine.htmand Medical his- needsto beclicked, displaying in a periodofusually tory on the net at http://www.anes.uab.edr.r/med- Iess than ten secondsa list of sites. The current hist.htm.At the other end of the spectrumare the popularsearch engines include Yahoo, Alta Vista, new and updatedsites that are added to the net, exciteetc. which can be perusedat New Medical sitesof the Search engines have evolved further with the week at http://www.pslgroup.com/medsites.htm. introductionof metasearchengines. Metasearch en- The intemet is a rapidly developingand usefultool ginesfunction as "yellow pagesof yellow pages" for emergencyphysicians. There is a website for and queriesmultiple searchengines, echoing the oft emergencymedicine aptly tilted E Medicine at repeatedjudgement" Why search when you can http://www.emedicine.com/emerg/index.Shtml[4]. metasearch?".The popular metasearchengines in- To caterto the needsof medicalstudents there is clude All the Web at http://www.alltheweb.com/, a "lounge"where common topics, interest, chat top- Dogpile at http://www.dogpile.com/,Hotbot at ics, job opportunitiesare dealt comprehensively: http://www.hotbot.com/, Metacrawler at IMS lounge http://www.medstudents.net/.Simi- http://www.metacrawler.com/and Savvysearchat larly, thereare sites dealing with Hippocratic Oath http://www.savvysearch.com/.For a list of search at http://chrononet.hypermart.net/hippocratic/, engines,Beaucoup is a site that has complieda Medical Audio items at http://www.medli- varietyof 1600search engines in-various categories brary.com/medlibrary/Audio/, Rare diseases in including metasearchengines: http://www.beau- children at http:llmcrc22.med.nyu.edu/murphp- coup.com/I metaeng.html. 0l/texthome.htm.Truly, medicalinformation on the On theflip sideof usingsearch engines, to begin net is not only measurelessbut endlesstoo.
6 Jour.Marine Medical Society, Jan-Jwt 2000, Vol. 2, No.I MEDICAL SPECIALITIES AND INTERNET http://www.mtsinai.org/diabetes.htmlwhile Acid Base tutorial ia an excellent infobase at Some of the absorbingand enticing specialities http://www.tmc.tulane.edu/departments/anesthesi medicalwebsites are reviewed here. The finestsites ology/acid/acid.html.The entire George Simon's on pathology are Pathmax at http://www.path- plain film collection is freely accessible at max.com and Weblab at http://www.med http://www.sbu.ac.u}
Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I ELECTRONIC BOOKS ON THE NET What's more there are sites which compare the A further significant feature on the net is the various web agenciesthat offer medline, namely accessto medicaltextbooks online which arefreely Medmatrix Medline Comparator at available. Some of the most popular e-medical http://www.medmatrix.org/info/medlinetable.asp books includes AIDS at http://hivin- and a site recentlv introduced at recentlv Invivo Medline List http://www.in- site.ucsf.edu/akbl1997l[6], Pediatric Critical popular Care at http://www.coiera.com/,Textbook of Vir- vivo.net/bg/medline2.html.Another site tual Anesthesia accessible at utilised for searchingthe net is Internet Grateful- http://www.usyd.edu.au/sr-r/anaesAr'AT/VAT.html,med at http://igm.nlm.nih.gov/[8]. There are sites Wheeless' Textbook of Orthopaedics at now available which focuses on articles derived http://www.medmedia.com/med.htm,Yale Univ from medicaljournalsbased in India, too. Theseare Heart Book at http://www.med.yale.edu/li- available at Indian Journals Medline database brary/heanbk/ Onlirre Merck's manual accessible http://www.qmedin.com/medsites/medlinejournal at http://www.merck.com,/pubs/mmanual/and Har- s.htm and Indian NIC Journals database at risons online at http://www.harrisonsonline.com/. http://www.qmedin.com/medsites/fulltext.htm. Furthermore,there are sites that periodically update JOURNALS ON THE NET a list of medical textbooksavailable online on the journals form the back- net. These are sourcedat Medical Text on the Net Medical undoubtedly http://www.elo.com.br/-gacferro/medtexts.html bone of scientific leaming and effective medical practice.There are sites have been compiled and at Online textbooks page that globe which a list of medical http://bubl.ac.uk/link/types/guides6 I .htm. acrossthe display joumals. The various medical journals are cata- SEARCHING MEDICAL LITERATURE logued at popular sites such as Medical Centre AND ARTICI,ES ON THE NET Libraries Journal Index at An importantfeature of the internetis the simple http://scilib.ucsd.edu/bml/medj_nz.htm,Med- and uncomplicatedmethod of obtaining authentic webplus Medical Journals http://med- academicliterature and articlesin a varietyof medi- webplus.com/subject/,Sciencekomm Medical http://www.sciencekomm.aVjour- cal disciplines.Medical article can be conveniently Journals nals/medicine/med-bio.html.An interesting site accessedand derived medline which is based in which adviseson the methodsto finding bioscience America.Medline is the nationallibrary of medi- and medicaljournal articles online is available at cine's premier bibliographicdatabase covering the fields of medicine, mursing, dental medicine,the http://www.sciencekomm.atladvicearticles.html. healthcaresystem, veterinary medicine, and the pre- Otherexcellent complication of medicaljoumals clinical sciences,available free on the intemet on the net is locatedat UNICA Biomedicaljournals throughmany agenciesincluding PubMed [7]. this list http://pacs.unica.iVperiod.htm,Stanford Medi- retrieval system allows usersof all skill levels to cal Journal Site at http://highwire.stanford.edu/, obtainimportant medical information. A shortcom- Teleport Medical Journal at http://www.tele- ing howeveris the full articlesmay not be available port.com/-heston/journal/chat.htm,Mednets Jour- freely. The widespreaduse of computersand the nal Links http://www.intemets.com/mednets/ob- internethave madesearching the medicalliterature gyn.htm, Webmedlit at easierand more accessibleto most physicians.The http://www.webmedlit.com/,Utah Online E-Jour- MEDLINE is a comprehensive,cross-referenced nals List http://medstat.med.utah.edu/data- databaseof citationsto the medicalliterature cover- base/ejoumal.htmland Science Direct Medical ing 1966to the present.The NLM maintainsseveral Journalshttp://www.sciencedirect.com. otherliterature databases that are also availableon- line. In 1996,the NLM beganproviding free, unlim- POPULAR MEDICAL JOURNALS ited accessto MEDLINE to all over theWrold Wide There are certain medicaljoumals, which com- Web. Pubmedis accessedthrough the portal Pub- prehensivelycater to a wide group of medicalpro- med: http://www.ncbi.ncbi.nlm.nih.gov/PubMed/. fessionalsmerging the barriersbetween various dis-
Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I ciplines. As an illustrative example,a small select usinge-mail for onlineconsultation recognizing the group of the popular medicaljournals availableon e-mail may be included in the patient's medical the intemet typically includes Lancet at record.Likewise, doctorsunderstand the ramifica- http://www.thelancet.com and NEIM at tionsof communicatingelectronically with patients http://www.nejm.orgBritish Medical Journal at and often obtaindocumented informed consentbe- http://www.bmj.com/, JAMA at fore using e-mail Il]. Medical practitionersmust http://www.amaassn.org/content/index.asp. keep patient information confidential, which will requiretaking precautions(including encryptionto CME ON THE NET prevent interception)to preservepatient informa- Continuingmedical education (CME) is meantto tion, trust,and the integrityof the patient-physician bridgethe gap betweennew scientificobservations relationship. andclinical practice However,traditional CME [9]. HELATH CARE AND INTERNET hasnot beeneffective at alteringthe behavioursof physicians.One reasonfor this failure of traditional Healthcareis a major candidatefor improvment in any vision of the kindsof informationhighways' CME programsmay be their inflexibility. In tradi- 'information tional CME, the clinician doesnot choosethe topic, and societies'that arenow being visu- thepace of theprogram, or theplace of leaming,and .alized.The medicalinformation managementmar- growing the CME materialcannot be easily deliveredto the ket is oneof thelargest and fastest segments point of carewhere the clinicians needs the informa- of thehealthcare device industry I I 2]. Medicineand tion. Computersand computernetworks have been healthcare is not merelya subjectmatter on national programs global the potential to accomplishthese goals. CME has but often has connotation.Some of begunto appearon the.internet;however, there have the global agenciesthat are authoritieson health beenfew evaluationsof its usefulness,acceptance, care, accessible on the internet include CDC and effectiveness.Moreever, severalobstacles to http://www.cdc.gov/ and WHO Health Topics wide use remain. Theseobstacles comprise issues http://www.who.org/home/map_ht.html. regardingtraining in using the intemet fo1 physi- MEDICINE AND NAVY cians,reluctance of physiciansto participatein on- A first aid manualwith particularemphasis for line commerce,and the cunent unavailability of the Navy is availableas The Navy Standard First CME to be deliveredin small-grainedquantities to Aid Course at http://www.vnh.org/Stand- the point of care. As these issuesare being ad- ardFirstAid/toc.html.This site comprehensively dressed,on-line CME can be experiencedfrom the covers health cducation topics such as basic life following sites at CME Medscape List support,bleeding, shock, soft tissue injuries envi- http://www.medscape.com/Home/CMEcenter/C ronmental injuries NBCD casualitiesrescue and MECenter.html CME Web at transportation.In additionthere is a Virtual Naval http://www.cmewebe.com/ and CME at Hospital Information accessible at http://www.cmeweb.com/ and CME at http://www.vnh.org/Providers.html.There is also a http://ahsn.lhsc.on.ca./ce. Navy Health Book at CONSULTATION ONLINE http://www.vnh.orgA.lHB/NHBHome.htmldealing with generaltopics suchas common medicalprob- Increaseduse of e-mail by physicians,patients, lems,dentistry, pharmacy, health promotion, occu- andother health care organizations and staff hasthe pationaland environmental health, procedures, first potentialto reshapethe currentboundaries of rela- aid, textbooks. administrative manuals. medical tionshipsin medicalpractice. By comparingrecep- journals, continuing education and professional tion of e-mail technologyin medical practicewith healthorganizations. its historical analogue,reception of the telephone, thereare new expectations,practice standards, and HEALTH CARE AND INDIA potentialliabilities thatemerge with theintroduction Websites dealing with the various issues of- of this new communicationtechnology [0]. Doc- healthcare in India areemerging fast. These include tors, at many placesaround the world have begun India Health http://www.healthlibrary.com/in-
Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I dia_file.html, a Med THE PRESENT http://www.qmedin.com/medsites/index.htm,Ox- At presentthe intemet and the world wide web fam Health Car.e in India http://www.ox- (WWW) haveemerged as trend breakingtechnolo- fam.org.uk/coolplanet/kidsweb/world/indhealth.h gies in promoting educationin medical world. In- tm, Weblndia Health India http://www.webin- temet sitesrelevant to practiceof medicineare ap- dia.com/vategoryArealthcare.html. pearing rapidly. Remote literature searchescan OTHER SITES IN MEDICINE query for clinical trials and results. Societiesare using the WWW for transmissionand review of In additionto the sitesdescribed above, there are publication materials. News groups interactively few internetsites that cover the spectrumof topics discusscurrent developmentsand trends.Medical influences "day to day" medical practice. that our professionalsacross the world are using personal Some of the these sites that are availableon the andinstitutional sites to adveriseservices I l4]. Sites intemet IIELBERS Links are Clay Statistics at are available which facilitates medical education http://www.execpc.com/-helberg/statistics.html, usingthe WWW, programinformation, symposium Electronic Tutor at http://www.stat- Statistics coordination,links to regional subspecialtysocie- Medical soft.com/textbook/stathome.html, Quota- ties, residencycataloging, patient question and an- tions at http://www.doctorspage.net/quotes.aspand swei forums, and multimedia proceduredescrip- Medical Humour at http://www.doctor- tions. spage.net/humor.asp. THE FUTURE THE FLIPSIDE The practiceof medicinewill be more integrated Internet and information and communication with the internet in the twenty first century [5]. technologiesmay help reduce health disparities conventionalslide shows will migratein largenum- through their potential for promoting health, pre- bers to the WWW for convenientdownloading for ventingdisease, and supportingclinical carefor all. doctorsand patients.Multimedia capabilitiesof the Unfortunatelyon the flipside, there are many pa- WWW that expandthe depth of informationtrans- problems tients with health leastlikely to have ac- mission will enableeducation emanating from re- cessto suchtechnologies. Barriers to accessinclude mote sites with narration and video depiction of geographic cost, location, iliteracy, disability, and procedures.These sophisticated tools will havereal people factorsrelated to the capacityof to usethese online applicationswith the prolific growth to tele- technologiesappropriately and effectivel I I 3]. medicine,telecardiology, teleradiology, telepathol- A goal of universalaccess to healthinformation ogy and so on. Basic tenetsofeffective healthcare andsupport is neededto augmentexisting initiatives delivery servicesin the future will revolve around to improve the healthof individualsand the public. authentichealth information to medical personnel Both public - and private-sectorstakeholders, par- and patientsaugmented by high-speedcommunica- ticularly govemmentagencies and privatecorpora- tion of voice/text/imagesacross the globe. tions, will need to collaborativelyreduce the gap betweenthe healthinformation "haves"and "have- CONCLUSION .nots".This will comprisea varietyof measuressuch The internetis a vastnetwork of computersspan- assupporting health information itechnology access ningthe entire globe. Equally limitless and knowing in homesand public places,developing applications no confinesis the world of medicineand its various for the growing diversity of users,funding research disciplines.When the fusion of the two occursas at on access-relatedissues, ensuring the quality of present,inevitably there is an explosionof informa- healthinformation and support,enhancing literacy tion. At the moment the explosion is yet to settle in health and technology,training health informa- with waves of information descendingupon the tion intermediaries,and integratingthe conceptof medicalfraternity. As far asone can see,it would be universalaccess to health informationand support impossibleto browse and evaluatecompletely all into healthplanning processes. the medicineand health care related sites.Conse-
l0 Jour.Marine Medical Socie\, Jan-Jun2000, Vol. 2, No. l quently, a variety of techniques are used presently medicine.I'arcet1999;12'353:2079' to access focussed medical infOrmation from the 7. putndmNC.SearchingMEDLlNEfreeontheintemetusing internet.These include medical searchengines, gen- thenational library of medicine;s PubMed. Clin Excell Nurse eral-purposesearch engines, medical metaJists,and Praa 1998;2(5) : 314-6. commercial sites on the web. This article strives to g. LayonBr, StavripZ, Hochstein DC, Nardini HG. Intemet outline medicine on the internet,in an aftemptto accessinthelibrariesofthenationalnetworkoflibrariesof facilitate all medical personnelto meaningfully and medicine.BuIl Mcd Libr Assoc1998; 87 (4) : a8G90. millenium quickly derive information. As the new 9. perersonMW, GalvinJR, Dayton c, D,AlessandroMp. beckons, it is apparent that the intemet" e-mail, Realizingthe promise : deliveringpulmonary continuing world wide web and the information superhighway ."di."l .du..iionover the internet. chest 1999; I 15(5) : is here to stay and medical education,teaching, and v2g-36. research,as well as clinical practice,will be affecrai t" innumerous dirrerent *uy. uy these advances. :,ffi'ffi'i:;:i":":iTlTi'[,il:]:iffi:,'"1ti,]i11 ' REFERENCES tionship.JAMA 1998;280 (15) : 1353-9' l. GlowniakJ. History,structure, and function ofthe internet. ll. SpicerJ. Gettingpatients off hold and oriline.Fant Pmct SeminNucl Med 1998;28 (2) : 135-44. Manag1999',6 (l) : 34-8. 2. VasasL. From vesaliusto the electroniclibruy, Om Hetil 12. Marsh A. The creationof a global telemedicalinformation 1999;25;140(30) : 1695-8. iety.Int J MedInf 1998;49(2) :173-93. 3. GraberMA, BergusGR, York C. Usingthe world wide web 13. Eng TR, Maxfield A, PatrickK, DeeringMI, RatzanSC, to answer clinical questions: how efficient are differcnt GustafsonDH. Acccssto healthinformation and support: a methodsofinformationretrieval?,lFarz Pract1999;48(1) publichighway or a privatermd? JAMA 1998;280 (15) : :520-4. l37l-5. 4. StephensGE. Emergencymedicine resources on the in- 14. Editorial : Electronicmedicine : possibilitiesand perils. remetJEmergMed198:l6(5)z763-7. tt;rl,cet1998:352(9134):l0?9. 5. Vcldenz HC, DennisJW. The intemetand educationin 15. LindbergDA, HumphreysBL. Medicineand hcalth on the surgery.Am Snrg 1998;64 (9) : 8?7-80. inremet: rhc good,the bad, and the ugly.JAMA 19p18;280 6. Larkin M. AIDS web gallery straddlesworlds of art and (15): 1303-4.
Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I II A STUDY OF INJURIESAMONGST NAVAL PERSONNELOF WESTERN NAVAL COMMAND (l 997-1999)
Surg Lt Cdr M ILANKUMARAN*, Surg RAdm VK PAHWA+, Surg Capt KK DUTTA GUPTAT, Surg Lt Cdr SUNDEEP BHANDARI**
ABSTRACT
Injuries are a major causeof mortality, morbidity and disability. They have beenrecognised world wide as a seriouspublic healthproblem. This study wasa descriptivestudy basedon injury reportsilAfy - 2006)initiated by various ships and establishmentsof WesternNaval Commandfrom 1997to 19t9. The incidenceof injuries showeda progressiveincrease from 15.8per 1000in 1997to 20 per 1000in 1999.The study revealedthat injuries were more cornmonamong junior officers and junior sailors.More than 60Voof total iqiuries among sailors occurredon road and onboard shipsand submarines.Injuries due to road traflic accidentswere more common amongjunior oflicers and-senior sailors. Iqiuries onboardships and submarinesand ashoreinjuries weremore commonamong junior sailors.The commonestcause for road traffic accidentsin bottrofficer and sailor categories was skid of two wheeledmotor vehicles,particularly scooter.The commonestcauses for injuries onboard ships andsubmarinesamong sailors were due to slip while climbing or dmcendingladder, object iell on the body whiie working' slip on evensurface and iqiuries involving hatch.Maximum injuries weresevere in nature amongboth oflicers and sailors.Out of the total injuries, 50Voto 60Vowere attributable to serviceamong both ofiiceis and sailors.
INTRODUCTION fatal accidents.There are almost 8.85 lakh deaths from road accidentsannually in the world. [2] In njuries are a very broad group of afflictions, 1997,there were 25 million injurieswhich occurred arising from many different activitiesand risk at work placesincluding 3.3 lakh deathsdue to factorsand can affect people ofall ages.Injuries accidentsat work all over the world. [3] In addition, are a focus of public health practicebecause of a for everydeath there are as many as 30 to 40 minor serioushealth threat, occur frequentlyand aretheo- injuriesand l0 to l5 seriousinjuries requiring long reticallypreventable. Since injuries are so diverse in periodsofexpensive care, nursing and treatment. [4] mechanismsof occurrence,formulating an organ- Accidentsare definitely on the increase ised and structuralapproach to studyingtheir inci- in India. In 1993,45,769 people were killed in road dence and characteristicswill help in their accidents asagainst 24,600 in 1980. Indiahas a fatalityrate prevention.Il] [5] in road accidentthat is 20 times higher than in the An estimated4 million people die yearly from developedcountries, one ofthe highestaccident rate injuries globally. Out of these,about 3 million die in the world. In 1994,an esrimared8 lakh people of unintentional injuries. The causesof uninten- died from injuries.[6] tional injuries include accidentson road, domestic Naval personnelare prone to injuries onboard accidents,industrial accidents, fire, drowning,poi- shipsand submarinesdue to confinedspaces with a soning, falls and natural disasters.In many coun- large numberof machinery,narrow alleywaysand tries, motor vehicle accidentsrank first amons all rollingand pitching during sailing. Though rhere are *PG recordeddetails on the hospitaladmission for inju- student in Preventiveand Social Medicine, SllO (Navy), 'Command ries, there are no data Mumbai. Medical Officer, Headquarters.Wesrern on the exact incidenceand iAssociare Naval Command,Mumbai. Prot'essor,Dept. of pSM, causesofthose injuries.To-date, no publishedstud- Armed ForcesMedical College,Pune. **Officer-in-Charge, SHO ies havedescribed in detailthe circumstancesunder (Navy), Mumbai. which injuries occur. Hence, an epidemiological
TZ Jour.Marine Medical Society, Jan-Jurt 2000, Vol. 2, No.I study of unintentionalinjuries amongstnaval per- roads inside their premises.This group also sonnelwas undertakento find out the distribution includedinjuries occuned in in-living rrcsses. and the determinantsof the problem. This study may iv. Domestic:Injuries at marriedaccommodations identify risk factors and high-risk groupsfor inju- or at home station(on leave). ries.With theseobservations, it might be possibleto v. Recreational: Injuries occurredwhile playing suggestsome measuresto reducethe magnitudeof any type of game,organised or unorganised. injuries. Dependingupon the severityof injury, injuries MATERIAL AND METHODS weredivided into the following threegroups: This study was a descriptivestudy with the fol- i. Mild:Bruises, laceratedwounds not involving lowing aims:- muscleand tendon,etc. i. to find out the incidenceof iniuries amonsst ii. Moderate: Ligament,muscle and tendoninju- naval personnel ries ii. to describe injuries by place of occurrence, ili. Severe: Fracturesand injuries to internal or- personand time gans iii. to assessthe severityof injuriesand OBSERVATIONS iv. to suggestmeasures to preventinjuries Incidenceof injuries The study populationwas all naval personnelof Western Naval Command. The study period was The overall incidenceof injuries amongstnaval threeyears, from 1997to 1999.The sourceof data personnelof WestemNaval Commandwas 15.8per was injury reports(IAFY - 2006). Intentionalinju- 1000,19 per 1000and 20 per 1000in 1997,1998 riessuch as suicide, self-inflicted injuries, etc., were and 1999respectively. The year-wiseincidence of excludedfrom the study. injuriesfrom 1997to 1999among officers and sail- ors is shownin Fig. l. The study populationwas divided into two cate- gories,officers and sailors.While the officerswere It is seenfrom Fig. I thatthe incidenceofinjuries further divided into four sub-groups,viz, Lieuten- amongboth officersand sailors shows a progressive ants(LT) and below, LieutenantCommanders (LT increasefrom 1997to 1999. CDR), Commanders(CDR) and Captains(CAtrI) Distribution of injuries by rank and above; the sailors were divided into five sub- The distributionof injuries by rank among offi- groups,viz, SeaI andbelow, Leading, Petty Officers cers and sailors is shown in Table I and Table 2 (PO), Chief PettyOfficers (CPO) and MasterChief respectively. PettyOfficers (MCPO). Juniorofficers included LT CDR andbelow and seniorofficers CDR andabove. It is seenfrom Table I that majority of injuries Juniorsailors included leading and below andseni also injuries occurredon road at home station i::E ra (on leave). ii. Ship: All injuriesoccurred onboard a ship or a [: rttt tlta ttta submarinewhile on duty or not. t-oTicri! c:t^'Lo-d iii. Ashore : All injuries occurredin shoreestab- lishments and naval dockyard, excluding on Fig. I : Incidenceof injuriesamong naval personnel. Jour.Marine Medical Societv, Jan-Jun 2000, Vol.2, No. I t3 TABLE 1 TABLE 3 Distribution of iqiuries by rank - Ollicers Distribution of iqiuries by placeof iqiury - Ollicers 1998 Place of injury 1997 1998 t999 LT andBelow l8 (58%) 23 (597o) 20 (48%) Road t6 (s2%) L9(499o) 14(339o) LT CDR 6 (rgEo) 13(33Vo) 12(29%) Ship 2('t%) 3 (8%) 4 (10%) CDR 5 (l6Vo) 2(59o) 9 (2l1o) Ashore | (3Vo) s (t3%) 4 (10%) Captand Above 2 (1Vo) | (3%) | (2%) Domestic 6 (l9Eo) 4 (l09o) 12(28%) Recreational 6 (rgEo) 8 (20%) 8 (r9%) Total 3t (1009o) 39(1W%) 42 (rW%) Total 3l (1009o) 3e(rffi%) 42(tm%\ TABLE2 Distribution of iqiuries by rank - Sailors TABLE 4 Distribution of i4iuries by placeof ir{ury - Sailors 199'7 1998 1999 Place of injury t997 1998 t999 SeaI and Below 59 (26Vo) 9t (34%) 83(30%) (29Vo) (30%) Leading 89 (39Vo\ 9t (34vo) 97(34%) Road 65 80 88(317o) (34%) (4r%) (30Vo) Petty Officer 40 (l8o/o) 4s (t7%) s8(2t%) Shrp 77 LO9 84 Ashore (I6Vo) (t3%) ( CPO 18(87o) 24(9%) 22(8Vo) 37 35 50 l8%) Domestic (rr%) (7%) (8Vo) MCPO 19 (97o\ r't (67o) 2r (7%) 24 t9 23 Recreational 22(L0Vo) 25(9%) 36(r3vo\ Total 22s(r00%) 268(t00c/o) 281(r0o%) Total 225(l0OVo\ 268(100%\ 281(lNVo') Distribution of injuries by placeof injury occurredon roadand onboard ships and submarines. The distributionof injuriesby placeof injury Highestproportion of injuries occuned onboard amongofficers and sailors is shownin Table3 and shipsand submarines except in 1999. Table4 respectively. Distribution of iqiuries by rank and placeof in- Table3 showsthat maximum number of injuries jury amongofficers were due to road traffic accidents (RTA).The proportion of injurieson roadshowed a Table5 showsthe distribution of injuriesby rank progressivedecrease from 52Vo(1997) to 33Vo andplace of injuryamong sailors. (1999).Injuries onboard ships and submarines were TheTable 5 showsthat in all thethree years, road veryless (1Voto lOVo). trafficaccidents were higher among senior sailors Table4 showsthat morethan 6QVo of iniuries thanjunior sailors.This is statisticallyvery highly TABLE 5 Distribution of iqiuries by rank and placeof iqiury - Sailors Place of Leadineand Below Petty Officer and Above injury 1997 1998 1999 1997 1998 r999 Road 30 (20%) 42 (23?o) 4O(229o) 35 (46Vo) 38(44%) 48 (419o) Ship 56 (38%) 88(48%) 6s (36%) 2t (27%) 2l (24Vo) 19(t9%) Ashore 28(t9%) 28(rs%',) 40(227o) 9 (t2%) 7 (8%) to(t0%) Domestic 16(tr%) lO (67o) t6 (9%) 8 (107o) 9 (lt7o) 1('1%) Recreational 18(lZVo) 14 (|Vo) 19(ll%o) 4 (5%) 11(l3%o) l'7(l1Vo) Total 148(100%) 182(l009o') 180000%) 77(lm) 86 (l0olo) l0l (100%) 14 Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I v t significantin all the thrgeyears (1997 -X'= 15.14; The day-wisedistribution of injuries among of- df = l;p < 0.001,199.8 -X'- 12.43;df = l; p < ficers did not reveal any significant findings. The 0.001 and 1999- X: = 19,26;df = l, p < 0.001). month-wisedistribution of injuriesamong both sail- Injuriesonboard ships and submarineswere higher ors and officers also did not revealany significant amongjunior sailors than senior sailors in all the findings. threeyears. This is statisticallyvery highly signifi- Causesof injuries cantin 1998and 1999(1997 -Xz=2.51;df = l;p >0.05,1998-X'= 13.86;df= l; p<0.001and 1999 i. Road trffic accidenls : The commonest cause - X' = 9.24;df = l; p < 0.001).It is alsoseen that for road traffic accidents among both officers injuries"ashore" were higher amongjunior sailors and sailors was skid of two wheeled motor thansenior sailors. There is no significantdifference vehicles,particularly scooter.This accounted in theoccurrence ofdomestic andrecreational inju- for 43Voto 62qo of total road traffic accidents riesbetween junior and seniorsailors. among officers and 457oto 5l%oof total road t2 traffic accidentsamong sailorsduring the pe- The distribution of injuries among officers by riod underreview. rank and place of injury revealedthat road traffic accidentswere higher among Lieutenant Com- ii. Ship : The commonestcauses of injuries on- t8 mandersand below (7'lVoto927o) than commanders . boardships and submarines among sailors were and above (8Vo to 23Vo) dunng the period under dueto slip while climbing or descendingladder -/.J review.Other injuries did not show any difference (24Vo-43Vo),object fell on thebody while work- asper rank. ing (l8Vo- 237o),slip on evensurface (l3Vo - lTVo)and injuries involving hatch (l lVo-l1Vo) 28 Distribution of injuries - Day-wise and month- during the periodunder review. wise Commoncauses could not be elicited from other Table6 showsthe day-wisedistribution of RTA injuries(Ashore, domestic and recreational)among 3l and injuries onboardships and submarinesamong both officersand sailors. Influence ofalcohol on the sailors. causationof injuriescould not be well establishedin 35 It is seenfrom theTable 6 thatthe number of road this study. Out of the total 886 injuries occurred traffic accidentshas shown a progressiveincrease from 1997 to 1999, only seven were related to 39 from 1997to 1999.The reasonfor increasein RTA alcoholconsumption. of Fridaysand Mondays(1997 and 1999)could not Distribution of injuries by severity of injury 45 be explained.It is also seen from the Table that injuries onboard ships and submarineswere very Table 7 shows the distribution of injuries by lesson Sundays. severityof injury amongboth officersand sailors.It 48 TABLE6 'tn Distributionof RTA and iqiuries onboardships and submarinesamong sailors - Day-wise 55 Day Road Traffic Accidents IniuriesOnboard Ships and Submarine t t, I 199'7 1998 1999 t997 1998 I Monday ll (l't9o) 5 (69o) 15(l7Vo) 13(l7o/o) 12(ll7o) ll (l3Vo) 58 I Tuesday 8 (129o) 8 (107o) 9 (107o) t2 (167o) 19(t1%) 14 (l1Vo) It Wednesday 8 (l24o) 16 (20Vo) t4 (16%) t8(23%) rs (t4%) t6(r9%) Thursday 4 (6%) l0 (llVo) 8 (99o'l 5 (69o) 20(l8t/o) 17(20Vo) Friday l'l (2'lok) 12(l1Vo) l8 (20Vo) rt (ts%) ll (l0vo) 9 (ll%o) 6l Saturday 8 (l2%o) ts (t9%) 12(l4Vo) t3 (t7%) 16(lS%o) e(rr%) Sunday 9 (l4%o) l4 (l'lVo) t2 (r4Vo) 5 (6Vo) 16(l1c/o) I (97o) 65 '17 Total 65 (1007c) 80(100%) 88 (1007o) (l007o'l 109(100%) 84(10070) Jour. Marine Medical Sociery,Jan-Jun 2000, Vol. 2, No. I t5 a is seenfrom the table that maximum injuries were objectfell on the body while working, slip on even severein nature,among both officersand sailors. surfaceand injuriesinvolving hatch. Distribution of injuries by attributability to Maximum injuries(more than 607o)among both service officersand sailors were severe in nature.Out of the total injuries,5OVo to 6OVowere attributable to serv- On an average,50Vo to 60Voof total injurieswere ice amongboth ofhcersand sailors. attributableto serviceamonq both officersand sail- ors during 1997- 1999. RECOMMENDATIONS DISCUSSION The following are the suggestedpreventive measuresto reduceinjuries:- From the observationsof this study,it is evident i. Health education that there has been a progressiveincrease in the on accidents/preventionof injuries. incidenceof injuriesfrom 1997to 1999among both officers and sailors. Injuries were more common ii. Have a good knowledge of traffic rules and amongjunior officersand junior sailors,possibly follow them correctly. due to the high proportion of junior officers and iii. Propermaintenance of two wheeledmotor ve- junior sailorspresent in service.These injuries com- hicles. monly occurredon road in caseof officers and on iv. Always follow standardoperating procedures road and onboard ships & submarinesin case of while operatingmachinery. sailors. v. Care while climbing and descendingladders Injuries due to road traffic accidentswere more onboardships and submarines, particularly dur- common amongjunior officers and senior sailors. ing sailing. This increasecould be due to the fact thatthe useof two wheeled motor vehicles is more common vi. To take extra precautionswhile using hatches amongjuniorofficers than senior officers and senior and doorsonboard ships and submarines. sailorsthan junior sailors.The commonestcause for vii. Use of protectivegears like helmet, goggles, roadtraffic accidentsboth in officer and sailorcate- gloves,anti-skid shoes, etc. gories was skid of two wheeled motor vehicles, particularlyscooter. Injuries onboard ships and sub- CONCLUSION marines and ashore injuries were more common The main objectivesof injury researchare to amongjunior sailorsthan senior sailors. The reasons prevent occurrenceof injuries and to reduce the for this are thatjunior sailorsare the working hands level of severity.Limiting injury preventionto any in Navy and they have less experience/skillthan single aspectof the many causesof injuries is an senior sailors.The commonestcauses for injuries ineffectiveand narrow approach;successful strate- onboardships and submarinesamong sailorswere gies will incorporatemany countermeasuresand I due to slip while climbing or descendingladder, involve manydifferent professionals. It is suggested I TABLE7 Distributionof injuriesby severityof injury Severity t9s7 1998 I 999 Offrs SLRS Offrs SLRS Offrs SLRS Mild s (16) 45 (20) 8 (20) 63(24\ 2(s) 35( l2) Moderate 6(le) 36( l6) 7 (18) 33( 12) 6 (14) 50(18) Severe 20(65) t44 (U) 24 (62) t72(u) 34(81) 196(70) Total 3l (100) 225( 100) 39( 100) 268( 100) 42 ( 100) 28I ( 100) Note : Values in the bracketsare percentages.Offrs : Officers; SLRS - Sailors t6 Jour. Marine Medical Society,Jan-Jutt 2000, Vol. 2, No. I I I that with the findings of this study as backgtound, 2. World Health OrganisatiorLGeneva" The World Health il more studies,particularly community basedreFo- Rcport. 1995. !. spectivestudies should be donebefore finalising the \l 3. World Health Organisation,Geneva. The World Health specific strategiesfor preventionofinjuries. I Rcporr.l9E. I REFEREI{CES (ll) I 4. RavindranNair G. SwasthHind. l9E2; 26 : /72. l. JessF Kraus, Corinnc Pcck-Asa,Dushyanthi Vimalachan- 5. Director GcncralHealth Services,New Delhi. Govemment dra"Injury control : Thc Public HealthApproach. In : Robert of India"Hcalth Information of India. 1993. B Wallace,Editor. Maxcy-Roscnau-Last.Public Hcalth and I Pr,eventiveMcdicinc. l4th Edition. htnticc-Hall Inrcrna- 6. World Health Organisation,Gcncva. Rcgional Health Re- tionalInc. l9E; 1209. poG South-EastAsia Region,'NewDelhi. 196. Jour. Marine Medical Society,Jan-lw 2000,VoL 2, No. I I7 MAGNETICRESONANCE IMAGING (MRI) IN TUBERCULOSISOF THE SPINE Surg LtCdr IK INDRAJIT*, SurgCdr S GANESAN**, SurgCdr P SARIN+,Surg Cdr CC VERMA+* ABSTRACT Tuberculousspondylitis (Pott's disease), described first by Sir PercivalPott in 1779,is a progressiveinfection by mycobacterium tuberculosis, involving one or more of the components of the spine, namely the vertebral body, intervertebral disc and ligaments, paravertebral soft tissues,and the epidural space.Magnetic resonance imaging (MRI) has emerged as a quality imaging tool aiding in the diagnostic evaluation of tuberculous spondylitis variably displaying intraosseous and paraspinal abscessformation, subligamentous spread of infection, vertebral body destruction and collapse,and extension into the spinal epidural space.The MRI characteristicsof 25 casesof tuberculous spinal infection were reviewed. Results : The commonest site was the lumbar spine (52Vo), often with three or more contiguous vertebrae involved (567o). Destruction of the vertebral body and the presence of paraspinal soft-tissuemasses were noted in60Vo of cases,while disc abnormalities were present in72Vo cases. Posterior element abnormalities, which is a significant ffnding were seenin 409o, a slightly lower incidence rate than in other reported series. Epidural disease(1OVo\ was more frequent than was realized. Magnetic resonance imaging should be consideredto be the imaging modality of choicefor patients with suspectedtuberculous spinal infection. KBY WORDS : Spinal tuberculosis; Potts Spine; Magnetic ResonanceImaging INTRODUCTION intramedullarygranuloma and rarely by bony frag- ments, ff'th. studyof tuberculosisis well calculatedto The diagnosisoften remainselusive because of I makea manthink regarding the meaning and I courseof all disease.These words of Sir the indolent nature of tuberculousinfection. As a Robert Philip cannot ring more true than today, at result,the radiographicfindings and the signs and thedawn of newmillennium. Tuberculous spondyli- symptomsare typically far advancedwhen the diag- tis (Pott'sdisease), described first by Sir Percival nosisis finally established.MRI hasemerged as a Pottin 1779[], is a progressiveinfection by myco- qualityimaging tool aidingin thediagnostic evalu- bacteriumtuberculosis, involving oneor moreof the ationof tuberculousspondylitis variably displaying componentsof the spine,namely the vertebral body, intraosseousand collapse,and extensioninto the intervertebraldisc and ligaments,paravertebral soft spinalepidural space. tissues,and the epiduralspace. Spinal tuberculosis, The MRI characteristicsof 25 casesof tubercu- the most common form of skeletalinvolvement, is lous spinal infection were reviewedto evaluatethe increasingin prevalencebecause of the resurgence morphologicalprofile of the lesion and the variety of tuberculosisduring the past decadein patients of spinalstructures involved. with AIDS and the ongoing spreadof tuberculosis in theexpanding population [2]. MATERIAL AND METHODS Clinically, spinal tuberculosishas an indolent In this study, the magnetic resonanceimaging course presentingwith persistentpain and local (MRI) characteristicsof 25 casesof tuberculous tenderness.It is important to understandthat sys- spinalinfection were reviewed.These cases were a temic manifestationoccur late. Neurologicaldefi- compositegroup of patients,namely l0 casesfrom cits suchas spinalcord compressionand paralysis INHS Asvini and l5 casesfrom Apolo Hospitals, occur in part of epidural tubercular abscessand Chennai.The MRI scanswere performedat Bom- *ClassifiedSpecialist in Radiodiagnosisand Imaging;**Head of Departmentof Radiodiagnosisand Imaging;INHS Asvini;'Classified *Classified Specialistin Orthopaedicsand Surgery; Specialistin Neurosurgeryand Surgery;INHS Asvini. I8 Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I bay Hospitalsand Apollo Hospitals,Chennai. The TABLE 1 predominant patientsincluded in the studywere thosepresenting Table showingthe locationof involvementof the spinecolumn with symptoms of Pott's spine for the first time including persistentpain, local tenderness,neuro- Location Percentage logical deficits suchas spinal cord compressionand Lumbar l3 52Vo paralysis, fever. The patients excluded from the Cervical 20% study were primarily thosecases who had contrain- Thoracic l2Vo Thoracolumbar z 8Vo dication to MR imaging such as claustrophobia, Sacral J lZVo pregnancy,cochlear'implants and pacemaker).The physicalexamination and MR imagingstudies were TABLE 2 performed at presentation and at 6 weeks and 6 Table showingthe levelof involvementof the spinecolumn monthsafter presentation. The caseswere evaluated for location,size, type of spinal structureinvolved, Location Number Percentage the predominantstructure involved. Singlelevel lesions ll 44Vo The MR imageexamination primarily consisted Multiple level lesions t4 564o of the following (a) Tl weighted sagittal images, 500115-25(repetition time msec/echotime msec), TABLE 3 with a256 x 256 matrix, four signalsavera ged, 27 cm Tableshowing the typesand distribution of multiple lesions field of view (FOV) and 3 mm sectionthickness; (b) Combination lesion Number Percentage Tl weightedaxial images,600 - 800/15-25(repeti- tion time msec/echotime msec),with a 256 x 256 Vertebrae and soft tissues 7 28Vo Venebrae, disc and l0 409o matrix, four signals.averaged,27cm field of view epidural space (FOV) and 3 mm sectionthickness; (c) T2 weighted Vertebrae,disc, 8 32c/o sagittalspin echo imagesor fast spin echo images, epidural spaceand 2000-4000/20-90 (repetition time msec/echotime soft tissues msec)with a256 x 256 matrix,one signalaveraged, 27 fieldof view (FOV) and 3 mm sectionthickness, TABLE 4 (d) Tl weighted coronal spin echo images500 to Tableshowing the typessnd distribution of vertebral body 600 | 10-25 (repetition time msec), with a256 x256 lesions matrix,four signalaveraged, 27 field of view (FOV) Vertebrallesion Percentage and 3 mm sectionthickness. Anterior vertebrae l5 ffi% OBSERVATIONS elementslesions only Posterior vertebrae 2 8% The commonestsite (Table l) was the lumbar elementslesions only spine (52Vo) often with three or more contiguous Both elements 8 32Vo vertebraeinvolved (56Vo)(Table 2). Destructionof Total posterior the vertebral body and the presenceof paraspinal vertebraeelements lesions soft-tissuemasses were notedin60Vo of cases,while discabnormalities were present in72Vo cases (Table different strains of mycobacterium tuberculosis. 3). Posteriorelement abnormalities, which is a sig- Pott's spondylitisrepresents a reactivationof latent nificant finding wen! seenin 4OVoa slightly lower disease,frequently years after the initial infection incidencerate than in other reportedseries (Table andis usuallythe resultof hematogenousseeding of 4). Epidural disease(1OVo) was more frequent than the vetebral body. Tuberculousspondylitis is an was realized(Table 3). infectioninvolving one or more of the components DISCUSSION of the spine, namely the vertebral body. Interverte- Tuberculousspondylitis (Pott's disease),is an bral disc and ligaments,pravertebral soft tissues, entity that produces a characteristic kyphotic de- and the epidural space.The vertebral column is formity, and was describedby Sir PercivallPott in affected in 25Voto 60Voof casesof skeletaltubercu- 1779. The causativeorganism belongsto one of the losis. Jour.Marine Medical Societv, Jan-Jun 2000, Vol. 2, No. I I9 n Theutility of MRI is excellentsince the modality identifiesdiseases and the location ofthe pathology, displaysthe extentof involvement,distinguishes it from othercauses, guides in biopsy/ drainagepro- ceduresand offers insight into theappropriate mode of treatment(medical vs surgical)[3]. The advan- tagesof MRI includesa high contrastresolution, directmultiplanar imaging, the ability to accurately depict.intraand extraosseouslesions, detection of bonemarrow lesions, delineation of soft tissueand Fig. la : Tuberculousspondylitis : Early lesion.A) Mid sagittal assessmentofepidural space [4]. Tl weightedimages (TR=500, TE=l l) showinginho- The basicMRI techniqueutilise Spin echo T1 mogenousdecrease in signalintensity in theL3 andL4 vertebralbodies with early focal lossofclarity at thedisc weightedimages in Sagittal/Axialplanes and T2 marginsin between.There is minimalepidural exten- weightedin Sagittal/Axial/Coronalplanes. In addi- sionof theinflammatory soft tissuemass and thc exact tion gradient echo and contrast enhancedTl extentof canalencroachment is clcarlv delinated. weighted images are obtained. From the Tl weightedimages, useful information is gainedon theanatomy of a varietyof structuressuch as verte- bral body,intervertebral disc, paravertebral tissues andspine cord. T2 weightedimages offers informa- tion on a varietyofpathology such as edema, casea- tion, and inflammatiqn.T2 weightedimages have beenused to demonsfratethe increased signal inten- sity in affectedareas because ofthe increasedwater contentin pathologicallyinvolved tissues.[5] Newer MRI techniqueshave also originated which depict the lesionsbetter. These include FLAIR, MTC and Fig. lb : Tuberculousspondylitis : Early lesion.B) Mid sagittal Fat suppressiontechniques. T2TSEweighted images (TR=2200, TE=120) showing inmhomogenoushigh signalintensity in theL3 andL4 Early diagnosisand prompt treatment is a com- vertebralbodies, This representsosteitis with a mild pellingneed in orderto minimizeresidual spinal abscesscomponent. deformityand/or permanent neurological deficit [4]. with spinal canal encroachment together with nerve Early diagnosisof spinaltuberculosis by MRI has root distortion.The diseasecanoften involve the becomea challengeto themedical fratemity around psoas,erector spinae at the lumbarregion and pre- theworld. MRI fulfillsthis need in apromising way. vertebraland paravertebral locations at thecervical OnTl - weightedimages there is adecrease in signal region.The lumbarand the thoracolumbarare the intensityofthe involved bone and soft tissues; while commonlyinvolved regions This finding cor- onT2 - weightedimages there is anincreased signal [7]. roboratedwith thevalues obtained in thisstudy. The intensity(Figs. lA and lB). Thereare threeearly sacrumand cervicalspine are lesscommon sites stagesof the disease,reflecting three different pat- with C2 to C7 regionbeing reported as involved in tems of infection dependingon the stageof the 37oto 5Vocases Solitaryvertebral lesions can disease: osteitis, osteitis with an abscess,and ostei- [8]. occur but multiple lesion are usuallyencountered tis with or withoutan abscessplus discitis [6]. [9]. Skip lesionoccur commonly necessitating the The typical MRI findings in a manifestcase mandatoryscanning of a largesection of the spine includesdestroyed vertebrae with intraosseousab- everytime [4]. Reportsfrom literatureindicate that scess(Fig. 2), paraspinalsoft-tissue mass with or the anterioraspect of spineis morecommonly in- without abscess formation, discitis, scoliosis, volved while posteriorelements involvement was. kyphosisand focal gibbusformation (Fig.4), skip found to be in the rangeof 2 to ll%o [0]. In this lesions,sometimes also involving the epidural space studythe involvementof posteriorelements was in 20 Jour.Marine Medical Society, Jan-Jun 2000, Vol.2, No. I Fig. 4 : Tuberculousspondylitis : Advanced lesion. Mid sagittal T2 weighted images (TR=2200, TE=80) showing par- tial incomplete collapseofL2 with anterior wedging and focal gibbus. The Ll and L3 vertebral bodies displays Fig. 2 : Tuberculousspondylitis : Advancedlesion. Mid sagittal abnormal marrow increasesignal intensity even though T2 weighted images (TR=2200, TE=80) showing par- the vertical height is maintained. There is a significant tial incomplete collapse of D8 and D9 vertebral bodies prevenebralsoft tissue component stripping the anterior which display inhobogenous increase in signal inten- ' longitudinalligament above and below the level ofthe sity. There is a significant prevertebral soft tissuecom- lesions.The intervening disc at Ll and L2 is destroyed. ponent stripping the anterior longitudinal ligament In additionthere is evidenceof extraduralextension of above and below the level ofthe lesions. The interven- the Iesioncompressing the caudaequina. ing disc at D8 and D9 is destroyed.In additionthere is evidence of extradural extension of the lesions. Fig. 3 : Tuberculousspondylitis : Paravertebrallesion. Axial T2 weighted images (TR=2200, TE=80) showing partial Fig. 5a: Tuberculouspsoas abscess : Bilateral lesion.A) Axial incomplete collapse of L4 vertebral body which display T2 weighted images (TR=2200, TE=80) showing a evidence of bony destruction at its left side. There is a paravertebralsoft tissue extension at L2 level into both paravertebral soft tissue extension into the left psoas, psoas, which is enlarged, displaying increased signal which shows abnormal signal intensity within. Impor- intensity within. In addition there is a small prevertebral tantly, the lesions displays an extradural componentthat component. encroachesthe neural foramina at left side, compressing the nerve roots and indenting the theca. and spinalcord narrowingand distortion(Fig. 3). the rangeof 4OVo.In contradistinctionto pyogenic The differential diagnosis includes pyogenic spondylitis,in tuberculosisthe corticaldefinition of spondylitis, fungal disease and echinococcosis, the affected vertebra is invariably lost [4]. The disc somecases of early degenerativedisease and lym- height is reducedin later stageofthe infection and phoma.The imagingfeatures favouring a diagnosis morphological changesof the paraspinalmuscle of tuberculousspondylitis includes involvement of commence.The normal uniform signal intensity of one or more segmentsof the spine, late deformity or the psoasmuscle is alteredwith asymmetricenlarge- destruction of the intervertebral disc, a large ment of the psoasbelly (Figs. 5A and B). Epidural paravertebralsoft tissue mass containing calcifica- involvementis identifiedby thecalsac displacement tion and absenceof reactivesclerosis. Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I 21 tuberculosishas no equal" by VA Moore. This no- tion holds well even today at the dawn of the new century[15]. To conclude,magnetic resonance im- aging shouldbe consideredto be the imaging mo- dality ofchoice for patientswith suspectedtubercu- losis spinal infection. Promising technical refine- ments in MRI are under progressat the moment, acrossthe globe. Clearly, these advances in technol- ogy hold the solutionsto the mysteriesof tuberculo- sis ofthe spine,in the future. REFERENCES l. PottP. Remarkson thatkind of palsyof the lower limb which is frequently found to accompany a curvature of the spine. Fig. 5b : Tuberculouspsoas abscess : Bilateral lesion. B) Coronal London,J Johnson.1779. Tl weightedimages (TR=500, TE=13) showinga ncar completecollapse of L2 vertebralbody with largepsoas 2. American Thoracic Society.Control of tuberculosisin the abscessseen as collection of dark signalintensity flank- . UnitedStates : Official Americanthoracic society statement. ing on both paravertebralregion. Ant RevRespir Disease 1992: 146: 1623. Besidesits role in diagnosis,MRI is an useful 3. Sharif H, Clark D, Aabed M, et al. Granulomatousspinal imaging tool for follow up of Spinal Tuberculosis infection: MR imaging.Radiology 1990t 177 : l0l-4. cases.Healing is identifiedby the variableappear- 4. HasanS Sharif, John L Morgan. Role of CT and MR imaging ancesof recoveryin vertical heightof the vertebral in the managementof tuberculous spondylitis. Radiologic body, reductionin sizeofparavertebral abscess and Clinics of North America 1995:'791-80/'. regression of extradural soft tissue component. 5. Modic M, FeiglinD, PirainoD, etal. Vertebralosteomyelitis Paravertebralsoft tissuemasses reach a maximum - assessmentusing MR. Radiology 1985; 157 : 157-63. size within 2 months of presentationand can take 6. Desai SS. Early diagnosisof spinaltuberculosis by MRL J (6) upto l5 monthsto resolveI l]. Bone Joint Surg Br 1994:'76 : 863-9. The role of intravenouscontrast has evolved into 7. HoggsonAR. Infectiousdisease of the spine./n Rothman RH, Simeone FAT (eds) : The spine. Philadelphia,WB an important strategyin management.Intravenous Saunders.1975;567. gadoliniumis usefulbecause it increasesdiagnostic confidence by characterizingand delineatingthe 8. Hsu LCS, Leong JCY. Tuberculosis of the lower cervical spineC2-C7. J BoneJoint SurgBr 1984;66 : l. disease process, detects reactivation in old and 9. WeaverP, Lifeso RM. healedTB, helpsin treatmentmanagement and may The radiologicaldiagnosis of tuber- culosisin the adult spine.Skeleral Radiology 1984; l2: 178. provevaluable in monitoringtherapy [2]. f 0. RahmanN. Atypical forms of spinal tuberculosis.J Bone CT is an alternativeimaging tool in theradiologi- Joirrt Surg8r 1980;62:.162. cal armamentariumavailable for evaluationof spi- ll. Boxer DI, Pratt C, Hine AL, et al. Radiologicalfeatures nal tuberculosis.What are the rolesof CT and MRI during and following treatmentof spinal tuberculosis.8r J in a given caseof spinaltuberculosis? It hasnow Radiol 1992:65 :4'16. beenascertained that CT imaging is ideal for dem- 12. Loke TK, Ma HT, ChanCS. Magneticresonance imaging of posterior onstrating integrity of bony structures tubercufousspinal infection.Australas Racliol 19971 4l (l) which provide spinalstability while MR imaging :7-12. obtainscrucial information on contentsand extent 13. Cremin BJ, JamiesonDH, Hoffman EB. CT and MR in the of the extradural mass that is causingthe paraly- managementof advancedspinal tuberculosis.Pediatr Radiol sis.Il3] MoreoverCT imagingdelineates disco-ver- 1993:23(4) : 298-300. tebral lesionsand paravertebralabscess clearly and 14. Lindahl S, Nyman RS, BrismarJ,Hugosson C, LundstedtC. MR imaging depicts soft tissuesand spinal canal Imaging of tuberculosisIV. Spinal manifestationsin 63 lesionsexquisitely [4]. patients.Acta Radiol 1996:.37 (4) : 506- I l. As early as l9l3 it has beensaid of mycobac- 15. Myers JA. Captainof all thesemen of death : Tuberculosis terium tuberculosisthat "As a destroverof man. historicalhighlights. St Louis, Warren H Green.1977. 22 Jour. Marine Medical Society, Jan-Jwt 2000, Vol.2, No. I AETIOLOGYOF UPPERGASTROINTESTINAL HAEMORRHAGES- AN ENDOSCOPICSTUDY Col HS PRUTHI*, Lt Col SK SHARMA#, Wg Cdr B SINGH+, Lt Col AC ANAND# ABSTRACT Six hundred ten patientsof upper gastrointestinalhaemorrhage were endoscopedover a period of eight years from July 1985to June 1996.Average age of the patientswas 39.2 years.82.69o were males and l7.4qo vtere females.Duodenal ulcer (31.57o), erosive mucosal disease (30.87o), oesophageal varices (31.57o) and gastriculcer (6.2Vo\were the major causes.Other causesincluded Mallory Weisssyndrome (10 patients),gastric polyp (3 patients),stomal ulcer (5 patients)and self-inducedbleeding (3 patients).Multiple lesionsresponsible for bleeding were detectablein 6.69oof patients.Endoscopy was non contributory in 50 (ll.2%o) patients.Haemorrhage was the first presentationin8.57o patientsofduodenal ulcer. A knownulcerogenic agent in2l7o ofduodenalulcer casesprecipitated the bleeding.77 .4Vo ofduodenal ulcer patientsresponded to conservativemanagement. Erosive gastritis(57.5 7o) was the commonestlinding in the erosivelnuscosal group. Alcohol and analgesicswere the major precipitatingfactors in thesepatients. Majority of oesophagealvarices was treated by sclerotherapy.Mortality was highestin the oesophagealvarices group (20Vo). KEY WORDS : Uppei gastrointestinalhaemorrhage, endoscopy. . INTRODUCTION Patientswith occult haemorrhagewere excluded. Resuscitationwas done prior to endoscopy.Detailed lll ndoscopydone within the first twenty-four historyand clinical examinationwas recordedin all H hoursof bleedis the mostdependable means l,)l of establishingthe sourceof uppergastroin- cases.Special care was taken to obtain history of testinalhaemorrhage (UGIH). A numberof studies previous bleeds,use of salicylates,steroids, non- (NSAID) have beendone in the WesternCountries to deter- steroidalanti-inflammatory drugs and al- cohol.Signs and symptoms of pepticulcer, cirrhosis mine the casesof UGIH [-4]. Few studieshave beendone in India in both pre and post endoscopic of liver and portal hypertensionwere looked for. After resuscitationand physical examination, an era [5,6]. Duodenalulcer and oesophagealvarices havebeen the most importantcauses reported from UGI endoscopywas performedto detectthe cause India, whereaserosive mucosaldisease of the gut of the bleeding.Once the causewas detected, inves- has beenreported to be importantin United States tigations and treatment were performed accord- ingly. Mortality occurringduring the sameadmis- of Ameria [7]. We conducteda study to determine the causesand outcomeof patientsof UGIH report- sion was recorded. ing to gastroterologycentres of tertiarycare hospi- RESULTS talsin India. A total of 610 caseswas studiedthus giving an MATERIAL AND METHODS averageof 56 patientsper year. Out of these503 This studywas carried out over a periodof eleven (82.6Vo)were males. The averageage was 39.2 years yearsfrom July 1983to July 1993in threegastroen- with a rangeof 9-76 years.Majority (86.2Vo)pre- terology centresat Delhi, Lucknow and Pune.The sentedwith a combinationof haemetmesisand me- studywas cross sectional, done sequentially and not lena. ll.57o presentedwith melena only whereas con-currentlyin thesecentres. A total of610 adult 2.2Vohad only haemetmesis.335 (74.5Vo)patients patientspresenting with UGIH were endoscoped. were endoscopedwithin 24 hours, in others the *Senior Adviser Medicine and Gastroenterology,INHS Asvini, Mumbai - 5; "Reader,Department of Medicine, Armed ForcesMedical +Classified College,Pune - 4l I 040; SpecialistMedicine and Gastroenterology,Command Hospital, Pune 4l I (X0. Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. l 23 endoscopywas delayed for I to 4 weeks.The aetio- Hundredpatients had varicealbleed (table 3). logic spectrum of UGI haemmonhage is shown in Theage group ofpatients ranged from 9 to 68 years. Table l. In l07oof patients,there was history of priorNSAID One hundred ninety two patients(3l.5vo) had intake.60,8Vo were cirrhotics, 33.7Vo non-cinhotic duodenalulcer that was bleeding. Characteristicsof portal fibrosis (NCPF) and 5.5Vocases had extra patients with bleeding duodenal ulcer are depicted hepaticportal hypertension(EHPH). 60 patients in Table 2. Majority of patients in this group be- (8lVo) of oesophagealvarices were treatedwith longed to the agegroup of 20-50 years.In 152(79Vo) endoscopicsclerotherapy using ethoxy sclerol patientsno precipitating causefor haemorrhagewas (I.57o).Immediate mortality was 20.2Voin this detected.History of intake of NSAID prior to onset group.Out of the fatal cases,four died of uncon- of haemorrhagewas availablein l4%o.148 (77.4Vo) trolled haemorrhage,whereas eleven died of liver patientswere treatedconservatively with H2 block- cell failure. ersgiven parenterally.32(22.6Vo)patients had to be TABLE3 subjectedto emergencysurgery in view ofcontin- Characteristics of patients with bleeding oesophagealvaries ued bleeding. There was no mortality in this group. (n=610) TABLEI Ser.'No.Parameter No. of patients Percentage Aetiologicalpattern of uppergastrointestinal haemorrhage (n=610) l. Total number 16.4 2. Average age 36 years Ser. No. Disease No. ofpatients Percentage 3. Males 93 93.0 4. Females 7.O L Duodenalulcer r92 31.5 5. hecipitating factor l0 10.0 2. Erosivemucosal disease 188 30.8 identified 3. Oesophagealvarices 100 t6.4 6. Treated with Gastriculcer 38 6.2 Sclerotherapy 8l 81.0 5. Miscellaneous 24 3.3 Conservative therapy t7 17.0 Mallory-Weisstear 10 Emergency surgery 2 2.0 Oesophagealulcer 3 8. Aetiology Stomalulcer. 5 Cinhosis 6l 61.0 Gastricpolyp 3 NCPF 35 35.0 Self induced J EHPH 4 4.0 No lcrion detected 68 tr.2 9. Mortality 20 20.0 Multiplc lesions 40 6.6 One hundredeighty eight patientshad erosive TABLE 2 mucosaldisease (Table 4). In this group,patients of Characteristicsof patientswith bleedingduodenal ulcer gastritis (n=610) age12 to 76 yearswere seen. Erosive ac- countedfor 52.5Voof thesecases. Nineteen (l0Vo) Ser. No. Parameter No.of patients Percentage patientshad bile reflux gastritisas a resultof prior gastrojejunostomy.NSAID wasthe majorprecipi- l. Total number r92 31.5 tatingfactor. History of alcoholintake prior to UGI 2. Males l8l 95.0 haemonhagewas available in 18 patients.Six pa- J. Females ll 5.0 tientshad history of combinedintake of alcoholand 4. Asymptomatic bleed l6 8.5 NSAID prior to onsetof bleeding.In threecases 5. Conservative therapy 148 7'1.4 ingestionof sharpforeign bodies was the causeof 6. Emergency surgery 44 22.6 erosions,whereas in five cases,bleed followed 7. Precipitating factor 40 2r.0 heavyphysical activity and on endoscopy,gastric 8. Average age 39.7years erosionswere detected to be the causeof haemor- 9. Mortality Nil rhage.Twenty four patientshad associatedillness like septicemia,uraemia, fulminant hepatitis, and 24 Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I TABLE 4 TABLE 5 Cbaracteristics of patients with bleeding erosivemucosal Characteristicsof patientswith bleedinggastric ulcers disease(n=610) (n=610) Ser. No. Parameter No. ofpatients Percentage Ser. No. Parameter No. of patients Percentages l. Total number 188 30.8 l. Total number 38 6.2 (Average age 40 years) (Average age 46.6 years) 2. Males 153 81.2 Males. 36 93.0 3. Females 2 7.O 1. Females J) 18.8 4. Benign 30 78.5 4. Precipitating factor present 170 n.1 5. Malignant 8 21.5 5. Conservative therhpy 182 96.6 6. Conservativetherapy 27 7t.4 6. Emergency surgery required 6 3.6 Emergency surgery ll 28.6 Aetiology 8. Mortality 3 7.8 Erosive gastritis 108 ) /.) Duodenitis 40 2t.5 Oesophagitis 2l 20.0 Post-GJ gastritis 19 10.0 TABLE 6 Precipitating factors Characterlsticsof patientswith combinedlesions (n=610) Analgesics 82 48.2 Ser.No. Parameter No. ofpatients Percentage Associated illnesses 3l 18.2 Alcohol 24 l4.l l. Total number 40 6.6 Steroids l0 5.7 varices Alcohol and analgesics 8 4.8 2. Oesophageal and ll 2't.5 gastritis Heavy physical exertion 5 3.0 Unknown l0 6.0 { Gastritisand oesophagitis 9 22.5 Erosive gastritis and 8 20.0 duodenitis terminal malignancy.In thirteenpatients (9.3Vo) of 5. Oesophagealvarices and r7.5 erosive mucosal disease, the haemorrhagewas oesophagitis spontaneouswithout history of any of the above 6. Oesophagealvarices and 5 12.5 factors. Majority of thesecases were managedcon- duodenalulcer servativelywith heavydoses of liquid antacidsand H2 blockers.Five patientswere subjectedto surgery (ll.5Vo) cases.Immediate endoscopy was possible in view of continuedbleeding. Overall mortality in in only ten cases,whereas in80Vo it wasdelayed for this group was lO.1Voand mainly included termi- l-4 weeks after the onset of bleeding.Of the ten nally ill patients. casesthat were bleeding actively and, endoscopy Thirty eight patients (6.2Vo) had gastric ulcer. was non-contributory, four recoveredon conserva- Characteristicsof thesepatients are depicted in Ta- tive therapy whereassix underwentsurgery. The ble 5. All gastriculcers were biopsiedat the time of diagnosis after the surgery was gastric ulcer (2 pa- initial endoscopyand 78.5Voof the lesions were tients),gastric erosions (2 patients)and post-bulbar benign.Conservative management with H2 block- duodenalulcer (l patient).In one caseno diagnosis ersshowed good results in7 |.4Vopatients. 28.6Vo of could be made after laprotomy. patientsrequired surgery. DISCUSSION Table 6 shows frequency and pattern of com- UGI haemorrhageis a major emergencyencoun- bined lesionsas a causeof UGI haemorrhage.Oe- tered in gastroenterologypractice and leads to a lot sophagealvarices along with gastritis or oesophagi- of morbidity even in the best of centres.In the tis were present in thirteen cases. Four cases of Armed Forcesit has a special relevance,because of oesophagealvarices had associatedduodenal ulcer. different working conditions and leadsto wastageof In the rest of thirteen patients combination of vari- trained manpower. Moreover modern diagnostic ous erosivemucosal disease was present. and therapeuticservices may not be availablein the Endoscopy was non-contributory in fifty far-flung and remote areasof the Armed Forces.In Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I 25 thereforeposes special problems. the co-existingvarices [0,] l]. Endoscopywas non patients.80Vo Endoscopywas possiblein 454 patientswithin contributoryin ll.57o of our of these -4 first 24 hoursof thebleed. In 156patients endoscopy underwent endoscopy after a delayof I weeksand it is possible were was done after a delay of l-4 weeks,because they that mucosallesions missedin patients. were referred from other hospitals. Only telltale these Howeverin theother2OVo endoscopy was performed evidenceon endoscopyin 75 ofthese patientsiden- during the bleed and still no cause tified source of bleeding. Year wise incidenceof could be found. UGI haemorrhagewas 56 patientsper year. Other Bleeding as the first manifestationof duodenal workers have noted similar yearly incidence[5-7]. ulcer was seenin 8.57oof our patientsas compared The youngestpatient was nine years old and the to 20Voreported in literature[2]. No precipitating oldestwas 76 yearsold. Age reportedin the westem cause was identified in majority (79Vo)of these studiesis higher and the male to femaleratio in our patients.22.6Vo of these patients required emer- study is 4.7 : I which is much higher than reported gency surgeryand otherswere managedconserva- elsewhere[5,7]. These differencesare due to the tively. Therewas no mortality due to bleedingduo- younger age and male preponderanceof patients denal ulcer in our series.The actual incidenceof reportingto us. erosive mucosaldiseases may be higher than the 30.87ofound by us,because ofdelay in endoscopic Duodenal ulcer, erosive mucosal diseasesand examinationin 25.5Voof our patients.Erosions are oesophagealvarices were the three main causesof well knownto healquickly.NSAIDs alone,alcohol UGI haemorrhageaccounting for 78.7Voof all pa- aloneand a combinationof thesetwo werethe major tients. Similar findings have been reported by a precipitatingcauses. In threepatients erosions were nationalsurvey of 2225 patientsof uppergastroin- causedby foreignbodies - fish bone,sewing needle testinalbleeding in USA in l98l An Indian [4]. and the screw being the offending agents.Erosive study has reportedoesophageal varices (45.5Vo) as gastritis, duodenitis and oesophagitisin various the major causeand found erosivemucosal disease combinationswere seen in seventeenof ourpatients. in only 8.5Voof their patients Gastric ulcer [6]. Patientswith erosivemucosal disease without major accountedfor only 6.2Voof our patientscompared underlyingillness had good prognosiswith conser- to2l.9Vo reportedin USA Mallory-Weisssyn- [6]. vative treatment.Cirrhosis of liver was the major drome, oesophagealulcers and stomalulcers were causeofoesophageal varices in our study.The other the other cuasesidentified in this study.The inci- Indian studyfound non-cirrhoticportal fibrosisand denceof Mallory Weisssyndrome is much lower in extrahepaticportal hypertension as the major causes our studythan about T.2Voreported in the west.This of varices[6]. Majority of our patientswere adults may be relatedto differencesin alcoholand analge- in whom thesediseases are not common.Immediate sic use betweenthe two populations.It is possible mortalitywas highest in the groupwith oesophageal that some casesof Mallory Weiss tear, acuteero- varices.Majority (817o)of the patientswere treated sionsand acuteulceration could have beenmissed by endoscopicsclerotherapy. No emergencyshunt due to delay in endoscopyin some of our cases. procedureswere done. Two patientswho underwent Three of our patients had self-inducedbleed by emergencyligation of the varicesdid not survive. causinginjury to buccalmucosa or drinkingred ink. REFERENCES Combinedlesions (6.6Vo) responsible for bleed- RM. ing havealso been reponed by anotherIndian study l. Katon Smith FU. Pan-endoscopyin the early diagnosis of acute upper gastrointestinal bleeding. Gastroe nte rology Westernstudies have describedbleeding from [5]. 1973;65:728. multiple sitesin much higherpercentage of patients PetersonWL. [8,9].We found oesophagitis,gastritis and duodenal 2. Barnett CC, Smith JJ, Allen MH, Corbett DB. ulcercoexisting with oesophagealvarices but active Routine early endoscopy in upper gastrointestinal tract bleeding was from varices in all except three pa- bleeding. NEJM l98l: 3O4 : 925. tientswhere it wasdue to gastritisorduodenal ulcer. 3. Schiller KFR, Cotton PB. Acute upper gastrointestinal In studiesfrom the west, as many as 38-68Voof haemorrhage.Clin Gastroenterol 1978; 7 : 595. patientsare reportedto bleedfrom lesionsother than 4. SilverstenFE, Gilben PA, TedescoFJ, et al. The national 26 Jour. Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I Americansociety of gastroenterologysurvey on uppergas- haemetmesisard rrclc;na.8t Med J l97t:2 : 5O5-9. trointestinal bleeding. Part I and II. Gastointest Endosc 9. Siaw CF, Wci Cl, PanS, Chcn PB. Pancdoocopy in upper l98ll./7:7682. gastrointestinalbleeding. Proceedings of the 2nd Asian pa- 5. Tandon RfL The causesof acute uppcr gastrointcstinal cific Congressof Endoscopy.1976; 80. haemohrrhagein New Delhi, India an endoscopicstudy. Giron GastroentEzd l9E0; 3 : l-8. 10. Khodadostt, GlassGB. Eroeivegastritis ard acutegastro- duodcnalulcerations as a souroeof upper gastrointestinal 6. AnandCS, TandonBN, Nandy S. Thc causes,management bleedingin liver cinhosis. Digestion 1972;7 : 129. andoutcome of acuteupper gastrointestinal haemorrhagc in an Indianhospital. Br J Surg1983;70 :fr9-ll. I l. FranccD, DcportcA, DurandyY, BismuthH. Uppergastro- 7. Allen & DykesP. A studyof thc factorsinfluerrcing mqtal- intcstinal hacmorrhgein hepaticcinhosis, causesand rela- tion to hepaticfailure and suess.Lancet 1977:| :218. ity ratesfrom uppergastrointcstinal hacllrrorrtnge. Qr J Med 1976:'45:533-50. 12. Chinn AB,'WeckcsserEF. Acute haemorrhagefrom peptic 8. CottonPB, Rosenbcrglrff, WaldramRPL. Early endoscopy ufccration,an analysisof 322 cases.Ann luen Med l95l; of oesophagus,stomach and duodenalbulb in patientswith 34:339. Jour, Marine Medical Society,Jan-Jun 2000,VoL 2, No. I 27 FIELD STUDY OF INSECTICIDES AGAINST MOSQUITOLARVAE Surg Capt KK DUTTA GUPTA{', Surg Capt MI JOHN+, Surg Capt S NANGPALT, Surg Cdr A CHATTE(ff,,p** ABSTRACT A lield study of certain insecticidesagainst Mosquito Larvae was carried out at Naval Base,Kochi. Fenthion and Temephoshave been found to be elfective in low doses.Pupae are more tolerant to insecticides.Malathion gave 100 percent mortality in field at two mgm/litre doses. KEY WORDS : Mosquito larvae, Insecticides INTRODUCTION used.Factor usedto convert cubic inch into litre was 0.016387and 28.316847to convert cubic feet into ulex quinquefasciatus,one ofthe vectors of litres. However, no attempt was made to estimate filariasis has developed resistanceto many surface area. Densities of culex quinquefasciatus insecticidesin someparts in India []. Anti- larvae were made by taking five dips by meansof a larval operation forms the basis of implementation laddle with 9.5 cm diameter in each breeding place. of National Filaria Control hogramme. Among the The data on prespraydensity was collected daily for methods of larval control, chemical control is more one week prior to date of first treatment and on the practical in developing countries becauseit results date of treatment. Post spray density was checked in systematic reduction of mosquito production, 24 hours later. Larval catcheswere made on alter- thereby proportionately increasingthe effectiveness native days. Appearanceof secondstage larvae was of other attack measures.In Armed Forces,weekly taken as an indication for the loss ofresidual toxic- larvicide operationsare undertaken.Therefore, it is itv. desirablethat periodical field trials be carried out to selectthe most effective larvicide for mosquitocon- RESULTS trol. With this background, a laboratory trial fol- Theresult of field trialsare set out in TableI - 3. lowed by a field trial was carried out at Kochi. The It was l00%o idea of carrying out a laboratory trial before field seenthat mortalityin the field was obtainedwith the same trial was to find out lethal concentration(LC) 50 and doseas found in laboratory. Temephosgave prolonged persistence. LC 90 with a view to select a dose which would be Fenthionin 0.625ppm gave 100percent mortality. It is also ideal [2]. evidentthat pupae are more tolerant to insecticides MATERIAL AND METHODS DISCUSSION The study *as conducted at Naval Base, Kochi. Mosquitogenicconditions like defectivedrains The field trial with different insecticideswas carried with stagnantwater due to faulty gradientcanals, out in eight different sectors.In each sector, areas broken septictanks, open disusedwells etc. can with stagnant pools of water/drains were selected causeserious public healthproblems. Engineering and marked for a particular insecticide.Two sectors measureslike repairingof drains,septic tank, desilt- were kept ascontrol. Total volume of stagnantwater ing of canalswill reducethe mosquitopopulation. in cubic inch/cubic feet was calculated.While meas- WorldHealth Organisation recommends target dose uring, averageofthree readingswas taken.Conver- of fenthionin thefield as 1 mgmper litre. Fieldtrial sion formulae of volume and capacity table was indicatesthat fenthion in muchlower dosescauses *Associate Prof, Dept of PSM, AFMC Pune. +Senior Adviser, Marine Medicine, **Specialist in PSM. 28 Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I TABLEI Summaryof fietd trial agalnstmosquito larvae (culex qulnquefasclatus) wlth tnsectlcidedoses cloce to whichl(X)% death achievedin laboratorytrid Insecticide hespray Percentreduction Re appearanceof (Postspray with dose density after 24 hours density)larvae after days (Total of 5 dips) (Iotal of 5 dips) 3710 t4 l7 days larva pupa larva pupa Chloropyriphos 2t5 20 100 90 Nil Nil SNTNT (0.625PPM) Temephos t96 t9 100 95 Nil Nil Nil 32 (0.12sPPM) Til Fenitrothion 245 l8 100 89 Nil Nil 34 NT NT (0.625PPM) Fenthion 238 25 100 92 Nil Nit NiI I7 NT (0.625PPM) Dichlorovos 229 t4 100 86 Nil 8 96 NT NT (0.625PPM) Malathion 182 18 100 100 Nil NiI 14 NR (2PPM) NT - Not taken. TABLE 2 Summara of field trids sgainst mmquito lanae (culex qulquefasclatus)wlth inscctlcide doses(LC 50 value) Insecticide Prcspray Density Reduction with dose &nsity aftcr 24 hours in immature (total of 5 dips) (Total of 5 dips) stages larva pupa larva pupa (Percent) Chloropyriphos 2M 19 9t 13 56 (0.250PPM) Temephos 3r2 26 E7 l8 72 (0.005PPM) Fenitrothion 190 16 l0l 9 47 (0.0loPPM) Fenthion 237 U 93 l0 6l (0.0l0PPM) Dichlorovos 244 18 tt2 15 54 (0.020PPM) Malathion 2t6 r7 r23 8 43 (0.050PPM) Tcmephosand fenthion showedhigher larval deathin fteld. But pupalstage shows less death indicating pupal stagesrequirc higher concentration for d€ath. 100perceni mortality and should be usedin field at with temephos(Table I ) till 17days. The prolonged weekly interval for the control of mosquitolarvae. rcsidual action of Temephos(Abate) could be due In a study,LC 90 valueof Malathion,Temephos, to the fact that this insecticidegets absorbedwith Fenthion,Chloropyriphos, Dichlorovos and feni- organicdebris from whereit getsreleased gradually. throthionwas found to be I mgm,0.07 mgm, 0.33 Beingcostly, its useshould be restrictedfor larvae mgm,0.19 mgm and 0.07 mgm per lihe respectively contol in thedrinking water [4]. t31. Immaturestages reappear€d in caseof Dichloro- Reappearanceof immature stage was delayed voson 7thday itself. This maybe due to thefact that Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No.I 29 TABLE3 Summaryof field trials rgninstmocquito larvse (culex qulnquefasciatus) with incecdcidedoces close to LC 90 nlue Insecticide Prespray Percentreductions Postspray Rcduction with dose density of 24 hours densitvafter in immature (total of 5 dips (total of 5 dips 7 days(immatue stagps(after larva, pupa) Iarv4 pupa) stage 7 days) Chloropyriphos 216 18 14 6 l6 93 (o.35oPPM) Temephos 264 27 Nil 2 Nit 100 (0.075PPM) Fenitrothion 2@2r376 3l 86 (0.075PPM) Fenthion t96 t4 Nil 3 (0.r25PPM) Dichloroves 243 22 5l 14 39 84 (0.020PPM) Malathion 238 19 44 l8 29 .88 (l PPM) Temephos and Fenthion resulted into lfi)% death of immature stage. Immature stages were not noticed even after one week. this insecticide breaks down into Dichloroacetalde- AK, GrcwalGS. Evaluation of susceptibilitystatus of culex hyde which is a gas and dimethyl phosphoric acid quinquefasciatuslarvae to commonlyused insecticides in (r):22. which is harmless[5]. IndianNavy' JMMS 1996;3 One hundred percent mortality of pupae obtained 3. MariappanT, ArunachalanN, SomacharyN, PanickerKN. with malathion is due to high dose used (2mgm per Susceptibilitystatus of culexquinquefasciatus against fen- litre) as compared to LC 90 value of I mgm per lifire. thionin Cochinarea - Proceedingsof sixthKerala Science congressThiruvahanthapuram' 1994:372-3' In this study dosageswere calculated on the basis of volume Of water as it iS more Scientific and 4. BhatnagarVN, JoshiGC, Waltal BL. Laboratoryand field agggratethan dOSeCalCUlatiOn baSed On SUrfaCe area. evaluationofAbate in thecontrol of culexpipiens larva.Jour comDisl96l:l:203-14' REFERENCES l. WorldHealth Organisation. vector resistance to pesticide. 5. SreeRamalu US. Chemistry of insecticidcsand fungicides' TechRep Ser No.816, 1992; 3-lg. Oxfordand IBH PublishingCo' Ncw Dclhi. 1973. 2. DuttaGupta KK, ChatterjeeA, NangpalS, John MJ, Singh 30 Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I t RESISTOTYPINGAND ZYMOGRAM STUDY OF KLEBSIELLAIN NOSOCOMIALINFECTIONS Surg Cdr RN MISRA*, Maj AD SEN* INTRODUCTION ANTIBIOTIC SENSITIVITY TESTING (AST) by lebs iella pneumoniae has been incriminated AST wasdone by Stokes'disc diffusion method dy, in 87oof all nosocomialinfections, particu- using NCTC 6571 Staphylococcusaureus, and ing larly from urinary tract infections(UTI), NCTCl0l l8 - E coli asstandards Confirmation blv [6] lower respiratory tract infections (LRTI), biliary dy of discresistance was carried out by minimumin- of tractand surgicalwound infectionsin that order[1]. hibitoryconcentration (MIC) method. ith Microbial drug resistanceis a major problemin the BREAKPOINT of treatmentof theseinfections. It is now well recog- MIC TESTING ;es. nized that resistance of enterobacteriaceaeto an Breakpoint MIC to variousgroups of antibiotics ate increasingnumber of antimicrobialagents is largely like p lactams,viz ampicillin, cefotaximeand lCe mediatedby conjugativeplasmids manyhos- ceftazidimeaminoglycosides (gentamicin, ami- nal [2].In pitals, Klebsiella are among the most resistantmi- kacin, netilmicin) fluoroquinolones.(ofloxacin, crobes due to their already natural occurring norfloxacin)and miscellaneousantibiotics (sul- resistanceto ampicillin,carbenicillin and their ready phamethoxazole,trimethoprim and chlorampheni- acquisitionof R plasmid,carrying resistance to ami- col), wasdone by the BSAC working partyproce- lg- noglycosideinactivating enzymes and a wide vari- dure[7]. ety of p lactamasesas well as other drug resistant Various antibioticsconcentrations were as genes To study the prevalence of [3]. of Klebsiellain follows: SA the hospitalenvironment, it is essentialto differen- .nd tiate and identify residentstrains by varioustyping Names of antibiotics Concentration (pgm/ml) methods. .Dlo- Phenotypingcharacterization by biotyp- Ampicillin 8 SA ing, serotyping,klebecine typing or antibiogram are Cefotaxime I lu- not satisfactoryin successfullydiscriminating the Ceftazidime 2 no subtypesamong Klebsiellafor epidemiologicalpur- "D Gentamicin 1,4 .he poses. Netilmicin t,4 A combinationof resistotypingand zymogram Norfloxacin t,4 studiesof Klebsiella hasbeen studied by us to detect )u- Sulphamethoxazole 32 the epidemiologyin the hospitalisolates. The main he Trimethoprim 0.5,2 aim was to detect the allelic variations xy at specific Chloramphenicol 8 genetic loci by electrophoresisof bacterialextracts Ofloxacin 2,8 for variousenzymes [4]. Arnikacin 4,16 MATERIAL AND METHODS ng "D Hundred Klebsiella pneumoniae strains isolated Stock solution of the antibiotics were prepared rus from routine clinical samplesfrom CH (SC), Pune and storedat -20oC. were included in the study. Identification of The Klebsiella pneumoniae strains were grown )m Klebsiella was carried out by using standardmor- ls, over night in nutrient broth to a concentrationof phologicaland biochemicalmethods [5]. :/a. m- l0e-12cfu/ml. This was then diluted l:100 in Ringersolution and l0a cfu/ml) wasspot inoculated - Ie0 *Classified Specialist, Pathology. INHS Asvini, Mumbai 400 005. Jour. Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I 3I to Mueller Hinton agar (MHA) containing appropn- RESULTS ate concentrationof the antibiotics with the help of a multipoint inoculator. STATISTICAL ANALYSIS The plates were incubated ovemight at 37oC. Geneticdiversity was calculated by thefollowing Presenceof growth indicated that the organism was formula resistantwhile no growth indicatedthat it was sen- H = I x 2 [n (n-l)] wherex was the frequencyof sitive. the allele, n is the number of the electrophoresis Multi locus enzyme electrophoresis (MLEE) types. The results were then expressedin the form (Zymogram study) : This involved the following of a dendogram. steps[8]. DISCUSSION (a) extracts by method of Preparation of bacterial Klebsiella are an important causeof nosocomial preservation -70oC sonication and at infections, particularly UTI, LRTI, and post opera- (b) Polyacrylamide gel electrophoresis(PAGE) : tive wound infections which constitute 87o of all Vertical gel electrophoresissystem was set up. infections [1]. In this study also 7.5Voinfections Gel dimension 200 mm x 200 mm x I mm (40 were contributedby Klebsiella.Tl'ris is mainly due ml gel). A comb of 20 cm width wasallowed to to colonization of GI tract by theseorganisms after set. Bacterial extracts were allowed to run at admissionto the hospital.[9] In our study most of the 200 V for 22 hours. infections were UTI (727o) followed by pyogenic infections(lOVo). (c) Electrophoretic transfer : The stored cell ex- tracts were transferred to nitrocellulose mem- Nosocomial Klebsiella arefound to be multi drug branes at25 ma for 5 minutes. It was cut into 5 resistant(MDR). In this studyalso, resistance to 6-8 strips of 0.5 cm width. The gel and the nitrocel- drugs was found in 347oof the organismsfollowed lulose papers were stained for the following by 3-5 drugsin269o, and 9-l I drug in 24Vo.T\ese enzymesby correspondingsubstrates. organisms was resistant to ampicillin (98Vo) and i. Alcohol dehydrogenases (ADH) 58-667owere resistant to third generation cepha- ii. Malate dehydrogenase (MDH) losporins which was due to production of extended iii. Lactatedehydrogenase (LDH) spectrum p-lactamases by acquiring R-plasmids iv. Glutamatedehydrogenase (GDH) [10]. Plasmid mediated drug resistancealso medi- v. Nucleoside phosphorylase (NSP) ates resistanceof aminnoglycosides,tromethoprim vi. Alkaline phosphatase (ALP) and sulphamethoxazole.The sizeof the plasmid also vii. a-naphthyl acetateesterase (EST) helps in epidemiological characterizationof the or- viii. L-phenyl alanine l-leucine peptidase (PEP) ganismsI l]. TABLE I Distribution of isolates from various wards and specimen Sputum ICU ) ) 3 l0 SURG 7 8 I l6 URO 33 I 34 BURN 2 I 4 I 8 NEURO 7 I 8 F'SURG 8 I I : l0 PAED l. I 2 POSTOP t2 T2 TOTAL t2 10 32 Jour. Marine Medical Society,Jan-Jun 20O0, Vol.2, No. I t TABLE 2 Antlbiotic resistancepettern ol Kleb Pneumoniaeislollates Ampicillin 98% ing Ceforaxime 6Vo Ceftazidime 58% K40 'of Gentamicin I p gm/ml 50% Ktl 4 p gm/ml 44% K5l rsis K5? Neltimicin I p gm/ml fi% K6l K70 rm 4 p gr/ml 50% K?: Amikacin 4 p gm/ml Kt9 38% K?5 l6 p gmlml 34% KEE KI Norfloxacin I pgm/ml 38% K] 4 p gm/ml 34% K4t rial 46 Ofloxacin 2ltgmlml 36% l0 ra- 8 p gm/ml 32% Klz K l.l all Sulphamethoxazole 709o K.l9 )ns Trimethoprim 0.5 p gm/ml 70Vo K23 lue 21t gnhnl 6% Klr Kl5 ler Chloramphenicol 66% 6? Koi the xti nic TABLE3 -ffi- -l;-r '' Grouping of resistancepattern l,,=l;-i;l; ;- rug 6-8 Resistantto 0-2 antibiotics l6 Fig. | : Dendogram ved Resistantto 3-5 antibiotics 26 showing the dc'grceol'genetic sinrilarity Resistantto 6-8 antibiotics between the various isolates. ese 34 Resistantto 9-l I antibiotics 24 md In the zymogram analysis MDH was produced ha- by 48Voof the isolates.Eight isolatesshowed same Jed TABLE 4 isoenzymes.387o showed positivity to ADH,l6Vo rids Percentageisolates showing enzyme bands to LDH. lSVoto NSP and 22Voto ALP. The isoen- :di- zymesand presence ofthese enzymeshas helped in ADH 38% rim constructionof a dendogramin genetic related-ness. MDH 48% 387oof the strainsdid not give any bandswith the rlso LDH t6% eight enzymes tested, 62Vo isolates were divided or- NSP 18% into ll groups, and each group can be represented ALP 22% as clonesfrom one organism.A secondgeneration can be explainedas having 85-90Vorelatedness.[8] TABLE 5 The variation is explainedby environmentalinflu- Distribution of enzymescombinalions enceslike exposureto antiseptics,antibiotics and host immunity. Four Enzymes ) (ADH, MDH, LDH, ALP) In conclusion, most of the hospital Klebsiella Three Enzymes 34 isolates can be grouped into I I genetic types by ADH, MDH, ALP l6 zymogram study and resistotyping but by combin- ADH, MDH, NSP 08 ing both, all K/ebsiellacouldbe groupedinto several ADH, LDH, ALP 04 more genetic types. MDH,LDH, NSP M REFERENC&S ADH,MDH,LDH 02 Two Enzymes 06 l. Hill R, Junt CE, Master JM. Nosocomial colonization with One Enzyme 2l Klebsiella in a neonatal intensive care unit associatedwith an out break ofsepsis, meningitis and necrotizing enterocoli- No band was shown by 38 isolates tis.J Paed 1974:415-9. o. 1 Jour. Marine Medical Society, Jan-Jun 2N0, Vol. 2, No. I 33 -{ 2. CasewellMW TalsaniaHG, Knights. Gentamicinresistant D: l-50. Klebsiella as sourceof uansferablemultiple resistance,J 8. CombeML, PonsJL,Sesbon& MartinJP. Electrqtrcrcsis Anti Chcml98l; 8 : 153-60. tra4sferfrom polyacrylamide-gelto nitrocellullosesheets, a 3. Knight S, CasewellM. Discrimination of resistanceplas- ncw methodto charcterisemultilocus.enzyme ginotypes of mids amonggentamicin rcsistant enterobacteria from hospi- Kebsiella strains.Spl and Environ M iero 1994;ffi : 2G3O. tal patientBMJ l98li 2 | i55-7. 9. MultandaLN, MansoorNNN, RehmanN, Molla AIVIrAn- 4. SelanderRK, CauganrDA, OchmanH, MusserJM, Gilmour tibiotic rcqistanceof emeiob.acteriaisolated frorh hospital- MN, Whittim TS. Methods of rirultilocrs enzymesclec- izeddianhoea pqtients. IJMR l98l; 74 : 610. trophroesisfor bacterialpopulation genesis arid systerqatics. Appliedand environMicro 1986;5l : 8?l-84: 10. SihiappaDA, HdydenMK, MatushenMK. Ceflazidime 5. Banow GI, FelthamRAK (eds).Cowan and Steel's manual rciistant Kebsielta pnewioniac and E coli bloqd stream fdr thc idcnlification of the medical bacteria.Cambridge infecdons;A gasecontrol and molecular epidemiololic in- UniversityPress 3rd Ed. 193;178-34. vestigationJ /n/€it Dis.1996:174: 529-36. 6. StokesEI, RidgwayGL WrenMWD. Clinical microbiology t t. Sirirt D, C.snnalPetil A, LabiaR. Kebsiellapneumoniac arf, 7th ed. Boston : EdwardArnold t993:251-2. other €nterobactgriaproducing novel plasmid mediatedp 7. A guide to sensitivity testing : Reportofworking party on lactamaserharkedly active againstthird generationcepha- antibiotic sensitivity rcsting. British society for antimicro- tosporins- epidemiologicalstudi es. RevInfeci Dis l99E; l0 bial chemotherapy.J Animic Chem l99l1' (2?) supplement (4):850. 34 Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I TRANSCANALTYMPANOPLASTY- SURGICALOUTCOME Surg Lt Cdr D RAGHAVAN* ABSTRACT This is a retrospectivestudy of 46 patientswho had undergonetranscanal tympanoplasty with tragal perichon- drium during an eighteen-monthperiod at INHS Asvini. This study was restricted to casesof repair of uncomplicatedperforations of the tympanicmembrane that did not require ossiculoplasty.Thirty seven(80.43 7o ) were successfulin terms of closure of the perforation and 35 (76.09Vo)patients had their hearing improved postoperatively.Various factors liable to influencethe successrate suchas statusof the middle ear, sizeand site ofthe perforations,surgical experience and presenceoftympanosclerosis were analysed. Only statusofthe middle ear, experienceof the surgeonand the presenceof tympanosclerosisat the time of surgerywere found to havea significanteffect on the final outcomeof surgery. KEY WORDS : Tympanoplasty,Transcanal Approach, Tragal Perichondrium INTRODUgTION ging methodsare still used in small perforations. tympanicmembrane dates back The presentstudy analyzed a number of factors 1.l epair of the postulated to affect surgical outcome in order to ft( more than a century. In 1878,Berthold re- ILported the successfulclosure of a perforation assesstheir utility in selectingsuccessful surgical with a full thicknessskin graft and introducedthe candidates.Tympanoplasty is a common surgical procedure term "myringoplastik"[]. Ely (1881)and Tange- andanalysis ofthese factors will certainly help mann(1884) soon followed suit [2,3].The introduc- in future selectionand careofpatients. tion of microsurgery and antibiotics in 1950 MATERIAL AND METHODS revolutionizedear surgery.Zollner and Wullstein introducednew techniquesin earsurgery at thattime Records of all patients undergoing transcanal [4]. Although initially skin continuedas the material tympanoplastywith tragal perichondrium in the of choice for tympanic membranerepair, before OtolaryngologyDepartment of INHS Asvini in an long,other tissues were introduced.Amniotic mem- l8 monthperiod (Feb. 98 to Jul. 99) were reviewed. brane,autologous mucous membrane,and comea, More recenttympanoplasty procedures as well as were all tried but were later abandoned as more those lost to follow-up were excluded to allow a suitabletissues were discovered.Periosteum, vein, minimum follow-up period of six months.Cases in connectivetissues, adipose tissue, and perichon- which ossiculoplastywas performedwere excluded drium, all proved of value and remain in use until from this study. The size of perforation was graded (less (50Vo the presenttime [4-ll.] In 1959, Ortegren intro- as small than507o, medium to75Vo)and duced fascia as a graft material and this remains, large (more than 75Vo). Other parameters ascer- over 20 years later, the most popular graft material tainedwere the statusof the middle ear at surgery, [2]. The technique of myringoplasty has also thepresence of tympanosclerosis,surgical approach changed with time. Though the original "onlay" and technique.Pre and postoperativeaudiograms methodis still practiced,there is a progressiveswing were evaluatedin terms of decibel (dB) changes. over the yearstowards the underlaytechnique intro- Duration of follow-up was noted.The outcomeof ducedby Austin and Shea[3]. Sandwichand plug- surgery was evaluated in terms of graft take and *Graded Specialist (Otolaryngology), INHS Asvini, Colaba, Mumbai - 400 005. Jour. Marine Medical Sociery,Jan-Jun 2000, Vol. 2, No. I 35 audiological improvement. Finally, various factors panic membranewith no evidenceof middle ear were analyzed to determine their influence on the disease.Based on.this,37 (80.43Vo)patiens had surgicaloutcome. successfulmyringoplasty including both primary andrevision surgery. Improvement of hearingwas RESULTS achievedin35 (76.09%)patients. The presgnceof There were a total of 46 transcanal tym- middle ear inflammationand tympanosclerosisat panoplasties done for 27 males and 19 females. the time of surgerywere fourid to hayesignificant Their ages ranged from 13 to 60 years with an effectson.the surgical outcome; P < 0.05.Compli- averageof 27 years. Duration of follow-up ranged cationsdid not occurrediir anyof thepatients. from six monthsto eighteenmonths with an dverage of nine months. The dominant etiological factor of DISCUSSION tympanic membrane perforation was infection dnd Stattusof Middle Ear at Surgery the majority of patients had their diseasefor more than three years.Central perforations were found in Infectionwas the major etiological fuctor of tym- all patients.Thirty one (67.39Vo)had large perfora- panicmembrane perforation. Only two percentof tions with a conductive impairment of 25 dB or more the perforati TABLEI Sizeof perforationand take rate percentage(it=46) Small Moderate Latge Total Perforation Perforation Perforation No. (%) No. (%) No.(%) No.(%) Successful l0 (83.33%) l6 (80%) u (7857%) 37 (80.43%) Grafting Graft failure 2 (16.67Vo\ 4 (20%) 3 (tr.43%) 9 (r9.57%',) Total t2(rN%) 20(t0n'%) 14(100%) 46(r0/J%) TABLE 2 l,ocation of perforation and take rate pcrcentage(n=45) Posterior Central Anterior Total Quadrants No.(%) Quadrants No. (%) No.(%) No.(%) Successful t3 (8r.2s%) 12(85.7t%) t2 (75%) 37 (80.43%) Grafting Graft failure 3 (r8.7s%) 2 (14.29%) 4(25%) 9 (r9.s7%) 16(100%) 14(rffi%\ l6 (100%) 46 (100%) 36 Jour. Marine Medical Society, Jan-Jun 20O0, Vol. 2, No. I In this study,statistical analysis showed no signifi- with adequateexposure, reduced operating time and cant difference in successrate between moderate decreasedmorbidity. The presenceof middle ear and small perforations. infection, relatively inexperiencedsurgeons and tympanosclerosishowever have an unfavo'urable Site of Perfo.ration effect on the surgicaloutcome. The surg.icalresults Problems may arise with perforations located in this studyare in agreementwith otherpreviously anteriorly.This may lead to anteriormedialisation publishedstudies in termsof final surgicaloutcome of the graft.These problems, can be overcomewith and hearing improvement thereby proving that improvedtechniques. Many authorshave found no trans-canaltympanoplasty can yield good results relation between site of perforation and graft take comparableto tympanoplastyby other approaches. rate [5,17]. This study did not revealany relation REFERENCES betweenthe site of perforation and graft take rate. l. E Myringoplastikzeitschrift fur. Ohernheilkunde1878; l2 : Tympanosclerosis r34. Histologically the tympanoscleroticplaques are 2. Efy ET. Haut-transplantation bei ch{onischer eiterung des von H zeitschrift fur. thought to have less blood supply. Some authors mittelohres uebersetzt Steinbrugge ' Ohrenheilkundel88lt l0: 146-8. havenot considbredthis a significantfactor [16,18]. In this study,plaques were removed if they involved 3. TangemannCW. Tympanic membranereplacement by skin the perforation margins and were mobile. Eighteen grafting zeitschrift fur. Ohrenheilkuntle 1884; 13 : 174-6. patientshad tympanosclerosis.The take rateswere 4. Schrimpf WJ. Repair of tympanic membrane perforation eleven (6l.ll%o) and twenty six (92.86Vo)respec- with human amniotic membrane.A nn Otolaryngol 1954; 63 tively and the differencewas highly significant,P < : l0l-15. 0.05. 5. Hall A. Central tympanic membraneperforations: treatment with prosthesisor free transplantation.Svenska ktkartidnrn- Surgical Technique gen.l956;53: 140-5. The level of training of surgeonswas found to be 6. Holewinski J. A trial of covering the tympanic rnembrane of significancein this study. Operationsdone by with a corneal graft. Otolaryngologia Polska 1958; 12 : surgeon! on staff were successfulmore frequently 349-50. (84.57o)than thoseby residents(68Vo). 7. Claros DomenechA. 100tympanoplasties practiced with the aid of the use of f.reeperiosteal mepbrane graft. Revue de Audiological Resul* Inryngologie, Otology, Rhinologie(Bordeaux) 1959: 80: The pre and postoperative audiograms were gt't-2r. availablein all cases.Thirty five (76,097o)had an 8. Shea JJ. Vein graft closure of eardrum perforation. Arclr improvementof l0 dB or morein hearingfollowing Orolaryngol 1960l.72 : 445-7. surgery. 9. Portmann G, Portmann M, Claverie G. The surgery of deaf- ness.Translated by W.{ Sultanaand W Mckenzib.Progress Complications PressCo Ltd. Valetta,Malta 1964;336. Permanenthearing loss can occur in 3Voof pa- 10. Ringenberg JC. Fat graft tympanoplasty. ktryngoscope tientsoperated on for chronicotitis media l9]. This I 1962:.72:188-92. iatrogenic hearing loss may be due'to excessive ossicular mobilization, fracture of stapedial foot ll. Goodhill V, Harris I, Brockman S. Tympanoplasty with perichondrialgrafr. Arch Otblaryngoit1964: 79 : l3l. plate, direct trauma, br introduction of toxic materi- als.In this study,no complicatiohswere seen. I2. Ortegren U. Trumhineplastik.forhandlingar i svensk oto- laryngologisk forening. 1959; 162. CONCLUSION 13. Austin DF, SheaJJ. A new systemoftympanoplasty using Chronic middle ear diseaseis common in the vein graft.Laryngoscope l96l; 7l :596-61 l. servicepopdlation and their dependents.Transcanal 14. Cibb AG, ChangSing-Kiat. Myringoplasty. J ktnngol Otol tympanoplastyis a minimally invasive procedure 1982:.96:915-30. Jour.Marine Medical Sociery, Jan-Jun 2000, Vol. 2, No. I 37 DF. Reconstructive technique for tympanosclerosis' 15. Sheehy JL, Anderson R. Myringoplasty. Ann Otol Rhinol 18. Austin 1988:9'l :6'10-4' Laryngot 1980;80 : 331-4. Ann otol Rhinolaryngol 19. SheehyJL, Simon c, David RE' Acquiredcholesteatoma in 16. shelton c. Tympanoplastyresults in a residencyproglam. adults.The oto|aryngol N Amer. Philadelphia,Pennsylva- orolaryngol 1985;93 : 103-?. nia' USA' WB Saunders.1989;22 :976' l?. Wayne MK, FiredmanEM' Trevor JL' e,zzJTympanoplasty . in children.Arch OtolaryngolHea.d Neck Surg 19901I 16 : 35-40. I 38 Jour. Marine Medical Society,Jan-Jun 2000' Vol. 2' No' IMPORTANCEOF PHOSPHORUS SUPPLEMENTATIONIN PREVENTION OF OSTEOPENIAIN PRETERMS SurgCdr GIRISH GUPTA, Dr SUSHMITA GUPTA, Surg Lt Cdr G KHULLAR, Surg Capt KS BAWA ABSTRACT This experimental,randomized, single blind study was conductedto evaluatethe importance of phosphorous supplementationon biochemicaland radiologicalparameters of osteopoeniain low birth weight neonates.This study included 36 low birth weight babiesweighing < 2000grams,admitted to NICU of INHS Asvini between May 96 and June 97 and who receivedbreast milk. Thesebabies wererandomly assigned to three groups.Group I neonatesreceived no supplementswhile neonatesof Group II receivedSyrup'O'containing calciumin doseof lE0-200mgs/t INTRODUCTION may manifestlater as decreased linear growth, frac- turesor overtrickets The osteopenicbones are n steopeniaof prematurity(ooP) is a meta- [5-8]. more susceptibleto fracturesduring minimally in- I lUolic bone disease(MBD) with an inci- \-t dence rate as high as 30-50Voin infants vasiveprocedures and even during routinehandling weighing lessthan 1500and 1000gms respectively while in the NICU. Poor mineralisationof the rib weak- at birth Il,2,31.It occursmore due to a deficit in bone cagesecondary to low bone P and muscular mineralslike calcium (Ca) and phophorus(P) and nessdue to hypophosphatemicmyopathy in babies not just vitamin D insufficiencyas believedearlier. with respiratorydistress contribute to difficulty in Pretermsbegin their life with less storesof Ca and weaningoff the ventilator. P as they are deprived of 80Voof the bone mineral In our countrythe commonpractice is to supple- accretion that occurs in the last trimester of preg- mentbreast milk with vitaminsand sometimeseven nancy[4]. A fall in the serumlevels of Ca and P are iron but rarely with Ca and P Parentralphosphorus compensatedby their reabsorptionfrom bonelead- is not availablein our marketsand a very few oral ing to osteopenia.The absenceof obviousclinical preparationsthat can be usedin the neonatecontain signscan delay the'diagnosisof osteopeniawhich this mineral.The importanceof this condition and. Neonatal Unit, Department of Pediatrics, INHS Asvini, Colaba, Mumbai - 400 005. Jour. Marine Medical Society, Jan-Jun 2000, Vol.2, No. l 39 the lack of awarenessand data on this subjectin a standardexposure of 54 KVP and l5 mAmps.The lndia has beenthe inspirationfor this study. first X-ray was preferably taken between the fifth andseventh day of life. The secondwas takenat the MATERIALS AND METHODS end of the third month.These X-ray's were read at This prospectivestudy which was carried out a professionallaboratory using an instrumentcalled over a l4 monthperiod included forty four low birth X-RITE Photodensitometer.The instrumenthas a weight neonatesweighing lessthan 2000 gms. In- light sourcewhich consistsof a siliconephotodiode. fantswho receivedany milk otherthan breastmilk, The light from this diodeis directedtowards the site did not form a part of the study. Parentswere ex- to be readon the X-ray film placedwithin. Depend- plained about the nature of the study and consent ing on the densityof the bone,a ceftain amountof was taken.Each baby was followed over a periodof light is reflectedback which is perceivedby a photo three months.During the courseof the study, one cell, quantified and displayed[3]. The density is baby died and seven were lost to follow up. The gradedon a scalebetween 0.00 and 4.00 with a lower remaining36 babieswere divided into threegroups readingindicating a denserbone. The site we chose by randomnumber tables. However randomization to usewas the lower third of the radius[14,15]. was not appliedin a few casesfor ethicalreasons. These X-rays were also reviewed by the radiolo- Group I : Receivedno supplementation. gist to look for changesof rickets and detect frac- Group II : Receivedonly Calcium supplements. tures / microfractures.Using the "Koo's scoring Group III : Receivedboth calciumand phospho- scale", the X-rays were graded into four categories rus. tl6l. - Babieswith no contrindicationsfor enteralfeed- o Normal Normal density of bony cortex along ing were startedon expressedbreast milk or were with normal dense white line at metaphysis put directly to the breastwithin a couple of hours with normal band of lucency in submetaphy after birth. Of these,the ones in Groups II and III seal region. were given the predecidedsupplements from the o GradeI - Lossof densewhite line at metaphysis fourth/fifth day oflife. The restreceived parenteral with increasedsub metaphyseallucency, and nutrition as per the daily requirementsof glucose thinning of cortex. and electrolytes.IV calcium was given to all these r Grade2 - Changesof grade l+ inegularity and babiesfor ethical reasonsas long as enteralfeeds fraying of metaphyses,with splayingand cup- were not started in a dose of l8 mg/kg/dose,6 ping, i.e. changesof rickets. hourly. Once on full oral feeds,they were put on o - supplementsaccording to their grouping.Group II Grade3 Changesof rickets with evidenceof receivedsyrup O containing82 mg of calcium/5ml. fractures. Group III was given syrupC composedof 66 mg of To removeany bias from the study,the radiolo- elementalcalcium and 30 mg of elementalphospho- gist, the observerfor densitometryand the labora- rus/5ml. The neonatesin GroupsII and III received tory personnelinvolved were blinded as they were approximately 180-200 mg/kg/day of calcium. not informed about the groups or supplementation About 85-100 mg/kg/dayof phosphoruswas given protocols. to the neonatesof Group III [9,10]. All babiesre- The biochemicaland radiological observations ceivedVitamin D in a doseof 400IU perday.These were thus obtained and a statisticalanalysis was 't' supplementswere continuedtill the babiesattained carriedout usingthe student testto find out if the a weightof 2000gms I I,l2]. supplementationhad a significanteffect on them. Venous blood wab collected from a peripheral RESULTS vein at l, 4, 8 and 12 weeksof life in plain bulbs I l]. This was sent to the hospital laboratoryfor The serumCa andP valueswere not significantly estimationof serumcalcium, phosphorusand alka- different in the supplementedgroups as pompared line phosphataseby an Auto-analyzer. to the group that receivedonly breastmilk. Each baby was exposedto two kidigramsusing As shown in the Table I and Fie. I below the 40 Jour.Marine Medical Society, Jan-Jun 2000, Vol.2, No.I 86Voincrease in Group II and only 23.6Voincrease in GroupIII whichis significantlyless as compared to GroupsI andII. The averapedensitometer reading in Group I increasedby 20:79oattheend of 12week which was significantlymore (p < 0.05) as comparedt TABLE I Comparison of alkaline phmphatase Averagedkaline phosphatase I. U/L (x I SD) lst week 4th week 8th week 12thweek GroupI 428t246 6t2+ 280 *862t 396 *1027r 598 Group II 625t52r 795t 3r7 978r 595 +l 165t 809 GroupIII 542t213 &4t 159 678r 185 67rt203 *significant(p < 0.01) TABLE2 Profile of patients with positive Koots scores. Sr Group Wt. in Gest. Complications Koo'sscoresKoo'sscores APat AP at DR at DR at No. Gms. age at I week at 12weeks I week' 12weeks I week 12weeks l. I 1960 34 weeks Hypoglycaemia 0 3 326 1450 1.0 t.73 2. I l72O 32 weeks HMD 0 676 2tt4 1.04 1.68 3. u 1380 28 wceks BA, Pneumonia,IVH, 2 3 1029. 1257 1.63 t.7 PDA, PIIHC, Anemia Apnoca Infection 4. l2O5 33 weeks HMD, Apnoea, 2126 l02l t.49 l.0l Feedintolerance 5. II 1590 32 weeks I 656 959 i.zs 1.88 6. II l165 30 weeks Apnoea,Infection, IVH 2 236 3132 0.98 1.5 '7 m 1405 35 weeks I 0 625 785 0.81 0.87 Jour. Marine Medical Society,Jan-Jun 2U)0, Vol. 2, No. I 41 TABLE 3 Profile of patientswith alkaline phosphatase> 1200IU at 12weeks ofpost natal life Sr. Group wt. in Gest.age in Complications Koo's score Koo's score DR at DR at No. gms. wks. at I week at 12 weeks I week 12 weeks l. I 1905 34 0 0 0.9 1.14 2. I 1960 34 Hypoglycaemia 0 J 1.0 r;13 J. I 1490 32 Infection, Feed intolerance 0 0 1.4 L89 A I 1720 32 Hyaline membranedisease 0 2 1.04 1.68 5. I r765 35 0 0 1.57 1.83 6. II l 165 30 Anoea, Infection, Intra - ventricular 0 2 0.98 1.5 haemorrhage '1. II t425 3l Apnoea, Infection 0 0 r.22 l.9 8. I 1380 28 BA, Pneumonia,IVH, PHHC, PDA, a J 1.63 |;1 Apnoea, Anemia, Infection HMD - Hyaline membrane disease; BA- Birth asphyxia; IVH - Intra-ventricular haemorrhage;PDA - Patent ductus arteriosus; PHHC - PosGhaemorrhagichydrocephalus; AP - Alkaline phosphatase;DR - Densitometerreadings. TABLE 4 theseobservations that by adequatelysupplement- Complicationcorrelates with positiveKoo's scoresand alka- ing bothcalcium and phosphorus we canprevent the phosphatasevalues > IU line 1200 occurrenceof metabolicbone disease which would GroupI GroupII GroupIII otherwiseadd to the already long list of illnesses known to occur in theseinfants. HMD IVH DISCUSSION PDA In our study,we ried to find the contributionof NEC calcium and phosphorusin the preventionof this Infection disease.The calcium and phosphorusvalues were Feed intolerance not significantly different in the supplemented * I ** | *** - Caseswith complicationsin ea'chgroup groups as comparedto the group that received only K - Positive Koo's scores breastmilk. Previousstudies were equivocal in their A - Alkaline phosphatasevalues > 1200 I. U/L calciumresults [1,2,6,9,16-19]. However many of these studies shows reduced serum phosphorus in None of the well supplementedGroup III babies affectedinfants at various periods during the course featuresin the above Table. All the babiesin this of follow up in unsupplemented babies table were preterrn, 67Vobeing less than 33 weeks. U,2,6,9,17,181.Koo's studiessupport our findings All the eight patients showed an increasein densi- of unchangedphosphorus [6]. tometryreadings at 12 weekswhich conelatedwell The natural history of plasma alkaline phos- with the high alkalinephosphatase values. phatasein normal full term infants is to rise over the The number of complications charted in the fig- first three weeksand then plateauuntil the ageofsix ure in Groups II and III are nine and eleven respec- weeksI l]. The GroupIII infants,who weresupple- tively and hence the groups are comparable.None mentedin an attemptto achieveintra-uterine min- of the patients in Group III who had the above eral accretion. demonstrated the same course of complicationsdemonstrated either positive Koo's plasmaalkaline phosphatase activity, despitebeing scoreor high plasma alkaline phosphatasevalues. bom prematurely.Rises that occur after this are seen On theother hand, all thegroup II infantshad at least in infants receiving low phosphatediets as in our one abnormal reading. Of them 897oshowed abnor- first two groups Illl. A rise of 1407oobserved in malities on both X-ray and serum alkaline phos- Group I indicates a rapid turnover of bone to main- phatasereadings. We can therefore conclude from tain serum calcium and phosphoruslevel in their 42 Jour.Marine Medical Societv, Jan-Jun 2000, Vol. 2, No. I mineral deprived state.A significantrise in Group The elevenfull-term but low birth weight infants II further emphasisesthat supplementationof cal- in this studywere unaffected irrespective of whether cium aloneis not sufficientto keepthe bonesin the they were supplementedor not. None of theseneo- bestof health.Difficulties arisein the interpretation nates weighed < 1500 gms. However among the of resultsof alkaline phosphataseand comparison preterms,even someof thosewho weighed> 1500 with other centres becauseof the use of different gms showedevidence of bone diseasewhen they assaysystems with widely varying rangesand dif- were denied the due mineral requirements.This ferent units of measurementI l]. As in previous supportsvarious studies that osteopeniais a disease studieswe haveused 1200I. U/L asthe cut off point of pretermlow birth weights|0,11,16,21,221. which is approximatelyfive times the normal adult Longer studieswith larger samplesizes are re- values[8]. Our studyalso demonstrates that risesin quired to refute or agree with our observations. plasmaalkaline phosphatase values correspond with Clinically thereappeared to be no adverseeffects of an increasein Koo's scoreand densitometryread- supplementationin our babies.However, estima- ings.Alkaline phosphatasehas received its due im- tions of serum25 (OH)D, serum parathyroidhor- portancein this as well as most other studiesas an mone, urinary and stool calcium and phosphorus early and reliable indicator of metabolicbone dis- would help uslearn more about the pathophysiology ease. of metabolic bone disease,study the amount of The measurementof BMC by varioussophisti- calcium and phosphorusactually retained by the catedmachines like single and dual photonabsorp- body and monitor patientsbiochemically or hyper- tiometry and X-ray absorptiometryhas yielded good calciuria. resultsto detectosteopenia and is practisedfor re- It is essentialtherefore to dither from our usual search purposesin the western countries.In our practicesof providingjust vitaminsand calcium and study the nonavailabilityof theseexpensive equip- resortto morecomplete supplementation containing mentsprompted us to choosea more feasibleand phosphorusalso. Considering our economicalcon- costeffective modality of diagnosis.The samekidi- straintsand the well known advantagesof breast gram was usedfor detectionof radiologicevidence milk, we do not wish to usepremature milk formu- of osteopenia.Our observationswere suggestiveof lae.However, presently we recommendthat all pre- a lossof bonedensity in the unsupplementedgroup terms should receive 180-200 mglkglday of cal- by the l2th week. cium, 85-100 mglkglday of phosphorusand 400- PJ Congdon et al in his study claims that bone 500 IU of vitamin D in additionto breastmilk. mineral depletion resolved spontaneouslyin pre- REFERENCES term infantswhen studiedupto a post conceptional L Callenback JC, Seehan MB, Abramson SJ, Hall RT. Etio- ageof 70 weeks[20]. A longerfollow up to look for spontaneousresolution of bone changesin the un- logic factorsin rickets of very low birth weight infants."/ Pedtuticsl98l:98 : 800. supplementedand partially supplementedgroups to concludewhether supplementsare neededat all is 2. Kulkarni PB, et al. Ricketsin very low birth weight infants. required.However, fracture and bonechanges at an J Pediatrics1980:96: 249. early age would definitely be deleteriousto the 3. SeinaY. Arch Dis Child l98l:'56:628. growth of the infant. Not having reachedthe ageof 4. Ziegler E, O'Donnel A, Nelson S, Fomon S. Body compo- weightbearing,many fractures would go undetected sition of the reference fetus. Growth 19'16:4O : 329. in early infancy. Our study showedpositive radio- 5. Pejaver RK, Hifzi AI. Osteopenia of prematurity. Indian logical changesin seveninfants including fractures Pediatrics 1997:'34 : 543. in three.These three babies did not receivephospho- 6. Chan GM. Growth and bone mineral status of discharged rus.The outcomeof this problemwill almostsurely very low binh weight infants fed different formulas or hu- inflict some morbidity to the infants in the days to man milk. J Pediar 1993:123:-439. come. All the infants with radiologicalevidence of - bonedisease were preterrn andS6Vo of themdid not 7. Lewis P Rubin.Cloherty's manualofneonatal care l99l; receivedadequate mineral supplementation. 3:446. 8. LucasA, BrookeOG, BakerBA, BishopN, Morley R. High Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I 43 r alkatirc phosphatascrctivity and growth in protcrm nco- S. Skclctalclangcs in prercrminfrnts . Arch Eis Child 1982: natc6.Arcrr Djs Child 1989;& :99?. 57:447. 9. GroesJS. Bonc miner-alizationin prctctm infantsfed iruman 17. Abrains $A. ScttanlcrJ, Garzp C. Bonc mimralizadqr in milk $ith irnd without mine.nl srpplcmcntation.J Pcdiar fornrcr vcry low blrth weiglrt infins fcd cithcr humanmilk l9E7;lll :450. or commcrtial frnaul a- J Pediatr.198',i. ll2 : 956. 10. SleicbenJI, Granon TI- TsangRC. Oseopcniaof pr,ema- lE. Rowc J, et d. Hypqphocphatcmiaand hypercalciurie in turity : Carne aird possibletre4qrcnt. J Pediur l9E0: 96 : snall prematureirthnts fd human milk : Eyidercc for 528. iriadcquatcdictary phosphoruslJ.Peiy',rrrur 1984; l& : ll2. I l. BishopN. Bone diseascin preterminfants (regulsr rcvicw). l9E9;64: 1403.. 19. Glascr K, ParlnclccAH, Hoffrmn WS: Corryarative efri- cacy of vitaninD pnoparationsin'pnophylactic trcatmcnt of 12. TsarrgRC. Celcium, phosphqus and mnpesium mctabri 'premuure irifarrts.A;n J Dis Child 1949;Tl : l. lisfn : Osteopeniaand rickqtp of prem*uriry. Nealrltat Physiotogybj Polcnlto, 1gg4;17 66. il. CottgdpnPl, ct al. Spontaneousresolutiort of bonemircral preterm 13. Gtn SM. An J ClinNwr l%2! lO : 69. &pletion in infahts.Arc& Dis Cftild 1990:65 : 1038. 14. WahnerHW. Easiell R, RiggsBt-. Bone.mirrcraldcnsily of 2.1. Iryon NJ, MclntoehN, Whgcla l(.Wrlliams IE. Radiologi- thc radius: When do wc stdnd?JNrc, Med 1985;26; 1139. .cd rickcr in cxtrenrcly low birth weight.infanis. Padictr 15. StcichenlJ,cral. Bonc mincralmcesurementinsmdlinfahrs nuiia lgllill :so. by singlc p[oton ahorpriorrcrry : Current rcnodologic 22. Hirsman A. Ry.anSSr, CongdonPI,TrusconJG, JamcsJR. isorcs.'JPediatr 1988; l13 : l8l. O*cqicnia.in extsemelylow birth wcight idants. Arch of 16. Km WWK, Gupta JM, NayanarW, Wilkinson M, Poscn Disinc//lid'8i89;64:,|85. ,t4 Jour. Marhe Medbal Society,Jan-Jun 2000,Vol. 2, No. I ESTIMATIONOF MCV IN CASES OF ALCOHOL DEPENDENCE Surg Cdr AA PAWAR*, Surg Cmde FS VALDIYA+, Surg Lt Cdr KK MISHRA++, Surg Cap MK GUPTA** ABSTRACT The purpose of this study was to estirnf,tethe significanceof estimating the Mean Corpuscular Volume (MCV) in alcoholdependence and thereasonfor the ssme.Onc hundrcdftesh casesof Alcohol dependencesyndrome who met the ICD 10 criteria were td(en and the MCV vahreswene comprned with fresh cascsof psycfriairic disorders. An attempt was alio made to correlate the MCV valrreswith the lrepatic errzymesSGOT, SGPT as well as,the averagedaily consumption and the duration of drinking reported by Orecases of alcohol dependence.Findings revesl that MCV valueswertsignificantly raised in cas€sof atcoholdepmdence.Therewas no correlation of MCV with the other factors. E"stimationof MCV can be e useful indicator in recognfsingthe presenceof alcohol abuse as well as an objective indicator of followup. KEY WORDS : Alcohol dependence,MCV INTRODUCTION AIMS OFTHE STUDY A lcohol cousumptbnis wideqpreadin India l. To studythe MCV in casesof alcoholdepend- ence, /l and especiallyin the services.Stories and l- lpoems of drunken sailors aboundin the 2. To comparethe resultsso obtained with a group Westernliterature [], Thecivilian looks with onvy of abstinentpatients.and test for significanceif at theman in.uniform and is willingto go a coxsid- any. erableextent to getthe liquor off hirn.Tiaditionally a landof prohibition,in whichalcohol consumption INCLUSION CRITERH wasfrowned upon by society,the situationhas un- l. All freshand relapse cases of alcoholdepend- dergonea seachange in ourcountry. Alcohol is now ence admittedin the Deaddictioncentre of freely servedby numerousretail oudets apd adver- INHS Asvini weretaken up for the study.The tisedon televisionchannels. Excise figures pirr the diagnosiswas made by the ICD l0 criteria. growthat fifteenpqrcent annually. EXCLUSION CRITERIA Alcohol consumptionis difficult to estimatein l. Haemoglobinless than 12 gmVo. any settingas peopleare adeptat concealingthe amountthey consume.Also peoplewho are diag- 2. Presenceof hepaticdisease i.e. clinicalliver greater nosedas alcohol dependent tend to denytheir drink- enlargementand/or serum bilirubin than percent. ing to avoid medicalcategorisation. It is therefore onemilligram necessaryto dependon the laboratoryto revealthe 3. Patientstaking any NSAIDs. truth.The MeanCorpuscular. Volume orMCV and 4. Patierttswith historyof pepticulcer. the enzymesSGOT and SGPTare reportedto be raisedin thesecases and thus serveas an indirect MATERIAL AND METHODS pointerof thedisease. The MCV is especiallyuseful All freshand relapse cases ofalcohol dependence asits riseis not linkedto anyorgan damage and can weretaken up for the study.A blood samplewas thusserve as a usefulpointer of continuingalcohol takenat the time of admissionand sent for estirna- consumption. tion of Hb, TLC, DLC, MCV, LFT includingen- 'Director, *Classified Specialist Psychiatry INHS Asvini Mumbai. Institute of Naval Medicine. Formerly Consultant Psychiatry to Indian * Armed Forces. Graded Specialist Psychiatry; **Senior Adviser Pathology INHS Asvini. Jour. Marine Medical Society,Jan-Jun 2400, Vol.2, No. I zymes.The controls were newly admittedcases to liverdiseaseand the macrocytosis of alcoholism[3]. the psychiatric ward who were not on any medica- Here the MCV rise is saidto be moderateand usually tion and who reported abstinence from alcohol. in the range of 100 to I l0 cu. Macrocytosis is Only male caseswere taken up for the study.The usuallyseen in 82to96Vo of chronic alcoholicsand groups were matched for age and the results were is unrelated to folate deficiency or liver disease. analysed.An attemptwas alsomade to correlatethe Anemia is usually absent.Macrocytosis persistsun- results with amount of alcohol consumedin one til the patient abstains from alcohol and usually sitting and the durationof consumption. retums to normal only after two to four months [4]. RESULTS Our study also confirms thesefindings. In our study the mean MCV in patientsof alcohol depend- the data reveal that both the A comparison of encewas 100 cu while that in the controlswas 9l groups were matched for age (Table l). A statisti- cu. The maximum value obtainedwas 140cu. Oth- result was obtained in the MCV cally significant ers havealso confirmed thesefindings in teetotalers. casesas comparedto results of alcohol dependence A study in Swedishpopulation has revealedthat the patients (Table l). There was a poor the abstinent mean MCV values in abstinent adults range from correlation of the MCV with enzymes SGOT and 79.5 to 91.5 cp [5]. A recentstudy has claimed that in casesof alcohol dependence. SGPT a MCV value of more than 94 cp can successfully recognise67Vo of the malesin the community who TABLE1 aredrinking hazardously[6]. Alcoholdependent Abstinent patients controls We attemptedto confirm thesefindings by trying Numberof subiects 100 30 to correlate the amount of alcohol consumed with the MCV value. A weak negative correlation was Age (years) Mean 31.9 35.8 obtained from the data indicating probably that the SD 8.54 8.34 extent of rise in MCV is not linked to the amount of MCV Mean 100.3** 91.5 SD 8.5 4.77 alcohol consumption.Similarly the duration of al- SGOT Mean 63.67 39.7r cohol consumeddid not correlatesignificantly with SD 30.87 9.8'l the MCV. SGPT Mean 77.25 36.83 The MCV valuesshowed a weak correlation with SD l6 14.28 hepaticenzymes SGOT and SGPT thus suggesting Averagedaily 5.87 consumption 2;77 that the rise in MCV is not due to liver damage Durationof drinking 12.72 induced by alcohol. The importanceof the MCV 8.08 datalies in the follow up of patientswho arealcohol dependent.As statedearlier, MCV values take two **Indicates * Note : significance at the < .01 level. indicates to four monthsto return to normal. Absenceof return significance at the < .05 level. to normality thus indicatespersistent alcohol con- sumption and becomes an objective indicator of DISCUSSION alcohol abuse in the absenceof withdrawal symp- Alcohol abuse is a common problem in the toms. MCV has been reported to have a high speci- Armed Forces.Cases of Alcohol dependenceoften ficity of about 957o [7] and being easy to estimate tend to deny the sameon follow up in the OPD. In can be useful in estimating alcohol abuse in the population the absenceof any mention of alcohol consumption ambulatory if othercauses can be elimi- in the AFMSF 10 report, it is necessaryto rely on nated. any objective evidence to confirm the consumption Other markers of alcohol consumption which of alcohol. The rise in MCV is said to be linked in a have beenreported in the literature are the enzymes linear dose relationship with alcohol abuse [2]. gamma glutamyl transferase, beta hexoseami- MCV rise in alcohol is said to be due to one of the nadase,alpha glutathione-s-transferase,mitochon- following four causes : folate deficiency, reticulo- drial AST, uric acid, triglyceride levels and carbo- cytosiscaused due to GI bleeding,macrocytosis of hydrate-deficient transferrin[8]. Estimationfacili- 46 Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No.I .\ e tiesofthese are however not avaiiablefreely. (2): l3l-8. esis coNcl,rJsroN 3. Wu A, C'hanarinI, Irvi AJ. Macrocytosisof chronic alco 5,4 holism.Zance, 194: | :829. sof I\t[eanCorpuscular volirme is significantlyraised .30. in patiantsof alcohofdependence in the absenceof 4. MyrhedM, BcrglundL, BottingerlE. Alcohol consumption anaemiabrhepdtic'damage. Its estimationcan help andhaematofogy. Acu MedScand 1977;N2 : ll. An- in the follow up study of such cariesas a reliable 5. Helander Vabo E, Lcvin Borg S. Intra and inrcr tal- A K indicator'ofabsence br persistenceof alcoholcon- individual variability of carbohydratedcficient transJenin, sumption. gammaglutamyl transferaseand moanco-muscular.volume ime REFERENCES amongteetotalers. Clin Chem198; 4a (10) :,212-G5. um l. 4odystun JA,.Perry JQC. Military Psychiatry.In C-ompre- 6. PcachHG, Bath NE, FarishS. Predictivevaluc of MCV for in- heqsiveText Book of Psychi*try.Third Edition, Edltbrs HI hazardou3drlnking in'the community. Clin Lab Haemat Kaplan"AM Fleedmaa'BJ Sadock Williams and Wilkins. 1997t19 (2):%-7. gaftimorc. and i98o : 3 : ?39b. 7. WhelanG.Biological markenof algoholisn A alstNZ J Med dp 2. WhiteheadTP. RobinsonD, Allaway SL, Hale AC. The t992:22(2):?.8-13. fia- effects of cigarctte slnolcingand alcotrol c,onsurnpiolr..on ;10 blmd haemoglobin,effiaytes an{ leucocycs : a dose E. SharpPC, McBride R, Archbold GP. Biochemicalmarkers relatedstudf on malesubjects. CIin L,abHaemaot 195; l7 of alcobol wi. Qtu 196; 89 (2) : 13744. c. I Jour.Marine trdedical Society, Jan-Jun20N, Vol.2, No.I 47 PROGNOSTICVALUE OF CLINICAL VARIAtsLES IN PATIENTSOF SEPSISSYNDROME AND CORRELATION WITH INTE,RLEUKIN6 SurgCdr YD SINGH*, Surg Cdr RN MISRA+, . Lt Col IsaacMATHEW#, Lt Col AS KASHYAP#,BrigAS KASTHURI,VSM xr, ABSTRACT SepstsSyndrome (SS) is a major problemin criticalcare medicine and is the mostcommon cause of deathin medicalICU. Cliniciansflaced with critically ill patientsneed to haveclinical and biochemicalprognostic criteria, becauseearly institution of appropriatetherapy is associatedwith improvedsurvival. Various clinical variables have been shown to have prognosticvalue in patientswith SS. Interleukin 6 0L-6) has beensuggested as an important marker of sepsis. This prospectivestudy wasdone to determinecorrelation of the clinical variablesand circulating IL-6 levelwith outcomeof SS patients.50 corsecutivepatients, who met the pre-dgterminedcriteria for SS,were studied.20 critically ill patientswithout sepsisfron medicalICU and 20 healthyvolunteers served as control. Followfngclinical variableswere studied: Clinical suspicionof infection(present in 767oof patients),fever(64Vo), tqpothermia (l8%o\, tachycandia(l0OVo) tachypnoea (86%), oliguria (26Vo),unexplained metabolic acidosis (LBqo\,hypotension (44Vo), recent change in nrentalstatus (347o) and unexplainedcoagulopathy (34Vo). Patient survival was 447o.Gram negativeorganisms were the commonestisolates. 929o patientsof SS had detectable l6vehof IL-6 (median120, range non-detectable to f480 pg/ml,). Levelswere highei than critically ill and normal cbntrol groups(p < O.ffif ). Prcsenceof Fever (p < 0.05)signifred better prognosis.Hypothermia (p < 0.01),unexplained metabolic acidosis (p < 0.01),unexplained coagulopathy (p < 0.001),and thrombocytopenia(p < 0.001),if present,signified poor prognosis.Other clinical variablesdo net correlatewith outcomein SS.High circulating IL-6 levels(median 210 pdml) predlct p INTRODUCTION procedures,increase in use of cytotoxic and immu- nosupressivedrugs and increasein antibiotic resis- espitecontinued advances in antibioticther- 1'\ tant infections[5]. The ever increasingnumber of apy andintensive care technology, mortality I f patientswith AIDS is also instrumentalin the dra- -4-, attributedto (SS) sepsissyndrome has re- matic increasein the incidenceof sepsisduring past mained in excessof 30Vo This catastrophic [,2]. decade[4]. Sepsisis reportedto be the most.com- syndromerepresents a majorproblem in criticalcare nnn causeof deathin the ICU [4]. medicine. The incidence of SS has continued to The clinician faced with a critically ill patient increase[3,4]. Indian data is not readily available, however the problem is of grave importance as we needsto have some prognostictool becausewhen are increasingly recognising patients with septic clinical diagnosisis made,the mortality rate is al- shock and multi organ failure. The incidence is ready high [6]. Early institution ofappropriate ther- steadilyrising due to increasedlongevity ofpatients apy is associatedwith lower incidence of septic proneto developsepsis. Other importantcauses for shockand improvedsurvival [7]. rising incidenceinclude increaseduse of invasive Advancesin understandingthe pathophysiology *ClassifiedSpecialist (Medicine), INHS Kalyani, Visakhapatnam,530 005.'Clmsified Specialist(Pathology), INHS Asvini, Mumbai 400 005. "Assoc. Professor: **Commandant. 158 BH C/o 99 APO. Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I t of sepsissyndrome have promptedthe development (d) Recentchange in mentalstatus of new prognostic markers [8]. Most of the patho- (e) Unexplainedcoagulopathy physiologic changesin septic shock result from a complex cascade of mononuclear phagocyte de- Laboratoryconfirmation of sepsisor admission rived endogenousmediators. to medicalICU at the time of inclusion in the trial was not a prerequisiteby protocol. IL-6, previouslycalled p cell growth factor,has been shown to correlate with mortality in patients Exclusioncriteria includedpatients with an un- derlyingdisease with sepsis[9,10]. Infusion of IL-6 causesno ad- otherthan sepsis, limiting expected versehaemodynamic changes. Studies suggest that survivalof lessthan two weeks(e.g. severe cerebral IL-6 may be a marker of systemic inflammation trauma,> SOVobums or terminal cancer).Patients who had receivednalaxone, pentoxifylline, gluco- rin ratherthan a mediatorof sepsist9-l ll. corticoides, growth hormones or bromocriptine in ria, This study was done to determine correlation of preceding24 hourswere also excluded. rles theclinical variablesand circulatingIL-6level with an the outcomeof SS patients. As soon as the patient was suspectedto have sepsissyfJrome and met the predeterminedinclu- dth PATIENTS AND METHODS sion criteria, seven ml blood was collected into ,20 This prospective study covered a period of two endotoxin-freetubes containing disodium ethylene years,during which, casesof septic syndromewere diaminetetra-acetic acid (EDTA). Plasmawas sepa- vo)' evaluated.The studygroup included 50 consecutive rated by centrifugation,aliquoted and frozen at - osis patientswith sepsissyndrome, 20 critically ill pa- 70oC until assayedfor cytokines.Patient survival ient tients without sepsisin the medical ICU and 20 wasdefined as being alive 30 daysafter inclusion in rble healthy controls. Sepsis'syndromewas diagnosed thestudy. Conventional clinical mercurythermome- mal using the criteria give by Bone et al l2l. ter with calibration from 35oC to 42oC (95oF to Every effort was made to identify patients with 108oDwere usedto measureoral temperature.Hy- Losis perthermia was defined as oral temperature more )oor sepsissyndrome as early as possible. Those who met than38.3oC/l0loF. 210 the criteriafor inclusionin the studywere clinically and examined and detail history was taken. PlasmaIL-6 wasmeasured using a onestep sand- Presenceof at least four of the following six wich IL-6 specific enzyme linked immunoassay criteriawas necessaryfor inclusionin the study. (IMMUNOTECH France),calibrated with WHO standard88-514 (l IU=200 pg), accordingto the l. Clinical suspicionof infection manufacturer'sinstruction. This assaydetected only rIIIU- 2. Fever (temp > 38.2ocll01oF IL-6, and the lower limit of detectionin our labora- ;sis- 3. Hypothermia(temp < 35.5oC/95.9oF) tory was 5 pg/ml. Recoveryof recombinanthuman :r of 4. Tachycardia(> 90/min) IL-6 from EDTA treatedplasma from septicpatients dra- who had low levelsof IL-6 was > 907o)(data pro- 5. Tachypnoea(> 2Olmin) past vided by the manufactures). :om- 6. At leastone of the followings Otherinvesti gations incl uded haemogram, plate- (a) Oliguria (Urine output< 30 ml or 0.5 ml/kg let count, peripheral smear, urine analysis, bio- tient body wt for one hour) chemical paramete;s (blood glucose, blood urea, rhen (b) Unexplained metabolic acidosis (or ele- serumcreatinine), liver function testsand coagula- s al- vated plasma lactate levels) tion parameters.Various body fluids culture, bone .her- (c) Hypotension/Shock(systolic BP < 90 mm marow aspiration/biopsyand Liver biopsy,as indi- )ptic Hg or decreaseof more than 40 mm Hg from cated, were done. X-Ray chest/USG aMomen/CT baselineresponsive to IV fluids andShock was scan,when indicated,were also done. Serumelec- logy defined as hypotension non responsive to IV trolytes, blood/serum for VDRL, HBsAg and HIV fluids occurring along with elevated plasma testingwere alsodone. rmbai lactatelevels or unexplainedmetabolic acidosis Standardstatistical methods were used io analyse with an aniongap). thedata. The levelof significancewas set at p < 0.05. No,I Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I OBSERVATIONS AND RESULTS highly significant predictive value for poor sui"vival This study was conducted on 50 consecutive in SS group. Hypothermia was not seen in normal patients suspectedto have sepsis syndrome (SS control group or in critically ill group. In sepsis study group) asperpredetermined clinical variables, group,all patientshaving hypothermiadied. Asso- 20 critically ill non sepsispatients (Crit ill group) ciation between hypothermia and outcome accord- and 20 healthy normal persons (Normal control ing to two studygroups is shownin Table 3. group). In SS study group,27 patientswere males FEVER and23 werefemales. Mean agein SSgroup was 43.4 Feveras a clinical variablehas shown years. Outcome profile of patients in normal con- significant predictivevalue for survival only in sepsisgroup. trols, crit ill and SS study group is shown in Table Patientsof sepsisgroup having fever l. Patientsurvival in SS group was 44Vo.The fre- had better survival. Fever was not noted in normal control quencyof occurrenceof the clinical variablesused group. Association between fever and in this study,for sepsissyndrome patients, is given outcome ac- cordingto two study groupsis in Table 4. in Table 2. shown METABOLIC ACIDOSIS TABLEI Outcomeprofile of patientsin normalcontrol, Crit ill Metabolicacidosis has shownhighly significant studygroup and SS study group predictive value for poor outcome in SS group but notin crit ill group. Metabolic acidosis was not Studygroup Outcome Total Survival Died Survived noted in normal control group. Association between metabolicacidosis and outcome accordingto two Normal control 0 20 z0 1009o studygroups is shownin Table 5. Crit ill control 6 1A 20 70Vo SS )9 22 50 44% UN EXP IA, I N ED COAG UL,rO PAT HY Unexplainedcoagulopathy has shown highly sig- Yatescorrected Chi square(normal control vs Crit ill) = 19;12. P < 0.001.Yates corrected Chi square(Crit ill vs SS)= 3.87.P nificant pretlictive value for poor outcome in SS < 0.05 group.In crit ill group it doesnot havea signifrcant predictive value for outcome. Criterion of unex- TABLE 2 plainedcoagulopathy was not notedin normal con- Frequencyof clinical variablesin patientswith SepsisSyn- trol group.Association between unexplairred coagu- drome (n=50) lopathyand outcome according to two studygroups Diagnostic criteria Percentage is shownin Table 6. '169o Clinical suspicionof infection 38 THROMBOCWOPENIA Hypothermia 9 l8vo Thrombocytopeniahas shown highly significant Tachycardia 50 10O7o predictive value for poor outcome in SS group. Tachypnoea 4J 86Vo Thrombocytopeniawas not seenin crit ill group or Fever 32 &% healthynormal control. Association between throm- Oliguria l3 26C; bocytopenia and outcome according to two study Metabolic acidosis 9 lSVo groupsis shownin Table 7. Hypotension )) 44% Recent change in mental status 54Vo In this, study SS gp patients 92Vohad detectable Unexplained coagulopathy t7 34% levelsof IL-6 (median,2l0; rangenon-detectable to 1480pg/ml). In all cases,levels were higher than those in critically ill patientswithout sepsis(p < (p ASSOCIATIONBETWEEN CLINICAL 0.05) and normal healthycontrols < 0.001). VARIABLES AND.OUTCOME In crit ill group, IL-6 levels possesssignificant predictivepower for poor outcome(p < 0.05),how- HYPOTHERMIA ever,in SSgroup, difference between IL-6 valuesin Hypothermiaas a variablewas found to have patients,who died or survivedis highly significant 50 Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I TABLE3 Associrdonbetwecn hypothcrmia aod out'co-e Criterion in Died(%) Survived(%) Total Statistical Crit ill group analysis Not present 6(3O%) 14(70%) 20 Prcsent 0 0 0 Total 6(30%) t4(70%) 20 Criterion in SS Fisher cxact 2 group tailed p value < 0.01 Not present t9 (46.3%) 22(53.6%) 4l Highly hcsent 9(lm%) 0 9 significant Total 28 (56%) 22(44%) 50 TABLE 4 Associadonbetween fever and outcome Criterion in Crit Died(%) Survived(%) Total Statistical ill group analysis Not prcsent s (27.7%) L3(72.2%) l8 Yates Prcsent I I 2 conected Chi squarc = 0.03, Total 6(30%) 14(70%) 20 p > 0.05 Not significant Criterion in SS goup Not present t4 (77.7%) 4 (22.2%) l8 square= 5.41, hescnt L4(43.7%) t8 (s6.2%) 32 p < 0.05. Total 28 (s6%) 22(4%) 50 significant TABLE 5 Associadonbetween metabollc acldmis and outcome Criterion in Crit Died (%) Survived(%) Total Statistical ill group analysis Not prcsent 6(3r.s%, l3 (68.4%) l9 Yates Prescnt 0 I I correctedChi square Total 6(3O%) 14(70%\ m =0.2,p<0.05 Not significant Criterion in SS Chi squarc group = 6.58,Fisher exact2 tailed Present 9 (lm%) 0 9 p value< 0.01. Total 28 (56%' 22(4%) 50 Highly Significant (p < 0.001).Thus,IL-6levels possess highly signifi- Presenceofclinical variablesviz. clinical suspi-. cant predictive power for poor outcomein sepsis cion of infection,tachypnoea, tachycardia, oliguria group.The detailedvalues are given in Table 8. andrccent change in mentalstatus did not correlate Jour.Marine Medical Society, Jan-Jun 20M, Vol.2, No. I 5I t with patientoutcome. 0.0s). Presenceof clinicalvariables viz. hypothermia(p High circulatingIL-6levels (median 210 pg/ml-) < 0.01),metabolic acidosis (p < 0.01),shock (p < predictpoor prognosis (p < 0.001) andcorrelate only 0.05),unexplained coagulopathy (p < 0.001)and/or with unexplainedcoagulopathy (p < 0.02), and thrombocytopenia(p < 0.001)predict poor progno- thrombocytopenia(p < 0.05). Thrombocytopeniashowed significant inverse sis. DISCUSSION relationshipwith IL-6 plasmalevels (p < 0.05)and correlatedwith poorprognosis(p <0.001).Presence .Sepsissyndrome consists of a collectionof clini- offever signifiedbetter prognosis and survival (p < cal manifestationsof sepsiswith evidenceof organ dysfunction.Patients with thissyndrome have a high TABLE 6 Associstion betweenunexplained coagulopathyand outcome Criterion in Crit Died (%) Survived(%) Total Statistical ill group analysis Not present 6(3o%) 14(70%) 20 Not possible Present 0 0 0 Total 6(3o%) 14(10%) 20 Criterionin SS Yates $oup corrected Chi 12.94, Not present 12(36.4%) 2r (63.6%) 33 p < 0.001. Present 16(94%) | (6%) t7 Highly Significant Total 28 (s6%) 22(44%',) 50 TABLE 7 Associationbetween lhrombocytopenia and outcome Criterionin SS DieA(%) Survived (%) Total Statistical , grouP analysis Not prcsent 10(30%) 20(6.6%) 30 Fisher exact CI = Prcsent 18(m%) 2(r0%) 20 3.3- t78.2 Yatescorrected Total 28(s6%\ 22(44%) 50 Chi square =13.42,p<0.001. Highly Significant TABLE 8 Measurc of central tendenciesand dispcrsion : interleukin-6 (p/ml) among thr€e study groups Studygroup Outcome SD Median Kruskal wallis test P value Normal Died control Survived ; in ; Criticallyill Died 76.67 ,10.83 80 Kruskal wallis H Survived 26.43 23.m 20 =6.M,p<0.05 Sepsis Died 360 340.2 2t0 Kruskal wallis H Syndrome Survived 97.73 r47.16 ,!0 =19.27.p<0.001 52 Jour. Maine Medical Society,Jan-Jun 2000, Vol.2, No. I mortafity rate ranging from 25 to 65Vo[3,8,12,13]. has shown highly significant correldtion with the In this prospectivestudy of 50 patientsof sepsis fatal outcome (p < 0.001). The most common syndrome,the mortality was56Vo. neurologicmanifestation of sepsisis changein men- Various variablesused in the study were core- tal status[6,20]. The mechanismfor this changein latedwith the patientoutcome. An alterationin the mentalstatus is thoughtto be relatedto alterationin perfusion thermoregulatoryfunction is one of the most com- cerebral or to the cerebral metabolism of mon clinical manifestationsof sepsis.Fever is more certainamino acids [21]. commonly seenthan hypothermia.We found fever IL-6 is a TNF-c, induciblecytokine that hasbeen in 66Vopatients. Hypothermia is most commonly detectedin high levelsin circulationduring a variety found in patients at the extremesof age, those who of inflammatory statesand appearsto function pri- have chronic debilitating or immunosuppressing marily as a mediator of the acute phase response conditions such as chronic renal failure, hepatic [22]. During inflammation,the inflammatorycytok- failure and alcoholism [4]. A large retrospective inesTNF-cr, IL-l and IL-6 are secreted,in that order studyfound l3%oincidence of hypothermiain sepsis [23],lL-6 then inhibits the secretionof TNF-cr and and the inability of a patient to generatea body IL-l to help control the inflammation [24]. Several temperaturegreater than 99.6oFhas been associated studieshave found IL-6 levels to be elevatedin with an increasedmortality [7]. In our study hy- patientswith sepsis,and suchhigh levelscorrelated pothermiawas seenin lSVopatients and it strongly with mortality [9,10]. Our study also confirms this conelatedwith mortality (p = 0.002).Tachypnoea observation.We found that mean IL-6 levels were and hyperventilation are two of the most common significantlyhigher in patientsof SSwho died com- pulmonary manifestations of the septic process pared with those who survived (p = 0.007). In pa- [5,16]. In our study, tachypnoeawas recordedin tients of SS with unexplainedcoagulopathy and 867opatients and did not correlatewith survival of thrombocytopenia,IL-6 levels were significantly patients.We found tachycardiain all our patients higher(p < 0.05). diagnosedto have sepsissyndrome. Tachycardia is This study showsthat in patientsof sepsissyn- an early and nonspecificindicator of sepsis.Renal drome, levels of IL-6 were higher than those in abnormalitiesin sepsismay take a varietyof forms. critically ill patients without sepsis and normal Oliguria is one of the organ perfusion or dysfunction healthy controls (P < 0.001 for all comparisons). manifestationsthat herald the development of septic IL-6 levelswere alsosignificantly higher (p < 0.05) syndrome[2]. Oliguria may developin absenceof in patientsofSS with unexplainedcoagulopathy and documentedshock or hypotensionI I 6]. In our study thrombocytopenia.Our datasuggest that IL-6 level 26Vopatients were found to have oliguria and it did may be chosenfor single level monitoring in pa- not correlatewith fatal outcome.The mostcommon tients with SS becauseit had the best correlation haematologicmanifestation of sepsisis leukocytosis with mortality. Othershave also made similar sug- [6]. Some patientsmay not manifestleukocytosis gestion[7]. and may evenhave leukocytopenia I l6]. Leuckocy- REFERENCES topenia and coagulation abnormalitiesare com- monly encounteredin septic patient [6,17]. The L Van Deventer SJ, Buller HR, Cate JW, el a/. Endotoxaemia mechanismfor this abnormality is unclear and is : An early predictor ofSepdcaemia in febrile patients.I-ancet probablymultifactorial.Upto 66Vo of septicpatients 1988;I :605. with ARDS havebeen reported to havethrombocy- 2. Bone RC, Fisher CJ Jr, Clemmer TP, Slotman GJ, Metz CA, topenia ll7l.4OVo of our patientshad thrombocy- Balk RA. SepsisSyndrome : A valid clinical entity. Methyl- topenia which correlatedwith poor outcome (p < prednisolone Severe Sepsis Study group. Crit Care Med 0.001).Abnormalities of coagulationare frequently 1989;17:389-93. encounteredin septicpatients [l6,18]. Upto66Voof 3. US centresfor DiseaseControl. Increasein national hospital septic patients have been reported to have abnor- dischargerates for septicaemia- United States, 1979-1987. malitiesin vitamin K dependentcoagulation factors MMWR 1987;39: l3-4. and prolonged prothrombin time [8,19]. Coagu- 4. Parillo JE, Panker MM, Natanson C, et al. Septic shock : lopathy was seenin only 34Voof our patientsand it advancesin the understandingof pathogenesis,cardiovascu- Jour.Marine Medical SocieO, Jan-Jun 2000, Vol.2, No. I 53 lar dysfunction and therapy. Atu Intern Med l99O; ll3 : ventricular dysfunction and dilatation similar to left ven- 227-42. tricular changes,characterised the cardiac depressionof septicshock in humans.Clresl l99O;97 :126. 5. Parillo JE. Management of septic shock : present and future. Ann Intem Med l99l: 115 : 491-3. t4, GleckmanR" Hibert D. Afebrile bactercmia:A phenomenon in geriatricpatients. JAMA 1982:.248:.1478. 6. SheagrenJN. Shock Syndrome related to sepsis' In : Cecil text book of medicine, l9th ed. Ed Wyngaarten JB, Smith 15. Balk RA. The sp€ctrumof pulmonarymanifestations of LH, Nennet JC. WB SaundersCo. Philadelphia. 1992;1584- sepsis.trlosp Prr)s 194o;26: l-24. 8. 16. HarisRL, MusherDM, Bloom K, et aI. Manifestationsof 7. Kreger BE, Craven DE, Mc Cabe WR. Gram negative bac- sr;psis.Arch Intem Med 1987;14? : 1895. featurcs and treat- teraemia IV : Re-evaluation of clinical 17. Balk RA, BoneRC. The adult respiratory distress syndrome' ment in 612 p tients. Am J Med 1980; 68 : 344. Med CIin Nonh Am 1983t67 : 685. RC. Plasmacytokines and endo' 8. Casey LC, Balk RA, Bone 18. BoneRC, Francis PB, Pierce AK. Intravascularcoagulation with survival in patientswith the sepsis toxin levels correlate associatedwith the adult respiratorydistress syn&ome. Am Med 1993; l19 : 771-8. syndrome. Ann Inteni J Med1976;61:585. 9. Waage A, Brandtzaag P, HalstensenA, Kierulf P, Espevik 19. Conigan JJ Jr. Vitamin K dependentcoagulation factors in pattern ofcytokines in serum from patients T. The complex giramnegative septicaemia. Am J Dis Child 1984;138 :240. with meningococcal septic shock : Association between HC, Dubin A, er al. Septic interleukin 6, interleukin I and fatal outcome. J Exp Med 20. Mizock BA, Sabelli InternMed 1990;150 : ,143. 1989; 169 :333-43. encephalopathy.Arch in sepsisand 10. Hack CE, De Groot E& Felt-Bersma RI, Nuijens JH, Strack 21. Mizock BA. Branchedchain amino acids Van Schijndel RI, Erenberg-Belmer AJ, at aL lncrcased hepaticfailurc. A rch lntem Med 1985;145 : 1284. plasma level of interleukin-6 in sepsis. Blood 1989;74 : 22. KishimotoT. The biologyof interleukin6. Blood 1989;74 1704-10. : l. ll. Preiser JC, Schmartz D, Van der Linden P, Content J, 23. Van DeventerSJ. Buller HR, ten CatesJW, AardenLA, Vanden BusscheP. Buurman W, er al. Interleukin-6 admini- HackCE, Struk A. Experimentalendotoxaemia in humans: stration has no acute hemodynamic or hematologic effect in analysisof cytokinerelease and coagulation,fibrinolytic, the dog. Cytokine l99l;3 : l-4. andcomplement pathways. Blood 199O;76: 2520'6. 12. Parker MM, ShelhamerJH, Bachach SL, er a/. Profound but 24. SchindlerR, MancillaJ, EndersS, GhorbaniR, Clark SC, reversible myocrdial depression in patients with septic DinarelloCA. Correlationand interactions in theproduction shock. An Intem Med 19841100 : 483. of interleukin6, IL-l andTNF in humanblood mononuclear zl0-7. 13. Parker MM, Mc Carthy KE, Ognibene FP, et al. Right cells: IL-6 suppressesIL-l andTNF.BJood 1990;75 : 54 Jour. Maine Medical Society,Jan-Jun 2AN, Vol' 2, No. I MERCURY SPHYGMOMANOMETER- IS IT TIME FOR FINAL CURTAIN CALL? Surg Cdr MSN MURTY'|', Lt Col AS NARULA* ABSTRACT Blood pressuremeasurement has been an integral part of the physicalexamination, and sphygmomanometerhas beenthe gold standardfor bloodpressure measurement for morethan hundredyears. But this instrumentis likely to be replaced in near future in view of the possible mercury toxicity to the environment and availability of automateddevices including 24 hour ambulatoryblood pressurerecording devices which do away with observer bias and is able to record serial readingsboth during day and night and during sleepand activity. INTRODUCTION chain [2]. he importanceof hypertensionas a predictor ALTERNATM TECHNIQUES OF BLOOD of cardiovasculardisease, morbidity and PRESSURE MEASUREMENT mortalityhas been well established Con- []. A number of automateddevices have come into sequently measurementof blood pressurehas be- the market and theseare improving in accuracyand come an integral part of the physical examination many have advantageof providing a print out with and mercury sphygmomanometerhas remainedthe the time and date of blood pressuremeasurement, gold standardsince Riva-Rocci invented it in 1896. therebyremoving the observerbias and error due to The clinical measurementof diastolic pressurehad poortechnique[3]. But automationis not without its to await the auscultatory modification of the tech- problems. These devices have been known to be nique introduced by Nicolai Korotkoff in 1905. notorious for their inaccuracy [4]. In view of these This mercury sphygmomanometer after being disadvantages,devices, which measure 24 hour the comerstone of blood pressuremeasurement for blood pressure,have been developed. more than hundred years,is likely to be replaced eventually because of three reasons : mercury is AMBULATORY MEASUREMENT OF likely to be bannedworld-wide from hospital use BLOOD PRESSURE becauseof danger of toxicity, accurate automated It has long been known that blood pressurefluc- devicesare now available to replacethe mercury tuatesgreatly within an individual and that casual sphygmomanometer and the advent of 24 hours office blood pressurereadings are not always typical ambulatory of blood pressuremeasurement devices, of the haemodynamicprofile of any particular pa- as a betteraltemative. tient. Such variability is seldom recorded by the relatively few office readingstaken by most practi- MERCURY.ECOLOGICAL MENACE tionersbut caneasily be identifiedby automatically Mercury is a toxic, persistentand bioaccumable recorded measurementstaken through out the day substance.It has been arguedthat many tonnesof and night. This variability often can be attributed to mercury supplied for the manufactureof sphygmo- physical activity or emotional stress but is fre- manometers and then distributed through out the quently without obvious cause.Hence unlessthe world to hospitalsfinds its way backto theenviron- readingsare alarming, the diagnosisof hypertension ment through sewageor in solid waste.It not only should be substantiatedby a number of readings. damagesthe marineenvironment but alsoaccumu- The diagnosisof hypertensionimposes a psycho- lates in soil and sediment,thereby entering the food logical and socioeconomicburden on an individual *Classified Specialist (Medicine and Nephrology). Jour. Marine Medical Society, Jan-Jun 2000, Vol.2, No. I )) and usuallyimplies a commitmentto life long ther- monitoring.In 1968Penaz patented a servoplathis- apy. Hence each decision must be individualised momanometerbased on the vascularunloading prin- dependingon the patientsaversion to risk, percep- ciple using a light sourceand photocell in a finger tion of the intrusivenessof the medical care in cuff. The Penaztechnique has been modified and is his/trerlife and tolerancetowards side effects. In being manufacturedas FinapresIl]. This device spiteof rigorouscriteria upto207o of hypertensives may prove to be an alternativeto direct intra arterial are finally diagnosedto have white coat hyperten- measurementfor the continuousrecordins of blood sion - the elevationinduced bv the medicalenviron- pressure. menr[5]. CONCLUSION INVASIVE 24 HOUR BLOOD PRESSURE If mercury is no longer permitted in clinical MONITORING practice,there are reliable automated devices, which Sir GeorgePickering was the first to demonstrate can replacethe age-old mercury sphygmomanome- by directintra arterialmeasurement, the fluctuations ter. But whether ambulatory blood pressuremeas- in blood pressurewith activity andthe profoundfall urementsare still better than office readings,one in blood pressureduring sleep[6]. Thesehad little still doesn'tknow. Prospectivecontrolled studies to effect on clinical practicebecause of the invasive test.the critical point are in progress[l2]. Mean natureof the procedureand its inherencedanger. while, out of office measurementscertainly can be used to sharpen the diagnosis, determine the effi- NON INVASIVE INTERMITTENT MEAS. cacy of therapy and better control of hypertension UREMENT OF AMBULATORY BLOOD PRESSURE tl3l. For now office sphygmomanometry will con- In 1962, Hinman er a/ described the first truly tinue to be the primary tool for diagnosing and portable ambulatory system for the non-invasive monitoring hypertensioneven iT mercury sphygmo- measurementof blood pressureRemler M-200 [7]. manometeris no more in use.Ambulatory monitor- With the developmentof compactpumps and solid ing should be increasinglyused to look for White state memory systems,the Remler system was re- Coat hypertension;to evaluateapparent resistance placedby devicescapable of automaticallyinflating to therapy; and to determine the adequacyof ther- the cuff and providing pressuresintermittently over apy,particularly during sleepand the early morning 24 hours [8]. It may now be anticipatedthat such hours. deviceswill becomeindispensable in theassessment of patientswith elevatedblood pressure.At present REFERENCES thereare over 40 systemsavailable for the measure- 1. Kannel WB. The role of blood pressure in cardiovascular ment of 24-hour blood pressureand many more are morbidity and mortality. Prog Cardiovasc Dis 1976:' l'7 : in the developmentphase [9]. 45-t23. NONINVASIVE CONTINUOUS MBASURE. 2. O'Brien E. Ave atque vale : the centenary of sphygmoma- MENT OF AMBULATORY BLOOD PRES. nometry. Lancet 1996:348 : 1569-70. SURE 3. O'Brien E, Mee F, Atkins N, Thomas M. Evaluation of three The main disadvantageof the intermittentsys- devices for self-measurementof blood pressure: according - tems are that they provide only intermittent meas- to the revised British Hypertension Society Protocol the HEM urementof 24 hour blood pressureand the subject Omron 705 CP, Philips HP 5332, Nissei Ds-175. Blood PressureMonit 1996; I : 55-61. hasto ceaseactivity during suchmeasurement. Al- though intermittentblood pressuresgive circadian 4. O'Brien E, Mee F, Atkins N, O'Malley K. Inaccuracyof blood pressurepatterns, which are close to intra sevenpopular sphygmomanometersfor home-measurement ofblood pressure.J Hypertens1990; 8 : 621-34. arterialpressures I l0], thesemeasurements interfere with normal ambulatoryactivity. The next step in 5. Pickering TG, James GD, Charlene Boddie, e, al. How the advancementof blood pressuremeasurement is common is White coat hypertension?JAMA 1988; 259 (2) likely to bethe development of accuratesystems that :225-28. will provide continuous 24 hour blood pressure 6. O'Brien E, Fitzgerald D. The history of blood pressure 56 Jour. Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I \F measu€nr€nt.J lfum4a Hypertens199,{; 8 : 73-84. intermittcnt blood presswemcrsurrnFnts in estimating24 ?. Himman AT, Engel BT, BicKord AF. Pqrable blmd prc.s- hour avcrageblmd prcssure.Illparrarsian 1983;5 : ?.*9. surc rccorder.Accuracy and preliminary use in evaluating I l. WesselingKH, Gizdulich P, BoeS{W. Whithercontinuous intradaily variations in pessure. Am Heart J 1962:63 : bloodp,rcssur,e measurencnt? Finaprcs intothe nextoentury. 653-68. Blood PressureMuit l9%: I (Suppl l) : Sl05-8. 8. Harshfield GA, Pickering TG, l,aragh IH. A validation of 12. Pri$nt I.Ivt, Botini PB, Carr AA. Anbulatory bloodpressure the &l mar avionicsambulatory systom- Arnbril Elcctear- monitoring: methodologicissues. An J lVapirol 19E6:16: diogran 1979:l :7-12. l9G20l. 9, O'Brien E, BecvarsG, Marsh8ll D. ABC of hypcrtcnsion 13. Grin IM, Mc€abc EI, White WB. Managementof hyperten- (3rd edition) Iondon, BMI Publicuions. 195. gim aftcr ambulatoy blood presswcmonitoring. Aru[Intcm 10. di RenzoM, GrassiG, PedoaiA, Marpis G. Continuousvis Med1993:ll8:833-837. Jour. Marine Medical Society,Jan-Jw 20N, VoL2, No. I 57 Upd,ateAticle HBOT AND AIDS Surg Lcdr C KODANGE*, Surg Capt S NANGPAL+, Surg Cdr B SUDARSHAN**, Surg Capt MJ JOHN+ INTRODUCTION d) Tat inhibitors which prevent transcription and pe of the most dreadeddiseases today is that posttranscriptional processing. causedby the human immunodeficiency vi- e) Proteaseinhibitors - saquinavir,ritonavir, indi- rus (HIV), which usually leads to the ac- navir and nelfinavir which inhibit the viron quired immunodeficiency syndrome(AIDS). There packagingand budding. have been reports that hyperbaric oxygen may be 2. Prevent and treat opportunistic infections by beneficial in the managementof HIV/AIDS or its initiating prophylactic therapy at the appropri- symptoms. This idea has exciting potential but un- ate level of immune suppression to prevent less its effectivenessis establishedscientifically, theseinfections. this form of therapy may be abused.It is thus impor- Cunently the medicationscurrently under devel- tant to explore the rationale in using HBOT for opment to treat AIDS and AIDS related conditions treating HIV infection and some of the associated include : 40 antiviral medicines. 23 medications to opportunistic infections and other problems associ- combat AIDS related cancers, 12 immunomodula- atedwith this disease[]. tors, 1l antiinfectives,eight antifungals,five gene HIV INFECTION AND TRBATMENT therapiesand 12 vaccines[2]. HIV is a retrovirus which replicates using the IIBO AND HIV enzyme reverse transcriptase.Individuals with al- Hyperbaric oxygen could be beneficial in HIV tered immune function due to HIV are at a risk to infectionby the following mechanisms: develop opportunistic infections causedby bacteria, viruses, fungi protozoa and also certain tumours. a) Effect on the virus They also develop other problems like fatigue, de- b) Adjunct in treating opportunistic infections mentia, diarrhea, weight loss as well as kidney and c) Relief of symptoms heart dysfunctions. d) Adjunct in radiotherapy in neoplasms There is presentlyno cure or AIDS. Therapiesfor HIV infected patients are imperfect at best. These EFFECT ON THE VIRUS aim at : The HIV has been described as a very fragile l. Inhibition of the virus at different stagesof the virus that is easily disruptedby a variety of chemical virus life cycle with the help of : agents and even mild physical conditions. HBO could affect the HIV at the following sites/ mecha- a) CD4 derivatives, polymers, plant lecithins nisms. which prevent cell attachment/fusion/entry. i. Cytoskeleton - The cytoskeleton is often an b) Reversetranscriptase inhibitors important participant in viral entry, formation (i) - Nucleosideanalogs zidovudine,didanos- of replication complexes, assembly sites and ine, zalcitabine,stavudine, lamivudine. virus release. HBO has been shown to alter (ii) Non-nucleo$ideanalogs - nevirapine,de- cytoskeletal structure in vitro by Piepmeier in laviridine, loviride. 1997 l3l. Therefore, there may be a role for c) Integraseinhibitors which prevent integration HBO in the treatment of HIV by altering cy- *Sr. **Classified *Post GraduateTrainee; Advisor, Specialist; Marine Medicine. 58 Jour. Marine Medical Society,Jan-Jun 2M0, VoL2, No. I toskeletai structure or function. being elucidated [3]. HBO can prevent the re- ii. Reillo in 1996 conductedstudies that suggest leaseofcytokines such as tumour necrosisfac- tor and interferon, which have been shown that HBO attenuatesHIV replication [4]. How- to ever there were insufficient controls or replica- reactivatethe cell cycle and result in releaseof tions to identify statistically significant effects infectiousHIV [3]. Other cytokinesassociated in the study. with HIV infectioninclude the interferons IL-1, lL-2,1L-6,IL-8, IL-10, L-12 and heat shock iii. HBO causeshyperoxia and cellular studiesin- proteins. Therefore the effect of HBO on HIV cluding thoseby Polonis in l99l showeda 15 could be studied through identifying its affect fold increasein HIV specific RNA in unstimu- on any of thesecytokines. lated T-cells within 24 hours of oxygen depri- - vation or anoxia, implying that HIV might be vri. Specific and non specific immune response inhibited by HBO. The increasedoxygen ten- The specific immune responseto HIV (such as sions could inhibit or depressHIV expression T-cell production) can actually enhance the tsl. ability of HIV to replicate.Further non specific immuneresponse may alsoenhance HIV repli- iv. During HBO, free radicals are producedwhich cation. The non specific responses includes could attack the viral membranesand the en- complementand antibodiessuch as IgA, IgM closed genetic material thereby causing cell or IgG isotopes that have polyspecific autore- disruption and inactivation. Since oxygen can activitywith viruses.While complementcauses penetratetissues, the oxygen in HBO could act inactivation and lysis of many viruses, it actu- even on tissueslike the lymph tissueswhere the ally enhancesthe infectivity of HIV. HBO, has virus seemsto concentrate.Free radicals gener- been shown to inhibit the specific and non atedin HBO and acceleratedby mild hyperther- specific immune responses respectively and mia (38.5 C) can penetratethe lipid covering of thus HBO could possibly stop the proliferation the virus before its entry into the monocytesand of the HIV virus.[9] thus prevent its proliferation [6]. viii. pH effects- HBO decreasesthe amount of hy- v. Glycoprotelns - Receptorsfor many virusesare poxic or anoxic (acidic) tissue in the body. cell membrane glycoproteins. These are the While some viruses such as the influenza virus same glycoproteins whose activity or expres- requirean acidic environment to infectthe cells, sion was shown to be inhibited by HBO. Xu HIV is able to fuse with the cell in both neutral demonstratedthis in 1997in CD4 cells. which and mildly alkaline pH states[0]. However contain the receptorsfor HIV [7]. other viral infections by increasingthe pH (de- - vi. Cell cycle/cytokines Viruses are also depend- creasing acidity) through the elevated oxygen ent upon the cell cycle for viral replication. delivery(HBO) could indirectly attenuateHIV Terminally differentiated or non replicating replication. cells do not allow viral replication. Therefore while HIV can enter resting macrophagesthe ADJUNCT IN TREATING OPPORTI.JNIS. virus is produced only after the cell cycle has TIC INFECTIONS beenactivated. Kalns et al in 1998studied the Individuals with altered immune function due to use of HBO to regulate the cell cycle with the HIV are at a risk to develop opportunistic infections goal of potentiating cancer chemotherapeutic caused by bacteria, viruses, fungi and protozoa. agents[8]. A similar study could be conducted Holmes and Gargesin 1987 showed that HBO is with anti AIDS drugs instead of anticancer effective in treating a number of opportunistic infec- drugs. Activation of T-cells is important for tions seenin AIDS I l]. Evidenceis also available HIV replication and associatedcellular proc- that HBO in synergism with suitable antimicrobial essessuch as activation of calcium dependent agentsis useful in treating tuberculosisand pneumo- protein kinase and other phosphorylation cystis which are the most prevalentopportunistic' events may also be important. The effect of infectionsseen in AIDS [12,13].Studies conducted HBO on these cellular processesis currently in the School of Naval Medicine have shown that Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I 59 experimentally induced tuberculosis in mice re- 3. PiepmeierEJ. Hyperbaric oxygen therapy and human immu- spondedwell to HBOT [14]. nodeficiency virus. Hyperbaric pharmacology update.Nov., 1999. SYMPTOMATIC RELIEFIN CHRONIC FA- 4. Reillo MR, Altieri RI. HIV antiviral effects of hyperbaric TIGUE SYNDROME oxygen.JAssco NursesAIDS care 1996;7 (1) :43-5. The debilitating chronic fatigue seen in AIDS 5. Polonis VR, Anderson GR, Vahey MT, Morrow PJ, Stolor patients seems to have a central origin. The brain D, Redfield NR. Anoxia induces human immunodeficiency lesions seen in positron emission tomographyin virus in infected T cell lines. J Biol Chem l99l:' 268 : chronic fatigue due to other causesoften resembles tt42t-4. the lesionsseen in AIDS cases[15]. HBO hasbeen 6. Textbook of hyperbaric medicine. Hogrefe and demonstratedto increasethe local brain blood flow Jain KK. Huber Publishers2nd edition. 1996; 13 : 181-99. and if the brain lesionsin HIV are ischaemicthen HBO might help. Freeman and Fife presentdata at 7 . Xt, et al. Differential sensitivities to hyperbaric oxygen of the UHMS meetingin 1993that l0 to 20 sittingsof lymphocyte subpopulations of normal and autoimmune onehour at 2.36 ATA providedsubjective improve- mice. Immuno len 1997; 59 (2) :79-84. ment in patientsmanifesting chronic fatigue syn- 8. Kalns J. The effect of HBO on growth and chemosensitivity drome[16]. .ofmetastatic prostaticcancer. Anticancer Res1998; 18 (lA) , :363-7. ADJI.JNCT IN RADIOTHERAPY IN NEO. 9. Olszanski, et al. Efficacy of HBO in atopic dermatitis. Bal/ PLASMS Inst Marit Trop Med Gdynia 1992; 43 (l-4) :79-82. A numberof proliferatingcells in many tumours 10. Nathanson N. Bovine spongiform encephalopathy (BSE) : are under severely hypoxic or anoxic conditions Causesand consequencesofa common sourceepidemic. Arz Also the reproductiveintegrity of suchcells is [17]. J Epidemiol 1997; 145 (l l) : 959-69. more resistant to damage by radiation than that of cells oxygenatedto normal physiological levels. I l. Holmes C, GargesL. Effects of hyperbaic oxygen. J Infec- tiousdisease 1987; 155 : 1084. Thus larger the number of cells that loose their reproductive capability, the greater the change of 12. Gottlieb SF, Rose NR, Maurizi J, Lanphier EH. Oxygen cure or palliation. Watson in 1978 has shown that inhibition of growth of mycobacterium tuberculosis.J Bac- HBO improved local control of tumour and ex- teriol 1964;87 : 838-43. tendedsurvival in casesof cervicalcarcinoma which 13. PesantiEL. Pneumocystiscarinii : oxygen uptake, antioxi- is a common neoplasm in female AIDS patients dant enzymesand suseptibility to oxygen-mediateddamage. [8]. Researchthus needsto be done as to whether Infect Immunol 1984; 4 : 4'19-87. HBO could help in the neoplasticdisorders seen in 14. Nangpal S, John MJ. Role of hyperbaric oxygen in experi- AIDS patients. mentally induced lesionscaused by mycobacterium tubercu- losis.AFMRC project. 1986; 1597. CONCLUSION 15. Neubauer RA, Gottlieb SF, Miale A Jr. Identification of There now seemsto be some evidenceand data hypometabolicareas in brain using brain imaging and hyper- justify controlled studiesand availableto clinical baric oxygen.Clin NuclMed 1992; l7 :477-81. clinical trials of hyperbaricoxygen in HIV or AIDS 16. Freeman DM, Fife W. Chronic fatigue syndrome : The patients.$BO in conjunction with other drug thera- effectivenessof HBO in relieving symptoms. Presentedat pies might help relieve a lot of pain and suffering joint meeting American college ofhyperbaric medicine, gulf that patient with AIDS undergo. The only way to coast chapter, UHMS, and the baromedical nursesassocia- find out is to try iton humanpatients oron the simian tion. Jul. 1993. AIDS model. 17. Henk JM. Does hyperbaric oxygen have a future in radiation REFERENCES therapy?Int J Radiat Onco Biol Phys 1986; 7 : I 125-8. positive patient. l. Myers RAM. The HIV Presentedat hyper- 18. Watson ER, Halnan KE, Dische S, er al. HBO and radiother- baric medicine conf, Columbia, SC. April 5-7, 1993. apy : A medical research council report. Br J Radiol 1978; 2. Various sourceson the internet. 5l :879-87. 60 Jour. Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I Commentam SUBMARINERESCUE - FUTURETRENDS Surg Cdr G VERGHESE* INTRODUCTION subjected to sea pressure.Somewhere in between these two generic systems lies the Self-Rescue 711his paper is basedon the report of a Prefeasi- for NATO's Indus- sphere,where the survivorsenter a specialin-build I bility Study conducted L trial Advisory Group (NIAG) and discusses chamberwhich can then be releasedfor buovant the problemsassociated with submarinerescue. ascentto the surface. The requirement to rescue survivors from a RESCUE METHODS sunkensubmarine is somethingthat one hopesand Some nations have followed the line of the prays,one will never have to do, but sadly history American McCann rescue bell. This system has shows us that there have been over 170 recorded beenshown to be lesseffective than usinga special- peacetimesubmarine sinkings since the beginning ised rescuesubmersible. The United StatesNavy of this century. pioneeredthis approachwith their Deep Submer- Submarinescan sink for a varietyofreasons, the genceRescue System the DSRV. Sincethen is other main ones being collision, nuclear accidents,fire nationshave followed a basicallysimilar line with leading to loss of ship-systems,pipework failure China,Japan,Italy, Russia, the United Kingdom and leading to flooding, loss of hydrodynamiccontrol Swedenall currentlyoperating a similar,though less and poor training. sophisticatedsystem. The American and Russian BACKGROUND systemsdiffer somewhatfrom the othersin that their rescue submersiblesare normally operated from a Should a submarinesink, there are two main mother submarine (a MOSUB), whereas all other methodsof evacuation of survivors. If the depth of nations operate them from some form of surface the distressedsubmarine (DISSUB) is sufficiently mothersvessel (a MOSHIP). shallowthe survivors can escape. However escaping subjectsthe escaperto seapressure equivalent to the Sometime back,it becameapparent that mostof depth of the DISSUB, and this can causea variety thesesystems are approaching the end oftheiruseful of seriousphysiological problems. Despite ongoing lives,and that someform ofsuccessorto the present research,a realistic maximum escapelimit of 200 systemsshould be sought. metersis all that is likely to be achieved.The es- REQUIREMENTS FOR ANY RESCUE SYS. problem capers is further complicatedby the various TEM gas concentrations within the DISSUB, before he attempts to escape.In case the depth of water ex- To establishthe feasibility of a rescuesystem, a ceeds 180 meters, or for a variety of other consid- setof key parameterswere defined againstwhich the erations,the survivor may be better off awaiting proposedsystem had to operate.The main key pa- rescue. rametersare as follows (Fig. l). Historically rescuehas beenconducted by one of (a) Time to First Rescue : The first problem is two methods.Eithera chamber is lowered to the knowing that there has actually been an accident. DISSUB or a rescuesubmersible is launched.Both Thereafter it is a matter of deploying the rescue are designed to make a watertight seal on the sub- system to the scene of the accident as quickly as marinesescape hatch. The survivors can then trans- possible. Though most submarines carry life-sup- fer to the bell or the submersiblewithout beins port storesto generatesoxygen and remove carbon. *Graded Specialist, Marine Medicine, INS Virbahu Vishakhapatanam. Jour. Marine Medical Societv, Jan-Jun 2000, Vol. 2, No. I 61 (a) Time to First Rescue 72 hours operablein high seastates. A Dynamic positioning. (b) Depth capability 1000 meters systemis a worthwhilebonus. (c) Current and Tide 2 to 3 knots (f) Endurancebetween recharges: Ideally it is (d) Rescueesper sortie l0 preferableto evacuateall survivors without having (e) Sea State limitation 6 to pausewhile the rescuevehicle is recharged.he- (0 Endurance between recharges 12 hours sentexperience is that an autonomousrescue vehicle (g) Portability Easily portable may achievea rescuecycle time of betweentwo and (h) Transfer under Pressure(TUP) Required up to 5 bar three hours. Thus with a rescue vehicle capable of Attitude control 45 degrees 0) lifting up to 15 men. one could hope to lift the (k) Cost [,ess than presentsystems complete crew of a submarine, with an endurance betweenvehicle rechargeof twelve hours. Fig. I : Main key parameters (g) Ponabiliry : It is obviously impractical to have rescuesystems positioned adjacentto all main finite endurance. dioxide, these stores have only a submarineoperating areas, and at some stageit will This endurancemay be further depletedby the am- be necessaryto move it by land or air to an embar- within it is bient conditions the DISSUB and hence kation port. The final phaseof deployment will have recommended that the rescue cycle should com- to'be by sea.Air freightingis the most constraining within hours.Air-freighting rescue mence 72 a sys- of limitationsfor both size and weight, but as long tem may seem an easy method of reducing the as these can be met, then land and sea portability deployment time but acquisition of suitable aircraft difficulties will both be eased. and the handling time involved can causeconsider- (h) pressure(TUP) The able delay. Eventually it will be necessaryto trans- Transfer under : capabil- ity pressure port the rescue system to the sceneof the accident, to transfer survivors under and then to and this can only be done by sea which again takes decompressthem at the correct therapeutic rate, is probably problems time. one of the most intractable in submarinerescue. There is little problem in transfer- (b) Depth: The depth capability is to be decided ring the survivors under hyperbaric pressurefrom taking into account a study of seabedtopography the DISSUB to the rescuevehicle itself, but to then most likely matchedagainst the operatingareas and transferthem from that vehicle to a suitable decom- possible possi- future crush depth of submarines.A pressionfacility is much more difficult aseach batch ble maximum rescue depth of 1000 meters was of survivors will be at a different stage of decom- decided upon. pression. This is an area which requires further (c) Current and Tide : There are few geographic detailed study. areaswhere the tidebr current consistently exceed Q) Auitude: It is difficult to calculatethe angle two knots, and the capability to sustain operations at which a distressed sub'marine will lie on the in a water flow of two knots should be adequate,but seabed.Much will dependon the extent of flooding, with a burst speedof 3 l/2 knots being desirable. the seabedtopography .and the various protuber- (d) Rescueesper Sonie: A balanceneeds to be ances,such as hydroplanes,on the DISSUB itself. drawn between the physical size ofthe rescuevehi- Most modem rescuesubmersibles can cope with 45 cle and the numbers of survivors that it can carry. degreesand some,by inclusion ofa wedge adaptor, The portability factor dictatesthe maximum size for can cope with 60 degrees. any rescue vehicle and this could cater to between (k) Cosl: The AmericanDSRV systemwas used l0 to 15 survivorsper sortie. as the comparator against which any future system (e) Sea State : There is little point in having a should bejudged. This was becausethis is really the rescue system which can only operate in calm only comprehensiveand world-wide system pres- weather conditions. One of the advantagesof the ently available. However such comprehensivesys- DSRV is that it is operatedfrom a MOSUB which tems do not come cheap.There is a complex equa- gives it considerable weather independence.How- tion of initial procurement cost, running costs and ever any surfaceMOSHIP operatedsystem must be mobilisation costs.all of which have to be balanced 62 Jour. Marine Medical Society,Jan-Jun 2000, Vol, 2, No. I $ ival against the area coverage provided within the re- THE RESCUE CAPSULE SYSTEM - mal quired time frame of Time to First Rescue a Cost This is a totally novel systemwhich has its ori- psis Effectivenessratio. gins in the McCann RescueBell concept. In an sso- attempt to overcome the difficulties of TUP and ord- MEANS FOR RESgUE. TIIE MAIN CON. TENDERS subsequentlengthy decompressionof survivors, one solution could be to retain them in batchesin differ- Over1600 different options for submarinerescue ent rescuechambers - the RescueCapsule concept. systemwere considered.These were thenjudged In this systema seriesof capsuleswould be lowered cant againstthe Key Parameters.This shortenedthe list to the seabed in the vicinity of the DISSUB. A lup. of possibleoptions to the following maincontend- specialannular ROV than hugs one and transportsit ltter ers. to the DISSUB'S rescueseat and obtains a hard seal. rtrol (a) Autonomous,manned, Submarine Rescue Ve- The survivors perhapsI 5 at a time, enterthe capsule ) ac- hicle(SRV) A for bouyone ascent to the surface. There it is col- l. (b) RemotelyOperated Rescue Vehicle (RORV) lected and lifted onboard the support vessel and (c) RescueCapsules. therapeutic decompression of the survivors can start. cant (d) Self-RescueSpheres. r but Meanwhile the special ROV collects another THE SUBMARINE RESCUEVEHICLE capsulefrom the seabed,and the cycle is repeated. not (sRv) veen Though this systemdoes seem to solve the TUP/De- two This is envisaged to be a free swimming, two compressionproblem neatly, it does also require a compartmentautonomous vehicle. The pilot is sepa- large numberof capsulesto caterfor a DISSUB with rated from the main rescuecompartment so that he a large crew. The capsules and the annular ROV is not subjectedto the DISSUBs pressure,nor to its would poseconsiderable air freight problems due to rsig- foul atmosphere.Initial studiesshow a vehicle of size and weight. Again, as with the RORV thereis rSS approximately l4 tonnes(to meet airfreight require- a requirementfor an umbilical winch, a control icant ment) capableof carrying some 15 rescuesto be the cabin and all the supporting equipment, together ,nex- ideal. The energy source would be batteries,and it with the problems of remote "mating" on the DIS- con- would be operated from a MOSHIP. However it SUB. Deckpaceon the supportvessel will alsobe at ragu- could be capableof transferring rescueesto another a premium. oups dived submarine. This would help overcome the TITE SELF RESCUE SPHERE problem of TUP and decompressionof survivors, while minimizing the sea-stateproblem. It is pgr,-. Here. each submarinecarries its own self-rescue haps the least radical of the four main contenders,- device.This is not a new conceptbut one developed icant but it follows a well-provenroute. by Professor Gabbler of IKL in Germany some roup. twenty years ago and already fitted in some subma- TIIE REMOTELY OPERATED RESCUE VE. upor rines. As soon as practical after the accident the HrcLE (RORV) rom- survivors enter the sphereand once the hatchesare ;tudy In this system,it is not necessaryto have a pilot shut, release it to the surface. It has several un- and thus the vehicle could be of single compartment doubtedadvantages in that it overcomesmost of the . design.The vehiclewould be drivenfrom a console problemsof ambientpressure and toxic gases,in- table in the supportvessel, and power and necessaryserv- curred in a long wait for rescue by other means. It rleto icestransmitted along its umbilical.This givescon- obviates the requirement for the authorities ashore than siderable weight advantagesand thus its carrying to realisethat therehas been an accident,and the first (p< capacity would be increased. Once launched it thing that they may know is that the survivors are would operatesimiliir to an SRV though it is debat- safely on the surface.There is an obvious increase icant able whether mating on the DISSUB's rescueseat in the initial procurementcost of each submarineso how- will be easily conductedremotely. However its sur- fitted, and there is a finite limit to the number of resin face support requires much more deck space and survivors who can pack into any one sphere, so icant weight than an SRV. larger submarinesmay need more than one. There No.l Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I 63 are someship-fitting difficulties which are fairly dent. easilyovercome. Whatis necessarynow is to look carofullyat the TIIE WAY AIIEAI)? submarineescape and rescuepolicy, to assess whetherthey are dependentsolely on the use of a With practically every present rescue system very distantrescue system in the DSRV. It is qsy usingrescue vehicles which aretwenty years now to think that if there is an emergencyother people is a need for a future generationrescue old, there will provide the necessaryassistance and that may system.Though the Americans presently provide an be theonly timethat the distressed nation will have effectivesystem in theDSRV, itmay not extremely to makeany financial confributionto the upkeepof reachthe DISSIJBearly enough.In thesedays of thesystem - but if thehelp does not arrivein timeto defensebudgets itois difficult to justify shrinking rescuepersonnel alive, it becomesa falseeconomy. expenseon whatmay be seen as an insurance policy againstthe unlikely possibility of a submarineacci- 64 Jour.Marine Medical Society, Jan-Jun 2000, Vol.2, No.I tt COMPARATIVE STUDY OF AUTOREF/KERATOMETER the WITH MANUAL KERATOMETERAND RETINOSCOPE ess rfa tsy Surg Cdr SSPannu* ple my ABSTRACT ave rof Performanceof retinoscopyand keratometryis an important componentof any Ophthalmicexamination. In our 3tO hospitals,refractive errors comprisea significantpercentageofcases in any EyeOPD. Autoref/Keratometer Nidek ny. ARK 700 was suppliedto this hospitalin Aug 98. This study was carried out to assessthe reliability, accuracy, speed,sensitivity and specificityof this instrumentin comparisonwith manual retinoscopyand keratometry.150 patientswere subjectedto retinoscopyby traditional hand held retinoscopeand NIDEK AutoreflKeratometer. Refractiveerrors including the cylinder and axis were compared.Anterior cornealcurvature of another group comprisingof 250eyes of 200patients was determined and readingsobtained by NIDEK autoref/keratometerand manual keratometer studied. The results in both groups showeda high degreeof accuracy and speedwith autoreflkeratometerand the readingsobtained were reproducible and comparableeven when repeated at interval of many days. Interpretation still remains a key factor as in few casesspurious astigmatism of 0.50 to l.fi) was induceddue to headtilt or disparity in fixation axis.It wasconcluded that autoreflkeratometeris a fast and reliable tool in performing keratometry and retinoscopyand savesthe Ophthalmologistvaluable time to perform other important operativeand diagnosticwork. INTRODUCTION age from comea's front surface (the Ist purkinje image) which is convertedinto the corneal radius n phthalmologyhas become a highly special- field with usingsimple vergence relationship of convexmirror I fised advent of sophisticated \-t equipment for diagnostic and therapeutic t4l. work. Electronic microcircuitory and computer The manual keratometer(Bausch and Lomb) has technology have combined to develop sophisticated been consideredthe gold standardfor keratometry. instrumentsfor refracting patients.There is no evi- It measuresthe anterior corneal curvature in two dence that indicates categorically that automated principal meridians by looking at the points on the refraction is better that manual retinoscopyand sub- comeal surface approximately 1.6 mm from the jective refraction. So it was decided to clinically visual axis. The actual power in dioptres and mm is evaluate autoref keratometer for both its functions read from the right and left dials of the keratometer and compare it with existing methods. tsl. Manual retinoscopy is performed using a light The auto keratometer uses three rays of near sourceand a refracting minor. The refractive status infrared light to measurecomeal curvature in three of the patient is determined by observing and neu- areason anterior comeal surface.The reflected rays tralising the movement of the red reflex created at are detected by three photodiodes. The distance the patients pupil by light reflected from his retina between the reflected images is converted into the by using a set of convex and concavelenses []. steepestand flattest meridian using vergencerela- Autorefractometers use the same principal using tionships[6]. infra red light and computerisedneutralising [2]. Modern keratometersare basedon the principal This study was thus undertaken to clinically of the first keratometer developed by Von Helm- evaluate and study the comparison of the readings holtz in the late 1800s[3]. The principal involves obtained by Autoref/Keratometer with manual reti- accurately determining the size of the reflected im- noscopy and keratometry. *Classified Specialist Ophthalmology, INHS Kalyani. to. I Jour.Marine Medical Society, Jan-Jun 2000, Vol.2, No.l 65 MATERJAL AND METHODS visual acuity were examined.The averagesphere The threeinstruments compared were obtainedby the autorefwas marginallyhigher than that obtainedby manualretinoscopy which was not i. Nidek Autoref/keratometerARK 700 for per- clinicallysignificant. But the cylinderobtained by forming automatedrefraction and keratometry. autorefin groupsI and2 i.e. normal vision and low The fixation targetis a multicolouredballoon at refractiveerrors was significantly higher than that the end of a high way and thereis an automatic obtainedby manualretinoscopy. However, in higher fogging systemto relax the accomodation.An refractive errors, the cylinder obtained by both inbuilt numerical confidence index reflects methodscorrelated well clinically and statistically whether your readings are of an acceptable (Table 1). Cycloplegic refraction was done in 32 level. A confidenceindex of lessthan sevenis cases,mostly children and young adultswith active not acceptable.. accommodation.The sphericalnumber induced by ii. A hand held retinoscopewith wall mounted accommodationwas neutralisedbut the cylinder ophthalmicbracket as a light source.Only the obtainedby both non cyloplegic and cycloplegic plain minor was used. refractionremained unchanged in power and axis iii. Bauschand Lomb keratometerfor performing (Table2). The speedof estimationof the refractive manualkeratombtry. power by autoref in all subgroupsremained same. The study population consistedof two groups. Manual retinoscopy showed a variation in time Group I comprised300 eyesof 150subjects of age taken for refraction of normal patientsand those l0-55 years.Unconected visual acuity rangedfrom with refractiveerrors. The autoref on an average 616to 5160.Cycloplegic refractionwas done in 32 took 28.1 secondsfor 3 readingsof both eyes and casesusing 0.5 7o cyclopentolate. was about four time fasterthan manual estimation (Table3). ExclusionCriteria:- The autokeratometryvalues were steeperthan i. Any mediaopacities manualkeratometry. The meankeratometry values ii. Squint were well corelatedin both horizontaland vertical iii. RetinalPathology meridians.The mean cylinder axis in the vertical Group II comprised250 eyesof 200 patients.A meridianwere well corelatedbut the meanhorizon- large number of thesepatients were cataractcases tal cylinder axis in manualkeratometry was closer for calculation of lens power of IOLs. Only the to 180axis. The meancylinder power estimatedby (Table keratometry readings were obtained without any both instrumentscorelated well 4). The av- attempt to correlate with retinoscopy.There was eragetime takenfor autokeratometerwas 22 times minimal overlap betweengroup I and II. The age fasterthan the manual method,as autokeratometer rangedfrom l8 to 78 years. took 3.5 sec as comparedto One minute and 25 secondby manualkeratometers. ExclusionCriteria:- i. Distortionof keratometrymires DISCUSSION ii. Very flat or steepcorneas (< 41 D or > 47 D) Refractive errors are by far the most common causeof poor vision. Fortunately,this is generally Readingsof each instrumentwere obtainedby the easiestto treat So retinoscopyforms a part one observeronly. The following parameterswere [7]. of any ophthilmic examination.Keratometry is es- compared sentialfor contactlens prescription and more impor- i. Horizontal meridianreading (Kl) tantly for calculationof intra occularlens power in ii. Vertical meridianreading (K2) cataractpatients undergoing IOL surgery. iii. The cylinderpower and axis The work load over last two decadeshas in- iv. Time takento obtain the readinss. creasedsignificantly while the staff strength has remainedstatic. In 1999,the OPD attendancein the RESULTS Eye OPD of this hospitalwas doublethat of 1991. 300 eyesof 150 subjectswith differentlevels of An instrumentwhich is speedyand accurate contrib- 66 Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I TABLE I Comparison of manual and automated refraction Patients Visuglacuity Automated Refraction Manual Refraction Range nE- r-e Group No Sph Cyl Sph cvl Sph cvl sph cvl I 58 6t6 -0.1I -0.32 -0.l0 -0.35 +0.025 -0.025 -0.M0 -0.012 ) 30 6t9-6n2 -0.78 -0.74 -0.81 -0.76 -0.67 -0.41 -0.69 -0.42 J 33 6lr8-6t24 -U34 -t.02 -1.31 -1.08 -t.22 -0.94 -r.23 -0.93 29 6t365tffi -2.31 -1.46 -2.41 -1.48 -2.26 -1.30 -2.27 -r.28 TABLE 2 Comparimn of cycloplegic end non cycloplcgic automated refraction No. of patients Normal Refraction Under Cyloplegic RE LE RE LE Sph Cvl sph cvl sph cvl Sph' Cyl 32 -1.36 -1.48 -t.32 - 1.45 +0.28 -t.43 +0.31 -1.42 TABLE 3 Time taken for refractioll of both eyes Patients Visualacuity Manual refraction Automated reftaction group range I 58 6t6 I min 03 sec 27.8*c 2 30 6t9-6^2 2 min 20 sec 28.2** 3 33 6n8-6t24 2 min 24 sec 28.3sec 4 29 6t36st& 2 min 41 sec 28.2sec TABLE 4 Comparimn of manual and automated keratometry Mean readings Instruments Meridian Kl (D) Meridan K2 Cylinder(D) (D) Horizontal Vertical Bauschand Lomb 43.068 44.r43 0.880 I 16.13 9r.23 Keratometer NidekARK 700 43.448 44.387 0.927 t54.34 86.23 Autokeratometer utes towards decreasingthe work load. Due to tech- Few studiesdone reportedthat the amountof nological advancement,many sophisticatedequip- astigmatismdetermined by manualand autokera- ment have been introduced which require a special- tometerwas found to be clinicallysignificant [10]. ist to operate them. Saving time on routine proce- Anotherstudy showeda gd corelationbetween dures will sparetime for these.Studies done earlier manualand automated keratometry [11]. . show that automatedrefraction techniquesare reli- Nidek autoref/keratometerwas evaluatedfor able and rapid for estimation of refractive errors in both functions.During refraction,the amountof children [8,9]. time takenper patienton autorefdid not showany Jour.Marine Medical Society, Jan-Jun 2000, Vol.2, No. I 67 variation while in manual refraction, the higher re- lems but interpretation of data and cross checking fractive errors specially astigmatism took a signifi- with manual and cycloplegic refraction in doubtful cantly longertime. On an average,autoref was about casescan avoid suchpitfalls. Small mediaopacities four times faster than manual refraction. Though the and anythingthat even marginally affectsthe cor- autoref uses a fogging mechanism, the machine neal reflex can give eroneous results in which case showeda higher false sphericalnumber as compared manual method is superior. One great advantageis to manualrefraction in non cyloplegicconditions in that even a nonspecialisedperson can operate the children and young adults. In subjectswith normal machine with minimal training. The confidence in- vision and low refractive errors, the autoref showed dex ensuresthat reading with low confidence index a significant cylinder in some casesas comparedto are rejected.This will savethe specialistvaluable manualrefraction. It.is likely to be due to headtilt time for more complex and critical diagnostic and or disparity between fixation axis and axis of operativework. autoref. In another study, spurious cylinder of 0.50 REFERENCES to 1.00 D was inducedwhen fixation varied by 10 l Parson's Diseasesof the eye, Stephen Miller 1998,Ed. Re- degree from autoref axis [12]. It is an accurate fraction and Optics, 53-59. instrumentfor determining the axis and cylinder power in non cyloplegic conditions in signihcant 2. Operating manual NIDEK ARK 700. refractive errors and much superior to the manual 3. Duke Elder System of Ophthalmology Vol. 5 : Ophthalrruc method specially in children. The confidenceindex Optics and refraction St Louis, CV Mosby. l97O;96-12'7. ensuresthat only thosereadings having high index 4. Hussain SE, Kohen T, Maturi R, Koch DDJ. Cataract and are accepted. Refractive surgery. 1996; 22 : 362-6. Though the values obtained by autokeratometer 5. Robert H Hales. Contact lenses - a clinical approach to were steeper than manual keratometry, they were fitting. First edition.Pub. Williams and Wilkins. 1980;54- not clinically significant.Automatic fine adjustment 55. focus and measurementsmade at high speedswhich 6. D Kumar. A text book ofcontact lense practice lst edition. are accurateand repeatablemakes it the instrument CBS Publishers.1985: 45-47. of choice for keratometry.Its speedof estimationof 7. Manual of Ocular diagnosis and therapy, Detrorah Pavan corneal curvature is 20 times faster than manual Langstone.37677. method. 8. Cordonnier M, Dramaix M. Screening for abnormal levels The primary role of this instrument at this time of Hyperopia in children. BJO 1988; 82 : 1260-4. appearsto be increasing the efficiency with which 9. Cordonnier M, Dramaix M. Screening for astigmatism in eye care is delivered to the patients. It is highly children.BJO 1999;83: 15?-61. accurateand rapid for estimation of corneal curva- ture, astigmatismand for screeningoflarge groups. 10. Leyland M, Benjamin L. Eye 199'l;' I I : 854-7. Spuriousspherical power induced in youngchildren ll. SaraniyaAS, Ananth RS. Insight. l7 : 38-41. due to accomodation and spurious cylinder due to 12. Banks MS. Infant refraction and accomodation.Int Ophthal- improper positioning and fixation can causeprob- mol Clinics 1980; 20 :205-32. 68 Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I Ernerging Trends MONITORING AND PATIENT CARE EQUIPMENT IN CLINICAL HYPERBARICCHAMBERS Cdr GEORGE PAUL*, Surg Cdr B SLJDARSHAN#,S,r"g Capt S NANGPAL+ INTRODUCTION environmentshould be designed,tested, and intrin- efficacy of hyperbaric oxygen (HBO) for sically safe for hyperbarichyperoxic conditions. fnht The designcriteria for suchequipment includes the I therapeutic use has been well established. L Most treatment regimes require presures following: from 1.8 to 2.8 ATA, for durationsranging from 60 (a) All equipmentand circuits must be pressure to 120minutes. Hyperbaric oxygen therapy(HBOT) tested,spark proof, water proof, explosion' can be administered in either a clinical monoplace proof,implosion proof and ratedfor the maxi- chamber,or a multiplace chamber.Each hasits own . mumworking pressure [2]. unique advantagesand limitations. The monoplace (b) It shouldbe protectedfrom the chamberfire is used to treat one patient at a time, in a lNVo suppressionsprinkler system [2]. oxygen environment. The multiplace chamber uses (c) In mostcases, only the probes,or sensors,are a compressedair environment to treat one or more 'introduced patients, who breathe oxygen through a mask, a intothe chamber, with wirespassing hood, or an endotrachealtube. throughspecially designed electrical penetra- tors, throughthe pressurehull. Powerwiring As awarenessof the benefits of HBO increases shouldnot share penetrators, or bebundled with in the medical fratemity, it is inevitable that we will physiologicalleads. The bulk of the electrical be called upon to treat a broad spectrumof disease circuitry, the monitoringmodule and moving severity. componentsof the equipmentcan remainout Most indicated conditions for treatmentinside a sidethe chamber [3]. chamberdo not require elaboratemonitoring or life (d) Systems,other than low voltagesystems must support equipment, provided a trained hyperbaric be providedwith a closednitrogen purge sys- medical technician is in attendance.The critically ill tem,if requiredto beused in sidethe multiplace patient, would require a higher level of monitoring chamber. and interventionary life support, as provided in the (e) ICU. Critically ill patients, with multisystem dis- All circuits must be supplied from an un- ease,who require complex supportivetherapy, pose groundedsystem, from line isolatingtransform- ers and groundfault intemrptersoutside the difficult problems for clinical hyperbaric staff [1]. Ordinarily available ICU equipment may not be chamber.with isolationmonitors and indica- suitable in a hyperbaric environment. Danger from tion lamps.Ultra isolationtransformers should fire, the possibility of explosion, implosion, explo- be usedin all 50-60Hz instruments,with leads sive decompression and atmospheric contamina- passingto patients[,2]. tion, require extensive modification to existing (f) All circuitsand equipment installed in a cham- equipment,or redesign,before it can be safely used bermust be intrinsically safe. This impliesthat inside a treatmentchamber. the maximumenergy that can be drawnfrom a power supplyeven under faulty conditionsis DESIGN CRITERIA limited to levelsincapable of causingignition All equipmentfor introduction into a hyperbnric I2l. rClassified *Clearanceand Deep Diving Oftrenand O'/C HyperbaricChamber Complex, SpecialistMarine and Hyperbaric Medicine; -Sr AdvisorMarine and Hyperbaric Medicine; Institute of NavalMedicine, Mumbai. Jour.Marine Medical Society, Jan-Jun 2000, Vol.2, No. l (g) The chamberis groundedwith a No. 6 AWG outputcan be approximatedby observingthe collec- coppercable to a separateground. All electrical tion receptacle,if the patienthas a catheter.Addi- and metallicequipment, the bunk and eventhe tionally, a two way microphonecum speakerar- patient should be connectedby ground cables rangementwould enablealert patientsto describe to the chamber. sensationsand feelingswhich are an importantele- (h) All equipmentand circuits both insideand out mentof monitoring.Visual andauditory monitoring side the chambershould have a normal and an can thereforebe effectedin a chamberby : Multi Mono altemateindependent sources of electricsupply a) Direct observation by the hyperbaric with an auto changeovercapability, effective medical attendant(inside the chamber) ! X within l0 secondsof failure [2]. b) Direct observationby the medical (i) All wiring and electricalequipment must com- attendant(out side the chamber) X ./ ply with the relevant nationalelectrical code. c) Closedcircuit television ! { (e.g.NFPA 70-Art 500, ClassI, Divison I)[2]. d) Two way communication system V ./ () Lubricantsmust be non toxic and non combus- CHAMBER ENVIRONMENT tible. .ln additionto the chamberpressure or depth,the (k) Componentsmqst not give off toxic gasesor following parameters,affecting the patients comfort decomposeunder pressuein a IOOVooxygen and well being,should be monitored: atmosphere. (a) Chamberatmosphere gas composition (primar- (l) Batteriesused in the equipmentmust be solid. ily oxygenand carbondioxide) They shouldnot liberategas as a by productof (b) Humidity the energy generationprocess. Pressure safe (c) Temperature re-chargeableNickel Cadmiumbatteries can be used. In a monoplace chamber, l00Vo oxygen is flushedthrough the chamber.Continuous monitor- (m) Conventionalelectrical insulationsuch as vi- ing of 02 and CO2 levels are routinely carriedout nyl, or rubber,should be replacedwith Teflon on line. Howeverin a multiplacefacility, if the CO2 or mineral insulators.All wiring shouldbe en- level goesup beyond0.57o surface equivalent par- closedin metalconduits [3]. tial pressure,the CO2 scrubberis activated,or the (n) To furtherreduce the risk of staticsparking, non chamberis ventilatedwith compressedair. Oxygen conductivepiping, like plastic, should not be level in the chambermust be kept below 237o.The used,for high flow requirements. maximum allowableconcentration is 25Voby vol- MONITORING REQUIREMENTS ume [4]. A gassampling line takenfrom chamberto extemally positionedelectronic analysersenables Monitoring requirements patientsfor HBOT of continuous,or periodic monitoring of the chamber arebroadly categorised follows : as atmosphere.The fuel cell, or paramagneticoxygen (a) Visual and auditory analysersare generallyused. (b) Chamberenvironment Relativehumidity below 507opromotes the build (c) Vital parameters up of staticelectricity. High humidity levels result in fogging on ascentand is uncomfortablefor the VISUAL AND AUDITORY MONITORING occupants.Humidity should therefore be main- [1,4,5] tainedbetween 50 and 90Volll. Temperaturemust For most patientstreated in the chamber,direct be maintainedat comfortablelevels. Humidity and or indirect observationis the bestmethod of moni- temperaturelevels can be monitoredusing an elec- toring. The respiratory rate and breathing effort are tronic probe in side the chamber,or by pressure evident.Agitation andanxiety are easily recognised. compenstatedinstruments kept inside the chamber It is also possibleto appreciatethe pulse rate by and visible to the attendantthrough a view port. observing the carotid pulse, the posterior tibial Relativehumidity is temperaturedependent and is pulse,or the apexbeat, if thechest is exposed.Urine not a problemduring mostshort durations therapeu- 70 Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I tlc sessrons. ECG AND RESPIRATORY RATE VITAL PARAMETERS Cardiacaction is monitoredby anelectrocardiog- raphic oscilloscopemounted outside the chamber. Dependingon the severityof the patient'scondi- ECG skin padsand other connectionsare standard tion the physician may like to monitor selected equipment.The five wires of the connector are parameterscontinously, or intermittently by non separatedand individually insulatedas they pass invasiveor invastivemethods : througha speciallydesigned hull penetratorof solid (a) non invasive I) Pulse epoxy construction.Respiraory rate via changesin U) Temperature chestwall impedence,can be recordedwith theECG m) Blood pressure electrodes. IV) ECG V) EEG EEG VI) Respiratory rate VII) Transcutaneousoxymetery Electroencephalograph(EEG) power spectrum (b) Invasive recordingand somatosensory evoked potential stud- I) Arterial blood pressure ies can be conductedsatisfactorilv. The electric II) Central venous pressure signalsobtained can be transfenedout of the cham- m) Anerial blood gases IV) Urinary output ber throughelectrical hull penetrators.As the signal levels are very low, the electrical connectors DIAGNOSTIC EQUIPMENT throughthe hull penetratorsmust meet impedence In - chamberexamination of patientsis possible criteria,to avoid signal distortion.For EEG moni- only in a multiplacechamber. Available instruments toring, the electrodesshould be attachedprior to can be used,provid6d the battery compaftmentis entry into the chamberand the collodion shouldbe vented.Diagnostic equipment that are required in allowed to dry becauseit is flammable in the wet the chamberinclude the following[4] : state.The international10-20 systemof electrode placementis generallyadopted [6]. (a) Basic medicalexamination tray (Including re- flex hammer,stethoscope) TRANSCUTANEOUS OXYMETERY (b) Ophthalmoscope Measurementsof transcutaneousoxygen (TcO2) (c) Laryngoscope are not recommendedin monoplacechambers due to the risk of fire. The TcO2 probe is extemally (d) Flashlight warmedto 43oC and thereforeincompatible with a PULSE AND BP pressurised1007o oxygen environment.In a multi- placechamber TcO2 measurementsare not consid- For patients for whom BP episodic measure- ered an excessiverisk, as the oxygen level is con- mentsare clinically indicated,non invasivemethods trolled and the heatedarea of the sensorhead is areacceptable. Non invasivemeasurement of pulse closelyapplied to thepatient's skin. Baseline studies and BP can be effectedremotely, by the use of an are done on surface,by measureingthe TcO2 on electronicstethoscope with inflation of the BP cuff, intact skin closestto the area of greatestcompro- from outsidethe chamber [5]. mise.Measurements are repeatedon IOOVooxygen In the compressedair environmentof a multi- at surfaceand then at treatmentdepth [,4]. placechamber, the useof the standardmercury BP apparatusis acceptable.Ambulatory electronicBP INVASIVE PRESSURE MONITORING and pulserecorders like the SchillerBR - 102,used Arterial blood pressure,central venous pressure the auscultatorymethod of measuringBP and heart (CVP), pulmonaryartery pressureand intracranial rateand the oscillomgtricmethod as a backup. This pressure(ICP), can be measuredin a chamber,using equipmenthas been tested successfully upto 3 ATA a disposablepressure transducing system. The tra- in the multiplace chamber, at Institute of Naval ducer must be of the vented type (e.g. Cobe) to Medicine enable it to referenceit to the ambient chamber Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No.l 7l pressure.For arterial pressurea indwelling catheter for hyperbaricuse should not be alteredby changing is placed in the radial artery and connectedto the ambient pressure or temeprature. The volume of transducer. The system from the patient monitor fluid administeredis a function of the pump setting interface to the transduceris identical to that usedin and the drip chamber type. A conversion chart, for theICU [l,6]. different drip chambertypes must be available.The ICP monitoring is indicated for patients with drip chamber should be inverted during pressurisa- head injuries and carebral oedema.The Richmond tion to allow the gas to enter. On depressurisation subarachnoid bolt system can be connected to a the drip chambermust be watched to avoid infusion standard arterial pressure transducer inside the of air into the patient as expansionoccurs. This is chamber.Subarachnoid bolts areprone to becoming easily avoided by squeezing the drip chamber to accidentallyjanedor loosenedduring repetitive pa- replacesome of the air with fluid []. tient transport,to and from the chamber [6]. IV infusion into a patient in a chambercan be achievedby one of the following methods: ARTERIAL BLOOD GAS ANALYSIS a) The solution is placed inside the chamber and Arterial blood gas samplescan be aspiratedfrom the infusion is controlled from outside. The the arterial line for analysisduring HBOT. Blood infusion is pressurisedwith a cuff, whose pres- samples can also be drawn from the patient in a . sure is regulatedfrom outside the chamber. sealedsyringe and assayed as quickly aspossible (< I Min) after it is passedout of the chamberthrough b) The infusion is kept outside the chamber and the medical lock [5]. Off gassingof the sample pumped under sufficient pressureto overcome during the decompression will however result in thechamberpressure, the patient's venous pres- reduced values of oxygen and CO2 content. It is sure and the flow restrictive pressures.The important to minimise the volume of dead spacein IVAC 530 is a commonly usedperistaltic hy- the lines and transducer. perbaric infusion pump that permits infusions Blood gas determinationscan also be carried out upto 3ATA. The pump should be checked for within the chamber to obviate the problem of off accuratedelivery ofIV fluids to patientsat both pressures. gassing.The electrical componentsused in side the ambient and treatment For IV drugs chamber are provided with a continuous nitrogen that require careful and controlled administra- tion, caliberatingthe particularinfusion pump purgeto minimise the fire risk [3]. is ecommended[5]. INTERVENTIONARY PROCEDURES c) In a multiplacechamber, the completeinfusion Interventionary proceduresfor critical care pa- apparatuscan be introduced ifrated for hyper- tients which may have to be initiated or continued baric use.Such pumps are operatedby pressure in a hyperbaric chamber include the following : proof rechargeablebatteries. The Abbot-Shaw (a) Infusion and transfusion Lifecare II D pump, is one such pump rated for (b) Drainage, suction, aspiration hyperbaric use. (c) Ventilation SUCTION (d) Cardiac defi brillation Nasogastric,oral, wound or pleural suction may (e) Cervicaltraction be requiredduring the courseofhyperbaric therapy. Endotrachealsuction is not recommendedas there INFUSIONS AI\D TRANSFUSIONS is potential for complications. Chest tubes should Critical care patientsoften require a vast number havean in line Hemlichone way valveor waterseal. of precisely conrolled infusions to maintain homeo- For patients with chest tubes, slow decompression stasis (Inotropic agents vasodilators, insulin, total ratesare recommendedto allow adequateventing of parenteralnutrition, etc.). Infusion pump should ac- any intrapleural gas that is present.Suction systems tively infuse a measuredvolume in a given time for chambers use vacuum regulators and suction overcoming treatment pressuresof upto 3ATA or canistersmounted within the chamber.The vacuum 6ATA as required. The function of infusion pumps hose that drives the regulator is passedthrough an 72 Jour.Marine Medical Society, Jan-Jun 2000, Vol.2, No. I IV passthrough a specialisedport out of the cham- therebyincreasig the exhalationtime. ber. The pressurisedchamber provides the neces- Appropriate sedationand even paralysis may be sary pressuregradient to operatethe vacuum regu- necessaryto treat intubatedpatients. In the non-par- lator. A glassbottle trap is generally installed in line alysed patient, pulmonary barotraumamay occur if and a regulator is fitted betweenthe bottle trap and the patient coughs againstthe ventilator or receives the penetratorto control the amount of suction ap- a mechanicalbreath after taking a full spontaneous plied to the glass bottle trap. Alternatively, suction breath.An elevation of arterial CO2 pressureraises can be generatedin the chamber itself by a venturi, the potential for CNS 02 toxicity. Seizuresmay not which is poweredby compressedair [3,5]. be obvious in the paralysedpatient. Air breaks may AIRWAY MANAGEMENT EQUIPMENT be provided to reducethe risk of seizures.Monitor- ing of arterial blood gas is advisable for mechani- If airway patency is doubted, the patient should cally ventialted patients to determine the adequacy be intubated prior to HBOT. The cuff is filled with of alveolar ventilation. sterile normal saline insteadof air, before compres- Somepopular ventilatorsrated for hyperbaricuse sion [3,4]. are listedbelow[4,5] : IIYPERBARIC VENTILATORS a) The Penlon Oxford Ventilator is a bellows type For patients with respiratory failure, ventilatory volume set, timed cycle device effective upto 6 supportcan be continued for the duration of HBOT. ATA, with minimal changesin tidal volume As electricaly powered ventilators are not recom- and respiratory rate with changing depth. mended, pneumatically ventilators gen- driven are b) The Seachrist500,{ is a pneumatictimed cycle erally used. Under hyperbaric conditions, altered ventilator that allows adjustmentof flow, inspi- gas density and flow characteristics will change ratory an expiratorytimes. volume and respiratoryrate during compressionde- compressionand at different depths.The ventilators c) The SiemensServo ventilator is a sophisticated should be small and light for use in a limited cham- volumeset timed cycle devices that is electroni- ber environment. Oxygen bleed in to the chamber cally controlled. shouldbe minimal to preventincrease in 02 concen- d) The Bird MK 14 ventilatoris effective upto 6 trationof chamberair. Continousflow ventilationis ATA. superior to a demand valve as it minimises the inspiratory work and maintains constant airway DEFIBRILLATION pressure.Intermittent mandatory ventilation allows Somepatients, e.g. with gas embolismor Carb- the patient to breathe spontaneously between on-monoxide poisoning are at risk for life threaten- breathsfrom the ventilator. ing cardiac arrythmias which may require defibril- The airway pressureshould be monitored closely lation during the course of HBOT. Defibrillation in with a manometerand the tidal volume with a spi- an oxygen filled monoplace chamber is absolutely rometer caliberatedto the HBO environment.Tidal contraindicated.For a multiplace chamber the defi- volume is a function of chamber pressure,the pa- brillator is kept outside the chamber and only the tients lung compliance, control module inlet pres- cables are run through a dedicated penetrator into sure and airway resistance.During compressionthe the chamber with sufficient length to reach any flow and inspiratory time are manipulatedto main- position in the chamber. The defibrillator paddle tain a constant tidal volume. The patient should be switches are removed and activation of the equip- decompressedslowly particularly when closerto the ment is from outside. There remains however a surfaceto allow adequateelimination of expanding dangerfrom arcing betweenthe defibrillatorpaddles alveolar gas. For patients with lung disease, the during an attempteddefi brillation. ventialtory rate should be reduced during decom- The defibrillator cables inside the chamber con- pression to allow more time for exhalation. Flow nect to two pre gelled self adhering pads that attach ratesare usually increasedallowing a shorter inspi- to the patient. The pad sets come in both adult and ratory time to maintain the same tidal volume and child sizes.In additionto defibrillation,the pads can Jour.Marine Medical Society, Jan-Jun 2000, Vol. 2, No.I 73 ? be usedfor simplecardiac monitoring. For defibril- 3. DavisJC, Hunt TK, Hyperbaric oxygen therapy. Undersea lation,either traditional paddle placement, apex-an- MedicalSociety. 1977; 25-59. terior,or apex-posteriorplacement is used.The apex . chambers'equipment' techniques and posteriorpracement is recommendedas it virtualiy ]1].|T:Tfitlaric medicine'2ndEd' ree6: eliminatesthe risk of interpad arcing ano neeas nl #HjfJlffi$,1tft*" patient contact by the inside aftendant[7]. A power lossof about L07oistobeexpectedduetothelength 5. WeaverLK. Monitoringand lifc support.In monoplace of the cable. the nuber of COnneCtiOnSand the COn- hyperbaricchamber safety guidelines, UHMS Sep. l99l; duction resistancethrough the gel in the pads. 3l-48. REFERENES 6. RockswoldGL, Ford E, AndenonJR, er al. Patientmonitor- l. Dauphine K, Gross cE, Myers RAM. The spectrumof ing in the hyperbaricchamber. Hyperbaric oxygcn review. monitoringin the multiplacehyperbaric chamber, Hyper- 1985;3: 16l-7' baricoxygen review' 1985;6 (3) : 169-81' 7. MartindaleLG, Milligan M, Friesp. Tesrof anR-2 defibril- 2. National fire protectionassocaition (NFDA) standards- latonadapterinahyperbaricchamber.Journalof HypMed NFPA53 M,56D, 70,99. 1987;2(l): 15-25. 74 Jour.Marine Medical Society, Jan-Jun 2000, Vol.2, No,I CaseReport MULTIPLE HYDATID CYSTSLUNGS AND LIVER Lt Col G RAVINDRANATH, YSM*, Maj SANJAYS_HARMA**, SurgCapt RAMESH KUMART,Lt CgJS SACHAR##, SurgLt Cdr AARTI SARIN NAIDU+## KEY WORDS: HydatidCyst, Bchinococcus, Albendazole INTRODUCTION Clinical examination revealed a well nourished,afebrile child. Gencral physical examinationrevealed no abnormality. is f Tydatid disease a zoonosisaffecting man Examinationofabdomen revealed a visible fullnessofepigastric dead-endhost. Although and Rt. hypochondrium regions. Liver was palpable five cms H u. an accidental I Iseveral speciesof echinococcuscan invade below right costalmargin, minimally tenderwith a predominant left lobe palpable.Respiratory system examination revealed no and cause clinical lesions in man, echinococcus abnormality.Examination of CVS andCNS was normal.Haemo- granulosusis usuallyresponsible for hydatiddisease gram and urine analysis were normal. X-ray chest revealed a in lungs,liver and other organs.Dog and wild ca- large,well definedregular, homogeneously dense opacity occu- nines are definitive hosts which harbourthe adult pying RMZ and RLZ with no calcification.hft lung showed featuresof a rupturedhydatid cyst in the form of'Water Lily' worm in their proximal small bowel. Cystsdevelop sign invofving LMZ andLLZ (Fig. I ). USG abdomenrevealed a in intermediatehosts - sheep,cattle, humans, goats, 5.8 cms diameteranechoic cystic lesionwith a well definedwall horsesand camels. Infection in man is acquired in the left lobeof liver. CT scanchest and upper abdomen showed while handlingdogs, by eatingraw vegetablesand a cyst in the right lung middle lobe and a ruptured cyst left lung lower lobe with floating membranesand a cyst in the left lobe of by consumingcontaminated water. Following ex- liver (Fig. 2). CT brain was normal. Immunodiagnosticstudies cretion in dog faeces,the eggsremain viable for a showedIgE level of416l IU/ml. Patientwas diagnosedas a case long time: severalweeks in water, upto an year in ofmultiple hydatidcysts lungs and liver andsurgery was advised. Patient was operatedupon on I 2 May I 999 and hydatid cyst right dry and temperateclimate []. Human hydatidosis lung was enucleatedthrough a right mini-thoracotomyusing the mostcommonly affects the liver, which receivesthe Barrett'stechnique. Chest wound was closedwith an intercostal hatchedembryos via ponal vein. Those embryos underwater drain. Hydatid cyst left lobe of liver was excised in that successfullypass through the liver capillaries the samesitting through a right sub-costalincision taking precau- reachthe lung anddevelop into hydatidcysts. Some tions againstspillage of cyst fluid into peritonealcavity and wound was closed without drainage, Intercostal tube was re- embryosmay passthrough the wall of stomachor moved on the 4th post-operative day and patient made on un- duodenuminto a lymphaticchannel and via thoracic eventful recovery. Post-operatively, patient was advised Tab. and mediastinallymph ducts,reach the lung, caus- Albendazole and Tab. Praziquentalfor 12 weeks for the ruptured cyst in his left lung. He was dischargedto home with adviceto ing isolatedlung hydatid cysts [2]. Most casesare continue medicinesand review in OPD monthly with serial detectedincidentally during routine ultrasoundor radiographs. X-ray. We presenthere, a caseof multiple hydatid cystsin lungsand liver. DISCUSSION CASEREPORT Hydatid diseasecan involve any organ of the A five year's old son of a serving sailor presentedwith pain body.The averagegrowth of thecyst is probably l-2 left side of chest, chronic cough and fever on and off, of one year cms per year [3]. The cystsoften remain asympto- duration.Pain was confined to left mammary region,was dull matic or may presentwith complications.Majority achingin characterand aggravatedby coughing.Cough was dry are diagnosedduring routine X-ray chest or ultra- with occasionalminimal expectorationand one episodeof mini- mal haemoptysis.Parents denied any history of breathlessnessor sound examinations.Lungs are involved in about oain abdomen. 257oof all cases[4]. The WaterLily signseen in less_ itClassified *ClassifiedSpecialist Surgery and Paediatric Surgery; **Trainee (Surgery);tsenior Adviser in Surgeryand HOD: Specialist in Radio-diagnosisl"*"Graded Specialist in Radio-diagnosis,INHS ASVINI, Colaba,Mumbai - 400 005. Jour.Marine Medical Sociery, Jan-Jun 2000, Vol. 2, No. I 75 Fig. 2b : CT abdomenshowing hydatid cyst liver. Fig. I : X-ray lungshowing hydatid c1'st (Rt) and water lily sign on (Lt) lung. Fig. 3 : Resectedspecimen. cyst with Barrett's techniquewith obliteration of pericystcavity by seriesof purse string suturesis standardtreatment and gives good results [6,7]. However, there are proponentsof enucleationof lung cyst with the pericystcavity left open for the lung to expand[7]. In our case,we closedthe peri- cyst cavity with pursestring suturesafter suturing Fig. 2a : CT lung - hydatidcyst (Rt ) with rupturedcyst (Lt). the bronchial leaks. Albendazoleis currently the drug of choicepost-operatively to manageruptured than l57o casesis the floating rupturedmembrane cysts,to preventrecurrence and to tackleundetected seenas a semi-lunardisc abovethe fluid level in a disseminateddisease [8]. Our patient is being fol- rupturedcyst. Diagnosisis basedon radiology,im- lowed up for resolutionof left lung cyst and detect aging and serology,which is positivein abouthalf any dissemination. of all cases.Our casedemonstrated classical features ofan intactcyst in theright lung andleft lobeofliver REFERENCES as well as thoseof a rupturedcyst in the left lung l. Smyth JD, Smyth MM. Natural and experimentalhosts of (Figs. 1,2). Surgery is the standardtreatment and echinococcusgranulosus with commentson geneticsof spe- carriesa mortality of 0.9-3.6Vowith recurrencerate ciation in the genusechinococcus. Parasitology 1964:54: years of upto ll.3Vo in five [5]. Enucleationof lung 493-4. 76 Jour. Marine Medical Society, Jan-Jun 2000, Vol. 2, No. I 2. BanetNR, Thomas. pulmonary and hepatic hydatiddisease. technique. Thorax 1972; 2j : 529_31. Brit J Surg1952;40:222-4. 7. Xanthakis D, Epthimiadis M. Hydatid disease of chest. 3. SasramR. Hydatidcyst of lung.J ThoracCardiovasc Suro Report of 9l patients surgically treated. Thorax 1971;62:663-5. 1972:27 : 517-9. 4. Nick R. Thoracichydatid cyst. Med J Austl96j; | :999. - 8. Gill Grande LA, Rodriquez - Caabeiro F, prieto GJ. er c/. 5. KumarA, Lal BK, CharropadhyayTK. Hydatidcyst of the Randomisedcontrol trial ofefficacy ofalbenrtazole in hyda_ - liver non-surgicaloptions. JApI 1993t4l :437_9. tid disease.BMJ l9}3t 286 : t03-4. 6. LichterI. Surgeryof pulmonaryhydatid cyst _ The barret Jour. Marine Medical Society,Jan-Jun 2000, Vot. 2. No. I 77 POSTVACCINATION HEPATITIS-B ANTIGENEMIA IN A CHILD WITH JAUNDICE A CaseReport Surg Lt Cdr SHANKAR NARAYAN*, SurgLt Cdr NAVNEET NATH**, SurgLt Cdr VIVEK HANDE:F{'!{' INTRODUCTION tion antigenemia[].Infact, eventhe manufacturers eportsof transienthepatitis -B surfacean- could not provide any data on post-vaccinationan- n tigenemiain children. ft( tigenemiaafter recombinanthepatitis-B I.Lvaccine arerare and have been reported only As happenedwith our patient,the transient, post- in neonates[-4]. We reporttransient hepatitis-B vaccinationantigenemia could leadto anxiety,con- surfaceantigenemia in a recentlyimmunized child fusionand misdiagnosis[]. Therefore,some work- whocoincidentally developed jaundice. ers recommendthat HbsAg testing should be de- lay'edl6 to l7 daysafter vaccinationto removethis CASE REPORT confoundingfactor [3]. A 8 year male without any past history ofjaundice, blood transfusionsor any major illnesswas administeredthe first dose In 1989,Katkov an co-workersreported the ab- of recombinanthepatitis-B vaccine (Engerix B - Sm.ithKline senceof Hepatitis-Bsurface antigenemia at one and BeechamPharmaceuticals) after confirming his HbsAg negative 24 hours after vaccinationof 12 adults with the status. plasmaderived vaccine Two days later, the child developedmild fever which was [7]. treatedat home with oral paracetamol.On the fifth post vaccina- The first caseof transientsurface antigenemia in tion day, the child was brought to hospital with vomiting and a vaccinatedneonate was reported in 1993. The jaundice. neonatebecame HBsAg negativeone week post- The only findings on examinationwere icterus and a soft vaccination Later, Challapalli et al found an- tender hepatomegalyof three cm below right costal margin. []. Serumbilirubin was 3.0 mg/dl, predominantlyconjugated, ALT tigenemiain 55Voof l8 neonatesat 33 to 55 hours 90 U/L, AST 65 UlL. Alkaline phosphatasewas normal. The aftervaccination [2]. Weintrauband associates con- child testedHbsAg Positive by Latex method (Austragen,Latex, ducteda prospectivestudy in 47 new bornsadmin- marketed by Span Diagnostics Ltd, a third generation test vide isteredEngerix B. They found transientantigenemia FDA, USA specifications). in lTVoofsubjects which clearedlatest by l6 to lTth The child was treated conservatively and showed clinical as well as biochemical improvement. On the l2th post-vaccination post-vaccinationday [3]. In another study on 19 day, he was an icteric (S.Bilirubin 1.24 mg/dl,) and HbsAg vaccinatedinfants under intensivecare, 65Vo were negative.Two weekslater. (26th postvaccination day), the child reportedto exhibit transientantigenemia, the long- showed complete clinical and biochemical recovery and re- estduration being eight days A searchoflitera- mainedHbsAg negative.' [4]. ture failed to revealany report on transienthepati- Six months of follow-up revealed an asymptomaticand HbsAg negativechild. tis-B surfaceantigenemia associated with jaundice in a recentlyvaccinated child. DISCUSSION Our patient'sclinical profile suggestedincubat- Infection with hepatitis-B is endemic in India ing hepatitisat the time of vaccination.Hepatitis-B and HbsAg is the most commonly testedserologic' virus as a causativeagent had been ruled out by marker [5]. Despiterecommendation by the World testing.The exactcausative agent could not be iden- Health Organisationfor the adoptionof universal tified dueto lack of comprehensivetesting facilities. hepatitis-B immunization [6], there is very scant Surfaceantigenemia detected five daysafter vacci- dataon the incidenceand durationofpost vaccina- nation,cleared up completelyby the l2th day. The +GradedSpecialist (Pediatrics); **Graded Specialist(Pathology); ***Graded Specialist(Medicine); INHS Dhanvantari,Port Blair - 744 to2. 78 Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I rl fiere s validity of the sensitivityof the AustragenLatex surface antigenemiain newbom infants vaccinatedwith than Testas claimed by themanufacturers (sensitivity 20 hepatitis-Bvaccine. Ped Infect DisJ 1993;12 : 878-9. ,snot ng/ml-)was confirmed by testingserial dilutions of 3. WeintraubZ, KhamayasiN, ElenaH, GershteinV, Oren- :d by EngerixB vaccineupto a concentrationof 30ng/ml steinL, Lahat N. Transientsurface antigenemia in newbom I low of HbsAg. infantsvaccinated with EngerixB : occurrcnceand duration. r that Theaim of reportingthis case is threefold- fimtly PedInfect Dk J 1994113 : 931-3. igher to bring to light post vaccinationtransient surface 4. BernsteinSr, KriegerP, PuppalaBI, CostelloM. Incidence both antigenemiain a child; secondlyto lay stresson the andduration ofhepatitis B surfaceantigenemia after neona- ically confoundingnature of this antigenemiain a child tal hepatitisB immunization.J Pediatr1994; 125 : 621-2. in 32 with symptomsand thirdly, to highlightthe lack of - pediatrics. rctive 5. Committeeon immunization Indian Academy of mentionof this transientantigenemia in textbooks, Imrnunity, immunization and infectious diseases.Repoa :d by medicalliterature as well asthe manufacturer'slit- and Recommendationsof thc Committeeon Immunizntion inder erature. 194: l15-20. rlegic I axis REFERENCES 6. KarrhikeyanG. Selectedsummaries - immunization of hepa- -3. rctive l. ChallapalliM, Naidu V, CunninghamDG. Hepatitis- B toccllular carcinoma.I ndian Pediat ric s 1997: 34 : I 14I same, surfaccantigenemia in a newbominfant aftervaccination. 7. Katkov WN, Mark AJ, Stuart DB. Abserrceof hepatitisB time PedInfect DisJ 1993;12 :408-9. surfaceantigenemia after vaccination,Arch Patholl"ab Med those 2. ChallapalliM, SlosarM, VasaR, CunninghamDG. Brief 1989:l13 : 1290. 'erage lsand ration r than rlalues ertical ertical rizon- closer tedby heav- Itimes )meter rnd25 ,IIlllOn nerally r a part 1is es- impor- rwerin us in- ;thhas I in the ' 1991. ontrib- 2,No. I Jour. Marine Medical Sociery,Jan-Jun 2000,Vol. 2, No. I 79 AIRCREW - AIRCRAFT INCOMPATIBILITY WITH A SEA VARIANT PERSONAL SURVTVAL PACK A CaseReport SurgCdr KV SUNDAR INTRODUCTION ments is a pilot, whose spine is flexed forwards as well as laterally,has a slight torsionalrota- he traditionalmethods of assessingaircrew's tion andat the sametime, is employinghis feet anrthropometriccompatibility with thecock- for applying rudder. These postureshave to be pit have employeddrawing board manikins adopted for almost the entire duration of the at the conceptual stage and fully kitted pilots at the sortie. mock up stage. In this processthe extremesof the pilot population are generally represented.Despite CASEREPORT this, individualsare still found to be too large,foul- . A 35 year old helicopter pilot presentedwith low backache ing cockpit equipmentor too small and unableto which was of a dull aching nature generally precipitated after flying Chetak helicopter with a PSP (sea variant) which is a reach the equipment.A caseof incompatibilityof squareshaped bag with a length of 35 cms and a breadth of 18 the pilot in relationto flying a Chetak(Alloutte-Ill) cms approximately. General systematicand local examination of helicopter fitted with a seavariant personalsurvival the spine did not reveal any overt abnormality. However, x-ray pack (PSP) which is placed in the seatpan of the of his lumbar spine showed spondylotic changes and loss of lumbar lordosis. The pilot's static antrhopometric measurements pilot's seat is discussed.The Chetak helicopteris taken, using the modified Morant's board were within normal usedin large numbersin the Indian Navy, both in limits (Fig. l). shorebased air stationsand on boardships. Fig. I : Static antrhopometric measurements Helicopter controls: The basic helicoptercon- trols need a mention in this context and are as a. Standingheight 162.5cms follows[] : b. Sitting height 84 cms c. Leg length 99 cms - (a) Two sticks the helicopter is controlled by d. Thigh length = 55cms cyclic in the centrebetween the rudderpedals and collectivewhich is by the sideof the pilots left thigh. When-ever the helicopter is to be Though within normal limits, most parameters raisedor lowered,the collectiveis to be raised arein the minimal acceptablelimits (lowestpercen- or lowered. tile). (b) Rudder - when ever the pilot comesup on the StaticCockpit Assessment (Chetak Helicopter With PSP) collective, this change of pitch in the rotary The pilot in full flying clothing was assessedin a Chetak wing causesa yawing movementof thehelicop- helicopter seat with PSP and was asked to adjust Rudder to his desired settings, lock safety harnessbelt and operate controls in ter. Therefore,when the pilot is pulling up his their operating rangesand the following were observed left arm and raising the collective,at the same a) The pilot could not operate the brakes with his left hand. time he is pressinghard with his right foot to He resorted to operating them with his fingers in extended maintain the opposite rudder. This causes a position. pelvic shift as well as rotation of the lower b) His grip on the collective when fully down was inadequate. Insteadof the grip being in his palm, it was in the grasp of fingers spine.In additicn,it is necessaryfor thepilot to only. be able to see the ground during landing and c) Both the lower limbs were in fully extended position to take-off period which necessitatesa flexion of operatethe rudder pedals. the spine.The overallresult of all theserequire- d) operation of friction control knob was not possible. Aeromedical Specialist, INS Rajali, Arakkonam. 80 Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I -:.- .= ar l !- e) The spine was flexed (20-25 degree) when operating the of low backachecould be relatedto the sitting pos- controls. ture of the pilot where in there is forward flexion of Static Cockpit Ass€ssment (Chetak without PSP) spinefor groundview and operatingthe very sensi- The pilot could reach and operate the collective lever, brakes tive cyclic level and at the sametime, lateralflexion and friction control knob comfortably. The torso was required to for operatingthe collective lever be flexed laterally by only about five degrees. as and when re- quired. Functional Assessment in The Air An IAF A sortie of45 mins duration was carried out on the helicopter study conducted,revealed that66.7Voof fitted with PSP with the subject pilot in the right hand seat,and pilots had low backacheand it was attributedto the a experiencedpilot on the left seat.The following was observed sittingposture [3,4]. According to someauthors, the a) The pilot had to perforce miss one ofthe vital actions of sitting postureassumed in helicopterflying leadsto locking the safety harnessdue to his inherent inability to control antero flexion of the spine which tends to force the the aircraft. nucleuspulposus posteriorly Such traumaover b) The pilot had to do extreme forward flexion for operating [4]. the brake lever and extreme lateral flexion to operate the collec- the yearsleads to radial tearsin the annulusfibrosus tive throughwhich the nucleuspulposus may herniate. c) During auto-rotation (a manouevre requiring sudden de- However, in absenceof definitive studies using scentofthe aircraft to land at a safesite during emergency)which methodssuch as MRI scan,any disc changesremain was simulated,the pilot had to bend laterally from his seatto hypotheticaland yet unproven. )I check whether the collective had been fully "DOWN" and to "RAISE' the same on completion of the manouevre. AEROMEDICAL DISPOSAL AND RECOM- 8 d) The lower limbs were fully extended for operating the MENDATION )f rudder pedals and infact at the extreme range of rudder move- ry ment, only the toes could reach the pedals with the respective The aircrew officer in this case was recom- )f heels raised off the floor board. rnended to be withdrawn from Chetak helicopter ts e) On completion of the sortie, the p,ilot complained stiff- of flying with PSP,and routed to the SeaKing helicop- al nessof the back which was reflected by paraspinalmuscle spasm on clinical examination ter wherein thereis a four way adjustableseat and a betterPSP fitment. Due to the spacelimitations of DISCUSSION the Chetakhelicopter and the requirementthat the In this casethe aircrew - aircraftincompatibility PSPdetaches and goes along with pilot ditched at is basicallydue to PSPplaced in the seatpan. In an seathere is no possibility of placing the PSPelse- opinion survey canied out amongst helicopter where.The only possibilityto avoid this incompati- flights of various units, 997oof the pilots pointed out bility is to designand developa more compactPSP that the PSP causesvarying degreesof discomfort which fits well in the existingseat or a total change duringthe entiresortie duration. In addition,46Voof of the seatdesign suited for fitting the sea variant )rs them reported that they also had problemsof reach- PSP. n- ing thecollective and brakes because ofthe increase REFERENCES in height of the sitting posture by the thick PSP l. Navathe PD, Nayar GS, Krishna NS. Helicopter placedin the seatpan [2]. As such,the seatof the controls : an ergonomic approach. Ind J Aerospace Med 1994;38 : ak Chetak helicopter is uncomfortablebecause of its l6-8. ris angularcontour and with the PSP it causesan un- ln naturalsitting posturecausing a changein flying by 2. Pinto LI. Backachein Helicopterpilots of the Navy.lnd J perspective.In this case the subjectpilot initially AerospaceMedl993;37 : ll-4. A presentedwith low 3. Goede R. Backache in helicopter pilots. Aerospace Safety :d backacheand the opinion survey also revealedaboutTO-7SVo of pilots experiencing 1978;14: 16. low backache,generally after about two to 2'12 4. Malik H, Kapur RR. Backache in helicopter piloas. Avi Med rs hoursof flying a Chetakwith PSP.The basiccause l98l;25:ll. Jour. Marine Medical Society,Jan-Jun 2N0, Vol. 2, No. I 81 AN UNUSUAL FOREIGNBODY IN THE BRONCHUS Surg Cdr PS TAMPI*, Surg Cdr S GANESAff, Surg Lt Cdr D RAGHAVAN+, Col HS PRUTHI**, Col BN BORGOHAIN## INTRODUCTION was no stridor. A chest x-ray (PA view) and left lateral view revealedthe pin of lAloreign body aspirationcan be the cause to be lying head-downjust behind the heart and could be seento J{ both upper and lower airway obstruction and pulsate wilh every heart beat on fluoroscopy. He was then sub- I canoccur both in adultand children. Children jected to a plain CT scan of the chest. The paper pin was located are likely to aspiratetoys, coins and hard candy, in the sub-segmentsofthe anterior basal segmentbronchus ofthe left lower lobe. The patient was taken up for fiberoptic bronchc. while adultsmore commonly aspiratefood particles scopy in the operating room under l'ocal anaesthesiaand con- like meat bonesand dental appliances.Inhaled or scious sedation.Despite all efforts and a thorough search,the pin aspiratedforeign bodies are known to cause acute could not be visualised through the scope.It was felt that the pin upper airway obstruction, laryngeal edema,central was possibly lying distal to the furthest point that could be traversedby the fiberoptic bronchoscopein the bronchial tree. obstructivecollapse and obstructiveemphysema. If The procedurewas repeatedagain but this time under fluoro' the obstruction is severeand acute it can even lead scopic guidance.The paper pin was confirmed to be lying head- to suddendeath. Sub acute and chronic complica- down about five centimeters beyond the tip of the fiberoptic tions include post obstructive pneumonia, lung ab- bronchoscope,but was still not visible through the bronchoscope. scess formation, bronchiectasis and foreign body Initially, a guide-wire was passedthrough working channel and extruded out of the distal end of the scope. An attempt to granuloma.Immediate removal of the foreign body mano€uvre it into the subsegment bronchus with the pin was and prompt resuscitation can often be life saving. unsuccessful.It was withdrawn and an alligator biopsy forceps One of the earliest uses of the bronchoscopeswas was then introduced through the working channel. Under fluoro- the removal of aspiratedforeign bodies. In the pre- scopic guidance,it was extendedbeyond the tip of the scope and with some difficulty and manoeuvering it was guided into the sent day, both rigid and fibreoptic bronchoscopes desired subsegmentalbronchus. The open forceps was then gen- have beenwidely usedfor this purpose.The ingenu- tly advancedand the pin was firmly graspedbetween its blades. ity of the bronchoscopistshas resulted in the inven- Thereafter, the bronchoscopeand the alligator forceps holding tion of various modified devices to remove foreign the pin were gently withdrawn together, the entire procedure being visualized on the fluoroscopy screen.The pin was success- bodies from the tracheobronchial tree. We report fully retrieved from the patient. one suchcase of an unusualforeign body in a distal A repeat fiberoptic bronchoscopy excluded any local injury bronchusthat was retrievedsuccessfullv. or hemonhage in the affected segment and the remaining upper and lower tracheo-bronchial tree. There were no complications CASEDETAILS of the procedure. The patient was conscious, cc'operative A paper pin held in the mouth of a young sailor accidently throughout and withstood the procedurewell. slipped beyond his oral cavity while talking. He immediately had a bout ofcoughing which persistedfor sometime, after which the DISCUSSION cough subsided spontaneously.But the paper pin.could not be located.The pin had neither beencoughed out nor could it be seen About two thirds of foreign bodies lodge in the within the oro.naso-pharynx. He did not have any foreign body main stem bronchuswhereas most of the remainder sensation or pain in his throat while coughing or swallowing. are found in the lobar bronchi []. They cause ob- There was no hemoptysis chest pain or respiratory difficulty. structive emphysema about five times as often as An immediate detailed ENT examination including an indi- obstructivecollapse. The Cafe Coronary Syndrome rect laryngoscopy was normal with no sight of the missing pin or any injury to airway or the oesophagus.Clinical examination of is the namegiven to the suddenaspiration of a bolus GI system and respiratory system was essentially normal. There of food, usually meat into the hypopharynx and *Classified +Graded Specialist (Medicine & Pulmonology); "Classified Specialist (Radiodiagnosis); Specialist (C:olaryngology); mProfessor **Professor & Head, Department of Medicine; & Head, Departmentof Otolaryngology; INHS Asvini, Colaba, Mumbai 400 005. 82 Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. l upperportionof thelarynx. This can result in sudden servedfor any signs of hemoptysisor subglottic respiratoryembarrassment while eatingand the vic- edema[4]. tim is suddenlyunable to talk or breathe.Here, the In the index caseabove, we have successfully Heimlich maneouyremay be lifesaving.Risk fac- removeda foreign body (paperpin) in left lower tors for foreign body aspirationinclude advanced lobe sub-segmentalbronchus under fluroscopic age,altered state ofconsciousness due to alcoholor guidanceusing a minimally invasive fiberoptic poor drugs, dentition and neurologicaldisorders bronchoscopeand an alligatorforceps, thereby ob- suchas Parkinson's disease and stroke [2,3]. viatingsurgical thoracotomy. Until the introductionof the fiberoptic broncho- scope,all procedureswere done through the rigid REFERENCES bronchoscope.The latter,being of a largecaliber l. Kryger M, Bode F, et al. Diagnosisof obstructionof tlp andrigid hasits obviouslimitations when exploring Upperand central urways. Am J Med 1976;6l : 85-93. the distalbronchial tree. Various types of grasping forceps,retrieval baskets and magnetic devices have 2. TiedenPA, KanerRI, et aI. AspirationEmergencies. C/in ChestMedl994i 15 : I 17. beendeveloped in orilerto removeforeign bodies of all kindsfrom the tracheo-bronchialtree. 3. HeirnlichH. A Life-savingmaneouvre to preventfood chok- ' Specialattention should be paid to the period ing.JAMA 1975;234:298. after removalof the foreign body - a time when 4. Kim I, er aL Forcign body in the airway : A review of 202 complicationscan occur. Patientsshould be ob- ca*s. Laryngoscope1973;83 :347. lour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I 83 Pe r sonal Communic ation CORRECTIVEFLYING SPECTACLES: TYPESAND DESIGNS Wg Cdr GKG PRASAD, VSM 111lying is a visually intenseoccupation with powernot exceedingi 3.5 OD. The pilot is advised providing pair while J{ visual cues approximatelySOVo of to carry an extra flying. L the information neededto fly an aircraft. In AIRCREW SPECTACLES OF HIGH the fighter aircraft, superb vision is still regardedas [PER- FORMANCE AIRCRAFT a pilot's greatestasset in spite of the plethora of [3] sensoryequipment available in today's modem air- In a study conducted on aircrew spectaclesfor craft [1]. Spectaclecorrection in ame - tropic air- high performanceaircraft, it was found that tear drop crewpresents some unique problems,. Properdesign shape frame of Rayban design with thin metallic and well fitting glassescompatible to flying envi- sidearm wascompatible with different mask/helmet ronmentis essential,as the pilot is requiredto wear combinationsused in variousfighteraircraft. CR-39 different flying head gear like helmet and mask plastic lenseswere found more comfortable than the combinationand is prone to exposureto aviation mineralglass lenses by thepilots as they were lighter stresseslike hypoxia, rapid decompression,accel- and impact resistant.The subjects were exposedto erative forces, vibrations, climatic extremes and aviation stresseson ground simulators and in actual pressurebreathing. Over and above,he is involved flying. In the human centrifuge,when the subjects in visual task such as target detection,reading of were exposedto a maximum of +5.5 GZ accelera- staggeringnumber of panel instruments,use of op- tion no displacementof spectacleswas noticed. tical aids etc. The Presbyopicpilot is required to During positive pressurebreathing and rapid de- wear proper glasses,keeping in view his visual compressionthe spectacleswere displaced upwards requirementsof seeingthe maps,and overhead pan- by lifting up of the oxygen mask. The mask was els at closedistance, the eye level instrumentpanel lifted up for theduration during which all the excess at intermediarydistance and visualtasks outside the volumeof gaswas eliminated from the mask.In hot cockpit at far distances[2]. cockpit studiesthe subjectsshowed fogging of the spectaclelenses. During inflight trials, the specta- The visual standardsof pilots followed in Indian cles were found to restrictthe field of vision when defence forces are - at initial entry glassesare not used with other optical devices like night vision permitted for flying pilot duties. For a trained serv- gogglesand gun sights and could not be adapted ing pilot of fighter stream relaxation upto uncor- with thesedevices. rectedvision of 6/18 in each eye is permittedpro- vided the vision is correctableto 6/6 and 6/9 with SPECTACLES FOR PRESBYOPIC AIR. correctiveglasses of maximum dioptericpower not CREWt4l exceedingt 3 O.D. The conventionalbifocal lensesin someaircrew However thesepilots would be made unfit for were found to causea bit of annoyanceand distur- flying aircraft where pressureclothing is mandatory. bancesdue todistortion and blurring atthe transition For the trained pilots of transport and helicopter zone. Therefore a comparative study was under- stream,relaxation upto uncorrectedvision of 6/36in taken between modulated power lenses(varilux-2) eacheye is permitted provided the vision is correct- and conventionalbifocals in the aircrew. In this able to 6/6 in the better eye and6112 in the other eye study it was found that the subjectswho were com- with corrective glasses of maximum diopoteric fortable and alreadv used to wearins conventional Classified Specialist (Ophthalmology), Institute of AerospaceMedicine, Bangalore 560 017. Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I \9 bifocals could not get adapted to the modulated Aviat Spne EnvironMed 1993 64 (6) : 541-S. powerlenses. Only those subjects who had problems 2. Miller RE tr, Kent JF, Green with conventionalbifocals during flying could Rp Jr. hescribing spectacles adapt for aviaton : USAF to the modulatedpower lenses. Experierrc,e,Aviru Space Environ Med In orderto benefit 1992;63: 8O.5. the presbyopicaircrew to seethe overheadpanel instruments,nifocal lenseswith top and Uottom 3. KumarR, PrasadGKG, BabooNS, MookherjeeTK, Kuldip Rai, Tyagi segmentcatering for closedistance and middle seg- P. Study of problems associatedwith use of spoctaclesfor mentfor far distance,,werestudied and the subjects flying high speedaircraft - AFMRC project foundthem useful and comfortable. No. l58d86Indian Air Force. RETERENCES 4. Nath HK, hasad GKG, SoodanKS. Study of problems associatedwith useof modutatedpower lenses(varilux _2) l. Micheal R prcvalence Mork, LaurenceA Watson. of conec- by presbyopic aircrew during flying _ AFMRC project no. tive lens wear in Iioyal Australian Air ForceFtight Crew. l85d9l Indian Air Force. ' - aa' Jour.Marine Medical Society,Jan-Jun20N, VoI.2, No.I 85 ELECTROENCEPHALOGRAPHYAND MAGNETICRESONANCE IMAGING AFTERDIVING AND DECOMPRESSION INCIDENTS: A CONTROLLEDSTUDY SA SIPINEN, J AHOVUO, JP HALONEN UnderseaHyperb Med 1999;26 (2) z 6l-5. ABSTRACT Diving incidentswith symptomsof decompressionsickness (DCS) and/or arterial gasemboli (AGE) might increase the degreeof pathologicchange in the electroepcephalogram(EEG) or magneticresonance imaging (MRI) of the supraspinalcentral nervoussystem (CNS). Diving itself,even without known symptomsof DCS and/or AGE, has beenproposed to increasethe number of CNS lesionsgsing either EEG or MRI. In the lirst part of a two-part study we examinedthe effectsof recompressiontreatment on EEG in decompressionincidents in a group.ofsport and professionaldivers comparedwith a control group ofhealthy naval divers.In the secondpart we recorded brain MRI from three groupsof volunteers: 1) diverswho weretreated for DCS in pressurechamber, 2) divers who had never had symptomsof DCS (and/or AGE), and 3) healthy normal controlswho were not divers.Our resultsindicate that DCSincreases the incidenceof pathologicEEG recordings,whereas recompression treatment decreasesthem. The resultsof MRI do not verify evidenceof increasednumbers of CNSlesions in normal divers as comparedto non-diving,healthy control subjects,whereas some of the divers treated for DCS in a pressure chamberhad hyperintenselesions in brain white matter.None of themhad any abnormalitiesin EEG, neurologic performance,or psychologicbehaviour. Both EEG and MRI are sensitiveand non-specificmethods for judging suspectedevidence of brain lesionsfrom diving or diving accidents.. FIBROBLASTRESPONSE TO RAPID DECOMPRESSIONAND HYPERBARICOXYGENATION EH PIEPMEIER.JE KALNS Aviat SpaceEnviron Med 1999;70 (6) : 589-93. ABSTRACT INTRODUCTION : The cellular basis for symptomsassociated with rapid decompressionand the use of hyperbaric oxygenationtreatment (HBO) is not established. METHODS : Imageanalysis, sulforhodamine B assayand bromodeoxyuridine(BrDU) incorporationwere used to identify cellular changesassociated with rapid decompression(RD) or hyperbaricoxygenation (HBO). Human libroblastswere exposed to RD or HBO and comparedwith untreatedcells. Immediately following treatmenl the fraction of cellssynthesizing DNA was measuredby detectionof cellsincorporating the BrDU. At I d and 3 d following the treatments,total cell protein adherentto the bottomof wellswas measured using a sulforhodamine B assay.Cell densitywas observedwith light microscopyand quantilied with imageanalysis. RESULTS : RI) increasedtotal protein significantly,(p < 0.05)relative to control, while HBO had lesselftcl The fraction of cellssynthesizing DNA wasincreased by HBO and reducedby RD relativeto control (p < 0.05).Image analysisshowed that cell densityat day I was: control > HBO > RD; and at day 3; RD > HBO > control, indicating Jour. Marine Medical Society,Jan-Jun 2000, Vol. 2, No. I * an increasein proliferation inducedby the treatments. CONCLUSION : This data showsthat HBO and RD increasethe proliferation of fibroblastsfor 24 h following treatmenl HBO increasedDNA replication.While therewas a decreasein DNA replicationfollowing RI), protein synthesiswas enhanced. BONEHEALING OF TIBIAL LENGTHENING IS ENHANCEDBY HYPERBARICOXYGEN THERAPY: A STUDY OF BONEMINERAL DENSITYAND TORSIONALSTRENGTH ON RABBITS SW UENG, SS LEE, SS LIN, CR WANG, SJ LIU, HF YANG, CL TAI, CH SHIH J Trauma 1998;44(4) : 676-8f. ABSTRACT We investigatedthe effect of intermittent hyperbaric oxygen (HBO) therapy on the bone healing of tibial lengtheningin rabbits. Twelve male rabbits were divided into two groupsof six animalseach. The first group went through 2.5 atmospheresabsolute of hyperbaric oxygenationfor 2 hours daily, and the secondgroup did not go through hyperbaric oxygenation.Each animal's right tibia was lengthened5 mm using an uniplanar lengtheningdevice. Bone mineral density (BMD) study was performed for all of the animals at I day before operationand at 3,4,5 and 6 weeksafter operation.All of the animalswere killed at 6 weekspostoperatively for biomechanicaltesting. Using the preoperativeBMD as an.internal control, we found that the BMD of the HBO group was increasedsignificantly compared with the non HBO group.The mean VoBMD at 3,4,5 and 6 weeks were 69,5Vo,80.19o,87.8Voand96.9Vo, respectively, in HBO group,whereas the mean VoBl[.fD were 5l.6Vo, 67.7Vo,70.5Voand79.2Vo,respectively,innon-HBOgroup(twotailedttest,p<0.01,p<0.01,p<0.0l,andp< 0.01at 3,4,5 and 6 weeks,respectively). Using the contralateral nonoperated tibia asan internal control,we found that torsional strengttr of lengthenedtibia of the HBO group was increasedsignificantly compared with the non-IIBO group. The meanpercent of maximal torque was 88.6Voin HBO group at 6 weeks,whereas the mean percentof maximal torque was 76.OVoin non-HBO group (two-tailedt test, p < 0.01).The resultsof this study suggestthat the bonehealing oftibial lengtheningis enhancedby intermittent hyperbaric oxygentherapy. RISK FACTORSFOR SYMPTOMATIC OTICAND SINUSBAROTRAUMA IN A MULTIPLACEHYPERBARIC CHAMBER DT FITZPATRICK, BA FRANCK, KT MASON, SG SHANNON UnderseaHyperb Med 1999;26 (4'l ; 243-7. ABSTRACT This retrospectivestudy examinesthe relationshipof multiplacechamber compression rates and the influenceof severalpredisposing factors on the risk of symptomaticbarotrauma. Data werereviewed from a 3-yearperiod of Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I 111patients who received2n394 routine hyperbaricoxygen treatments. A total of 35 patientsreported symptoms of barotrauma,with an overall rate of 3.05cases per 100treatments. Most symptomsoccurred during a patient's initial three treatmentsand with minimal increasedpressure. The most frequently affectedarea was the ears (957o)with objectivefindings noted inlSVo of patientsreporting fullnesscompared to39Vo of patientsreporting pain. Referraldiagnosis was not relatedto the incidenceof barotrauma.Although the overall risk of symptomatic barotrauma increasedas the compressionrate increased,it wasnot significant(RR = 1.57,CIO.95 = 0.65,3.80). Femalepatients were at significantly increasedrisk (RR = 2.14,CIO.95 = 1.37,3.34) comparedto males,and patients less than age 40 were at higher risk than those age 40 and older (RR = 3.00, CIO.95 = 180, 5.03). Well-designedprospective studies are neededto more clearly definerisk factorsand identify compressionrates with the leastrisk of barotrauma. CARDIAC AND HUMORAL CHANGESINDUCED BY RECREA- TIONAL SCUBADIVING C MARABOTTI, F CHIESA, A SCALZINI, F ANTONELLI, R LARI, C FRANCHINI, PG DATA UnderseaHyperb Med 1999;26 (3) : 151-8. ABSTRACT . The aim of this study wasto evaluatethe prevalenceand the possibleclinical relevance of circulatingbubbles after a recreational scuba dive. Twenty healthy subjects(18 male,2 female; age range 25-36 year) underwent a Doppler-echocardiographicstudy in basalconditions and 1.9+ 0.2h after a recreationalscuba dive. Venous blood sampleswere taken just before the two ultrasonicstudies to obtain leukocyteand platelet counts and plasma activity of angiotensin-convertingenzyme (ACE; assumedas pulmonary endothelial damage marker). Circulating bubbleswere observedin the right heart chambersof 12 subjectsafter the dive. The echocardiographicand humoral data were evaluatedbefore and after diving in subjectswith and without circulating bubbles.At the postdiveevaluation, a signilicantincrease in right ventricular dimensions(37.4 !3.9 vs. 40.7+ 4.0 mm; P < 0.01) and a signilicant reductionof early diastolicfilling velocitiesof both right (59.1+ 16.4vs. 48.9I 6.9 cm x s-(-l); P < 0.05)and left(76.2!9.9 vs67.5 + 10.2cm x sGl);P < 0.02)ventricle were observed in thegroup with circulating bubbles.In the samei;roup, significantincreases in ACE activity (92.9! 4l.l vs 105.9t 41.7U x liter (-l); P < 0.05),platelets (217 !34 vs 232+ 35 10 (3) x microl GIX P < 0.01),and granulocytes(3,704 ! 715x microl (.1) vs. 5,212+ 1,995x microl (-l); P < 0.001)were observed.The bubble-freegroup showedonly a postdivesignificant decreaseof left ventricular early diastoliclilling velocity(74L6.8 vs 62.6+ 4.5 cm x sGl); P < 0.005).These data may indicate that circulating gas bubblesare associatedwith cardiac changes,suggesting a right ventricular overloadand an impairment of ventricular diastolicperformance. Postdive humoral and hematologicchanges are consistentwith the hypothesisthat "silent" gasbubbles may damagepulmonary endotheliumand activate the reactivesystems of the human bodv. 88 Jour. Marine Medical Society,Jan-Jun 2000, Vol.2, No. I r,lxfinc m ,@