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EDITORIAL BOARD Chief Editor Dr. Viren Patel MD (Pathology), USA Associate Editor Dr. Sunil Nayak MD (Community Medicine), Patan, Gujarat Executive Editor Dr. Harsh Shah, MD (Skin & VD)

Associate Executive Editor Mr. Bhaumik M Members

Dr. Chirag Mehta MS (ENT), Palanpur

Dr. Mehul Gosai, MD (Pediatric), Bhavanagar

Dr. Deepak Agrawal, MD (Pathology), Agra

Dr. N K Gupta, MS, MCh (CTVS), PGDHHM, Lucknow

Dr. Deepak Parchivani PhD (Biochem), Bhuj

Dr. Praful J. Dudharecha MD (Medicine), Rajkot

Dr. Deepak Shukla MD (Medicine), Surat

Dr. Rajesh Solanki, MD (TB & Chest), Ahmedabad

Dr. H. R. Jadhav, MS (Anatomy), Ahmedabad

Dr. Gunvant Kadikar MD (Ob. & Gy.), Bhavnagar

Dr. Hitendra Desai MS (Surgery), Ahmedabad

Dr. Indira Parmar, MD (Pediatric), Vadodara

Dr. Kaushik Kadia MS (Surgery), Patan

Dr. Rudresh Jarecha, DMRE, DNB (Radio.), Hydrabad

Dr. Uma Gupta, MD (Ob. & Gy.), Lucknow

Dr. Suprakash Chaudhury, MD (Psychi.), PHD, Ranchi

Dr. Shalini Srivastav MD (PSM), Greater Noida

Dr. Vani Sharma, MD (Ob. & Gy.), Himachal Pradesh

Dr. K. M. Maheriya MD (Pediatrics), Ahmedabad

Dr. Gurudas Khilani, MD (Med & Pharmac), Patan

All the views expressed in the articles are personal views of the authors and not the official views of the National Journal of Medical Research or the Association. The Journal retains the copyrights of all material published in the issue. However, reproduction of the published material in part or total in any form is permissible with due acknowledgement of the source as per ethical norms.

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NATIONAL JOURNAL OF MEDICAL RESEARCH

NATIONAL JOURNAL OF MEDICAL RESEARCH Volume 4│Issue 1│Pages 1 – 115│Jan - Mar 2014

Table of Content

Original Article Risk Stratification of Body Mass Index B L Preethi, G Jaisri .................................................................................................................................................................

1-6

A Community Based Cross-Sectional Study to Assess the Unmet Need of Family Planning in Urban Slums and It’s Determinants in Western Part of India Beena Patel, Kapil Gandha, Hetal Koringa, Jitesh Mehta, Dipesh Parmar, Sudha Yadav ............................................

7-9

Scalpel in the Surgical Removal of Fibrous Hyperplasia Efficacy of the Harmonic Gerusa OM Cardoso, Vivian Narana El Achkar, Tássia Botrel, Walter Niccoli-Filho .................................................. 10 - 13 Synergy®

Study of Maternal Outcome of Emergency and Elective Caesarean Section in A Semi-Rural Tertiary Hospital Suja Daniel, Manjusha Viswanathan, Simi B N, Nazeema A ............................................................................................. 14 - 18 Morphological Study of Vault Suture & Its Correlation with Age in Central Rajasthan William F Masih, Sumit Gupta, Pratima Jaiswal, Anita E Chand, Pramod Kumar Saraswat ........................................ 19 - 22 A Comparative Study on Symptoms and Microbiological Status of Tuberculosis in HIV Positive Persons Jayant B Chauhan, Ghanshyam B Borisagar ....................................................................................................................... 23 - 26 Subclinical Systolic Dysfunction among Newly Diagnosed Hypertensives with Preserved Left Ventricular Ejection Fraction Using Two Dimensional Strain Imaging Method; Hospital Based Observational Study Tulika Madaik, Prakash C Negi, Anita Padam, Urmil Gupta............................................................................................. 27 - 32 A Comparative Study of Alternate Iron and Folic Acid Supplementation Regimes in Childhood Anaemia Bhuwan R Sharma, Hemant D Mahajan ............................................................................................................................... 33 - 36 Clinical Study of Ectopic Pregnancy in a Rural Setup: A Two Year Survey Smita SinghMahendra G, Vijayalakshmi S, Ravindra S Pukale........................................................................................... 37 - 39 Clinical Features and Pattern of Presentation of Breast Diseases in Surgical Outpatient Clinic of a Tertiary Hospital Jagdish B. Karia, Mukesh D. Kothari, H D Palekar, Upendra A. Patel, Jay Patel .......................................................... 40 - 43 A Hospital Based Study on Opportunistic Pulmonary Infections in Human Immuodeficiency Virus (HIV) Positive Patient in Relation to CD4 Count and Its Therapeutic Outcome Umesh Prasad, Vidya Nand .................................................................................................................................................... 44 - 47 Role of Ventilation in Cases of Acute Respiratory Distress Syndrome /Acute Lung injury Hemant M Shah, Shilpa B Sutariya, Parul M Bhatt, Nishil Shah, Shweta Gamit............................................................ 48 - 52 Effect of Chronic Obstructive Pulmonary Disease on Body Composition Parameters and Exercise Capacity by Comparison with Age Matched Healthy Controls Mann Randeep, Dogra Chauhan Archana, Sarkar Malay, Padam Anita .......................................................................... 53 - 57 Palliative Radiotherapy in the Management of Advanced Pediatric Malignancies Prashant Kumbhaj, Rameshwaram Sharma, Aseemrai bhatnagar, Peeyush Kumar Saini ............................................. 58 - 60 Surgical Site Infections Following Open Reduction and Internal Fixation of Ankle Fractures Amit Patel, Bharat Sutariya, Ankit Desai, Sadik Shaikh ...................................................................................................... 61 - 64 Breast Lumps in a Teaching Hospital: A 5 Year Study Chiragkumar L Prajapati, Rajesh kumar K Jegoda, Upendra A Patel, Jay Patel .............................................................. 65 - 67 Relation between Weight, Height, Glycemic Status and Parasympathetic Functions in Nondiabetic Offspring of Type 2 Diabetes Mellitus Sangeeta Tuppad, Swati Jangam ............................................................................................................................................. 68 - 70 Sacral Index is More Reliable than Kimura’s Base Wing Index for Sex Determination of a Sacrum Shweta Asthana, Sumit Gupta, Mahendra Khatri, GC Agarwal ........................................................................................ 71 - 74 Post-Operative Pain after Knee Arthroscopy and Related Factors Bharat Sutariya, Amit Patel, Ankit Desai, Sadik Shaikh ...................................................................................................... 75 - 78 Profile of Chest Trauma in a Teaching Hospital Chiragkumar L Prajapati, Mukesh D Kothari, Upendra A Patel, Jay Patel .................................................................... 79 - 81 Subcutaneous Cysticercosis: Role of High Resolution Ultrasound in Diagnosis Sachin Lohra, Sonia Barve, Parul Lohra, Sandeep Nanda, Navtej Nalwa, Priyanka Sharma ........................................ 82 - 86 Volume 4│Issue 1│Jan – March 2014

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A Review Article Role of Medical M Social Workers W in Maanagement of Anxiety A and Strress Among Bllood Donors w with Transfusiion Transmissiible Infections Umakkanth Siromani,, Thasian T, Ritaa Isaac, Dolly Daniel, D Selvaraj KG, K Joy Mammen, Sukesh C Nair ..................... 87 - 88

Case Serie ies Diagnosiss of Strongyloides Stercoraliss by Stool Micrroscopy: Screen ning Tool in High-Risk H Patieents Rakesh K. Babariya, Arunima Banerrji, , Ashwini B. Jajee J .................................................................................................. 89 - 91

Case Rep port Acute Pan ncreatitis due to t Rupture of the t Hydatid Cyyst into the Billiary Tract: A Case C Report Zülfüü Bayhan, Sezgın n Yılmaz, Cagrı Tıryakı, Ertugruul Kargı, Bercıs Imge Ucar ............................................................ 92 - 94 Primer Ep piploic Append dagitis Mimick king Appendixx Duplication Cağrıı Tiryaki, Murat Burc Yaziciogluu, Mustafa Celallettin Haksal, Alli Ciftci, Selim Yigit Y Yıldız .................................. 95 - 97 Anaplastiic Thyroid Carccinoma and itss Osteoclastic Variant V Mahiima Sharma, Van ndana Sharma, Anuja A Sharma, Arvind A Khajuriaa ............................................................................... 98 - 100 Acute Pullmonary Edem ma after Evacuaation of Molar Pregnancy Mayuur R Gandhi, Guunvant K Kadikkar ................................................................................................................................... 101 - 103 Marfan Syyndrome Preseenting with Billateral Retinal Detachment Subraata Chakrabarti, Koushik Pan ........................................................................................................................................... 104 - 105 A Case off Sodium Cyan nide Poisoning in a Young Male Nikh hil Dikshit, Mudiita Tiwari, Arun na Dewan ....................................................................................................................... 106 - 108 Rare Pressentation of Su uperficial Leiom myosarcoma off Scalp Vimaal Bhandari, Gop palakrishnan Guunasekeran, Deb basis Naik, Ashw wani Gupta, A.SS.N. Rao...................................... 109 - 110 Neurocyssticercosis with h First Presentaation as Generralised Tonic Clonic C Seizuress Subraata Chakrabarti, Koushik Pan ........................................................................................................................................... 111 - 112 Small Celll Carcinoma of the Ovary of Hypercalcemiic Type: A Raree Tumor Varun n Goel, Chandrragouda Dgoudaa, Sajjan Singh, Shubhra S Raina, Vineet Talwar, Nivedita N Patnaikk, Sunil Pasriccha ......................................................................................................................................................................................... 113 - 115

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ORIGINAL ARTICLE

RISK STRATIFICATION OF BODY MASS INDEX B L Preethi1, G Jaisri2 Authors’ Affiliation: 1Associate Professor; 2Professor, Department of Physiology, MS Ramaiah Medical College and Hospital, Bangalore, India. Correspondence: Dr. B L Preethi, Email: [email protected]

ABSTRACT Introduction: Body Mass Index (BMI) is the simplest & commonly used method of measuring obesity in a general population. BMI has its limitations as it does not directly measure body fat, it is an indicator of heaviness rather than fatness, & cannot distinguish body fat from fat-free mass. Highly sensitive C reactive protein (hs CRP) has been found to be increased in subjects with central obesity& it may be useful in sub classifying BMI. Objective: To investigate the relationship between BMI and hs-CRP in healthy subjects & to evaluate feasibility of using hsCRP as a tool for risk stratification of BMI Material & methods: 79 normal healthy adult volunteers, age 18 to 25 years were enrolled for the Study. a detailed general physical & laboratory evaluation, BMI & hsCRP was done. Subjects were grouped as Group A: BMI 24 ( n=30). Results: Mean age 19 +1.7 years. Male: 41.3% & Female: 58.8%. Mean BMI of the Study population was 22.37+4.0 and the mean hsCRP was 1.43 + 2.1. Group B subjects with higher BMI were significantly taller with higher waist hip ratio & their hsCRP was also significantly higher (A v/c B - 1.03 v/s 2.03) p 24 P value (n=50) (2-tailed) mean SD 19.13 1.78 0.624 13 0.631 17 120.93 5.87 0.17 74.73 6.02 0.162 67% (n=20) 48% 0.021 162.953 9.91 0.02 69.767 11.04 0.736 83.317 9.994 0 100.567 6.218 0 0.8267 7.14E-02 0.053

triglycerides and LDL. The hsCRP was also significantly higher Group A: 1.03 v/s Group B : 2.03 (p 24 (n=50) Mean SD 165.533 23.218 98.667 28.389 41.267 4.283 19.7 5.621 104.233 22.266 2.08 2.08747 81.333 10.807 118.433 23.101 96.6 23.221 9.733 8.143 73.5 62.967 44.207 37.133 1.94881 1.56937 352.7 549.43% 58.1182 21.5915

Significance (2-tailed) 0.025 0.021 0.382 0.342 0.079 0.032 0.172 0.015 0.022 0.708 0.179 0.596 0.107 0.042 0.093

tion and prevention plays a key role in tackling this potentially huge economic and health care burden of the obesity-related disorders 24.

3.5 y = 0.254x - 3.882 R² = 0.978

3 2.5 2 hsCRP

Total Cholesterol Triglycerides HDL VLDL LDL hs CRP Glucose 0min Glucose 30min Glucose 120min Insulin 0min Insulin 30min Insulin 120min HOMA_IR HOMA %B ISI(0-120)

Group A: BMI < 23.9 (n=50) Mean SD 152 27.064 94.78 28.005 40.3 5.019 18.58 4.725 93.428 28.446 1.03878 2.03304 81.88 9.591 106.58 19.153 88.74 15.544 7.48 5.042 66.048 56.174 33.176 29.642 1.53756 1.10752 181.89% 157.59 66.9201 22.9313

1.5

y = 0.038x + 0.173 R² = 0.765

Table 3: Correlation BMI & hsCRP BMI 24 25 28

hsCRP 2.08 2.494737 3.266667

Significance p value 0.033728 0.010726 0.025412

1 0.5 0

The subjects were grouped into lower quartiles and higher quartiles at various BMI cutoff values and hsCRP was found to significantly increase as BMI increases , subjects in lower quartiles also showed an increase in hsCRP as BMI increased but within near normal ranges of less than 1.5 hsCRP, higher quartile subjects always showed hsCRP values > 1.5(Figure 1). DISCUSSION The impact of obesity has been considerable in both developed and developing countries. Overweight and obesity have reached epidemic proportions in many Asian countries. And the population at large are bound to face a grave burden i.e, increase by many folds of obesity-related disorders such as diabetes, hypertension, cardiovascular diseases & cancers etc, which develop at much younger age than in Western populations. The major causative factors being lifestyle changes occurring due to rapid socioeconomic transition1,2,11. Early detecVolume 4│Issue 1│Jan – Mar 2014

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BMI hsCRP Lower Quartile hsCRP Higher Quartile Linear (hsCRP Lower Quartile) Linear (hsCRP Higher Quartile)

Risk Stratification of BMI with hsCRP: Blue: Low / High BMI subjects - demonstrate increasing hsCRP with increasing BMI

Figure 1: Subjects with BMI < 23.9 and BMI >24, hsCRP increases with increasing BMI in both the groups Most epidemiologic studies identifying strong associations between hs-CRP and obesity indicators predominantly use anthropometric indexes 17-24. Consequently, a strong positive association has been found between measures of obesity, such as waist circumference (WC) and body mass index (BMI), with CRP 25,26. Moreover, Page 3

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while some studies have observed a relationship between T2D and higher CRP levels 27. In a study from India, by Ambika et al, there has been a significant increase in abdominal obesity in both sexes in the last two decades, The prevalence of overweight rose from 2% to 17.1% 27. Prevalence of overweight/obesity among Adolescents (14-18 yrs) in Delhi is reported to be 29.0%. The risk of diabetes increases with a body mass index (BMI) of >23 kg/m2 and waist circumference of 85 cm for men and 80 cm for women in Asian Indians3. In our study subjects with BMI > 24 had significantly higher waist circumference (83.3cms+9.9). Oliveira et al in a study of 1319 subject, 833 women and 486 men in Portugal. reported central obesity has been shown to be significantly associated with increased levels of the inflammatory marker hs-CRP in men, while a high proportion of peripheral subcutaneous fat was inversely associated with hs-CRP in women28. In a study from Egypt, 150 children in the age range 616, BMI was 27.20 ± 12.30 kg/m2 in the obesity group and was 16.68 ± 2.00 kg/m2 in the control group. Obese group (n=100) had significantly higher hs-CRP levels than control group, hs-CRP levels were 1.40 ± 0.78 mg/dL vs. 0.56 ± 0.47. mg/dL, p < 0.01 29. a similar picture was seen in our study, subjects with BMI >24 had significantly higher hsCRP values 2.08+2.08 compared to 1.03+2.0(normal range) in subjects with BMI24 had hsCRP levels which are similar to those found in subjects with metabolic syndrome 32. Our study has demonstrated that there is association between BMI and hsCRP, as BMI increases hsCRP also increases significantly. The importance of hsCRP in Sub classifying individuals into low and high risk groups within the BMI groups was also observed. Measuring waist circumference also helps screen for possible health risks that come with overweight and obesity. Subjects with Fat around the waist rather than at hips, are at a higher risk for heart disease and type 2 diabetes. This risk goes up with a waist size that is greater than 35 inches for women or greater than 40 inches for men. The BMI of 62.5% of the health Indian adults range from 18.5-24.99, this can empirical be applied as internationally recommended BMI cut-off points. The higher BMI, the higher is the risk for certain diseases such as heart disease, high blood pressure, type 2 diabetes, gallstones, breathing problems, and certain cancers. For Indian subjects BMI is termed UnderVolume 4│Issue 1│Jan – Mar 2014

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weight Below 18.5, Normal18.5–24.9, Overweight 25.0– 29.9, Obesity30.0 and Above. Our health study subjects had a mean BMI of 22.3+4.08, hsCRP 1.43+2.1. Hs-CRP being an easily measured inflammatory biomarker and is released by the liver under the stimulation of cytokines, including interleukin-6, interleukin-1, and tumor necrosis factor-alpha. It has been shown hs-CRP has associations with endothelial dysfunction and insulin resistance syndrome 33. Although a relationship has been found between hs-CRP and DEXA-measured trunk fat 34, our findings demonstrate that hs-CRP is associated BMI, indicating that %Fat Mass is the obesity indicator that can capture the inflammatory phenomena that are responsible for the higher likelihood of diabetes and cardiovascular events. "High sensitivity" CRP assays is a simple and inexpensive test that has been endorsed by both the Centers for Disease Control and Prevention and by the American Heart Association as a part of the routine global risk assessment to better determine risk of heart disease and prevent clinical events. levels of CRP less than 1, 1 to 3, and greater than 3 mg/L (milligrams per liter) discriminate between individuals with low, moderate, and high risk of future heart attack and stroke 19. Despite its lack of specificity, CRP has now emerged as one of the most powerful predictors of cardiovascular risk. Even more remarkable, CRP’s predictive power resides in the range between 1 to 5 µg/mL, which was previously regarded to be normal in the era preceding the high-sensitivity CRP test, hence a high sensitive assay is required 18. High CRP concentrations significantly correlate with insulin resistance and the metabolic syndrome in adults 19,20. Such high risk subjects are known to future development of non communicable diseases like diabetes, Cardiovasuclar diseases and others. Such sub classification with in BMI groups has relevance in early institution of Preventive measures in high risk BMI groups like Diet, Exercise and life style modification. The WHO Expert Consultation 34 concluded that the proportion of Asian people with a high risk of type 2 diabetes and cardiovascular disease is substantial at BMI's lower than the existing WHO cut-off point for overweight (= 25 kg/m2). However, the cut-off point for observed risk varies from 22 kg/m2 to 25 kg/m2in different Asian populations and for high risk, it varies from 26 kg/m2 to 31 kg/m2 . In addition, sub-classify subjects into high and low risk within Normal or lower BMI levels using hs-CRP was evaluated in our study. This finding of our study has important implications for obesity screening in community surveys 36. In our study higher hs-CRP (>1mg/L) levels correlated significantly with BMI, waist circumference, WH ratio. 30min Glucose and120 insulin also correlated with hsCRP. An important observation of this study is the presence of good correlation between hs-CRP and surrogate markers of insulin resistance especially ISI0-120 which take into account the 0 to 120 min Insulin and glucose values in efficiently interpreting the IR indices, unlike the other indices based on fasting values. Page 4

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Data from the IRIS-II study also showed that hsCRP may also be a good marker of macrovascular risk in type 2 diabetic patients. In the state of pathologically increased demand on the beta cells, intact proinsulin appears in the plasma along with insulin and C-peptide due to the inability of enzymes to cleave excess proinsulin 37. elevated levels of plasma high-sensitivity Creactive protein (HSCRP) are associated with insulin resistance/hyperinsulinemia and cardiovascular autonomic dysfunction in type 2 diabetic patients without insulin treatment 38. Diabetes mellitus (DM) counts as a CHD risk equivalent. In our study subjects % Beta was significantly higher in subjects with BMI>24. C-reactive protein (CRP) has been shown to be associated with type 2 diabetes, but whether CRP has a causal role is not yet clear. A meta-analysis of Rotterdam Study to evaluate the association of baseline serum CRP and incident diabetes during follow-up was investigated. The risk of diabetes was significantly higher in the haplotype with the highest serum CRP level compared with the most common haplotype (OR 1.45, 95% CI 1.08–1.96). These findings support the hypothesis that serum CRP may also play role in the development of diabetes 39. Obesity prevention and controlling for CRP levels may be necessary to eliminate its contributions to develop diabetes and cardiovascular disease (CVD) Wajiha Farooq et al in their study on subject in the age group 39.1±11.3years. Subject with BMI 30 with hsCRP 2.06±0.71(p value 1.5. In this study significant increase in hsCRP was seen with increasing BMI and Waist Circumference which are clinical markers of Insulin Resistance. It was also observed that as Insulin Resistance increases hsCRP also increases. This finding of this study point to a significant role BMI in combination with a simple blood test of hsCRP can play in the early detection of future metabolic syndromes. CONCLUSION Link between obesity and inflammation is evident by raised hsCRP in obese individuals with higher BMI. Inflammation also plays role in atherosclerosis and other metabolic syndromes, thus it is important to screen and spread awareness regarding obesity and its outcomes in our community. BMI is a useful tool in evaluating obesity, hsCRP can be used to sub-classify BMI into high and low risk normal subjects. Our study substantiates the role of incorporating hsCRP in addition to BMI for risk stratification of normal & healthy individuals. REFERENCES 1.

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Huffman FG, Wh hisner S, Zarini G GG, Nath S.Waist circumfec rence and BMI in n relation to serum m high sensitivity C-reactive C protein (hs-CRP) in Cuban Americcans with and with hout type 2 diabetes. Int J En nviron Res Public Health. 2010 Marr;7(3):842-52. doi: 10.3390/ijerp ph7030842.

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Deniz Gokalp1, Alpaslan A Tuzcu1, Hatice Akay2, Sen nay Arikan1 & Mithat The association of high ssensitivity C-reactiive protein levels with body fat f mass and bodyy fat distribution Endocrine E Abstracts (2007) 14 1 P238.

18.

19.

20.

21.

Cham mbers JC, Eda S, Bassett B P, Karim Y, Y Thompson SG, Gallimoree JR, Pepys MB, Kooner K JS: C-reacctive protein, insullin resistance, central obesityy, and coronary heeart disease risk in n Indian Asians A from the United U Kingdom compared with Euuropean whites.Circulation w n 2001, 104:145-1550.

Kitsio os Konstantinos, Papadopoulou P Maaria, Kosta Konstaantina, Kadogglou Nikolaos, Paapagianni Maria, Tsiroukidou T Kiriakki. High--Sensitivity C-Reacctive Protein Leveels and 
Metabolic Disorderss in Obese and Ovverweight 
Childrren and Adolescen nts . Journal of Clinical Reseearch in Pediatric Endocrinology (JCRP PE). Year: 2013 Month: M 3 Volume: 5 Issue . Doi: 10.42774/Jcrpe.789.

22.

Thoraand B, Baumert J, Doring A, Herdeer C, Kolb H, Rath hmann W, Giiani G, Koenig W: W Sex differences in i the relation of body b composition to markers of inflammation n. Atherosclerosis 2006, 184:2116-224.

23.

Ambaady Ramachandran n* and Chamukutttan Snehalatha . Rising R Burdeen of Obesity in Asia A . J Obes. 20100; 2010;2010. pii: 8685773. doi: 10.1155/22010/868573. Epuub 2010 Aug 30

24.

Festa A, D'Agostino R,, Williams K, Kartter AJ, Mayer-Davvis EJ, Tracyy RP, Haffner SM: The relation of body b fat mass and distribution n to markers of ch hronic inflammation. International JourJ nal off Obesity 2001, 255:1407-1415.

25.

Santos AC, Lopes C, Guimaraes G JT, Barrros H. Central obesity as a majo or determinant off increased high-seensitivity C-reactivve protein in n metabolic syndro ome. Int. J. Obes.. 2005;29:1452–14456.

26.

Shemesh T, Rowley KG G, Jenkins A, Brim mblecombe J, Bestt JD, O’Dea K. Differential association a of C-rreactive protein wiith adiposity in men and women w in an Aboriiginal community in northeast Arnhem Landd of Australia. Intt. J. Obes. 2007;311:103– 108.

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ORIGINAL ARTICLE

A COMMUNITY BASED CROSS-SECTIONAL STUDY TO ASSESS THE UNMET NEED OF FAMILY PLANNING IN URBAN SLUMS AND IT’S DETERMINANTS IN WESTERN PART OF INDIA Beena H Patel1, Kapil M Gandha2, Hetal T Koringa1, Jitesh P Mehta3, Dipesh V Parmar4, Sudha B Yadav4 Authors’ Affiliations: 1Final year resident; 2Assistant Professor; 3Associate Professor; 4Professor, Department of PSM, MP Shah Govt. Medical College, Jamnagar Corresponding Author: Dr Kapil Gandha, Email: [email protected]

ABSTRACT Context: Unmet need is a valuable indicator of National Family Planning Programme. It shows how well the programme achieves the key mission of meeting the population’s felt need of family planning. It is added to the 5th MDG as an indicator concerned with maternal health. Aims: To find out 1.) Unmet need of family planning and 2.) Its determinants. Settings and Design: A community based cross sectional study was done among married women of age 15-45 years of urban slums in Jamnagar city. Methods and Material: total 200 study participants were selected by systemic random sampling and interviewed by using pretested semi-structured Performa. Statistical analysis used: Microsoft excel was used for data entry and analysis done by software Epi-info. Results: overall level of unmet need was 20.50%. It was found to be influenced by various socio-demographic factors (age of women, gender of last child and accessibility to the service providers) and these associations were found statistically significant. Number of living children, occupation, and period of active married life, religion and collective decision had no any effect on unmet need. (No statistically significant associations). Major reasons for not using any methods were inconvenience (51.22%), refusal by spouse/family members (21.95%) and lack of knowledge (19.51%) Conclusions: unmet need was higher in more fertile age-group therefore program should focus more on this agegroup. Female education contributes significantly in reduction of unmet need. By encouraging inter-spousal communication and male participation for family planning decision-making is important in bridging the gap between met and unmet need. Key words: Unmet need, contraception, family planning, reproductive health, Urban Slums INTRODUCTION The concepts of unmet need for family planning points to the gap between some women’s reproductive intentions and their contraceptive behaviour[1]. Unmet need included all women who are married and presumed to be sexually active, who were not using any method of contraception and who either did not want to have any more child or wanted to postpone their next birth for at least two more years [2]. In 2006, unmet need for family planning was added to the 5th millennium development goal (MDG) as an indicator for tracing process on improving maternal health [3]. Family planning can reduce maternal mortality by reducing the number of pregnancies, number of abortions and the proportion of births at high risks. It can help to reduce infant mortality, slow the spread of HIV/AIDS, promote gender equality, Volume 4│Issue 1│Jan – Mar 2014

reduce poverty, accelerate socio-economic development, women empowerment and promote the environment [4]. Unmet need is a valuable programme because it shows how well they are achieving a key mission: meeting the population’s felt need for family planning [5]. Unmet need can be a powerful concept for family planning .It poses challenge to family planning programme - to reach and serve millions of women whose reproductive attitude resembles those of contraceptive user but who are for some reason or combination of reasons are not using contraceptives. According to NFHS-3- 13% of married women have unmet need for family planning down from 20% in NFHS-1 and 16% in NFHS-2 [6] [7].The present study was carried out with the objectives to estimate the magnitude of unmet need for family planning among married women of reproductive age, to identify socio demographic factors associPage 7

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ated with unmet need for family planning and to explore common reasons for unmet need for family planning. SUBJECTS AND METHODS A community based cross sectional study was done among married women of reproductive age group (1545 years) of randomly selected urban slums in Jamnagar city. Pretested semi-structured performa was used. Sample size was determined by applying the formula 4pq / L2 where P is proportion of woman having unmet need .q is the proportion of woman not having unmet need & L is allowable error is 5 percent. So, 4x13x87/ (5)2=181.Non response rate was taken 10%.So, Sample size of 200 women was decided according to 13% prevalence of unmet need (NFHS-3). Data was collected through house to house survey with

informed consent. Unmet group included all women who were married and presumed to be sexually active, who were not using any method of contraception and who either did not want to have any more children or wanted to postpone their next birth for at least two more years. Those who want to have no more children were considered to have unmet need for limiting birth or limiters, while those who want more children but not for at least two more years were considered to have unmet need for spacing birth or spacers. Separated, divorced and widows were excluded. Data entry was done in Microsoft excel and analysis was done using chi-square test. RESULTS: In present study unmet need is higher in age-group of 25-34 year and is statically significant.

Table 1.socio-demographic profile of the study participants Socio-demographic profile of women Age-group 15-24 25-34 ≥35 Education ≤ 10 ≥20 Occupation House wife Working Religion Hindu Muslim Type of family Joint Nuclear

Unmet need (n=41)

No unmet (n=159)

07(12.96%) 31(28.18%) 03(08.33%)

need

Total (n=200)

X2

P value

47(87.04%) 79(71.82%) 33(91.67%)

54 110 36

9.135

0.010

29(24.27%) 12(14.81%)

90(75.63%) 69(85.19%)

119 81

2.145

0.143

40(21.74%) 01(06.25%)

144(78.26%) 15(93.75%)

184 16

1.321

0.250

39(21.79%) 02(09.52%)

140(78.21%) 19(90.48%)

179 21

1.064

0.302

17(18.68%) 24(22.02%)

74(81.32%) 85(77.98%)

91 109

0.165

0.685

(p10

Unmet (n=41)

need

No unmet (n=159)

need

Total (n=200)

X2

P value

17(15.04%) 24(27.59%)

96(84.96%) 63(72.41%)

113 87

4.006

0.045

30(18.29%) 11(30.56%)

134(81.71%) 25(69.44%)

164 36

2.023

0.155

26(21.49%) 14(26.92%) 01(03.70%)

95(78.51%) 38(73.08%) 26(96.30%)

121 52 27

6.603

0.048

12(18.46%) 21(25.61%) 06(15.00%) 02(15.38%)

53(81.54%) 61(74.39%) 34(85.00%) 11(84.62%)

65 82 40 13

2.431

0.488

14(20.59%) 15(23.44%) 12(17.65%)

54(79.41%) 49(76.56%) 56(82.35%)

68 64 68

4.650

0.199

(p2 children. It was found that unmet need was higher in women with active married life up to 10 years, after that it was decreased. Table 3 mentions various reasons amongst those who had unmet need for the family planning. On the top of the list was inconveniency, followed by refusal by spouse, lack of knowledge due to side effects and unclassified.

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found that unmet need for spacing is highest (38.9%) among the women having no child or only one child and unmet need for limiting was observed to be maximum in women having 2 or more children i.e.45.8% [10]. Supriya Satish Patil in her study observed common reasons for unmet need were lack of information about contraceptive methods and its source (57.6%), Opposition from husband, families and communities (18.6%), Health concerns and side effects (10.2%) [10]. CONCLUSION: Unmet need is higher in 25-34 years age group which is the age for higher fertility; it is also higher in those women who have at least two children. So, programme should focus on them to prevent unwanted pregnancy. Female education contributes significantly in use of family planning practices and reduces unmet need. In patriarchal Indian society, decision making through encouraging inter-spousal communication and male participation for family planning decision-making is important in bridging the gap between met and unmet need. REFERENCES 1.

S. K. Bhattacharya, R. Ram, D. N. Goswami, U. D. Gupta, K. Bhattacharyya, S. Ray. Study of Unmet Need for Family Planning among Women of Reproductive Age Group attending Immunization Clinic in a Medical College of Kolkata. Indian Journal of Community Medicine 2006;31:73-5

2.

Robey B, Ross J, Bhushan I. Meeting unmet need: new strategies. Popul Rep series J Family Planning Prog 1996; 43:1-35

3.

Bernstein S, Eduard L. Targeting access to reproductive health: giving contraception more prominence and using indicator to monitor progress. Reproductive Health Matters 2007;15:186-91

4.

Reynolds HW, Janowitz B, Homan R, Johnson L. The value of contraception to prevent perinatal HIV transmission. Sexually Transmitted Diseases 2006;33:350-6.

5.

John Cleland, Stan Bernstein, Alex Ezeh, Anibal Faundes, Anna Glasier, Jolene Innis. Family planning the unfinished agenda. Lancet 2006;368:1810-27.

6.

National family health survey NFHS-2, 1998-99 International Institute of Population Sciences. Mumbai India.

7.

National family health survey NFHS-3, 2005-06 International Institute of Population Sciences. Mumbai India.

8.

Indu D. Unmet needs for family planning in urban slums of Trivandrum corporation area. Calicut Medical Journal 2011;9:5

9.

Ferdousi SK, Jabbar MA, Hoque SR, Karim SR, Mahmood AR, Ara R et al. Unmet need of family planning among rural women in Bangladesh. J Dhaka MedColl 2010;19:11-15.

10.

Supriya Satish Patil, MP Durgawale and SR Patil.Epidemiological Correlates Of Unmet Need For Contraception 2010, Al Ameen J Med Sci;3:312-16.

Table 3 Reasons amongst the unmet need group Reasons for un-met need Inconveniency Refusal by spouse/family member Lack of knowledge Due to side effects Others

No (n=41) 20 9

Proportion 48.78 21.95

7 3 2

17.07 7.31 4.87

DISCUSSION According to NFHS 3 data unmet need was 13% and study done by Indu D, it was 17%. In our study it was 20.50%, which was higher than both [8]. In our study unmet need is higher in age-group of 25-34 year, in study of FERDOUSI SK about half of the respondents (51.8%) were in the age group of 20-30 years [9]. Indu D. in her study found that unmet need was higher in Hindu religion and nuclear family which was similar to our results. [8]. In our study, women who had inter-spousal communication related to family planning had less unmet need (18.29%) compared to those who did not communicate (30.56%) Indu D. in her study found similar results that was unmet need was higher (62.9%) in women with poor spouse participation in family planning as compared to those had good spouse participation (37.1%).[8]. Supriya patil et al. in her study

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ORIGINAL RESEARCH

EFFICACY OF THE HARMONIC SYNERGY® SCALPEL IN THE SURGICAL REMOVAL OF FIBROUS HYPERPLASIA Gerusa OM Cardoso1, Vivian Narana El Achkar1, Tássia Botrel1, Walter Niccoli-Filho1 Authors Affiliation: Sao Paulo State University, School of Dentistry - UNESP Correspondence: Walter Niccoli-Filho, Email: [email protected]

ABSTRACT Introduction: There have been countless surgical techniques developed for the purpose of removing the hyperplasia (FH) and improving the alveolar ridge to provide a better adaptation to full prostheses. Techniques used for this procedure may lead to post-operative complications, including oedema, pain, difficulty in swallowing, compromised movement, haemorrhage and/or infection. With the advent of the harmonic scalpel, removal of FH can be completed more quickly and less traumatically for the patient due to its intrinsic properties. With standard excision, episodes of pain, swelling and bleeding may be experienced post-operatively, leading to dysphonia and dysphagia, creating challenges to the surgeon. Objectives: The aim of this study was to examine the efficacy of the Harmonic Synergy® scalpel (HSS) (Johnson & Johnson, Suprimed - Brazil) in the surgical removal of FH. Methods: eleven patients underwent FH removal with HSS. Post-operative examination was conducted at 3, 7 and 30 days after surgery. In all instances, the surgeon was consistently able to control the tissue volume and maintain adequate surgical margins. Results and conclusions: The results demonstrated that the use of the HSS offered better haemostasis, reduce the possibility of post-operative infection and, principally, provided more comfort when compared with a conventional scalpel. Re-establishing an aesthetic and functional state was also quicker with HSS. Keywords: fibrous hyperplasia, harmonic scalpel, repair chronology INTRODUCTION Inflammatory fibrous hyperplasia (IFH), resulting from poorly adapted prostheses, presents as a conjunctive tissue tumour closely related to a fibroma and, in many cases, they are indistinguishable1,2. Clinically, it presents as a smooth-surfaced, raised lesion, with the coloration of normal mucosa, most commonly with a sessile base. The size of the lesion directly corresponds to the amount of surface area involved in the contributory trauma and may reach several centimetres. Its form is flabby in most cases and may be ulcerated, depending on the intensity of the trauma2,3. The aetiology of IFH is trauma, and its location is directly related to the areas subjected to this trauma. Edentulous areas within the arch may cause the patient to form abnormal habits, such as sucking of the adjacent mucosa or tongue interposition, contributing to the appearance of this lesion as an irritative response4. It is well known that hyperplasia related to denture use originate from chronic irritation. Patients and their relatives express anxiety when reporting to dental clinics for examinations. To avoid denture induced hyperplasia, dentures must be examined more often after their construction and delivery, the patients must be informed Volume 4│Issue 1│Jan – Mar 2014

about cleansing and disinfection measures, and warned not to wear them a whole day at a time5. The indicated treatment is surgery through conservative excisional removal, and recurrence is rare, provided the causal habits are eliminated and/or the contributing prosthesis is properly adjusted3. Recovery from this type of surgery, mainly when involving large areas, has been widely improved with the advent of the harmonic scalpel. Upon consulting the literature, it is noted that there are no previous reports of the use of the harmonic scalpel in dental and maxillofacial surgery. This led us to examine the intrinsic qualities of this type of scalpel as well as the necessity of casuistry to state that this is a technique that actually substitutes conventional techniques, mainly considering the benefits to the patient. MATERIALS AND METHODS After approval of this protocol by the Commission of Bioethics of the School Of Dentistry of Sao Paulo State University – UNESP, eleven patients with maxillary or mandibular complete dentures were evaluated. Thorough case histories and clinical examinations confirmed Page 10

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that they had poorly adapted prostheses, requiring the confection of new dentures. Prostheses were unstable due to a poor adaptation to the edentulous ridge which exacerbates bone resorption and can cause a fibrous tissue response in the adjacent vestibular mucosa (Figure 1). These changes led to deficiencies in the prostheses with respect to occlusion, aesthetics and function, accentuating the reduction in the vertical dimension, poor centric relation and inappropriate facial profiles. The X-ray examination did not reveal any relevant alterations in the bone.

Figure 1 - Clinical view

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After surgery, all patients received post-operative antibiotics and anti-inflammatory therapy for seven days consisting of 500 mg cephalosporin every six hours plus 50 mg diclofenac every eight hours. All cases were photographed before and immediately after the operation, as well as 24 hours, 7, 15 and 30 days after the surgery. RESULTS In all instances, the surgeon was consistently able to control the tissue volume and maintain adequate surgical margins. Minimal bleeding was noted except in one case where the size and location of the lesion necessitated the suture of an artery in the surgical field. The HSS proved adequate for removal of tissue and did not appear to cause any vascular complications by compromising the blood supply to the surgical site (e.g., local ischemia and/or clinical evidence of soft tissue necrosis). At one week after the surgery, all cases showed satisfactory initial re-epithelialization of the surgical site. All patients reported minimal discomfort during the first 48 hours after surgery, and only one patient reported bleeding episodes, which were treated with cloth compression. This is in stark contrast to the typical experience with standard scalpel excision for similar tongue lesions, where it is common for patients to present immediately after surgery and for several days following with complaints of significant pain and difficulty speaking or eating. In addition, with conventional surgery, the associated post-operative oedema interferes with hygiene practices, further impairing healing. After 30 days, all patients demonstrated full reepithelialization of the mucosa with satisfactory aesthetic and functional results (Figure 3) Histopathological examination of all surgical specimens confirmed that all tissue margins were disease free.

Figure 2 - Surgical removal with HSS After careful surgical and prosthetic planning, patients were administered anaesthesia via local infiltration. The hyperplastic tissue delimited through fixation with Allis callipers. A Harmonic Synergy® system (Ethicon EndoSurgery®, Johnson & Johnson Medical - Suprimed, Brazil) consisting of a generator supplying an alternating electric current through a high-frequency transducer and active surgical tips (Figure 2). The HSS has a dissecting blade with adjustable length between 4.8 and 10 cm and an integrated manual override. A 5 mm diameter tip was used for tissue removal. Each of the patients, as well as the surgeon and team, were protected with safety glasses, and the excised specimens were submitted for anatomical and pathological examination. Volume 4│Issue 1│Jan – Mar 2014

Figure 3 - Clinical aspect after 30 days DISCUSSION IFH is a common clinical condition in dental practice that can cause episodes of pain, swelling and bleeding in Page 11

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the post-operative state with standard excision leading to dysphonia and dysphagia. Minimizing these outcomes can prove challenging to the operating surgeon6. For conventional surgeries, Tucker 7 suggests three techniques, depending on the size of the lesion. When minimal, electrosurgery provides good results. When the tissue mass is moderately sized, simple excision and placement of the remaining tissue may result in the full elimination of the vestibule. For cases when extensive areas of tissue are to be removed, an incision must be made superficial to the periosteum, creating a clean supraperiosteal tissue bed over the alveolar ridge, and the unaffected margin is sutured at the height of the vestibular periosteum using an interrupted suture technique. A surgical template or the patient´s own prosthesis, covered with tissue conditioner, is reinserted and should be worn continuously during the 5 to seven days immediately following surgery. The harmonic scalpel was introduced into surgical practice nearly a decade ago in order to minimize risks associated with electro-surgical technologies, including energy damage at peripheral locations and complications associated with monopolar energy8. This type of scalpel is characterized by the conversion of electrical energy into mechanical energy, causing the blade to actively vibrate at 55,500 Hz per second. This mechanical vibration transfers energy to the tissue, resulting in simultaneous incision and coagulation9. Given the intrinsic properties of this technology, its use in tissue repair is worthy of examination. Traditional scalpel surgery and harmonic scalpel surgery were compared to identify relevant differences. The HSS is a cutting instrument providing simultaneous haemostasis and its properties are advocated by several authors 8-13. The present study confirmed the homeostatic property of the HSS by demonstrating no significant bleeding during surgical procedures. Localized gingival enlargements represent a group of lesions with distinctive clinical manifestations. They are reactive lesions emanating from the superficial fibers of periodontal ligaments and their rapid growth. After the removal of these lesions a follow-up is required to ensure the early diagnosis of any recurrence14. Sinha and Gallagher 15 describe a study of the oral mucosa that demonstrated that the use of the HSS promoted delayed healing when compared to conventional scalpel surgery, laser radiation and electrocautery. However, in our study there was no visible delay in the healing of patients undergoing surgery using the HSS. The primary advantages of HSS surgical treatment include prompt haemostasis, reduced operative trauma and a better post-operative clinical condition with unaltered haemoglobin levels, which likely enhance the efficacy of postoperative radiotherapy. Postoperative results of HSS surgery showed wound sterilization and sealing of the adjacent lymphatic vessels 11-13. The length of surgery is greatly reduced according to results reported in other studies 11-13, and the healing process is Volume 4│Issue 1│Jan – Mar 2014

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usually shorter and less painful as compared to healing following electrosurgery and cryosurgery techniques. Minimal or no suturing for surface lesions is an apparent advantage in this set of patients, except in those instances where the size of the defect and the influence of muscles adjacent to the site necessitated additional stabilization and the utilization of sutures. A larger amount of sample may be judged necessary to better evaluate the results of this surgical technique in cases of FH. In the present study, the extent and clinical characteristics of the hyperplasia led us to elect operative excision after potential surgical and post-operative complications were taken into consideration. The primary postoperative interest was patient comfort. No evidence of recurrence has been observed. CONCLUSION The clinical results indicated that, when compared with conventional scalpel surgery, the use of the HSS provided better haemostasis, eliminated the possibility of infection, good visualization of the surgical field and, principally, increased postoperative comfort while immediately re-establishing aesthetics and function. Acknowledgments We would like to thank Suprimed – R. Gonçalves Suprimentos Médicos LTDA – BRAZIL, to the invaluable financial support and FAPESP (Protocol no. 2011/17868-8). REFERENCES 1

Neville BW, Damm DD, Allen CM, Bouquot JE. Patologia Oral e Maxilofacial. 1ª ed. Philadelphia: W.B Saunders Company; 1995.

2

Starshak TJ, Sanders B. Vestibuloplasty In: Mosby, editor. Preprosthetic oral and maxillofacial surgery Saint Louis1980. p. 165-213.

3

Regezi JA, Sciubba JJ. Oral pathology: clinical-pathologic Correlations. . Philadelphia: W.B. Saunders Company; 1989.

4

Cerveira Netto H. Prótese Total Imediata. 1th edn ed. São Paulo: Pancast Editorial,; 1987.

5

Canger EM, CelenK P, Saadettin K. Denture-Related Hyperplasia: A Clinical Study of a Turkish Population Group. Braz Dent J. 2009;20(3):243-8.

6

Niccoli-Filho W, Almeida IMR, Santos DT, Schuwab C. Use of carbon dioxide laser for the treatment of early squamous cell carcinoma and severe leukoplakia. . ACTA STOMATOLOGICA CROATICA. 1998;32(4):621-5.

7

Tucker MR, Peterson LJ. Cirurgia Pré-Protética Básica. In: Guanabara Koogan, editor. Cirurgia Oral e Maxilofacial Conteporânea. Rio de Janeiro1996. p. 286.

8

Matthews B, Nalysnyk L, Estok R, Fahrbach K, Banel D, Linz H, Landman J. Ultrasonic and nonultrasonic instrumentation: a systematic review and meta-analysis. Arch Surg. 2008;143(6):592-600.

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Kadesky KM, Schopf B, Magee JF, Blair GK. Proximity injury by the ultrasonically activated scalpel during dissection. J Pediatr Surg. 1997;32(6):878-9.

13

Sood S, Corbridge R, Powles J, Bates G, Newbegin CJ. Effectiveness of the ultrasonic harmonic scalpel for tonsillectomy. Ear Nose Throat J. 2001;80(8):514-6, 8.

10

Koch C, Friedrich T, Metternich F, Tannapfel A, Reimann HP, Eichfeld U. Determination of temperature elevation in tissue during the application of the harmonic scalpel. Ultrasound Med Biol. 2003;29(2):301-9.

14

Savage NW, Daly CG. Gingival enlargements and localized gingival overgrowths. Australian dental journal. 2010;55 Suppl 1:55-60.

15

11

Metternich FU, Sagowski C, Wenzel S, Jakel K. [Tonsillectomy with the ultrasound activated scalpel. Initial results of technique with Ultracision Harmonic Scalpel]. HNO. 2001;49(6):465-70.

Sinha UK, Gallagher LA. Effects of steel scalpel, ultrasonic scalpel, CO2 laser, and monopolar and bipolar electrosurgery on wound healing in guinea pig oral mucosa. Laryngoscope. 2003;113(2):228-36.

12

Sherman JA, Davies HT. Ultracision: the harmonic scalpel and its possible uses in maxillofacial surgery. Br J Oral Maxillofac Surg. 2000;38(5):530-2.

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ORIGINAL ARTICLE

STUDY OF MATERNAL OUTCOME OF EMERGENCY AND ELECTIVE CAESAREAN SECTION IN A SEMI-RURAL TERTIARY HOSPITAL Suja Daniel1, Manjusha Viswanathan1, Simi B N1, Nazeema A1 Author Affiliation: 1Sree Gokulam Medical College & Research Foundation; Sree Gokulam Medical College & Research Foundation Correspondence: Dr. Manjusha Viswanathan, Email: [email protected]

ABSTRACT Introduction: Caesarean section is one of the most performed surgical procedures all over the world. It is associated with high morbidity, although, the morbidity has come down over the years(1)Morbidity and mortality are seen to be more with emergency procedures than elective procedure. Aim: To study the maternal morbidity of elective and emergency caesarean sections in a tertiary care teaching hospital in semirural area Methodology: It is a comparative study on the maternal outcomes in elective and emergency caesarean sections. Total 165 patients undergoing caesarean section in the tertiary teaching hospital in semi- rural area were studied. Data was collected and analyzed Conclusion: Maternal morbidity was found to be more in emergency caesarean section than in elective caesarean section. Keywords: Caesarean Section, Maternal outcome, Diabetes Abbreviations CS-Caesarean section GDM-Gestational Diabetes Mellitus GHT-Gestational Hypertension CPD-Cephalopelvic disproportion\ IUGR-Intrauterine growth retardation UTI- Urinary tract infection PPH- post- partum hemorrhage APH –antepartum hemorrhage INTRODUCTION Caesarean delivery is defined as the birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy). This definition does not include removal of the fetus from the abdominal cavity in the case of rupture of the uterus or in the case of an abdominal pregnancy. Caesarean section is a lifesaving procedures that is firmly ensconced in obstetric practice. Today, it is one of the most commonly performed surgical procedures, but unfortunately caesarean sections are associated with a great deal of maternal morbidity. Before the availability of wide spectrum antibiotics, blood transfusion facilities and good anesthetic techniques, caesarean section was used only to save the life of the mother and was met with the mortality of 5070%. With the immense advances in anesthetic services Volume 4│Issue 1│Jan – Mar 2014

and improved surgical techniques, the morbidity and mortality of this procedure has come down considerably. In a previous study it was found that maternal mortality due to caesarean delivery was 2.2 per 1,000,000 in the United States(1).Elective caesarean is a term used when the procedure is done at a pre-arranged time during pregnancy to ensure the best quality of obstetrics, anesthesia, neonatal resuscitation and nursing services. The procedure is termed as emergency caesarean section when it is performed due to unforeseen or acute obstetric emergencies(2) .It is seen that morbidity and mortality are associated more with emergency procedures than with elective procedures (3)(10) With this background the study was conducted to Study maternal morbidity of elective and emergency caesarean sections in a tertiary care teaching hospital in semirural area. METHODOLOGY This was a Observational study conducted in a tertiary care teaching hospital in a semi-rural area during one year period. Inclusion criteria: All caesarean sections performed at the hospital during the one year period was included. There are no exclusion criteria.

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The patients were divided into those undergoing elective caesarean section and those undergoing emergency caesarean section. Detailed history and examination was done and the indications for caesarean section, the peroperative findings and complications noted in detail with the help of a proforma. Information regarding post-operative morbidity was also collected. Consent from the subject was obtained, prior to collection of any data No interventions were made in this study The outcomes studied were-Incidence of elective and emergency caesarean sections, indications, age distribution, gravida, antenatal complications, intra-operative and post- operative complications Duration of hospital stay of more than 6 days was considered as an indicator for post-operative morbidity. The data collected, were coded and fed into the computer using MS Excel and analyzed using SPSS V 19 with the assistance of a statistician. Descriptive statistics such as mean, standard deviation and percentage was used and to find association chi square test was used. Ethical clearance was obtained from the hospital ethical committee. RESULTS During the study period the total number of deliveries was 575. There were 165 cases of caesarean section (28.7%), out of which 76 cases were elective (46.06%)and 89 cases were emergency caesarean sections (53.9%). The mean age in elective and emergency group was 28yrs and 25yrs respectively.

140 120 emergency

100

elective

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Table 1: Distribution of Study Participants according to Gravida Obstetric

Elective CS (%)

Primi Multi

15(19.7%) 61(80.3%)

Emergency (%) 63(70.8%) 26(29.2%)

CS

In elective caesarean group 1.3% were early preterm, 1.3% late pre term and the rest 97.4% term CS. In the emergency caesarean group 1.1% was early pre-term 16.9% late pre-term and the rest 82% term. Mean period of gestation in which caesarean section was done was similar in both groups, i.e. 38 weeks Occurrences of antenatal complications were found similar in both groups i.e. 48%. In the emergency caesarean group, incidence of GDM, Gestational Hypertension and malpresentation was less than that in the elective caesarean group. Table 2: Distribution of Study Participants according to Antenatal complication Antenatal complications GDM GHT Malpresentation Twin gestation IUGR Oligamnios Obstetric cholestasis Heart disease APH

Elective (%) 16(21.1) 9 (11.8) 10(13.2) 0 4(5.3) 3(3.9) 0

CS

1(1.3) 1(1.3)

Emergency (%) 15(16.9) 4 (4.5) 6(6.7) 5(5.6) 9(10.1) 5(5.6) 4(4.5)

CS

0 3(3.4)

Most of the elective caesarean sections were done for previous caesarean section (78.9%) and malpresentation (14.5%). In emergency caesarean section group, fetal distress (30.3%), previous caesarean section (18%) and failed induction (18%) were the main indications.

80

Table 3: Distribution of Study Participants according to Indications of Caesarean section

60 40

Indications

20 0 30

Fig 1 Distribution according to the age In Elective caesarean section group 19.7% were primigravida and 80.3% multigravida whereas in the emergency caesarean section group it was 70.8% and 29.2% respectively

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Previous caesarean section Dystocia Mal presentation Fetal distress Failed induction CPD Abruption Placenta praevia Twins Maternal request IUGR

Elective (%) 60(78%) 0 11(14.5) 0 0 1(1.3) 0 1(1.3) 0 0 3(3.9)

CS

Emergency CS (%) 16(18) 8(9) 4(4.5) 27(30.3) 16(18) 8(9) 3(3.4) 1(1.1) 4(4.5) 1(1.1) 1(1.1)

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Emergency caesarean section was found to be associated more with intra operative complications than elective caesarean section. The difference found was not significant. Excessive bleeding was the complication present in both groups. No cases of bladder injury was seen in both the groups. Post-operative complications were found to be significantly higher (47.2%) in emergency caesarean saections when compared to elective caesarean section (17.1%). 70 elective emergency

60 50 40 30 20 10 0 no compli

Hemorrhage

Fig 2: Intra-operative Complications Infections contributed to 43.9% in emergency caesarean section whereas it was 11.7% in elective caesarean sec-

tion. Infections seen were UTI, respiratory infection, wound infection. Respiratory infection contributed to 4.5% in emergency as compared to 3.9% in elective caesarean section (p-0.862). Wound infection contributed to 12.4% in emergency as compared to 3.9% in elective caesarean section. (p-0.053).UTI contributed to 27% in emergency caesarean section as compared to 3.9% in elective caesarean section (p-0.001). The only anesthetic complication seen in both the groups was spinal headache which contributed to 3.4% in emergency and 3.9% in elective groups. This difference was not statistically significant (p-0.084%). There was no case of thromboembolism in both the groups. One case of secondary PPH was reported in emergency caesarean section and one case of caesarean hysterectomy was done for atonic PPH in one of the elective caesarean section case. Re-hospitalization was required in one case each of elective and emergency caesarean section. Extended hospital stay is found more in emergency caesarean section group when compared to elective caesarean section group; this is due to the increased post-operative morbidity associated with emergency caesarean section. In the elective CS group 96.1% had hospital stay for 6 days and 92.1% of the emergency group, had hospital stay of 6 days. When the chi square test was applied X2=1.11, with p value of 0.293 which was found to be significant.

Table 4: Distribution of Study Participants according to Post-operative complications Post OP complications Spinal headache UTI Respiratory Infection Wound Infection Thrombo- embolism Secondary PPH Re- Hospitalization Vesico Vaginal Fistula Caesarean hysterectomy

Elective CS (%) 3(3.9) 3(3.9) 3(3.9) 3(3.9) 0 0 1(1.3) 0 1(1.3)

Emergency CS (%) 3(3.4) 24(27) 4(4.5) 11(12.4) 0 1(1.1) 1(1.1) 0 0

χ2 0.04 15.87** 0.03 3.74 0.86 0.01 1.18

P 0.844 0.001 0.862 0.053 0.354 0.910 0.278

** significant at 0.01 Table 5: Distribution of Study Participants according to Neonatal complications Neonatal complications Present Absent

Elective CS (%) 7(9.2) 69(90.8)

Emergency CS (%) 38(40.4) 56(59.6)

χ2

P

21.04**

0.001

In the present study, 40.4% of babies delivered by emergency caesarean section developed neonatal complications whereas only 9.2% of babies delivered by elective caesarean section developed neonatal complications. The difference was significantly higher. DISCUSSION Caesarean sections have been long practiced as a lifesaving procedure for the mother and fetus. The incidence Volume 4│Issue 1│Jan – Mar 2014

of caesarean section has risen considerably over the years and is done for even trivial indications. The advances in the field have reduced maternal mortality considerably. But the problem of maternal and fetal morbidity after caesarean section is high. In the index study the rate of caesarean section was 28.7% out of which elective caesarean section was 46.06% and emergency caesarean section was 53.9%.This is comparable to the caesarean section rate in tertiary hospitals in Raipur, India (26.2%)(3) The mean age in elective and emergency group was 28 years and 25years. respectively. In a previous study the mean age was 28 years in both the groups(4)In another study 77.7%patients were in the age group of 20-30 yrs.(4).There is regional differences in the age group as evidenced by different studies

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In the elective caesarean section group 19.7% were primigravida and 80.3% multigravida whereas in the emergency caesarean section group it was 70.8% and 29.2% respectively in our study. In elective caesarean section group the percentage of multi gravida was high because 78% of elective caesarean sections were done for previous caesarean section cases. In a study reported primigravida was 22%, multigravida were 78% in emergency caesarean section group and 8% primi gravida and 92% in elective caesarean section group(11).In our studymore multigravida underwentelective caesarean sections and major indication was previous caesarean section In the index study 97.4% had term elective caesarean sections and 82% had term emergency caesarean section In elective caesarean section group 48.7% had antenatal complications, those complications being 21.1% GDM, 11.8% Gestational Hypertension, 13.2% Malpresentation, 5.3% IUGR, 3.9% Oligamnios, 1.3% Heart disease and 1.3% Antepartum hemorrhage. In the emergency caesarean section group 48.3% had antenatal complications, the complications being 16.9% GDM,4.5% Gestational hypertension, 6.7% Malpresentation, 10.1% IUGR,5.6% twin gestation, 5.6% Oligamnios, 4.5% Obstetric cholestasis and 3.4% antepartum hemorrhage. In elective caesarean section group, previous caesarean section was the main reason for caesarean section accounting for 78%, others being malpresentation 14.9%, IUGR 3.9%, CPD 1.3% and placenta preavia 1.3%. This is comparable to other reported studies where repeat caesarean section was 30.7% and malpresentation 17.1%(5).The increased incidence of repeat caesarean section is due to the absence of patients opting for vaginal birth after caesarean section. In emergency caesarean section group fetal distress was the main reason for caesarean section, accounting for 30.3%. Others were 18% each for previous caesarean section and failed induction, 9% each for dystocia & CPD, 4.5% each for malpresentation and twins, 3.4% for abruption, 1.1% each for placenta preavia, IUGR and caesarean delivery on maternal request. In a previously reported study the leading indication for emergency caesarean section was cephalopelvic disproportion (39.3%), while antepartum hemorrhage and fetal distress followed in that order(6).Fetal distress is by far a major indication for emergency caesarean section In the index study, intraoperative complications were more for emergency group (30.3%) when compared to elective group (19.7%). The major complication that developed in both groups was excessive bleeding 30.3% and 19.7%. The difference was of no statistical significance(p-0.119). There were no cases of bladder injury in both the groups. In studies reported previously also intra operative complications were associated more with emergency caesarean section than with elective caesarean section. Massive hemorrhage was the most common complication seen (4).

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In our study postoperative complications were significantly more in emergency group(47.2%) when compared to elective group(17.1%).Similar conclusions were obtained in previous studies done (38.67% vs 22.28%)(7). Infections contributed to 43.9% in emergency caesarean section whereas it was 11.7% in elective caesarean section. Infections seen in our study included UTI, respiratory infection and wound infection. Respiratory infection contributed to 4.5% in emergency as compared to 3.9% in elective caesarean section (p-0.862). Wound infection contributed to 12.4% in emergency as compared to 3.9% in elective caesarean section (p-0.053). UTI contributed to 27% in emergency caesarean section as compared to 3.9% in elective caesarean section (p0.001). The results obtained are comparable to various studies reported in the literature(8)(6). In one study, postoperative complications were more in patients who had emergency CS compared with patients undergoing elective CS such as fever (26.0% and16.1%), wound infection (12.7% and 6.5%) and urinary tract infection (14.3% and 5.4%)(8). In our study, the only anesthetic complication seen in both groups was spinal headache which contributed to 3.4% in emergency and 3.9% in elective groups which was not statistically significant. There was no case of thromboembolism in both groups. One case of secondary PPH was reported in the emergency caesarean section and one case of caesarean hysterectomy for atonic PPH reported in the elective caesarean section. Re-hospitalizationwas required in one case each of elective and emergency caesarean section. In both cases it was for wound infections. There were no maternal deaths during the period of study in both cases. In the present study only 3.9% patients in elective caesarean section group required more days of hospital stay whereas in emergency caesarean section group 7.9% required more days of hospital stay. This was significant as duration of hospital stay was one of our study criterions to assess the maternal morbidity. In a previous study also it was found that postoperative hospital stay was significantly prolonged in patients who had undergone emergency caesarean section when compared to elective caesarean section (12) CONCLUSION Maternal morbidity was found to be more in emergency caesarean sections than in elective caesarean sections. Emergency caesarean sections are unavoidable. But we can definitely bring down the rates of emergency caesarean section by proper selection of cases for induction of labor and by initiating active management of labor. This study is to highlight the fact that caesarean sections done as an emergency for any indication has its share of Page 17

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problems to the mother and hence caution must be exerted in proper planning of the cases. Further audits are mandatory to study the present indications for emergency caesarean sections and avoid any unplanned interventions. REFERENCES 1.

Clark Sl, Belfort M, Dildy G, Herbst M, Mayaers J, Hankins G. Maternal death in the 21st century: caus... [Am J Obstet Gynecol. 2008] - PubMed - NCBI. American journal of obstetrics and gynecology. 2008 Jul;1(199):36.

2.

Gasprovic Elvedi, Klepac P, Peter B. Maternal and fetal outcome in elective versus ... [Coll Antropol. 2006] - PubMed NCBI. Coll anthropology. 2006 Mar;1(30):113–8.

3.

National Vital Statistics Reports Volume 62, Number 1 June 28, 2013 - nvsr62_01.pdf [Internet]. [cited 2013 Dec 19]. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf

4.

Ghazi A, Karim F, Hussain A, Ali T, Jabbar S. Maternal morbidity in eme... [J Ayub Med Coll Abbottabad. 2012 Jan-Mar] PubMed - NCBI. Journal Of Ayub Medical College Abottabad. 2012 Mar;24(1):10–3.

5.

Najam R, Sharma R. Maternal and fetal outcomes in elective and emergency caesarean sections at a teaching hospital in North India. A retrospective study. - Journal Of Advance Researches In Biological Sciences (A Peer Reviewed Indexed Medical Journal) - ScopeMed.org - Online Journal Management System. Journal Of advanced researches in Biological Sciences. 5(3):5–9.

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print ISSN: 2249 4995│eISSN: 2277 8810 6.

Nwobodo E, Isaah A, Panti A. Elective caesarean section in a tertiary hospital in Sokoto, north western Nigeria Nwobodo E I, Isah A Y, Panti A - Niger Med J. Nigerian Medical Journal. 2011;52(4):263–5.

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Maternal morbidity associated with emergency versus elective CS [Internet]. [cited 2013 Dec 21]. Available from: http://www.jpmi.org.pk/index.php/jpmi/article/download/14 32/1288

8.

Pomela J, Harmesh Bains, Vidhushi B, Annika J. A Comparison of Maternal and Fetal Outcome in Elective and Emergency Caesarean Sections - Indian Obstetrics and Gynaecology. Indian Obstetricsand Gynecology [Internet]. 2012 Sep [cited 2013 Dec 20];2(3). Available from: http://iog.org.in/index.php/originalarticles-issue-july-september-2012/73-a-comparison-ofmaternal-and-fetal-outcome-in-elective-and-emergencycaesarean-sections?showall=1&limitstart=

9.

Gary Cunningham F, Kenneth J. Leveno, Steven L.Bloom, John C Hauth, Dwight J. Rouse, Catherine Y. Spong. Caesarean delivery and peripartum hysterectomy In Williams Obstetrics. 23rd edition. McGraw Hill Medical Publishers. 2010; pp. 544-562.

10.

Muhammad Ali, et al. Maternal and fetal outcome -comparison between emergency and elective caesarean. The Professional. January - March 2005; Vol. 12 (1): pp. 32-38.

11.

B Unnikrishnan A recent way of evaluating cesarean birth. J Obstet Gynecol India. November-December 2009; Vol. 59(6): pp. 547-51

12.

Soltan MH, Chowdhury N and Adelusi B. Post opeartive febrile morbidity in elective and emergency caesarean sections. Journal of Obstetrics and Gyanecology. 1996;16(6):508-512.

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ORIGINAL ARTICLE

MORPHOLOGICAL STUDY OF VAULT SUTURE & ITS CORRELATION WITH AGE IN CENTRAL RAJASTHAN William F Masih1, Sumit Gupta2, Pratima Jaiswal1, Anita E Chand3, Pramod Kumar Saraswat4 Authors’ Affiliations: 1Associate Professor; 2Assistant professor, Department of Anatomy, Govt. Medical College, Kota; 3Professor, Department of Microbiology , Govt. Medical College, Kota; 4Professor, Department of Forensic Medicine, JLN Medical College, Ajmer Correspondence: Dr. William F. Masih, Email: [email protected]

ABSTRACT Introduction: The suture closure of skull has a time and sequence of their union and study of suture closure can be correlated to its age and the obliteration of sutures is affected by sex, race, climate, heredity and diet Aims: To study the closure of vault sutures on both inner and outer surface of skull and its correlation with age. Methods: Total 200 skulls in autopsy cases (157 males and 43 females) from all age groups were studied. Results: In males the minimal age of fusion in endocranium were 40 years for both sagittal suture (SS) and coronal suture (CS) & 50 years for lambdoid suture (LS). In females it was 40, 33 and 53 years for SS, CS & LS respectively. The maximum age of non-union of suture on endocranium in males was 42, 45, 55 years for SC, CS & LS respectively. In females it was 45, 45 and 55 years for SC, CS and LS respectively. 2 males (1% of all cases) showed nonfusion of vault sutures at the age of 70 years at ectocranium. Among the females maximum age of non-union of ectocranium was observed to be 59, 58 and 69 years for SS, CS and LS respectively. Conclusion: The fusion of endocranial vault sutures occurred 5-10 years earlier as compared to ectocranium and it is more reliable. The obliteration sets little early and proceeds more slowly in the females than in males. Key words: Cranial suture, suture, skull suture, Age estimation,Vault suture INTRODUCTION The sutures are easily seen in the young adults but in the skull of old persons the sutures are more or less obliterated. Vault is arched roof of skull and has three main sutures i.e sagittal, coronal and lambdoid . Bregma is the point where sagittal and coronal sutures meet and it is the site of anterior fontanelle while lambda represents the site of junction of sagittal and lambdoid sutures and is represented by posterior fontanels1. Growth of the skull and obliteration of vault suture depends upon brain development. The premature closure of fontanelle and sutures is common in microcephaly. The suture closure has a time and sequence of their union and study of suture closure can be correlated to its age.2 Vault sutures exhibits progressive closure from midtwenties 3. Any visible fusion will at least indicate that the skull is of mature individual and it is unlikely below the age of 20 year4. The obliteration of sutures is affected by sex, race, climate, heredity and diet5. Suture closure begins at endcranium and then proceeds to ectocranium and sometime there may be a lapsed union 6. Lapsed Union is characteristic of ectocranial sutures that tend to remain in a state of incomplete union, in some individuals it is of very high degree3. A Volume 4│Issue 1│Jan – Mar 2014

number of studies have been conducted abroad on closure of cranial suture as an indicator of age viz., Dwight T (1890)7, Frederic J (1906)8, Todd TW and Lyon DW (1924)3 and Singer R (1953)9. In India the available studies on the subject are of Yadav SS and Puri PR (1997)10, Pardeep et al (2001-2004)11 and Parmar P et al (2012)12. As closure begins internally, without inspection from both sides observations are misleading9. As the present study is on autopsy basis, so vault sutures were observed with naked eye both externally and internally and it was also correlated with age of the person. OBJECTIVES Objective of the study was to study the closure of vault suture on both inner and outer surface and its correlation with age and compare the results with other studies in India and abroad. MATERIAL AND METHOD This study was done in the Department of Anatomy in association with Department of Forensic Medicine at JLN Medical College, Ajmer. A total of 200 skulls in bodies brought for autopsy (157 males and 43 females), Page 19

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from all age groups, were studied. The age of subjects under study was enquired from police and relatives.

50 years and 51-55 years each and 2.5% of 56-60 years respectively (Table-I).

The calvarium was removed by sawing and chiseling along with its three sutures under study, i.e sagittal suture (SS), coronal suture (CS) and lambdoid suture (LS). Each suture was divided into its segments by marking pencil both on ectocranium and endocranium.

Table 1: Age and Sex Wise Distribution of Cases (N=200)

Stages of closure were scored according to Frederic Rating Scale (1906)8 and after modifying it as followsA. : Non Union B. : Beginning of Union C. : Closure of suture OBSERVATIONS In the present study there were 78.5% male and 21.5% female and male to female ratio was 3:1. In all age groups male subjects dominated the female. 14.5% cases were from 26-30 years age group followed by 13.5% in 31-35 years, 11.5% in 36-40 years of age and 8% of 16-20 years. Remaining 7.5% individuals were from 46-

Age in Years 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86-90 Total

Male (%) 2 (1.0) 3 (1.5) 5 (2.5) 6 (3.0) 22 (11.0) 26 (13.0) 24 (12.0) 17 (8.5) 10 (5.0) 13 (6.5) 13 (6.5) 4 (2.0) 2 (1.0) 2 (1.0) 3 (1.5) 3 (1.5) 1 (0.5) 1 (0.5) 157 (78.5)

Female (%) 2 (1.0) 2 (1.0) 10 (5.0) 6 (3.0) 3 (1.5) 3 (1.5) 5 (2.5) 2 (1.0) 2 (1.0) 2 (1.0) 1 (0.5) 1 (0.5) 1 (0.5) 2 (1.0) 1 (0.5) 43 (21.5)

Total (%) 4 (2.0) 5 (2.5) 5 (2.5) 16 (8.0) 28 (14.0) 29 (14.5) 27 (13.5) 22 (11.0) 12 (6.0) 15 (7.5) 15 (7.5) 5 (2.5) 3 (1.5) 3 (1.5) 5 (2.5) 3 (1.5) 2 (1.0) 1 (1.0) 200 (100)

Table 2: Minimum Age (in years) of Union of Vault Sutures Suture Sagittal(SS) Coronal(CS) Lambdoid(LS)

Male Endocranium Ectocanium 40 42 40 45 50 60

Female Endocranium Ectocranium 40 48 33 48 53 58

Table 3: Maximum Age (in years) of Non- Union of Vault Sutures Suture Sagittal(SS) Coronal(CS) Lambdoid(LS)

Male Endocranium Ectocanium 42 70 45 70 55 70

Female Endocranium Ectocranium 45 59 45 58 55 69

The minimal age of fusion on endocranium was 40 years each for SS and CS in males. Whereas for LS it was 50 years .Among the females the minimum age of fusion of CS, SS and LS on endocranium were 33, 40 and 53 years respectively (Table-II), (Fig-1). The maximum age in male showing non-union of suture on endocranium was 42 years on sagittal, 45 years on coronal and 55 years on lambdoid suture (Table III). In female it was 45 years on SS and CS and 55 years on LS.In 2 males i.e. 1% there was no fusion of any of the vault suture even at the age of 70 years on ectocranium. Among the female maximum age of non-union of ectocranium was observed to be 59 years on SS, 58 years CS and 69 years for LS respectively (fig- 2). Figure-1: Showing Unfused Endocranial Sutures marked by arrows (1 showing CS & 2 showing SS) Volume 4│Issue 1│Jan – Mar 2014

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DISCUSSION The cases in the present study ranged from a new born to the age of 89 years of which maximum belong to middle age group.

Figure-2: Ectocranium Showing Lapsed Lambdoid Suture (marked by arrow).

The commencement of the sutural obliteration on the endocranium of sagittal was observed at the age of 2530 years in both sexes which completed by the age of 46-50 years. The study showed that fusion of endocranium began first on pars lambdica & last on pars bregmatica in both sexes. On ectocranium it started five years after endocranium, in males at 31-35 years, whereas in females it started at the age of 36-40 years i.e 10 years after endocranium . The completion of sutural obliteration in present study occurred at the same age i.e (51-55 years) in both sexes.

Table 4: Comparison of Time of Closure of Sutures with Other Studies in India & Abroad Author

Region

Method

Reddy K.S.N ((2007)16 Nandy A.( 2001)5 Pradeep et al(2001-2004)11 Parmar P et al(2012)12 Present Study

Andhra Pradesh West Bangal Punjab Pondicherry Ajmer, ajasthan

X-ray X-ray CT Scan X-ray Autopsy study Ecto suture Endo suture

In males, 16.6% cases there was delayed union on pars lambdica, par obelica and pars verticis and in 33.33% in pars bregmatica. Females did not represent any incidence of non- union, delayed union on ectocranium of SS at any part. Parikh CK (2010)13 has reported fusion on posterior 1/3 of sagittal suture by the age of 30-40 years and anterior 1/3 by the age of 40-50 years. It could probably be because of climate, dietetic and racial factors influencing the sutural fusion. In India study by Yadav SS and Puri PR (1971)10 on 100 skulls in Uttar Pradesh had reported finding parallel to our study as regards to obliteration of SS. Commencement of fusion of endocranium on CS and its completion in either sex was simultaneous to the fusion of endocranium on SS in both sexes. It started by the age of 25-30 years and was completed at the age of 46-50 years .The fusion of endocranium on CS occur first on the lower half and then on the upper half i.e it was early on sutural part away from the bregma. The age of commencement of fusion of ectocranium in both male and females was 31-35 years, whereas completion of obliteration occurred five years earlier in male (51-55 year) than female (56-60 years). In our study commencement and completion of the sutural fusion on SS and CS was noted simultaneously among the male whereas in females the completion of union of CS lagged behind five years as compared to SS. The age of CS obliteration in various Western studies mainly Todd and Lyon (1924)3, McKern and Stewart (1957)14 were earlier as compared to our study and other Volume 4│Issue 1│Jan – Mar 2014

Age of closure of Sutures Sagittal Coronal 40 to 50 years 50 to 60 years 45 to 50 years 45 to 50years 45 to 50 years 45-50 years 50 to 60 years 50 to 60 years

Lambdoid 45-50 years 50 to 55 years 45-50 years 50 to 60 years

46-50 years 46-50 years

56-60 Years 46-50 years

46-50 years 46-50 years

studies in India (Table IV). This difference of few years is because our is a autopsy study while others were radiological studies. The radiological appearance of union appears earlier than union indicated by gross examination (Reddy KSN 2007)16.The sequence of obliteration at various parts of suture in our study is similar to other studies. The sequence of obliteration on endocranium is more reliable than ectocranium. The same was observed by Patil TL et al (1981)15 during his study on vault sutures in 150 skulls and by Todd and Lyon (1924)3 and Mckern and Stewert (1957)14. Lapsed union in the present study has been observed in 1% case only, where there was no obliteration on any part of ectocranium of all three vault sutures. The obliteration of SS and CS in our study have been observed simultaneously followed by LS in the last. The obliteration of vault sutures was noticed earlier in male than in female at all three vault suture. CONCLUSION In males age of commencement of obliteration at endocranial suture was 25-30 years for both SS and CS and 31-35 years for LS whereas as completed at the age of 46-50 years on SS and CS and at 56-60 years on LS. In female age of commencement of obliteration on endocranial suture was 25-30 years on both SS and CS and31-35 years on LS, whereas its completion was at the of 46-50 years on both SS and CS , 56-60 years on LS. Page 21

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In males obliteration started on ectocranium of SS and CS at 46-50 years of age while on LS it started at 51-55 years, The completion of fusion took place at the age 51-55 years on both SS and CS and above the age of 60 years on LS. In females on ectocranial suture obliteration started at the age 46-50 years on SS, 51-55 years on CS and above the 60 years.It completed on SS. 35 years on CS and 51-55 years on LS while completion of obliteration was observed at

3.

Todd TW and Lyon DW Jun. Cranial suture closure. Its progress and age relationship. I Am J of PhyAnthro.1924; 7: 325-384.

4.

Bernard Knight; Forensic Pathology, 2ndEdn, Oxford University Press Inc.198 Madison Avenue: New York, 1996; p 122.

5.

Nandy A. Principal of Forensic Medicine, 2nd Ed. New Central Book Agency (P) Ltds Calcutta. 2001 .p78-80

6.

Krogman WM. The Human Skeleton in Forensic Medicine, 3rd edi, Charles C. Thomas Publisher U.S.A. 1978;, 76-91.

In males the fusion started and completed simultaneously on SS and CS, whereas it occurred in the end on LS both on endocranium and ectocranium. In females the endocrainum showed obliteration simultaneously both at SS and CS whereas at ectocranium it started earlier on SS.

7.

Dwight T. The Closure of the cranial sutures as a sign of age. Boston, Medical Surgical J.1890; 122: 389-392

8.

Frederic J .Untersuchngenuber die normal der schadelnap the zeitschrift of morphologic und Anthropologic1906;9:373-456

9.

Singer R. Estimation of age from cranial suture closure,report on its reliability.J Forensic Medicine,1953;1:52-59

10.

Yadav S.S. and Puri R.R.. J. Indian Academy Forensic Science January. 11: (1971)

11.

Pradeep et al. Age estimation in old individual by CT scan of skull, Journal of Indian Academy of Forensic Medicine20012004; 26(1):pp10-13.

12.

Parmar P. et al. Determination of age by study of skull sutures, Int J Cur Res Rev, Vol 04, issue 20, Oct.2012; p 127-131

13.

Parikh CK. Parikh’ Text Book of Medical Jurisprudence Toxicology, 5th Edn.Medical center Calabrs. Mumbai2010; pp. 44-45

14.

Mckern TW and Stewart TD. Skeletal age changes in young American male analyzed from stand point of identification. Headquarter QM; Res, and Dev. Command, Natick. MA 1957.

15.

Patil TL, Bhargava and Qureshi AA . The study of cranial suture closure of the vault of the skull. Anat Soc. of Ind.1981; 3038.12.

16.

Reddy KSN. Identification: the Essential of of Forensic Medicine and Toxicology, 20thEdition.2007, p 50-84.

The fusion occurred 5-10 years earlier on endocranial as compared to ectocranium on all vault sutures. The obliteration on endocranial suture is more reliable than the ectocranial suture, where the delayed union or lapsed union is more. Incidence of lapsed union was 1%. The sequence of fusion of vault sutures started first on the part near to lambda and away from the bregma. The fusion of vault suture sets little early and proceeds more slowly in the females than in males. BIBLIOGRAPHY 1.

Susan Standring. Gray Anatomy: the anatomical basis of clinical practice, 39 thEdition, Elsevier Churchill livingstone, 2006, p 484-487.

2.

Chandrasekhar P. Identification of skull from its suture pattern. Proceeding of the 1st Asian- Pacific Congress on Legal Medicine and Forensic Sciences, Singapore 1983; pp 311-315.

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ORIGINAL ARTICLE

A COMPARATIVE STUDY ON SYMPTOMS AND MICROBIOLOGICAL STATUS OF TUBERCULOSIS IN HIV POSITIVE PERSONS Jayant B Chauhan1, Ghanshyam B Borisagar2 Authors’ Affiliation: 1Associate Professor , Department of Tb & Chest Diseases, GMERS Medical College, Sola, Gujarat; 2Associate Professor, Department of T.B. and Chest Diseases, P.D.U. Government Medical College, Rajkot, Gujarat Correspondence: Dr. Jayant B. Chauhan, Email: [email protected]

ABSTRACT Background: In HIV positive and HIV negative individual clinical symptoms of Tuberculosis (TB) varied widely. Chances of Smear negative tuberculosis are high in HIV positive cases and it is the leading cause of death of HIV patients. Objective: To study the relationship between bacteriological status of TB cases and TB symptoms in HIV patients. Methods: A cross-sectional analytical study was conducted during 2011 in a representative sample of 100 HIV infected persons visiting a tertiary care hospital located in western India. Laboratory investigation of Tuberculosis was done by AFB staining and culture in Ogawa medium. Data collected in structured questionnaire and laboratory profile of the patients were entered into Microsoft excel and analyzed using Epi-info. Results: Twenty three percent prevalence of TB is observed in HIV patients. Eighty one percent of the total TB cases were smear negative cases. Significant relationship was observed between the TB symptoms and Smear positive TB cases (p0.05). Prevalence of Mycobacterium avium complex was higher than M. tuberculosis. Conclusion: In HIV patients, the utility of direct microscopy of AFB stained smear is limited because most of these patients were smear negative and are asymptomatic. So, direct microscopy in combination with Culture is recommended for higher case finding of TB in HIV patients. Key words: HIV, TB, smear negative, smear positive, culture INTRODUCTION Among different HIV related opportunistic infections, tuberculosis is the most common one as suggested by the fact that more than a quarter of the 42 million people infected with HIV worldwide are also coinfected with TB.1 HIV associated TB has a marked increased mortality rate: up to 25% of patients with Sputum smear positive results and 40-50 % of those with AFB smear negative results die of TB.2 As the types of TB in HIV positive patients differs from those occurring in HIV negative individual, particular features must be taken into account in the case detection, diagnosis and treatment of TB in HIV positive patients. Of importance, the bacteriological status is the key issue concerned with the management of HIV related TB. “Smear negative” and “Smear positive” are the most important bacteriological classification of pulmonary TB cases. Smear positive TB cases means those TB patients with at least two sputum specimen positive for AFB by microscopy or at least one sputum specimen positive for AFB by microscopy, Volume 4│Issue 1│Jan – Mar 2014

and abnormal chest radiography/Culture positive for Mycobacterium tuberculosis. Smear negative TB cases means those TB patients with at least 2 sputum specimen negative for AFB by microscopy and culture positive for M.tuberculosis.3 Directly observed treatment Short-course (DOTS) is the worldwide accepted TB control strategy which still relies on passive case finding methods. This basic approach in TB control is supposed to be insufficient to control TB in high HIV prevalence region.4 Cough is the most common symptom of TB and present in 95% of the smear positive cases. However, it is not a specific sign of TB since it is present in many conditions affecting the lower respiratory tract i.e. most patients with cough do not suffer from TB. Similarly, cough and smear positive TB is less common in HIV patients. Often a PTB suspected patients (i.e. PTB suspects) has one or more of the following symptoms as well as cough:

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Respiratory symptoms: Shortness of breath, chest pain, haemoptysis. Constitutional symptoms: Weight loss, loss of appetite, fever, night sweat and tiredness.3 Although microscopic examination of appropriately stained sputum specimen for tubercle bacilli is the quick and easier method it is less reliable in certain cases because it requires between 5,000–10, 000 tubercle bacilli per milliliter sputum for detection of AFB. So, examination by bacteriological culture provides the definitive diagnosis of tuberculosis because as few as ten viable bacilli per milliliter sputum can be detected. Culture increases the number of TB cases often by 30-50 times and it is essential to distinguish different mycobacterial species.5 Atypical mycobacterial lung disease, mainly due to Mycobacterium avium complex, is most prevalent in HIV patients.6 Until now in developing countries diagnosis of smear negative Tuberculosis is rarely done due to concerns regarding the feasibility and cost. However several studies have revealed that smear negative tuberculosis constituted the significant proportion in HIV patients.3 So far, the guidelines and policies concerning the case detection of TB in HIV patients are same as that of normal population. The RNTCP program primarily relied on DOTS and quality assured microscopy. With this back ground, this study was planned to examine the relationship between bacteriological status of TB cases and TB symptoms in HIV patients. METHODOLOGY This research was approved by Institutional ethical committee and carried out in a department of TB & Chest in a tertiary care centre in western India during 2011. The cross sectional study was conducted in a representative sample of 100 HIV infected persons registered to Anti Retroviral Treatment (ART) centre of the same hospital. Sampling was done by random sampling method. In this process, the name of all the HIV patients registered in the ART centre were written in sepa-

rate papers and 100 of them were selected by simple random technique without replacement. After taking informed consent, pre structured questionnaires were filled on the basis of which the patients were identified as symptomatic or asymptomatic. Those patients who self reported cough for about 2 weeks along with chest pain and other constitutional/respiratory symptoms are considered as symptomatic; otherwise asymptomatic. Every attempt was made to reduce bias during filling up of questionnaire. Two sputum specimens were collected as per WHO guidelines. As asymptomatic patients could not produce the sputum readily, they were instructed to inhale 3-5% saline mist for 15 minutes to obtain induced sputum. Diagnosis of tuberculosis by conventional methods such as direct microscopy of AFB stained smear, AFB culture and identification tests in Mycobacteriology Laboratory. In direct microscopy three sputum specimens i.e. 1st spot specimen, early morning specimen and 2nd spot specimen were collected, stained by ziehl-Neelsen staining technique and then reporting was done according to WHO positively grading system.7 In culture technique, early morning specimen was subjected to modified petroff's method for decontamination and then inoculated into 3% Ogawa medium followed by incubation at 370c for 8 weeks. In identification tests, the observation of growth rate and pigmentation, Niacin Test, Nitrate Reductase Test and Catalase Test were performed according to WHO manual, 1998.5 The data obtained from questionnaire and laboratory results were entered into Microsoft excel and χ2 tests and other relevant statistical tools were applied using Epi-info software. RESULTS Of the 100 HIV infected persons, 66 (66%) were males and 34 (34%) were females. Majority of them were in the age group 21-30 (60%) followed by 31-40 (31%). The overall prevalence of tuberculosis (including atypical mycobacterial lung disease) was 23%. More males were co-infected than females ( male:female = 17:6), and the age group of 21- 30 were predominantly coinfected as shown in table 1.

Table 1 Distribution of HIV patients by TB status, age group and gender Age group 11-20 21-30 31-40 41-50 51-60 Total

TB positive Male (%) Female (%) 0 (0.0) 0 (0.0) 12 (70.6) 3 (50.0) 3 (17.6) 3 (50.0) 1 (5.9) 0 (0.0) 1 (5.9) 0 (0.0) 17 (100) 6 (100)

TB negative Male (%) Female (%) 1 (2.0) 1 (3.6) 25 (51.1) 20 (71.4) 20 (40.8) 5 (17.8) 2 (4.1) 2 (7.2) 1 (2.0) 0 (0.0) 49 (100) 28 (100)

Among 5 smear positive cases, 4 cases (80%) presented TB symptoms (Both respiratory and constitutional) showing significant relationship between TB symptoms and smear positive tuberculosis (χ2 =4.01 , p0.05) as shown in table 3. Analysis of individual symptoms presented by Smear positive, smear negative and Non TB cases reveals that as high as 80% of Smear positive TB cases presented all symptoms of TB where as 38.8% to 55.5% smear negative TB cases presented Page 24

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different TB symptoms. Cough, the major symptom presented by both the TB cases, is less common (only 28.5%) in Non TB cases (Table 4).

Table 3 Relationship between TB symptoms and Smear negative TB in HIV cases

Table 2 Relationship between TB symptoms and Smear Positive TB in HIV cases

Yes No Total

Smear positive TB Yes No Total X2, P value -4.01, (p0.05) Note: Although 10 smear negative TB cases reported cough, only 7 of them reported chest pain along with cough. So, smear negative TB cases with TB symptoms (including chest pain) would be 7.

. Table 4 Relationship between clinical symptoms of TB and bacteriological status of TB in HIV Positive patients Symptoms Fever Cough Chest pain/ shortness of breath Night sweat Weight loss

Smear +ve TB cases (n=5) (%) 4 (80.0) 4 (80.0) 4 (80) 4 (80.0) 4 (80.0)

Smear -ve TB cases (n=18) (%) 7 (38.8) 10 (55.5) 8 (44.4) 7 (38.8) 10 (55.5)

TB negative cases (n=77) (%) 29 (37.6) 22 (28.5) 31 (40.2) 22 (28.5) 39 (50.6)

Total (n=100) (%) 40 (40.0) 36 (36.0) 43 (43) 33 (33.0) 53 (53.0)

Note- Actually 7 cases are chest pain and one case is shortness of breath (but not chest pain). So if consider only those persons exhibiting cough for 2 weeks along with chest pain also, as the TB symptomatic, we should consider only seven cases as TB symptomatic. This is because we are considering those patients complaining merely shortness of breath (but not chest pain) as TB asymptomatic, whether or not they complain cough.

Although culture detected higher number of TB cases in comparison to direct microscopy of AFB stained smear, one case was detected only by direct microscopy (Table 5). Although one case was culture negative, there was no doubt in smear positive result because the morphology (shape and size) of the mycobacteria is exactly same as that of positive control AFB slide; and positivity grading result of the case was 2+. Table 5: Comparative evaluation of direct microscopy with cultural technique for TB diagnosis in HIV Positive patients AFB culture

AFB staining AFB found AFB not found Total Culture positive 4 18 22 Culture negative 1 77 78 Total 5 95 100 Inference: Direct microscopy in combination with culture is appropriate technique for TB case finding in HIV patients.

Table 6 Distribution of Mycobacterium species in HIV Positive patients Mycobacterium Species M. avium complex (MAC) M. tuberculosis M. kansasii M. fortuitum M. chelonae Total *One species could not be identified negative

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isolates 9 6 4 2 1 22* because it was

% 40.9 27.3 18.2 9.1 4.5 100 culture

Furthermore it was known that the patients were under DOTS treatment and hence dead bacilli might have been seen in direct microscopy but not in culture (which require live bacilli to produce colony). Among 22 culture positive isolates, the predominant species was M. avium complex (40.9%) followed by M. tuberculosis (27.3 %) as shown in table 6. DISCUSSION In this study the prevalence of tuberculosis (including atypical mycobacterial lung infection) is found to be 23% in HIV positive patients which is in concordance with WHO/UNAIDS report stating one third of HIV/AIDS patients co-infected with tuberculosis.8 In context to India, it was observed that during 19912000, 66% of AIDS cases were co-infected with TB.9 Comparatively Lesser prevalence in our study may be due to inclusion of both HIV as well as AIDS cases. Studies done in United Mission Hospital, Tansen showed that TB prevalence in HIV cases increased from 10.8% in 2002 to 39.5% in 2004.10,11 These studies shows that high variation of TB prevalence in HIV patients depending on the nature of surveillance. If sampling is done in patients visiting HIV/STI clinics/ hospital bed, the prevalence will be obviously high. One of the important findings of this study is that HIV patients mostly suffers from smear negative tuberculosis (as high as 81.8 % of the total TB cases) and are usually asymptomatic. Other studies have also shown that the usual symptoms of TB are less common in this group of immune-compromised persons.3 So, they require bactePage 25

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riological investigation of through culture which is found to be more than 4 times effective than direct microscopy. It has been observed that in general, culture increases the case finding rate by 30–40%.5 Furthermore, several comparative evaluation of different diagnostic technique for tuberculosis have concluded that case detection rate of direct microscopy is very low although it is simplest and cost effective.13 This study suggests that unlike the case finding strategy for general population, the TB case finding strategy for HIV patients needs to adopt different approach / policies because higher number of asymptomatic cases were found to be positive for tuberculosis. Another important finding of this study is the documentation of alarmingly higher rate of atypical mycobacterial lung disease (mainly due to Mycobacterium avium complex). It was documented that as high as 50 % of HIV/AIDS patients of western countries were coinfected with Mycobacterium avium complex.12 This can be justified that the HIV patients being highly immunecompromised, even these less virulent mycobacteria (which are abundantly found in environment) can cause serious lung disease. Diagnosis of smear negative tuberculosis is a difficult task. In developing countries, the majority basis of clinical and chest radiographic findings. Without a standardized clinical work up, the misdiagnosis rates have been estimated as high as 35% to 52%.14 So, it is recommended to adopt policies concerning the sputum culture, wherever possible. CONCLUSION This study has demonstrated that significantly higher number of asymptomatic HIV patients suffer from smear negative TB. The disease is mainly due to atypical mycobacteria which are rarely detected in direct microscopy. Hence, culture is recommended to detect higher number of TB cases in HIV patients.

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REFERENCES 1.

Corbett E L, Watt C, Walker N, et al. The growing burden of tuberculosis: global trends and interaction with the HIV epidemic. Arch Intern Med 2003; 163: 1009- 1021.

2.

Stop TB partnership. Working group on TB-HIV. Scientific panel. Guidelines for implementing collaborative TB and HIV program activities, Geneva, Switzerland: World health Organization, 2003.

3.

World Health Organization. Tuberculosis Handbook, 1998; WHO/TB.98.253

4.

World Health Organization. First meeting of the Global working group on TB/HIV. 2001. WHO, Geneva.

5.

World Health Organization Laboratory Services in Tuberculosis Control, Tuberculosis culture, 1998;WHO/TB.98.258

6.

Grange J M. Tuberculosis. Smith G and Easman CF (editors). Topley and Wilson’s principle of Bacteriology, Virology and Immunity, Volume III, 8th edition. BC Decker Philadelphia Hamilton, 1990; 94 –117.

7.

Cheesbrough M. District Laboratory Practice in tropical countries. Part II Cambridge University Press, 2002, 71- 211

8.

Sharma SK, Mohan A, Kadhiravum T HIV/TB Coinfection: Epidemiology, diagnosis and management, Indian Journal of Medical Research 2005; 121:550-567

9.

Subedi BK HIV-TB co-infection in Nepal. Journal of Institute of medicine 2003; 25 (19-21)

10.

Ghimire P, Dhungana JR, Bam DS and Rijal BP Tuberculosis and Human Immunodeficiency Virus Co-infection in United Mission Hospital-Tansen. SAARC Journal of Tuberculosis and Lung disease 2004;1(1):32-38

11.

Luitel BR, Lamgade A, Busal L and Napit I. Trends of HIV infection in united Mission Hospital, Tansen: A retrospective Glimpse. Journal of Nepal Medical association, 2005, 44:16 ( 63)

12.

Brroks GF, Butel JS, Morse SA. Medical Microbiology. 22nd edition LANGE publication. 2002; 275 – 284.

13.

Abdurahman A, Beyene G, Wadajo N. Comparative study of direct sputum microscopy with different sample pre-treatment procedures for examination of acid fast bacilli. Jimma Institute of Health Sciences, Ethiopia(In press)

14.

Gordin FM, Slutkin G, Schecter G, Goodman PC, Hopewell PC. Presumptive diagnosis in treatment of pulmonary tuberculosis based on radiographic findings. Am Rev Respir Dis 1989, 139: 1090- 1093.

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ORIGINAL ARTICLE

SUBCLINICAL SYSTOLIC DYSFUNCTION AMONG NEWLY DIAGNOSED HYPERTENSIVES WITH PRESERVED LEFT VENTRICULAR EJECTION FRACTION USING TWO DIMENSIONAL STRAIN IMAGING METHOD: HOSPITAL BASED OBSERVATIONAL STUDY Tulika Madaik1, Prakash C Negi2, Anita Padam3, Urmil Gupta4 Authors’ Affiliations: 1Final Year Postgraduate Student , Department of Physiology, IGMC, Shimla; 2Professor And Head, Department of Cardiology, IGMC, Shimla; 3Professor And Head; 4Professor , Department of Physiology, IGMC, Shimla Correspondence: Dr. Tulika Madaik, Email: [email protected]

ABSTRACT Background: Heart failure is the major cause of morbidity and mortality in hypertension. Early detection of subclinical systolic heart failure thus is an important step in prevention of clinical heart failure. There are limited studies evaluating the presence and determinants of subclinical heart failure along axial, circumferential and radial axis among hypertensives with normal Left Ventricular Ejection Fraction (LVEF) using strain imaging methods. Present study aimed to detect the subclinical global and regional systolic dysfunction in longitudinal, circumferential and radial axis and its determinants in hypertensive patients with normal LVEF. Material and Method: 2-dimensional echocardiographic (2DE) images of the Left Ventricle (LV) were acquired in apical 4-chamber and parasternal short-axis view at mid ventricular levels to assess global and regional strain in longitudinal, radial and circumferential axis in 72 hypertensive patients with normal LVEF and 57 healthy controls using speckle tracking method. LV Mass and LVEF were measured using 2D guided M Mode scan and diastolic function was assessed in early diastole with tissue Doppler imaging. Results: The regional strain in longitudinal axis was significantly reduced at Apex and Apico lateral segment of LV in hypertensive population compared to normotensive group (-17.99± 5.21 Vs-19.77±4.17; p140/90 mmHg not on anti hypertensive medications were the patient population screened for enrollment in the study. Patients with LV systolic dysVolume 4│Issue 1│Jan – Mar 2014

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function with LVEF of 3

No. of patients ( % ) 5 ( 20 ) 10 ( 40 ) 6 (24 ) 3 (12 ) 1 (4 )

Tablle 3: Risk facttor wise distrribution of stu udy particip pants Risk k Factor Tubaal Surgery Prevvious Abortion Prevvious Ectopic PID IUCD D

No. of patients (%) 10 ( 40 ) 8 ( 32 ) 2(8) 4 ( 16 ) 2(8)

Tablle 4: Clinicall presentation n wise distrib bution of stud dy participantts Symp ptom at presen ntation Pain abdomen Bleed ding PV Ameenorrhea Shocck

No. of patients (%) 24 ( 96 ) 13 ( 52 ) 12 ( 48 ) 8 ( 32 )

The classic triad of ectopic prregnancy comprising of h of pain abdomen, blleeding per vvaginum and history amen norrhea was no oted in 60% of the cases.

Fig 1: Case of tubal ecttopic pregnancyy Fig 3: A casee of tubal abortio on alongwith a simple ovarian n cyst

Fig 5: Hemoperitoneum due to rupture of tubal ectopicc

Fig 2: A case c of ruptureed cornual preg- Fig 4: A casee of tubal ectopic pregnancy nancy

Fig 6: Ectopic m mass adhered to o omentum after rupture off tubal ectopic

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96% of the casees which is ssame as Boueeyer et al he tube was the most (95.55%)8. Ampullaary part of th comm mon site refleccted in 44% o of the cases. One case of ovariian pregnancy was noted. CON NCLUSION

F 7: A case of tubal ectopicc pregnancy Fig Table 5: Site wise disttribution of study particip pants Site of ecctopic Ampulla Isthmus Cornua Tubal abo ortion Ovary

No. of patients (%)) 11 ( 44 4 ) 5 ( 200 ) 3 ( 122 ) 5 ( 200 ) 1(4)

The fallo opian tube em merges as the most m common n site accountin ng for 96% off the cases. A rare r case of ovvarian pregnancy was noted.

Ecto opic pregnancyy is a nightmaare for the ob bstetrician. Earlyy diagnosis andd early referraal are the key to t successful management. m It is better to o over diagnose an a ectopic pregn nancy especiallly in a rural seetup. Due to advance diagnostic ttechnique, co onservative ment is also a viable option n but follow up p with betreatm ta-HCG makes it a limitation in a resource po oor setting as ouurs. The main challen nge in modern n clinical pracctice is to identtify and treat as early as po ossible cases of o ectopic pregn nancy and at the same timee to minimizee interventionss in those destined to be reesolved withouut causing any harm h 9. The dictum shoulld be to ‘THIINK ECTOP PIC’10 in a man in reproduuctive age gro oup with pain abdomen wom or blleeding PV or when she com mes in shock irrrespective of tuubal ligation.

SSION DISCUS In the prresent study most m of the paatients belongged to the age group g of 20 – 30 years, whiich may be beecause this is thee most fertile period p with inffrequent contrraception usagee. Total 92% of o the patients were multiparra. Risk factors were asso ociated in 60% % of the cases. The mmon risk factor was tubal surgery reflectted in most com 40% of the patients. 32% had a history h of preevious P abortion while 16% gavve history of PID. a 8% had a history of prrevious ectopicc which is in agreement witth the result of o Levin et all5 and is conssistent with the hypothesis th hat a woman with w a previouus ectopic preegnancy has a greater proclivvity towards a subsequent ectopic e pregnan ncy6. The mostt common sym mptoms at presentation weree pain abdomen n and bleedingg per vaginum m depicted in 96% and 52% of patients reespectively. Paain abdomen as a the mmon presenttation was also o observed byy and most com Chudharyy et al (94.3%))7. 52% of the patients were without the history h of amen norrhea suggeesting that the presentation might m be beforre missed perio od. Urine preegnancy test was w positive in n 60% of casees and inconclussive in 36% off the cases. On n examination n 60% patients presented p with h marked pallo or and 32% cam me in shock wh hich is comparrable with 35% % in study of ChudC hary et all7. All cases weere managed by b surgical inteervention. Onee case of laparoscopy was co onverted to lap parotomy. Thee most commo on site of ecto opic pregnancyy was the fallop pian tube in the t present stuudy accountin ng for

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FERENCES REF 1.

Barbara l. Hoffm man, John O. Sch horge, Joseph I. Schaffer, Lisa M. Halvorson, Karen K D. Bradshaw w, f. Gary Cunniingham. Williams Gynecologyy. 2nd edition. MccGraw-Hill Comp panies. USA. 2012. p198.

2.

Jonathan J S. Berekk, Deborah L. Beerek. Berek & No ovak’s Gynecology. 15th editio on. Lippincott, W Williams & Wilkin ns, a Wolters Kluwer business. USA.2012. p627.

3.

John J A. Rock, Howard H W. Jonees III. Te Linde’s Operative Gynecology. 10th edition. Lippinco ott, Williams & Wiilkins, a Wolters Kluwer busin ness. USA. 2008. p p798.

4.

F, Gary Cunninggham,Kenneth J.. Leveno, Steven n L. Bloom, John J C. Hauth, Dwight D J. Rouse, C Catherine Y. Spo ong. Williams Obstetrics. 23rdeedition. McGraw--Hill Companies. USA. 2010. p238.

5.

nbaum SC, Stubb blefield PG Ectopic pregnancy Levin AA, Schoen and prior inducedd abortion. Am J P Public Health 1982;72253-6

6.

Mark A. Fritz, Leeon Speroff. Cliniccal Gynecologic EndocrinoloE gy and Infertility.. 8th edition. Lipp pincott, Williams & Wilkins, a Wolters Kluwer business. b USA. 2011. p1385

7.

Chudhary et al, The T managementt of Ectopic Preggnancy, Irish Medical journal;2008 : 101(3);22-288

8.

Grenier C, Aussel L, Job-Spira Bouyer J, Saurel-Cubizolles MJ, G N. Ectopic pregn nancy and occup pational exposuree of hospital personnel. Scanddinavian Journal of Wrk, Enviro onment and Health 1998;24:998 103

9.

D. Keith Edmon nds. Dewhurst’s Textbook of Ob bstetrics and Gynecology. 7th edition. e Blackwell Publishers. USA.. 2007. p121

10.

Pratap Kumar, Narendra N Malhotra. Jeffcoate’s Principles P of Gynecology. 7th edition. Jaypeee brothers medical publishers.India. 2008. p149.

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ORIGINAL ARTICLE

CLINICAL FEATURES AND PATTERN OF PRESENTATION OF BREAST DISEASES IN SURGICAL OUTPATIENT CLINIC OF A TERTIARY HOSPITAL Jagdish B Karia1, Mukesh D Kothari1, H D Palekar2, Upendra A. Patel1, Jay Patel3 Authors’ Affiliation: 1Associate Professor; 2Professor, Department of Surgery, GMERS, Patan; 3MBBS, Patan Correspondence: Dr. Jagdish Karia Email: [email protected]

ABSTRACT Objective: The objective of thedu was to characterize the clinical features and pattern of presentation of breast diseases as observed in our practice. Materials and Methods: A prospective study of 121 consecutive patients with breast complaints presenting in our Surgical Outpatient Clinics. The relevant data were collected using the prescribed forms and was analyzed using Epi Info 2003, Mann–Whitney (test of two groups) Chi-squared and Fishers exact test was used to compare parameters of benign and malignant groups. P value 112.60 24 57.14

The observations showed that in case of the Kimura's base-wing index method; the range for males was 36 to 87 and in case of females it was 55 to 96 ; mean for males was 61.60 and for females it was 79.40 as shown in table-2. Table 2: All the parameters of Kimura’s Base Wing Index Parameters Range Mean Sd Mean + 3Sd Demarking point Bones identified by DP % of bone identified by DP

Male 36 – 87 61.60 10.88 28.96-94.24 < 45.98 6 10.34

Female 55 – 96 79.40 11.14 45.98-112.82 > 94.24 4 9.52

Thus by using (mean±3S.D), the demarking point for males was 45.98 and for females was 94.24. The present study had found 6 readings of male falling within the demarking point and 4 readings of female falling within demarking point. Therefore, the percentage of sacrum identified by demarking point ,for males was 10.34 and for females was 9.52 as shown in table-2.

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As per table no.3, the mean length of male bones was 106.96 & for females it was 90.52 It was observed that the mean length of bones was found to be higher in males as compare to females. The mean difference in length of bones of two sex statistically differ highly significantly i.e. P0.05 Table 3: Mean +3 SD of parameters Parameters Length Breadth * Non significant

Male 106.96 + 6.88 103.07 + 9.00

Female 90.52 + 3.91 102.67 + 7.41

P-value < .001 > .05*

Table -4: Sex wise Mean+ 3SD of parameters Parameters Transverse diameter Ala *Highly significant

Male 50.17 + 3.81 30.84 + 6.31

Female 41.88 + 2.86 33.26 + 5.04

P-value < .001* < .05

Table 1 and 3 shows that the length of sacrum and sacral index are important parameters as far as the sex determination of sacrum is concerned because 46.55 % of male bones and 57.14% of female bones could be identified by using the DP for the above parameters. The mean value of transverse diameter of Body of 1st Sacral vertebra of male bones was 50.17 & for females it was 41.88. It was observed that the mean value of transverse diameter of Body of 1st Sacral vertebra of male bones was found to be higher in males as compare to females. The mean difference in value of transverse diameter of Body of 1st Sacral vertebra of bones of two sex statistically differ highly significantly i.e. P1.05);reduced upper-to-lower body segment ratio, which was 0.73(normal- 0.86). Urgent ophthalmological assessment revealed bilateral complete retinal detachment. However lens dislocation was not noted. B-scan ocular ultrasonography confirmed retinal detachment in the both eyes.General examination showed presence of pectuscarinatum with

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long slender fingers and high arched palate with malocclusion of teeth with generalised joint laxity. Scoliosis was not present. Cardiovascular assessment suggested presence of aortic regurgitation which was later confirmed as mild aortic root dilation on echocardiography. The thumb and the little finger overlapped well while wrapping the other wrist (positive Walker's sign) and when enclosed within the clenched fist, the thumb protruded beyond the ulnar border (positive Steinberg sign). Keeping a diagnosis of Marfan syndrome in mind, specific interrogation revealed that a strong family history was present. His grandfather and father was also affected by similar physical features. His elder brother died suddenly of dissecting aneurysm of aorta. Routine blood tests including peripheral blood counts, renal and liver function tests, serum electrolytes were within normal limits. Chest X ray showed no bullae or pneumothorax. Aortic root dilation with no mitral valve abnormalities was noted on Echocardiography. Karyotyping was done and it was found to be normal (46 XY)with no structural or numerical abnormalities. In accordance with Ghent criteria, patient was diagnosed as having Marfan syndrome, complicated by bilateral retinal detachment. Patient was treated urgently along standard surgical lines by vitreolensectomy with cryotherapy and intraocular tamponade with silicon oil. Patient made a slow but uneventful recovery with best vision 6/24 in boyh eyes after 3 months.

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Figure 1: Positive Walker’s Sign

Figure 2: High Arched Palate With Malocclusion Of Teeth

DISCUSSION Marfan syndrome is an inherited connective tissue disorder that is transmitted as an autosomal dominant trait and is named after the French pediatrician Antonin Bernard Marfan, who first summarized the symptoms in 1892.Itis a connective tissue disorder with clinical variability and pleiotropic manifestations. The diagnosis is based on Ghent diagnostic criteria. [4] In adults, the combination of the major criteria in two different body systems and minor criteria in the third system amongst the cardiovascular, skeletal, ocular, pulmonary, skin, nervous systems provides the clinical diagnosis in majority of the cases. In children, genotyping may contribute to the diagnosis, especially if family history is negative. The clinical manifestations are due to mutation in the fibrillin-1 (FBN-1) gene located on chromosome 15q21. [1] It is inherited in approximately 75% of cases and occurs due to spontaneous mutation in the remaining 25%. More than 150 different mutations of the FBN-1gene have been isolated, and each family often has a unique genetic mutation for the syndrome. [1] This could explain the considerable variability in the clinical presentations of Marfan syndrome. The condition may manifest in the cardiovascular, musculoskeletal and ocularsystems. Myxomatous degeneration of aortic valve, lens dislocation, pectusexcavatum orcarinatum, arachnodactyly, dilatation of aorta, high arched palate with malocclusion of teeth with generalised joint laxity are the classical features of Marfan syndrome. Other musculoskeletal manifestations include scoliosis, duralectasia, protrusion acetabuli, and ligamentous laxity[2]. The fingers can be wrapped completely around the opposing wrist with overlapping (positive Walker's sign) and when enclosed within the clenched fist, the thumb protrudes beyond the ulnar border (positive Steinberg sign. Other system involvement includes respiratory and skin manifesting as bullae and spontaneous pneumothorax and multiple striae in skin. Compared with patients with idiopathic scoliosis, patients with Marfan syndrome tend to have scoliosis

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Figure 3: Pectus Carinatum

that progresses at a faster rate[5].Progression of skeletal abnormalities, especially scoliosis and anterior chest irregularity, can be dramatic during periods of rapid growth, such as puberty. Evaluation and follow up by an orthopedician is indicated in these cases. Aortic root dilation, aortic regurgitation, mitral valve prolapse ,dissection of aorta are main cardiovascular manifestations and also the most common cause of death[6-7].It is essential to identify and correct high refractive error or amblyopia in childhood in order to preserve and maximize visual function. Individuals with the Marfan syndrome are at increased risk for glaucoma, cataract formation, and retinal detachment, even in the absence of ectopialentis. For this reason, the eye evaluations should be performed every year. This case depicts a dangerous as although not a life-threatening but a permanent sight threatening complication of Marfan syndrome which although does not require any underlying disease specific treatment but only timely appropriate management failing which may render a person permanently blind. REFERRENCE 1.

Robinson PN, Godfrey M. The molecular genetics of Marfan syndrome and related microfibrillopathies. J Med Genet 2000;37:9-25

2.

Rangasetty UC, Karnath BM. Clinical signs of Marfan syndrome. Hosp Physician April 2006:33-38

3.

Dean JC. Marfan syndrome: Clinical diagnosis and management. Eur J Hum Genet 2007;15:724-33.

4.

De Paepe A, Devereux RB, Dietz HC. Revised diagnostic criteria for the Marfan syndrome. Am J Med Genet 1996;62:417-26.

5.

Shirley ED, SponsellerPD.Marfan syndrome. J Am AcadOrthopSurg :. 2009 ;17(9):572-581.

6.

De Backer J. Verh K .Cardiovascular characteristics in Marfansyndrome and their relation to the genotype. AcadGeneeskdBel: 2009; 71(6):335-371.

7.

O. R. Brown, H. DeMots, and F. E. Kloster, “Aortic root dilatation and mitral valve prolapse in Marfan's syndrome. An echocardiographic study,”Circulation, vol. 52, no. 4, pp. 651–657, 1975.

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CASE REPORT

A CASE OF SODIUM CYANIDE POISONING IN A YOUNG MALE Nikhil Dikshit1, Mudita Tiwari1, Aruna Dewan2 Authors’ Affiliation: 1Rugved Multispecialty Hospital; 2Centre for Education, Awareness and Research on Chemicals and Health Correspondence: Nikhil M Dikshit Email: [email protected]

ABSTRACT Cyanide poisoning is frequently lethal, because of the early onset of severe symptoms and difficulty in the diagnosis. But early institution of supportive care, especially in mild to moderate poisoning can be life-saving. We describe one such case of a 26 year old male with history of ingestion of concentrated (98%) sodium cyanide tablets, used in the cleaning and electroplating of jewellery. The antidote was not available commercially, and early supportive care was therapeutic. Clinicians should be aware that cyanide is used commercially in a wide array of industries and although it is not easily available on retail, prompt and correct diagnosis and treatment of poisoning can be beneficial, even in the absence of antidotes. This case demonstrates that mild to moderate cyanide poisoning can be treated with supportive care. Keywords: Sodium Cyanide Poisoning, Antidote INTRODUCTION Cyanide is traditionally known as a poison and has been used in mass homicides, in suicides and as a weapon of war. It was used as an agent of genocide in gas chambers by the Nazis during World War II. Sodium and potassium cyanide salts are widely used in many industries like ore extracting processes for the recovery of gold and silver, electroplating, case-hardening of steel, dyeing, printing, photography and in the synthesis of organic and inorganic chemicals (e.g., nitriles, amides, esters and amines) and the production of chelating agents. Industry widely uses nitriles as solvents and in the manufacturing of plastics. Nitriles may release HCN during burning or when metabolized following absorption by the skin or gastrointestinal tract. A number of synthesized (eg, polyacrylonitrile, polyurethane, polyamide, urea-formaldehyde, melamine) and natural (eg, wool, silk) compounds produce HCN when burned. Acute cyanide poisoning in humans is rare and is predominantly caused by smoke inhalation from fires and much more rarely by intentional ingestion of cyanide salts as in suicide or homicide attempts (1,2). Other sources of exposure could occur by accidental contact in laboratory workers and iatrogenic exposures of the antihypertensive drug Sodium Nitroprusside, which is 44% cyanide by molar weight. Cyanide groups released from the nitroprusside molecule enzymatically, serve as potential cyanogenic agents. Symptoms of cyanide poisoning can occur within seconds of inhalation of hydrogen cyanide gas, within minutes following oral ingestion of cyanide salts, and within hours of organic cyanide ingestion. Sodium and potassium salts of cyanide are lethal to adults in doses of 150 – 200 mg.(3,4) Because of the early onset of seVolume 4│Issue 1│Jan – Mar 2014

vere symptoms and difficulty in diagnosis, cyanide poisoning is frequently fatal. A situation of panic often develops if a case of cyanide poisoning is reported to a hospital. Although effective antidotes are available, general supportive measures should not be ignored and may be life-saving. CASE REPORT A 26 year old previously healthy male was brought to the emergency ward with alleged history of ingestion of sodium cyanide tablets. He was employed in the cleaning of jewellery in an electroplating industry, which involved the use of sodium cyanide tablets (of very high purity – 98%) besides hydrochloric acid and some other chemicals. According to co-workers, he had accidentally ingested a small amount of sodium cyanide about 1½-2 hours prior to arrival in the hospital. This history seemed doubtful and ingestion was most probably intentional. Immediately the patient had vomited thrice and started developing agitation and irritable behavior. On arrival, after a quick physical examination, a nasogastric tube was inserted to collect gastric lavage for anaylsis of the aspirate for cyanide. Activated charcoal suspension was administered and supportive care in the form of I/V fluids and high flow O2 @ 4L/min was started. Blood samples were taken for arterial blood gas (ABG) analysis and a toxicology consult was requested. Simultaneously, a search for cyanide antidotes (Hydroxycobalamin or Sodium thiosulphate and nitrite) was initiated. Physical examination showed a confused state with a GCS score of 12 (E3M5V4), P: 126/min, RR: 34/min, Page 106

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SpO2 – 94% on room air, BP: 104/66 mm Hg. Pupils were normal sized and equally reacting to light. There was no evidence of cherry red discoloration of his skin, with his dark skin tone, and neither his breath, nor did the aspirate smell of the characteristic bitter almond aroma. The systemic examination was unremarkable. ECG was normal, except for sinus tachycardia. Hb-18.2 gm%, TC-34,400 (N68 L27 E1 M4), PC 2.99 lakh, Na+ 144, K+ 3.9, Mg++ 2.6 mg% (1.8-2.6), SGPT-54 IU/L (5-45) Creat-1.8 mg%. ABG revealed severe metabolic acidosis (Table-1). Supportive treatment was continued in the form of I/V fluids and oxygen and patient was given I/V Sodium bicarbonate in a dose of 100 mEq over 10 min followed by 20 mEq/hr. At the end of the first hour, the patient started to develop obtundation, and GCS score decreased to 11 (E2M5V3). P-144/min, RR-40/min, SpO2 – 89%, BP110/74 mm Hg. High flow O2 was increased to 10 L/min and bicarbonate infusion was continued. The search for cyanide antidote kit proved futile as it was not available anywhere. Even the company manufacturing the sodium cyanide tablets was contacted for the antidotes, which was unavailable there as well. After 2 hours of treatment, patient still had sinus tachycardia (P-120/min, RR-30/min, BP-130/80 mm Hg), but sensorium started improving to a GCS score of 13 (E4M5V4) and SpO2 increased to 93%. A repeat ABG was ordered (Table-1), which showed improvement in the metabolic acidosis. The bicarbonate infusion was halved to 10mEq/hr. After 5 hours, patient was fully conscious, P – 90/min, RR – 24/min, BP – 130/80 mm Hg and SpO2 - 100% on oxygen at 10 lit/min. Bicarbonate replacement was stopped. He was kept under observation for two days. By the second day, oxygen was no more required to maintain SpO2. His CBC also showed marked improvements – Hb – 15.2 gm%, TC – 14,700 (N76 L19 E3 M3) and PC – 2.03 lakh. With an uneventful stay, he was discharged with stable hemodynamics on the next day.

Cyanide has a special affinity for ferric ions found in cytochrome oxidase, the terminal oxidative respiratory enzyme within the mitochondria and an essential catalyst for tissue utilization of oxygen. When cytochrome oxidase (at cytochrome a3) is inhibited by cyanide, cellular respiration is inhibited due to uncoupling of mitochondrial oxidative phosphorylation and histotoxic anoxia occurs as aerobic metabolism becomes inhibited. As anaerobic metabolism continues, there is a lactic acid accumulation, producing severe metabolic effects.(6,7) The tissues with the highest oxygen requirements (brain and heart) are the most profoundly affected. Although effective antidotes against cyanide (i.e. Hydroxocobalamin and Cyanide Antidote kit) are available, general supportive measures should not be ignored and may be life-saving. According to Jacobs’ experience of 104 industrial poisoning cases, the use of specific antidotes is only indicated in cases of severe poisoning with signs of deep coma, with wide non-reactive pupils and respiratory insufficiency with circulatory insufficiency.(5) Aggressive airway management with delivery of 100% oxygen can be lifesaving.(6,8,10) It can also treat concomitant carbon monoxide exposure. Oxygen accelerates the reactivation of cytochrome oxidase and protects against cytochrome oxidase inhibition by cyanide.(11) Even if a patient is unconscious, an antidote does not necessarily have to be administered immediately unless vital signs deteriorate.(9) Supportive care should include: •

Airway control, ventilation, 100% oxygen delivery (because cyanide causes a decrease in oxygen utilization).

•

Crystalloids and vasopressors, as needed, for hypotension.

•

Sodium bicarbonate according to ABG and serum bicarbonate level.

CONCLUSION Table 1 : Serial ABG Analysis (ISTAT1-Abott-USA) Parameter

(Units)

pH PCO2 PO2 HCO3 BEecf Total CO2 SaO2 Serum Na+ Serum K+ Ionic Calcium Hct Hb

(mmHg) (mmHg) (mmol/L) (mmol/L) (mmol/L) (%) (mmol/L) (mmol/L) (mmol/L) (%PCV) (g/dl)

2 hours (on admission) 7.074 24.8 71 7.2 (-23) 8 87 142 3.7 1.19 54 18.4

DISCUSSION

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4 hours 7 hours 7.288 39.6 110 19 (-8) 20 98 143 4.7 1.16 49 16.7

7.404 39 174 24.4 0 26 100 145 4.2 1.19 48 16.3

This report aims to highlight that the prognosis in cyanide toxicity is reasonably good if rapid supportive intervention and effective antidotal therapy are provided. Mild to moderate poisoning can be managed with prompt and effective supportive care. Although the incidence of acute cyanide poisoning is rare, the availability of its antidotes is even rarer. And, in spite of cyanide being a very potent poison, its use in various industries is high. REFERENCES 1.

Fortin JL, Desmettre T, Manzon C, Judic-Peureux V, PeugeotMortier C, Giocanti JP, et al. Cyanide poisoning and cardiac disorders: 161 cases. The Journal of emergency medicine. 2010;38(4):467-76.

2.

Chin RG, Calderon Y. Acute cyanide poisoning: a case report. The Journal of emergency medicine. 2000;18(4):441-5. Page 107

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Musshoff F, Schmidt P, Daldrup T, Madea B Cyanide Fatalities: Case Studies of Four Suicides and One Homicide. Am J Forensic Med Pathol 2002; 23(4):315 – 320.

4.

Holland MA, Kozlowski LM: Clinical features and management of cyanide poisoning. Clin Pharm 1986; 5:737 – 741.

5.

Jacobs K (1984) [Report on experience with the administration of 4-DMAP in severe prussic acid poisoning. Consequences for medical practice.] Zentralbl Arbeitsmed, 34:274-277 (in German).

6.

Holland M, Kozlowski L. Clinical features and management of cyanide poisoning. Clinical pharmacy. 1986;5(9):737-41.

7.

Baskin S, Horowitz A, Nealley E. The antidotal action of sodium nitrite and sodium thiosulfate against cyanide poisoning. The Journal of Clinical Pharmacology. 1992;32(4):368-75.

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Edwards AC, Thomas ID. Cyanide poisoning [letter]. Lancet 1978; 1(8055):92-93

9.

Peden NR, Taha A, McSorley PD et al. Industrial exposure to cyanide: implications for treatment. Br Med J (Clin Res Ed). 1986;293(6546):538 OP CIT

10.

Hall AH, Rumack BH. Clinical toxicology of cyanide. Ann Emerg Med 1986; 15:1067 – 1074.

11.

Takano T, Miyzaki Y, Nashimoto I, & Kobayashi K (1980) Effect of hyperbaric oxygen on cyanide intoxication: in situ, changes in intracellular oxidation reduction. Undersea Biomed Res, 7: 191-197.

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CASE REPORT T

RARE E PRESE ENTAT TION OF F SUPERFICIA AL LEIO OMYOSA ARCOM MA OF SC CALP Vimal Bh handari1, Gop palakrishnan Gunasekeran n1, Debasis Naik N 1, Ashwan ni Gupta1, A.S S.N. Rao1 1V.M Autors’ Affiliations: A M.M.C. and Safddarjung Hospitaal, New Delhi Correspon ndence: Dr. Go opalakrishnan Gunasekaran G em mail: gpgopalakrrishnan1987@gm mail.com

ABSTRACT u maalignant smootth muscle tum mours, mainly derived d from vvessels or visceera. SuperLeiomyossarcomas are uncommon ficial leiom myosarcomas are rare, repreesent only 7 - 10 % of leiom myosarcoma caases. Superficiial leiomyosarccomas can be primarry or secondarry. Primary sup perficial leiomyyosarcomas arrise from the dermis d (cutaneous leiomyosaarcoma) or subcutaneeous tissue (suubcutaneous leeiomyosarcom ma) in the skin.. They have diistinctly differeent histologic and prognostic feaatures from each other. The most affectedd parts being th he extremities, especially low wer extremitiess, followed by head and a neck regio on. In head andd neck region,, primary tumo ors are presentt in only 3 - 100% of cases. We W present the case of o a 48 year olld female, with h no family hiistory of maliggnancy, diagno osed with prim mary superficiaal leiomyosarcoma of scalp with frontal bone lysis l and intracranial extensiion. The pecuuliarity of this case is the rarrity of this ncommon locaation and bonee involvement which has beeen seen only in n approximately 10% of the cases. tumor, un Keyword ds: Superficial leiomyosarcom ma; scalp; bone lysis; intracraanial extension n DUCTION INTROD Leiomyossarcomas acco ount for 7% of o soft tissue sarcos mas, preedominantly of o visceral loccation such as a the uterus, th he gastrointesstinal tract orr retroperitoneum1. Superficiaal leiomyosarccomas are rare, malignant sm mooth muscle neoplasms thatt arise in derm mis or subcutan neous tissue. Th hey account fo or only 3% off all soft tissue sarcomas2. We W report a caase of superficcial leiomyosarrcoma of left fronto-tempor f o-parietal reggion of scalp with bone invo olvement.

he left frontal bone was foun nd eroded Intraaoperatively, th with an intracraniaal component of size 4x3.5 cm without involvement of o dura. Widee local excisio on of the extraa cranial part of the tumouur with nibbliing of the invollved bone wiith complete removal of in ntracranial part of the tumouur was done. D Dura was left intact and the defect d was clo osed with rotaational scalp flap. f Postoperrative period was w uneventful..

EPORT CASE RE A 48 yearr old housewiffe presented with w a painless swelling on th he left fronto--temporo-parieetal region of scalp for the past p 6 months and bleedingg from the sw welling followingg any trivial in njury for 3 mo onths. She hadd history of faall and acquirin ng an abrasion n on the left frrontal region. on, there was a scalp swelliing in On physiical examinatio the left fronto-tempor f ro-parietal regi gion, measurin ng approximately 13x10 cm with multiplee ulcerations of o the welling overlyingg skin. Surfacee was irregulaar and the sw was fixedd to underlyingg bone (figure 1). Basic laborratory investigattions, ECG an nd Chest X-rayy were normall. The CT Scan examination confirmed c thee presence of a well obulated heterrogeneously en nhancing soft tissue defined lo lesion in left fronto- teemporo-pariettal region with h erou left frontal bone with an assocciated sion of underlying extraduraal component (3.5x2.7x3.7ccm), suggestivve of soft tissuee tumour (figuure 2).

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Fig 1: Scalp sweelling in thee left fronto--temporoparieetal region, measuring m ap pproximately 13x10 cm with h multiple ulcerations of th he overlying skin s Page 109

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n in only 60% % of cases. Cytokeratin C expreession is seen (CK)) and S100 sttains may rareely be positivee. Smooth musccle actin and desmin may assist in diffeerentiating leiom myosarcoma frrom atypical ffibroxanthomaa and dermato ofibrosarcoma protuberancee which stain negatively with them. Additiionally, CK an nd S100 stain ns may be ntiating leiom myosarcoma frrom other helpfful in differen spind dle cell neoplaasms such as sqquamous cell carcinoma c and malignant m melanoma7. Wheen leiomyosarrcoma was do ocumented, the t whole bodyy investigation ns confirmed that there waas not any otherr site for this sarcoma, so iit was documeented that, this is i primary leiom myosarcoma o of scalp.

Fig 2: Th he CT Scan examination e Histo-patthological Exaamination revealed, a partiallyy skin covered grey white tuumour measurring 13x10x9.5 cm with prottrusion. Micro oscopically, thee tumour con nsisted of spindlee cells showingg severe degreee of pleomorp phism and high mitosis (3-5 / histopathologgical field), arraanged ositive in herringgbone and paalisading patteern. It was po for Smoo oth muscle acttin and Desmiin and negativve for Cytokerattin and S 100 protein. p

CT is i useful in determining d tuumour extent,, planning surgiical therapy an nd assessing th he presence of metastasis, especially e in th he lungs. MRII can provide additional inforrmation regardding neurovasccular details, but is more usefuul in deeply in nvasive lesion[3]. Ultrasoun nd can detect presence of tumour, t preseence of necrosis, somem) tend to times bone involvement. Small tumour (